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Jbrile- Minnesota Department of Public Safety <br /> *�� ALCOHOL AND GAMBLING ENFORCEMENT DIVISION ` .,. 4if 444 Cedar Street Suite 222, St.Paul MN 55101-5133 <br /> '""�` (651)201-7507 Fax(651)297-5259 TTY(651)282-6555 <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 DATE ORGANIZED TAX EXEMPT NUMBER <br /> Church of St. John the Baptist June 24, 1902 21203 <br /> STREET ADDRESS CITY STATE ZIP CODE <br /> 835 2nd Avenue NW New Brighton MN 55112 <br /> NAME OF PERSON MAKING APPLICATION BUSINESS PHONE HOME PHONE <br /> Alan Foley (651) 633-8333 ( ) <br /> DATES LIQUOR WILL BE SOLD A ril 9, 201 1 TYPE OF ORGANIZATION X <br /> p CLUB CHARITABLE RELIGIOUS OTIIERNONEROFIT <br /> ORGANIZATION OFFICER'S NAME ADDRESS <br /> (Rev. ) Michael Skluzacek 835 2nd Avenue NW, New Brighton, MN 55112 <br /> ORGANIZATION OFFICER'S NAME ADDRESS <br /> Tom Cronin 835 2nd Avenue NW, New Brighton, MN 55112 <br /> ORGANIZATION OFFICER'S NAME ADDRESS <br /> Cary Becker 835 2nd Avenue NW, New Brighton, MN 55112 <br /> Location license will be used. If an outdoor area,describe <br /> St. John's Fellowship 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 Brighton DATE APPROVED <br /> CITY FEE AMOUNT $100.00 LICENSE DATES <br /> DATE FEE PAID Fee waived <br /> SIGNATURE CITY CLERK OR COUNTY OFFICIAL 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 />