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1',. IvTnnesota Department of Public Safety <br /> Y *3 '; Alcohol and Gambling Enforcement Division <br /> „ may 444. Cedar St —Suite 133 *. <br /> r „� St. Paul, MN 55101 - 5I33 <br /> (651)296 -6439 TDD (651)282-6555 <br /> APPLICATION AND PERMIT <br /> FOR A TEMPORARY ON -SALE LIQUOR LICENSE <br /> TYPE OR PRINT INFORMATION <br /> NAME QF ORQANIZ ATION, DATE OR TAX EXEMPT NUMBER <br /> C.'erlery i l l t 4: n it s C L,,b 7 / / 7 <br /> STREET ADDRESS ` 1 L CITY / STATE ZIP CODE <br /> 7,24 Plain .7te ter Cent'evvi at M/./ S"$D 3 $ <br /> NAM OF PERSON MAKING APPLICATION BUSINESS PHONE HOME, PHONE <br /> 'li.. Mavr.l.. (t57) 4.35 (657) 4S3 -34/9' <br /> DATES LIQUOR WILL BE SOLD TYPE OP ORGANIZATION <br /> J 30 Ja 3/ ZCLUB DCHARITABLE ORELIGIOUS OOTH'ER NONPROFIT <br /> ORGANIZATION Z S1 <br /> N OFFICER'S NAME ADDRESS / <br /> bave - 7/70 a / A- vensgp. (.1'MTP.✓viie, <br /> ORGANIZAfO QPFIC,FR'S NAME ADDRESS <br /> Jet //eln, 1746 M444 5+Yat# e'ttePe.u:& <br /> ORGA I`r r z/a TMO.rq OFFICER'S NAME ADD S <br /> Mar a /octe- - 7. 2 1-0 Mai. , .54-yea Cato r.✓vi fie. <br /> e., <br /> Locrl n n n stem ligonse will be -c✓nse <br /> o k lf an - - (' area de etr /lfr . t/ ea r ✓ ,ANie.. u e.s# +/ a- s <br /> �en%eo' o-I': ti - n 5lde. /!r a y 'l' <br /> Will the applicant conaart for intoxicating liquor services? If so, give the name and address of the liquor licensee providing the aerate. <br /> Nn <br /> Will the applicant carry liquor liability 4 sutam:c? if so, the caner s name and 9• of coverage. <br /> (NOTE: Insurance is not mandatory.) re, ao r n.a'fe row- - 1 As / 1 006 o 00 <br /> APPROVAL <br /> APFLTCATTON MCST BE AFFRONTED BY CITY OR COUNTY BEFORE SORTIIT TNG TO ALCOHOL & GAM:SUNG E tTORCL:NEN't <br /> CITY /COUNTY DATE APPROVED <br /> CITY.FEE AMOUNT LICENSE DATES <br /> DATE FEE PAID <br /> SIGNATURE CUT/ CLERK OR COUNTY O?•= <C1AL APPROVED Alcohol & G.biinr Edaaracm bircc:ar <br /> Note: Do not separate three two part, mod both path to the addles an sat 9m original slpmd by thb dirteloa <br /> will be retmaed as the Mane. Submit to the dt7 or Cots at least 30 days before the meta <br /> PS-99979 (re9S! <br />