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Minnesota Department of Public Safety <br /> ' ••- LIQUOR CONTROL DMSION <br /> sLS ou •. <br /> 444 Cedar St./Suite IOOL <br /> St. Paul, MN 55101-2156 <br /> (612)296-6439 TDD (6 1 2)282-6555 <br /> APPLICATION AND PERMIT <br /> FOR A 1 TO 4 DAY TEMPORARY ON-SALE LIQUOR LICENSE <br /> TYPE OR PRINT FORMATION <br /> NAME OF ORGANIZATION DATE ORGANIZED TAX EXEMPT NUMBER <br /> Church of St. Rose of Lima 1739 ES32148 <br /> STREET ADDRESS CITY - STATE ZIP CODE <br /> 2048 Baalin►e Ave. N. Roseville I MN 1 55113 <br /> NAME OF PERSON MAKING APPLICATION BUSINESS PHONE NOME PHONE <br /> rt (65b 645-9389 <br /> DATES LIQUOR WILL BE SOLD(I to 4 days) TYPE OF ORGANIZATION <br /> SeRIL, _24,2000 ❑ CLUB ❑ CIHARITABLE j RELIGIOUS ❑ OTHER NONPROFIT <br /> ORGANIZATION OFFICER'S NAME ADDRESS <br /> 2048 Hazline Ave. N., Roseville 55113 <br /> ORGANIZATION OFFICER'S NAME ADDRESS <br /> ORGANIZATION OFFICER'S NAME ADDRESS <br /> Location where license Will be used.Jf an outdoor area,descrn <br /> Will the applicant contract for intoxicating liquor services? If so,give the name and address of the Liquor license providing the service. <br /> No <br /> Will the applicant cary liquor liability insurance?If so.the carrier`s name and amount of coverage. <br /> (NOTE: Insurance is not Nu►tual Insurance. <br /> APPROVAL <br /> APPLICATION MUST BE APPROVED BY CITY OR COUNTY BEFORE SUBMMING TO LIQUOR CONTROL <br /> CITY/COUNTY o —)11 I lzr— DATE APPROVED <br /> C ITY FEE AMO�NT SO <br /> LICENSE DATES <br /> DATE FEE PAID I S1 a D <br /> LSIGNATURE CITY CLERK OR COUNTY OFFICIAL APPROVED LIQUOR CONTROL DIRECTOR <br /> NE <br /> NOTE: Do not separate these two parts,send both parts to the address above and the original signed by this division <br /> will be returned as the ficeam Submit to the City or County at least 30 days More the event. <br /> PS-0"79(5135) <br />