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Minnesota Department of Public Safety <br /> .• LIQUOR CONTROL DIVISION <br /> 444 Cedar St./Suite 100L <br /> St. Paul, MN 55101-2156 <br /> (612)296-6439 TDD (612)282-6555 <br /> APPLICATION AND PERMIT <br /> FOR A 1 TO 4 DAY TEMPORARY ON-SALE LIQUOR LICENSE <br /> TYPE OR PRINT INFORMATION 4 L fx,6" <br /> N + OF ORGA TIC t DATE ORGANIZED TAX EXEMPT NUMBER <br /> L.,Rkolt vai.-STREET A JID S - CI ST TE ZIP CODE <br /> v . <br /> AME OF�'ERSON G APPLICATION BUSINESS PHONE HOME PHONE byL_ <br /> dtv) <br /> DATES LIQUOR WML BE SOLD(1 to 4 days) TYPE OF ORGANIZATION <br /> P.... ; <br /> ro ] -1, 11tv-2) ❑CLUB ❑ CHARITABLE RELIGIOUS ❑ OTHER NONPROFIT <br /> 0 WANIZATION OFFI 11S NAW ADDRESS <br /> ORGANIZATION OFFICER'S NAME ADDRESS <br /> ORGANIZATION OFFICER'S NAME ADDRESS <br /> Location where Wense wiR be used. If an outdoor area,descrit�e . <br /> 10 A!!!� <br /> U,p (o �:� <br /> I:& <br /> Lf,._ [,jt )26 &&ab, d4 <br /> V U - <br /> W* the applicant on�ract for intoxicating liquor services? If so, dive the name and address of the Liquor license providing the service. <br /> r � l <br /> WWI the applicant cant'liquor liability' an ? If so,the car' s name and amount of' a e• <br /> (NOTE: Ins+arance is not mandato ���dyLz, `, <br /> APPROVAL <br /> APPLICATION MUST BE APPROVED BY CITY OR COUNTY BEFORE SUBMITTING TO LIQUOR CONTROL <br /> C I T Y DATE APPROVED <br /> CITY FEE AMOUNT 4 <br /> So <br /> � o -' LICENSE DATE <br /> S <br /> DATE FEE PAID . . <br /> SIGNATURE CITY CLERK OR COUNTY OFFICIAL APPROVED LIQUOR CONTROL DIRECTOR <br /> NOTE: Do not separate these two parts,send both parts to the address above and the original sigeed by this division <br /> wiH he returned as the license. Submit to the City or County at least 30 days before the event. <br /> P"9079(8f95) <br />