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<br /> <br />tervi[[e <br />'Estaii[ishd 1857 <br /> <br />1880 'Main Street _ Centervi{{e, 'M7{ 55038 <br />(651) 429-3232 _ '[a,(651) 429-8629 <br /> <br />CITY OF CENTERVILLE <br />APPLICATION FOR A 1 TO 4 DAY TEMPORARYIEVENT ON SALE LIQUOR LICENSE <br />(Organization or location limited to 3 permits in a 12 month period) <br /> <br />Type or Print Information <br /> <br />Name of Organization <br />\w.tc'- ..~ S -e<"\.... \ ,J <br />Street Address <br />-1og, G,...,~~ @..6, <br />NJl!Tle of P~rson Completing Application <br />lee,\, r S <br />Dates Liquor Will Be Sold (1 to 4 days) <br />a.~ .H" I 00 <br />Organization Officer's Name <br />~( , t"'\.'U f \~ c.\d. <br />Organization Officer's Name <br /> <br />Date Organized <br /> <br />Tax Exempt Number <br />2.542.0 <br />State Zip Code <br />('I\N 5So'38 <br />Home Phone <br /> <br />Cit <br />te~r,n'le <br />Business Phone <br />"5\-,,\'Z,q-'lQ""31 <br />Type of Organization <br />o CLUB 0 CHARITABLE'" RELIGIOU <br />Address <br />S (k "" <br />Address <br /> <br />o OTHER NON- <br /> <br />Organization Officer's Name <br /> <br />Address <br /> <br />Location where license will be used_ If an outdoor area, describe: <br />"c <br /> <br /> <br /> <br />Will the appliCljl1t carry liquor liability insurance? If so, the carrier's name and amount of <br />covera e. \.:0.",",0\,.(:. ~o.'- $ 50e OC!lO <br /> <br />APPROVAL <br />APPLICATION MUST BE APPROVED BY CITY COUNCIL PRIOR TO SUBMISSION TO LIQUOR CONTROL <br />CITY OF CENTERVILLE DATE APPROVED <br />FEE AMOUNT $ LICENSE DATES <br />DATE FEE PAID <br /> <br />City Clerk <br />NOTE: Submit to the City of Centerville at least thirty (30) days prior to event. <br /> <br />Signature of Applicant: <br /> <br />~c.l....Q. G.,RrvJ <br /> <br />Ch,,~G\ S~c('e.-\<<'''-' <br /> <br />~\.~~~ ~~,,,.. .r~es <br />