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Minnesota Department of Public Safety
<br /> Iflll Alcohol and Gambling Enforcement Division
<br /> 445 Minnesota Street, Suite 222, St. Paul, MN 55101
<br /> 651-201-7500 Fax 651-297-5259 TTY 651-282-6555
<br /> Alcohol&Gaintfing IEnfor er�leat APPLICATION AND PERMIT FOR A 1 DAY
<br /> ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, TO 4 DAY TEMPORARY ON-SALE LIQUOR LICENSE
<br /> Name of organization Date organized Tax exempt number
<br /> Centerville Lions Club 4-27-1974 23-7391509
<br /> Address City State Zip Code
<br /> 7155 Brian Drive Centerville Minnesota 55038
<br /> Name of person making application Business phone Home phone
<br /> Greg Kieselhorst 952-361-4159 651-325-6408
<br /> Date(s)of event Type of organization
<br /> July 20,21 and 22,2018 0 Club 0 Charitable 0 Religious 0 Other non-profit
<br /> Organization officer's name City State Zip Code
<br /> Greg Kieselhorst Centerville Minnesota 55038
<br /> Organization officer's name City State Zip Code
<br /> Tom Wilharber Centerville Minnesota 55038
<br /> Organization officer's name City State Zip Code
<br /> Terry Sweeney Centerville Minnesota 55038
<br /> Organization officer's name City State Zip Code
<br /> Minnesota
<br /> Location where permit will be used. If an outdoor area,describe.
<br /> Laurie LaMotte Memorail Park in Centerville.Beer Cooler Trailer up by the(3)Softball Fields.
<br /> If the applicant will contract for intoxicating liquor service give the name and address of the liquor license providing the service.
<br /> NA
<br /> If the applicant will carry liquor liability insurance please provide the carrier's name and amount of coverage.
<br /> West Bend Mutual Insurance Co, 1900 S 18th Ave,West Bend,WI 53095 Each Common Cause 1 M,Aggregate 1 M and General Agg 2M
<br /> APPROVAL
<br /> APPLICATION MUST BE APPROVED BY CITY OR COUNTY BEFORE SUBMITTING TO ALCOHOL AND GAMBLING ENFORCEMENT
<br /> City or County approving the license Date Approved
<br /> Fee Amount Permit Date
<br /> Date Fee Paid City or County E-mail Address
<br /> City or County Phone Number
<br /> Signature City Clerk or County Official Approved Director Alcohol and Gambling Enforcement
<br /> CLERKS NOTICEm Submit this form to Alcohol and Gambling Enforcement. Division 30 days prior to event.
<br /> INIE SUBMISSION IPIER IEMAIL,APPLICATION ONLY.
<br /> IPILIEA IE PROVIDE A VALID E.-MAIL AIDIDIRIESS F IR TIHIE CITY/COUNTY AS AILIL TIE IPOI AI Y PIERMIT APPROVALS WILL IBIE SIENT
<br /> (BACK VIA IE AIIIL. IE- AIIIL'1 HIE APPLICATION SIGNED IBIS CITY/CC
<br /> N'1rY'1r IE:1rIE IP I AI YAIPIPILIICA'1r11OINCaTA'1rE. IN.LV
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