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7 <br /> { <br /> 1 : ter'z'itte <br /> 1830 grain Strew • ( °errrendfiet rV 5506 <br /> Estiz6[ij /i 6 1S -.. (15174 9 -1232 • a47651)429 -!429 <br /> • <br /> CITY OF CENTERVILLE <br /> APPLICATION FOR A 1 TO 4 DAY TEMPORARY/EVENT ON SALE LIOUOR LICENSE <br /> (Organization or IOOatlon timfted to 3 penults In a 12 month period) <br /> Type or Print Information <br /> Name of Organization Date Organized _ . Tax Exempt Number <br /> ,i i -.ise .tf Li s t9 7 2 - 73915t1 <br /> Street Address City State Zip Code <br /> 71 t3Wa L" L �TL +t a-L k wti t X5 <br /> Na ero_f Person Completing Application Business Phone 'Home Phone <br /> L 1G4..e r , ' b 2=2? -t— 917- <br /> Dates Liquor Will Be Sold (1 to 4 days) T,yPe of Organization <br /> F P7. Zt> 2C iv }Q 4W(3. b CHARITA&LE O REUOIOU tj OTHER NON - <br /> Organization Officer's Name Address <br /> ,4Q G ttzaStLb4 TZ4C ` . SS -'H- -3 <br /> Organization Officers Name Address <br /> USA t t -H-p i t7t % 27? l <br /> Organization Officer's Name Address <br /> rbt� ' a 4 412 4' fi r LAr 2-7 <br /> Location where license will be used. If an'otddoor area, describe' <br /> 1.--14:0,4 9 . t. at_ /.raa> IC <br /> • <br /> Will the applicant contract tor intoxicating Ilquor services? if so, give the name and address of the <br /> Liquor license providing the service. r , tr, <br /> Wig the applicant carry liquor liability insurance? If so, the carrer's name and amount of <br /> covetage. 7� 5 , I L — rr-/. Ftt,Gt. i X I S , \irL1 2.O <br /> . . .APPROVAL; <br /> APPLICATION MUST BE APPROVED BY CITY COUNCIL PRIM TO SUBMISSION TO LIQUOR CONTROL <br /> CITY OF CENTERVILLE DATE APPROVED <br /> FEE AMOUNT $ LICENSE DATES <br /> DATE FEE PAID <br /> City Clerk <br /> NOTE: Submit to the City entervin at leeassi thirty (30) days prior to event, <br /> Signature of Applicant: <br /> 34 <br />