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/ � <br />� <br />MINNESO�A �EPAHTMENT OF PUBLIC 9AFETY <br />� � � � � <br />Name of orc�anization <br />Minnesota Department of Public Safety <br />Alcohol and Gambling Enforcement Division <br />444 Cedar Street, Suite 222, St. Paul, MN 55101 <br />651-201-7500 Fax 651-297-5259 TTY 651-�82-6555 <br />APPLICATION AND PERMIT FOR A 1 DAY <br />TO 4 DAY TEMPORARY ON-SALE LIQUOR LICENSE <br />Address <br />1 � - �c� Y�� �f7'� � <br />Name of person makinq application <br />Date(s) of event <br />� Organization officer's name <br />X -fi �%� �`'� i�� #-�/c, G� <br />Add New �fficer. - <br />Date organized Tax exempt number <br />� �� � ° ���� �!-3� <br />City State Zip Code <br />���'�� �/LL �� Minnesota ���� <br />Business phone Home phone <br />� �� i �- ��s�-.�" � -- � <br />Type of organization <br />� Club � Charitable � Religious� Other non-profit <br />City State Zip <br />���� /�t G � Minnesota �� �� � <br />Location where permit will be used. If an outdoor area, describe. <br />� .`°�'J�G F �►� a�?� �L � <br />�.S � � l%/C ? 1J ��%,,/�. �1 . ���' � �I � �� l'✓LL %� �✓1✓ _'7� � � � <br />If the applicant will contract for intoxicating liquor service give the name and address of the liquor license providing the service. <br />If the applicant will carry liquor liability insurance please provide the carrier's name and amount of coverage. <br />APPROVAL <br />APPLICATION MUST BE APPROVED BY CITY OR COUNTY BEFORE SUBMffTING TO ALCOHOL AND GAMBLING ENFORCEMENT <br />City/Cou nty <br />City Fee Amount <br />Date Fee Paid <br />Date Approve <br />Permit Date <br />Signature City Clerk or County Official Approved Director Alcohol and Gambling Enforcement <br />NOT[: Submit this form to the city or county 30 days prior to event. Forward application signed by city and/or county to the address <br />above. If the application is approved the Alcohol and Gambling Enforcement Division will return this application to be used as the <br />permit for the event. <br />Page 1 of 1 <br />