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di.``°`""410 10 '* <br /> i' ty Minnesota Department of Public Safety :' ` <br /> L ALCOHOL AND GAMBLING ENFORCEMENT DIVISION � . ' `' <br /> �� .l. .;: <br /> tier �. 444 Cedar Street Suite 222,St.Paul MN 55101-5133 <br /> a Mm (651)201-7507 Fax(651)297-5259 TTY(651)282-6555 *+ w. <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 FF 3/f ir DATE ORGANIZED TAX EXEMPT NUMBER <br /> )ea.J QQ<<r111.1'0/J L 4 Lem /0-3 - 76 93 30 2 3 <br /> STREET ADDRESS CITY STATE ZIP CODE <br /> 56 S OL1 Hwy g Ai etta reAlArco Mk) ss//:Z <br /> NAME OF PERSON MAKING APPLICATION BUSINESS PHONE HOME PHONE <br /> 6 r.;,i t a k xsc ht) &c ci6cy f'cz �S (6's . CAr — q 16 9 <br /> DATES LIQUOR WILL BE SOLD t Te�fL <br /> 7 TYPE OF ORGANIZATION <br /> .guyUst /© // /lN CLUB CHARITABLE RELIGIOUS OTHER NONPROFIT <br /> ORGANIZATION OFFICER'S NAME ADDRESS Y Cot Airs: <br /> M I c 1 a eL. S 14axiLd,J r/W l S% via.- m,-1.c-cY2,/ <br /> ORGANIZATION OFFICER'S NAME ADDRESS id.ii <br /> R V sS e 1-.L Ma,S /Illy/ Q LI//mac-y f Btuc/ /1E m,u crYiy <br /> ORGANNIZATIION OFFICERS NAME ADDRESS <br /> 7 po Le'A/ 4/L kid hio .c-57/2__ <br /> Location license will be used. If an outdoor area,describe <br /> 40 A.,l L.-1 /t z io,..r L_ 4-4 K le_ , v'vltr# Ttt- - <br /> P4uiI6,0A'i <br /> Will the applicant contract for intoxicating liquor service? If so,give the name and address of the liquor licensee providing the service. <br /> p 0 <br /> Will the applicant carry liquor liability insurance? If so,please provide the carrier's name and amount of coverage. <br /> i/cS N tejAF 7y y140 T u a I_ 4-NA i,o ape c 0 <br /> owe moo, ` 0 <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 />