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Minnesota Department of Public Safety <br />1 <br />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 & Gambling Enforcement I <br />APPLICATION AND PERMIT FOR A 1 DAY <br />TO 4 DAY TEMPORARY ON -SALE LIQUOR LICENSE <br />Name of organization <br />Date organized Tax exempt number <br />CENTERVILLE LIONS CLUB <br />Jan 1, 1974 <br />Address <br />6849 CENTERVILLE ROAD <br />Name of person making application <br />THOMAS WILHARBER <br />City State Zip Code <br />CENTERVILLE I ,Minnesota 55038 <br />Business phone Home phone <br />651-587-1250 <br />Date(s) of event Type of organization ❑ Microdistiliery ❑ Small Brewer <br />APRIL 22, 2023 /0 am — // arr� ❑ Club ❑ Charitable ❑ Religious M Other non-profit <br />Organization officer's name City State Zip Code <br />IRON HOGAN, LION PRESIDENTCENTERVILLE Minnesota J 55038 <br />Organization officer's name <br />THOMAS WILHARBER, LION TREASURER <br />Organization officer's name <br />Organization officer's name <br />City State Zip Code <br />_CENTERVILLE (Minnesota 55038 <br />City State _ Zip Code <br />CENTERVILLE °Minnesota 155038 <br />City State Zip Code <br />LMinnesota <br />Location where permit will be used. If an outdoor area, describe. <br />St. Genevieve's Church Parish Community Center - 6559 Centerville Road, Centerville, MN 55038 <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 />Certificate on File from the West Bend Mutual Ins. Co <br />APPROVAL <br />APPLICATION MUST BE APPROVED BY CITY OR COUNTY BEFORE SUBMITTING TO ALCOHOL AND GAMBLING ENFORCEMENT <br />Centerville <br />City or County approving the license <br />Will VA — <br />Amount <br />Date Fee Paid <br />Signature City Clerk or County Official <br />Date Approved <br />Permit Date <br />City or County E-mail Address <br />City or County Phone Number <br />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/COUNTY TO AGE. EMPORARYAPPLI ATION STATE.MN.US <br />