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Minnesota Department of Public Safety <br />o�.'��. LIQUOR CONTROL DIVISION �°�'"'� <br />:�t�c ou x '''' <br />:�� �'�`� 444 Cedar St./Suite 100L <br />- St. Paul, MN 55101-2156 <br />��� � �-� (612)296-6439 TDD (612)282-6555 � <br />°�`�i+,�. � : <br />APPLICATION AND PERMIT <br />FOR A 1 TO 4 DAY TEMPORARY ON-SALE LIQUOR LICENSE <br />TYPE OR PRINT INFORMATION <br />N� OF QRGANIZ TION- ,� DATE GAI�TIZF.D TAX EXEMPT NLIMBER <br />�1�'���" 1 � � � � i� � 7� �" � ��� 1 �3 � 4-�� <br />STREF,T D,SS - CI Y � 5TATE ZIP CODE <br />o�; i�=vU���� �. �v� �c���,�� Il.�� Nt N � 5 1 l� <br />NA OF PERSON ING' PLICATION BUSINESS PHONE HOME PHONE <br />�G�� �i1��� 5 ,' `, G� 3 � ( � <br />DATES LIQUOR WILL BE SOLD (1 to 4 days) TYPE OF ORGANIZATION <br />���- � ❑ CLUB 0 CHARITABLE �RELIGIOUS ❑ OTHER NONPROFIT <br />ORGAI�IIZATCON bFFICER'gNAME , � ADD SS - <br />� <br />,� �... �;���c�� ���� � � �< < j ��, ��.�s - t l 51� � <br />ORGANIZATION OFFIC R'S NAME ADDRESS <br />ORGANIZATION OFFICER'S NAME ADDRESS <br />Location where icense w' be used. If an outdoor area, escribe <br />---- - - _ <br />r ��`Vl%i.� ' ti. �, <br />Will the applicant contract for into�cating liquor services? If so, give the name and address of the Liquor license providing the service. <br />(uC. <br />Will the applicant carry liquor liability ind�c�ance? If so. the carrier' s name and amo nt of covera e. � <br />(NOTE: Insurance is not mandatory) �� -QO 1`i'._ (��f{ .(� �7!�(\�� �r. 1,�� <br />APPROVAL <br />APPLICATION MUST BE APPROVED BY CITY OR COUNTY BEFORE SUBMITTING TO LIQUOR CONTROL <br />CITY/COUNTY �OS ��1 i.,L .� DATE APPROVED <br />CITY FEE AMOUNT � S O� LICENSE DATES <br />DATE FEE PAID S� 2S �� I _ <br />SIGNATURE CITY CLERK OR COUNTY OFFICIAL APPROVED LIQUOR CONTROL DIRECTOR <br />NOTE: Do not separate these two parts, send both parts to tbe 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(S/95) <br />