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Minnesota Department of Public Safety <br />Alcohol and Gambling Enforcement Division <br />444 Cedar St-Suite 133 <br />St. Paul.MN 55101-5133 <br />(651 )296-64391DD (651 )282-6555 <br />APPLICATION AND PERMIT <br />FOR A TEMPORARY ON-SALE LIQUOR LICENSE <br />TYPI- OR PRIM INFORMATION <br />NAME OF ORGANIZATION <br />ORONO Rotarv <br />STREE^5g§R|^^rtown Rd. <br />NAME OF PERSON MAKING APPLICATION <br />sanne ManolesChry <br />DATES LIQUOR WILL BE SOLD <br />4A27/04 <br />ORGANIZATION OFRCER S NA.ME <br />ORGANIZATION OFFICER S NA.ME Kurt Baldry <br />ORGANIZATION OFFICER S NAME <br />Mike Bash <br />DATE ORGANIZED <br />2/U/2001mno <br />TAX EXEMIT NUMBER <br />STATE MN <br />BUSINESS PHONE <br />(QS7)- Lift I SSI <br />HOME PHONE <br />^ ^ s ame <br />TYPE OF ORGANIZATION <br />ECLLfB nCHARITABLE GRELIGIOUS GOTHER NONPROFIT <br />ADDRESS <br />ADDRESS <br />1A72 Meadow Lane, Maple Plain, MN 55359 <br />ADDRESS <br />1680 Bo Hum Lane, Lor.c Lake, liN 55356 <br />Location where license will be used. If an outdoor area, describe <br />MlnnpFonlffl Canroi- for rha ARTP; ?9Zifl N^^T•^h ghn-ro Ttri oo nyrmrtStjtOt <br />(Indoors) <br />Will the applicant contract for intoxicating liquor services? If so, give the name and address of the liquor licensee providing the service <br />NO <br />Will tlie applicant carry liquor liability insurance? If so, the carrier’s name and amount of coverage, aah non <br />(NOTE: Insurance is not mandatory.) yes . Aon -Ri-".lv-Ser-v-ice5 , Inc . of -I <br />APPROVAL <br />APH.1CATION MUST BE APPROVED BY CITY OR CXH’VTY BEItNlE SCBMITriNG TO ALCOHOL & GAMBLING ENFORCEMENT <br />CITY/COUNTY____________________________________DATE APPROVED_________________________________ <br />_____________________________LICENSE DATES__________________________________CITY FTiE AMOUNT <br />DATE FEE PAID___ <br />SIGNATURE CITY CLERK OR COUNTY OFFICIAL APPROVED Akohot A CuDbling EofcrceineGi Directoi <br />Note: Do not icparate Umm Ino parte, send both parts to Uw address above and Bm origiaal signed by Uns diviston <br />vriM be retamed as ibe Uccasc. SabaiM to ibe city or Coaaty al least 30 days befare tbe event. <br />PS-0M79(teW| <br />1