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0F Minnesota Department of Public Safety <br />Alcohol and Gambling Enforcement Division�t Y <br />444 Cedar St Suite 133 <br />St. Paul, MN 55101 -5133 �C <br />'� � 1✓3aR} <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 OF ORGANIZATION <br />DATE ORGANIZED <br />TAX EXEMPT NUMBER <br />rl `. Q_ �' 1 ' j f, . t <br />P <br />0"- <br />- <br />STRE�ET ADDRESS } <br />CITY <br />STATE <br />ZIP CODE; <br />NAME OF PERSON MAKING APPLICATION <br />BUSINESS PHONE <br />HOME PHONE <br />DATES LIQUOR WILL BE SOLD <br />TYPE OF ORGANIZATION <br />e ' <br />0 CLUB aCHARITABLE DRELIGIOUS ❑OTHER NONPROFIT <br />ORGANIZATION OFFICER'S NAME <br />ADDRESS <br />t0. t.,t <br />"211 N <br />ORGANIZATION OFFICER'S NAME <br />ADDRESS <br />ORGANIZATION OFFICER'S NAME <br />ADDRESS_ <br />Location where license will be used. If an outdoor area, describe <br />Will the applic "nt contract fnr. nto 'caring liquor services? If sq�,�giv,gg�/trhhe rla�ne and address of the liquor licensee providing the service. <br />r; 1 C �zC �L'ti�r <br />t <br />Will the applicant carry liquor liability insurance? If so, the carrier's name and amount of coverage. <br />(NOTE: Insurance is not mandatory.) <br />APPROVAL <br />APPLICATION MUST BE APPROVED BY CITY OR COUNTY BEFORE SUBMITTING TO ALCOHOL & GAIVIBLING ENFORCEMENT <br />CITY /COUNTY %1 -' "We— DATE APPROVED <br />CITY FEE AMOUNT 5 �- u v LICENSE DATES <br />DATE FEE PAID <br />SIGNATURE CITY CLERK OR COUNTY OFFICIAL APPROVED Alcohol & Gambling Enforcement Director <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 license. Submit to the city or County at least 30 days before the event. <br />PS -09079 (6/98) <br />