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0 <br />• <br />Minnesota Department of Public Safety <br />ALCOHOL AND GAMBLING ENFORCEMENT DIVISION <br />444 Cedar Street Suite 133, St. Paul MN 55101-5133 <br />(651) 201-7507 Fax (651) 297-5259 TTY (651) 282-6555 <br />WWW.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 />Churrh of qt;- John the Ba"i st <br />DATE ORGANIZED <br />, 1902 <br />TAX EXEMPT NUMBER <br />21203 <br />STREET ADDRESS <br />CITY <br />STATE <br />ZIP CODE <br />835 2nd Avenue NW <br />New Brighton <br />MN <br />55112 <br />NAME OF PERSON MAKING APPLICATION <br />BUSINESS PHONE <br />HOME PHONE <br />Robert Mike <br />(651) 633-8333 <br />DATES LIQUOR WILL BE SOLD <br />Se tember 11-13 2009 <br />TYPE OF ORGANIZATION <br />CLUB CHARIJARLP RELIG,10115 X <br />ORGANIZATION OFFICER'S NAME <br />ADDRESS <br />(Rev.) Michael Skluzacek <br />835 2nd Avenue NW, New Brighton, MN 55112 <br />ORGANIZATION OFFICER'S NAME <br />ADDRESS <br />'Fan Cronin <br />835 2nd Avenue NW New Brighton, MN 55112 <br />ORGANIZATION OFFICER'S NAME <br />ADDRESS <br />Cary Becker <br />835 2nd Avenue NW, New Brighton, MN 55112 <br />Location license will be used. If an outdoor area, describe <br />St. John's Parking Lot and Fellowship <br />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 />APPROVAL <br />APPLICATION MUST BE APPROVED BY CITY OR COUNTY BEFORE SUBMITTING TO ALCOHOL & GAMBLING <br />ENFORCEMENT <br />CITY/COUNTY New Brj&htnn <br />DATE APPROVED <br />CITY FEE AMOUNT $100.00 <br />LICENSE DATES <br />DATE FEE PAID Fee Waived <br />SIGNATURE CITY CLERIC 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 (05/06) <br />