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Minnesota Department of Public Safety <br />ALCOHOL AND GAMBLING ENFORCEMENT DIVISION <br />444 Cedar Street Suite 133, St. Paul MN 55101-5133 <br />(651) 215-6209 Fax (651) 297-5259 TTY (651) 282-6555 <br />WWWDPS.STATE.MN.US <br />APPLICATION AND PERMIT <br />FOR A I TO 4 DAY TEMPORARY ON-SALE LIQUOR LICENSE <br />TYPE OR PRINT INFORMATION <br />NAME OF ORGANIZATION <br />STREET ADDRESS <br />NAME OF PERSON MAKING APPLICATIONl^NM <br />(SlA\ <br />DATES LIQUOR WILL BE SOLD *=K\n \o <br />DATE ORGANIZED <br />S\\\\o^S3l <br />CITY <br />Iua«a4a CAKe <br />TAX EXEMPT NUMBER <br />STATE <br />BUSINESS PHONE <br />((•^ *1\C OS(*«t <br />ZIP CODE <br />HOME PHONE <br />ORGANIZATION OFFICER'S NAME <br />CS-\VUJS'^WfiV^ <br />OROANIZA'tlON OFFICER'S NAME <br />ORGANIZATION OFFICER'S NAME <br />TYPE OF ORGANIZATION <br />[CHARITABLE RELIOrOUf; OTHER NQNPROFfT <br />ADDRESS <br />ONCe SS*^S(p <br />ADDRESS <br />ADDRESS <br />Location liocnte will be used. If an outdoor area, describeSX»'Vrvo»^ C *^jCS <br />Will the applicant contract for intoxicating liquor service? If so, give the name and address of the liquor licensee providing the service. <br />Will the applicant carry liquor liability insurance? If so, please provide the carrier's name and amount of coveraae. <br />APROVAL <br />APPLICATION MUST BE APPROVED BY CITY OR COUNTY BEFORE SUBMITTING TO ALCOHOL & GAMBLING <br />ENFORCEMENT <br />CITY/COUNTY /Ortne <br />CITY FEE AMOUNT ^ O <br />DATE APPROVED <br />UCENSE DATES <br />DATE FEE PAID <br />SICNATtRC CITY CLERK OR COUNTY OFFICIAL APPROVED DIRECTOR ALCOHOL A.ND GAMBLING ENFORCEME.NT <br />NOTE: Subnit Ihli forn to tkc city or county 30 days prior to e^ent Forward application titncd by city and/or couoiy to the address <br />above. If ibe applicati** approvaO lO* Akobol aod CambUag Eaforccimat DKiiion will rcnini tail appileatiea le be ywd at the Limtc for Mr rveat <br />PS-09079 (O’/OJ) <br />1