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Minnesota Department of Public Safety <br />ALCOHOL AND GAMBLING ENFORCEMENT DIVISION <br />444 Cedar Street Suite 222, St. Paul MN 55101-5133 <br />(6S 1) 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 />DATE ORGANIZED <br />TAX EXEMPT NUMBER <br />STREET ADDRESS <br />CITY CITY <br />STATE <br />ZIP CODE <br />I!0 i-, <br />NAME OF PERSON MAKING APPLICATION <br />BUSIN .SS PHONE <br />HOME PHONE <br />fisA ( f <br />�l a <br />DATES LIQUOR WILL BE SOLD <br />a� asI <br />CX <br />TYPE OF ORGANIZATION <br />CLUB CHARITABLE QTIJER49&�Uz <br />ORGANIZATION OFFICER'S NAME <br />ADDRESS <br />ORGANIZATION OFFICER'S NAME <br />ADDRESS_ .t <br />v?7 3g /`j�'1 ��n^a� iV ti,-) <br />J��� <br />ORGANIZATION O FICE S NAME <br />ADDRESS <br />0 0 <br />Location license will be used. If an outdoor area, describe <br />Will the applicant contract for intoxicating liquor service? If so, give the name and address of the liquor licensee providing the service. <br />Itl o <br />Will the applicant carry liquor liability insurance`? If so, please provide the carrier's name and amount of coverage. <br />APPROVAL <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 $100 <br />LICENSE DATES <br />DATE FEE PAID 3/25/2010 <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 (12/09) <br />