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Minnesota Department of Public Safety <br /> Alcohol and Gambling Enforcement Division <br /> 445 Minnesota Street,Suite 222,St. Paul, MN 55101 <br /> AMC) 651-201-7500 Fax 651-297-5259 TTY 651-282-6555 <br /> Alcohol&GaTnbling Enforcaimaat 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 Lion Club August 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 F Microdistillery 0 Small Brewer <br /> 4/27/2019 F Club 0 Charitable F Religious F Other non-profit <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 /> Tom Wilharber Centerville Minnesota 55038 <br /> Organization officer's name City State Zip Code <br /> Mary Lou Wilharber 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 /> St.Genevieve Parrish Center in Centerville MN 55038.6995 Centerville Rd. <br /> If the applicant will contract for intoxicating liquor service give the name and address of the liquor license providing the service. <br /> If the applicant will carry liquor liability insurance please provide the carrier's name and amount of coverage. <br /> West Bend Mutual Insurance Company <br /> 1900 South 18th Avenue <br /> West Bend WI 53095 <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 /> ®IME SUBMISSION IPIER IEMAIIII...„AIPIPII..,IICA"I olm OImII...Y. <br /> IPII...IEASIE IPI OVIIIDIE A VAII...IIID IE-MAIIII...AIDIDIRIESS FOR'irii-m CII"II"Y/CCIDINTY AS All nEMIPO AI Y IPIEIRMIIT AIPIPIROVAILS WIL.11..,IBIE SIEINT <br /> IBACK VIA IEMAIIII.... IE-MAIIII..."riff AIPIPII..,IICATIIOIN SlICII4IEID BY CirirY/C wTY'm IE.IrIE.II .IP JR IR JPIPII,,.1ICXi 0N. "irXlrIFAb II�.w <br />