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Minnesota Lawful Gambling <br />LG215 Lease for Lawful Gambling Activi <br />5/06 <br />Page 1 of 2 <br />Check applicable item: <br />.1. Lease for new application. <br />Submit <br />premises <br />amended <br />in the <br />be <br />and <br />10 <br />with new premises permit <br />permit renewal. <br />lease within 10 days <br />lease: Rent Premises <br />application. <br />after new <br />lessor assumes ownership. <br />name Booth/bar <br />Date effective <br />change <br />/ / <br />-.2, Renewed lease. Submit with <br />3. New owner. Submit new or <br />_ <br />4. Amended lease <br />Other <br />• Check the change(s) <br />Date that changes will <br />• Both parties must initial <br />• Submit changes at least <br />effective / / <br />_Activity <br />date all changes. <br />days prior to the change. <br />Organization name <br />1 'rl/ / <br />. 1 / - License number <br />• <br />/ / 71 ' ✓ '? CCCC: C.C.3 <br />Daytime phone <br />96 4'-Lle57 <br />Name of leased premises <br />7/p('QS0)42CLZ -19 <br />Street address J City <br />215- ! it W/C27 St: N /i�'r i9fi �/) /f <br />v <br />State <br />Zip <br />•J-i /�J <br />Daytime phone <br />41�/` /- /LW 2 <br />Name`Iogal owner of premises <br />%ha -TriOs %I DU,2fiFy <br />Business /street address i City <br />i/(;) Se I/ /'V' Kic .it /,4. ( ,IMM <br />I State <br />Mit) <br />Zip Daytime phone <br />55 7 F `71‘S'y- %D6 i <br />Name of lessor (if same as legal <br />owner, write in "SAME') <br />5/iTh& <br />Business /street address i City <br />I <br />State <br />Zip <br />Daytime phone <br />Check all activities that will be conducted: <br />X Pull -tabs _Pull-tabs with dispensing device _Tipboards _Paddlewheel Paddlewheel with table _Bingo 1�'' Bar bingo <br />Pull -tab, Tipboard, <br />Booth operation - sales of gambling equipment <br />(or volunteer) of a licensed organization <br />that is distinct from areas where food and <br />r Does your <br />L from <br />If you answered yes to the question <br />based on the following combinations of <br />- Booth operation <br />- Booth operation and pull -tab dispensing <br />- Booth operation and bar operation <br />- Booth operation, bar operation, and <br />The maximum rent allowed may <br />per month for all organizations at <br />Complete one option: <br />Option A: 0 to 10% of the gross profits <br />Percentage to be paid /0 % <br />and Paddlewheel <br />by an employee <br />within a separate enclosure <br />beverages are sold. <br />organization OR any other <br />a booth operation at this <br />above, rent limits are <br />operation: <br />device <br />pull -tab dispensing device <br />not exceed $1,750 in total <br />this premises. <br />per month. <br />or less per month, $0 to <br />to be paid $ . <br />Bar <br />premises <br />food <br />location? <br />If you <br />based <br />- Bar <br />- Bar <br />- Pull <br />The <br />per <br />Complete <br />Option <br />Percentage <br />Option <br />to $200 <br />Option <br />of gross <br />20% <br />over <br />Rent (No lease <br />operation - sales of <br />by an employee <br />and beverages are also <br />organization conduct <br />Yes <br />answered no to the <br />on the following combinations <br />operation <br />operation.with pull <br />-tab dispensing device <br />maximum rent allowed <br />month for all organizations <br />one option: <br />A: 0 to 20% of the <br />to be paid <br />required <br />gambling <br />of the lessor <br />sold. <br />gambling <br />No <br />for raffles.) <br />equipment <br />from a common <br />above, rent <br />of operation: <br />device <br />not exceed <br />at this premises. <br />profits per month. <br />% <br />$1,000 or less <br />to be <br />may be paid <br />$ <br />within a leased <br />area where <br />J <br />limits are <br />$2,500 in total <br />per month, $0 <br />paid $ <br />question <br />-tab dispensing <br />only <br />may <br />gross <br />Option B: When gross profits are <br />$400 per month may be paid. Amount <br />Option C: $0 to $400 per month <br />of gross profit. Amount to be paid <br />10% of the gross profits may be <br />over $4,000. Percentage to be paid <br />$4,000 <br />may <br />$ <br />B: When gross profits are <br />per month may be paid. Amount <br />C: $0 to $200 per month <br />profits. Amount to be paid <br />of the gross profits may be paid <br />$1,000. Percentage to be paid <br />be paid on the first $4,000 <br />. Plus 0% to <br />on the first $1,000 <br />. Plus 0% to <br />paid per month on gross prof is <br />% <br />per month on gross profits <br />Bingo <br />Option D: 0 to 10% of the gross <br />gambling activities held during bingo <br />Percentage to be paid <br />Rent <br />profits <br />occasions, <br />% <br />per <br />foot <br />Board. <br />per <br />per month from all lawful <br />excluding bar bingo. <br />square foot not to exceed 110% <br />for leased space, as approved <br />No rent may be paid for <br />square foot. <br />verified by the organization, <br />costs to be paid by the <br />by <br />bar <br />to <br />Bar <br />option F: <br />Bingo Rent <br />No rent may be paid for bingo <br />conducted in a bar. <br />Option E: A rate based on a cost <br />of a comparable cost per square <br />the director of the Gambling Control <br />bingo. Rate to be paid $ <br />New Bingo Activity <br />For any new bingo activity not previously <br />included in a Premises PermitApplication, <br />attach a separate sheet of paper listing the <br />days and hours that bingo will be conducted. <br />The lessor must attach documentation, <br />confirm the comparable rate and all applicable <br />organization to the lessor. <br />5 <br />