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4 -0 <br />OLID, <br />Alcohol & Gambling EMarcement <br />Minnesota Department of Public Safety <br />Alcohol and Gambling Enforcement Division <br />445 Minnesota Street, Suite 1600, St. Paul, MN 55101 <br />651-201-75071TY 651-282-6555 <br />APPLICATION AND PERMIT" FOR A 1 DAY <br />TO 4 DAY TEMPORARY ON -SALE LIQUOR LICENSE <br />Name of organization <br />Centerville Lions Club <br />Organization Address (No PO Boxes) <br />1784 Meadow Lane <br />Name of person making application <br />Greg Kleselhorst <br />Date of organization Tax exempt number <br />4-27-1974 J 92-0905708 <br />City State Zip Code <br />Centerville Minnesota 55Li38 <br />Business hone Home phone <br />651-325-6408 <br />Date(s) of event <br />Type of organization Microdistillery ® Small Brewer <br />July 14th-16th _ <br />❑ Club [3 Charitable <br />E] Religious © Other <br />non-profit <br />Organization officer's name <br />City <br />State <br />Zip Code <br />Ron Hogan <br />Centerville <br />Minnesota <br />55038 <br />Organization officer's name <br />City <br />State <br />Zip Code <br />Katie Hogan <br />Centerville <br />Minnesota <br />550313 <br />Organization officer's name <br />City <br />State <br />Zip Code <br />Melissa Lawlis <br />Centerville <br />I Minnesota <br />55038 <br />Location where permit will be used. If an outdoor area, describe. <br />Laurie LaMotte Memorial Park Centerville, Beer Garden by Softball Fields and Hockey Rink. <br />If the applicant will contract for intoxicating liquor service give the name and address of the liquor license providing the service. <br />Mr -Donald Distributors <br />1255 South Frandsen Ave, Rush City MN 55069 <br />If the applicant will carry liquor liability insurance please providethe carrier's name and amount of coverage, <br />West Bend Mutual Insurance Company <br />1900 5. 18th Avenue, West Bend, Will 53095 1 Each Common Cause: $1M I Aggregate Limit: 51 M ( See Certificate for more Details) <br />APPROVAL <br />APPLICATION MU5T BEAPPROVED BYCITY OR COUNTY BEFORE SUBMITTING TO ALCOHOL AND1GAMB_.ING ENFORCEMENT <br />City or County approving the license <br />Fee Amount <br />Event in conjunction with a community festival © Yes r] No <br />Current population of city <br />Please Print Name of City Clerk or County Official <br />Date Approved <br />rmit Dale <br />City or County E-mail Address <br />Signature City Clerk or County Official <br />CLERKS NOTICE: Submit this form to Alcohol and Gambling Enforcement Division 30 days prior to event <br />No Temp Applications faxed or mailed. Only emailed. <br />ONE SUBMISSION PER EMAIL APPLICATION ONLY. <br />PLEASE PROVIDE A VALID E-MAIL ADDRESS FOR THE CITY/COUNTY AS ALL TEMPORARY <br />PERMIT APPROVALS WILL BE SENT BACK VIA EMAIL. E-MAIL THE APPLICATION SIGNED, BY <br />CITY/COUNTY TO AGE. TEMPORARYAPPLICA TION@STA TE.MN.US <br />