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FOR BOARD USE ONLY <br /> LG214 BASE <br /> (7/29,91) PP <br /> FEE <br /> Minnesota Lawful Gambling CHECK <br /> Preises Permit Application Part 1 of 2 INITIALS <br /> DATE <br /> Class of premises permit <br /> 1 Renewal (check one) <br /> organization base license number A 03191 0 A ($400) Pull -tabs, tipboards, paddlewheels, raffles, bingo <br /> Premises permit number B ($250) Pull -tabs, tipboards, paddlewheels, raffles <br /> 'I/fl New C ($200) Bingo only <br /> D ($150) Raffles only <br /> Name of Organization <br /> ROSEVILLE AREA YOUTH HOCKEY ASSOC. <br /> Business Address of Organization Street or P. 0 Box (Do not use the address of your gambling manager) <br /> 203 WEST SKILLMAN AVE. ROSEVILLE MN. 55113 <br /> City State Zip Code County Daytime phone number <br /> ROSEVILLE MN. 55113 RAMSEY (61$ 488 8926 <br /> Name of chief executive officer (cannot be your gambling manager) Title Daytime phone number <br /> ANTHONY LEE BORASH PRESIDENT (612) 488 8926 <br /> Bingo Occasions <br /> If applying for a class A or C permit, fill in days and beginning ending hours of bingo occasions: <br /> No more than seven bingo occasions may be conducted by your organization per week. <br /> Day Beginning/Ending Hours Day Beginning/Ending Hours Day Beginning /Ending Hours <br /> to to to <br /> to to to <br /> to If bingo will not be conducted, check here <br /> f .wH <br /> <:t:.. .t.r;> ins• <br /> IBS >��O.TI>[I <br /> :;G�mbli >e a atia> dr...::.::::>::.::<:.:.;::.:.:.:::.:>::.:;::.::.;:>:::;.:: <br /> Name of establishment where amblin will be conducted use g g Street Address( do notuse ap ostofficebox number) <br /> FALCON LANES 1550 LARPENTEUR AV. W. FLCN.HTS. <br /> Is the premises located within city limits? LA Yes O No If no, is township organized O unorganized I= unincorporated <br /> City and County where gambling premises is located OR Township and County where gambling premises is located if outside of city limits <br /> RAMSEY <br /> Name and address of legal owner of premises City State Zip Code <br /> JAMES P BIGELBACH ST PAUL MN. 55105 <br /> Does your organization own the buildng where the gambling will be conducted? ED YES C__ NO <br /> If no, attach the following: <br /> a copy of the lease (form LG202) with terms for at least one year. <br /> a copy of a sketch of the floor plan with dimensions, showing what portion is being leased. <br /> A lease and sketch are not required for Class D applications. <br /> sto a ce <br /> dame 8.T�� <br /> Address City State Zip code <br /> a( SAME i L'� <br /> ter; 6-5-11-)) <br />