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� <br />� <br />� �� <br />Alcohal & Gam6iing Enfareemea! <br />Minnesota Department of Public Safety <br />Alcohal and Gambling Enfarcement Divisian <br />444 Cedar 5treefi, Suite 222, St. Paul,''MN 55101 <br />651-241-75a0 Fax �i51-297-5259 TtY 651-282-6555 <br />APPLICATtON AND PERMIT FOR A 1 DAY <br />TO 4 DAY TEMPORARY �N-SALE LIQUOR LICERISE <br />Name af arganization <br />� ur�.k o-� Cvr��cs �„ r�s t <br />Address <br />a � 3 t(--c�;t����. v� N <br />Name of person makinq application <br />Date(s} af event <br />3 �� � Y �.J x'� �7 �_I I <br />Organizatio ofFicer's name <br />X .� � <br />Add New Officer <br />Location where permit wili be used. If an outdoor area, describe. <br />c���-1. ��-��� ���- �r-�4 <br />Date arganized Tax exempt number <br />� ��� �q�� �'�j � 5 a� ��y. <br />City State Zip Code <br />l�as,e�� /j� Minnesota�� s sll 3 <br />Business phane Home phone <br />� GS 1— fo 3�— �'$`��' �ra:5! --�34�—�7 �! S' <br />7ype af organization <br />� Club � Charitable � Religiaus [] C?ther non-profit <br />City State Zip <br />i`�1, p��v � 1 �� Minnesota �'~511 � <br />ff the appticant will cantract for intoxicating liquor service give the name and address of the liquor license praviding the service. <br />t�. �A <br />If the applicant will carry liquor liabi[ity insurance please provide the carrier's name and amount af coverage. <br />CQ�L���. 1'��l'�ua� V1iat�'y � i/t�LqL4L='l'L. WQ�U� ����i�\47� ��jr0 / <br />� <br />APPROVAL <br />APPLICAIION MUST BE APPROVED BY CfTY OR COUfVIY BEFORE SUBMf7TING 7Q ALCQH4L AND GAMBLING ENFORCEMENT <br />City/Caunty Date Approved <br />� JC� <br />City Fee Amount Permit Qate <br />bate Fee Paid <br />Signature City Cierk or C�unty Offitiai Appraved Directar Alcohal and Gambling Enforcement <br />NOTE: Submit this form to the city or county 30 days prior to event. Forward application signed by city and/ar countyto the address <br />at�ove. lf the ap�lication is approved the Alcohol and Gambling Enforcement Divisian wifl return this application to be used as the <br />permit for the event. <br />Page 1 of 1 <br />