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Minnesota Department of Public Safety <br />- <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 tray - <br />W W W.DPS.STATE.MN.US <br />APPLICATION AND PERMIT <br />FOR A 1 TO 4 DAY TEMPORARY ON -SALE LIQUOR LICENSE <br />TYPE OR PRINT INFORMATION <br />NAME OF ORGANIZATION <br />DATE ORGANIZED <br />TAX EXEMPT NUMBER <br />St. John the Baptist Catholic Church <br />June 24, 1902 <br />21203 <br />STREET ADDRESS <br />CITY <br />STATE <br />IP CODE <br />835 2nd Avenue NW <br />w Brighton <br />MN <br />L112 <br />NAME OF PERSON MAKING APPLICATION <br />BUSINESS PHONE <br />HOME PHONE <br />Robert Mike <br />(651) 633-8333 <br />( ) <br />DATES LpIOUOR WILL BE $0 <br />Se tZ'mbE 13 14 2 <br />TYPE TYPE OF ORGANIZATION <br />X OTHERNONPROFIT <br />ORGANIZATION OFFICER'S NAME <br />ADDRESS <br />(Rev.) Michael Skluzacek <br />ORGANIZATION OFFICER'S NAME <br />ADDRESS <br />Tom Cronin <br />835 2nd AVenue NW New Brighton, MN <br />ORGANIZATION OFFICER'S NAME <br />ADDRESS <br />CAry Becker <br />_Ea 2nd Avenue <br />Location license will be used. If an outdoor area, describe <br />St. John's Parking Tnt and Falb <br />czhip Hall <br />Will the applicant contract for intoxicating liquor service? If so, give the name and address of the liquor licensee providing the service. <br />No. <br />Will the applicant carry liquor liability insurance? If so, please provide the carrier's name and amount of coverage. <br />Catholic Mutual <br />APROVAL <br />APPLICATION MUST BE APPROVED BY CITY OR COUNTY BEFORE SUBMITTING TO ALCOHOL & GAMBLING <br />ENFORCEMENT <br />CITY/COUNTY New Brighton <br />DATE APPROVED <br />CITY FEE AMOUNT Fee waived <br />LICENSE DATES <br />DATE FEE PAID N/A <br />SIGNATURE CITY CLERK OR COUNTY OFFICIAL <br />APPROVED DIRECTOR ALCOHOL AND GAMBLING ENFORCEMENT <br />NOTE: 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 License for the event <br />PS -09079 (02/05) <br />