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Minnesota Department of Public Safety <br /> Kik 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&Gamhling Enforcement 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 DriveCenterville 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 F Club ] Charitable ❑ Religious ❑ 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 WilharberCenterville Minnesota 55038 <br /> Organization officer's name City State Zip Code <br /> Terry SweeneyCenterville 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 NOTICE:Submit this form to Alcohol and Gambling Enforcement Division 30 days prior to event. <br /> ONE SUBMISSION PER EMAIL,APPLICATION ONLY. <br /> PLEASE PROVIDE A VALID E-MAIL ADDRESS FOR THE CITY/COUNTY AS ALL TEMPORARY PERMIT APPROVALS WILL BE SENT <br /> BACK VIA EMAIL. E-MAIL THE APPLICATION SIGNED BY CITY/CCNNTY TO AGE.TEMPORARYAPPLICATION@STATE.MN.US <br />