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Minnesota Department of Public Safety <br />ALCOHOL AND GAMBLING ENIFORCEMENT DIVISION <br />444 Cedar Street Suite 133} St. Paul MN 55101 -5133 <br />(651) 201 -7507 Fax (651) 297 -5259 TTY (651) 282 -6555 <br />WWW.DPS. NTN. US <br />APPLICATION AND PERMIT <br />FOR A I TO 4 DAY TEMPORARY ON; ALE LIQUOR LICENSE <br />TYPE OR PR.IINT INFORMATION <br />NAME OF ORGAINIZATION e I� <br />/1 r Ir <br />Cif <br />STREET ADDRESS <br />NAME OF PERSON MAKING APPLICATION <br />DATES LIQUOR WILL BE SOLD <br />ORGANIZATION OFFICER'S NA11rI.E <br />ORGANIZATION OFFICER'S NAME <br />ORGANIZATION OFFICER'S NAME <br />Location license will he used. If are outdoor area, describe <br />IV— <br />TAX EXEMPT NUMBER <br />TYPE OF ORGANIZATION <br />ADDRESS <br />ADDRESS <br />ADDRESS <br />ZIP CODE <br />X5`11 <br />HOM E PH ONTE <br />Will the applicant contract for intoxicating liquor service? If so, give the name and address of the liquor licensee providing the service. <br />2�zc_7 <br />Will the applicant carry liquor liability insurance? If so, please provide the carrier's name and amount of coverage. <br />APROVAL <br />APPLICATION MUST BE APPROVED BY CITY OR COUNTY BEFOR8 SUBMITTINC TO ALCOHOL & GAMBLING <br />ENFORCEl .ENT <br />CITY /COUNT <br />CITY FEE AMOUNT <br />DATE PEE PAID <br />DATE APPROVED <br />LICENSE DATES <br />SIGNATURE CITY CLERK OR COUNTY OFFICIAL APPROVED DIRECTOR ALCOHOL AND GAM13LING ENFORCEMENT <br />NOTE: Submit this form to the city or county 30 days prig to event. Forward application signed by city and/or county to the address <br />ah ave, If the application is approved the Alcohol and Gambling Enforcernen t Division will return this application to be used a s the License for the event <br />PS -09079 (05J06) <br />