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Minnesota Lawful Gambling <br />(LG200R) Lawful Gambling License Renewal Application <br />Corrections should be made directly on this application <br />Submit one check for all renewal fees, payable to State of Minnesota <br />Board Use Only <br />Organization requirements: <br />1. An annual organization license fee of $350 is required. <br />Current license term: 4/1/2004 to 3/31/2006 <br />Renewing license term: 4/1/2006 to 3/30/2008 <br />Authorization: 1485 <br />Organization: North Suburban Youth Foundation <br />1970 Oakcrest <br />a • . 1 - <br />CEO: Richard R Matson <br />2774 Dellwood St, Roseville, MN 55113 <br />Treasurer: Dale L Maristlien <br />5705 Dunlap Ave, Shoreview, MN 55126 <br />Annual Goal for Charitable Contributions <br />(612)638 -4600 <br />oun o amsey <br />Check this box if your <br />organization qualifies for 1 <br />the waiver of the $350 1 <br />or anization license fee <br />I defined in MN Statute. I <br />I 349.16 Subd. 6 I <br />(612)889 -4463 <br />(651)780 -9872 <br />Premises permit requirements: <br />1. An annual premises permit fee of $150, <br />2. A separate resolution of approval including the site address from the local unit of government, (The local unit of <br />government does not sign this renewal application) and <br />3. A LG215 lease agreement for each site your organization does not own is required. <br />Site number 010 <br />Little Canada Bingo Hall <br />2900 Rice St, Little Canada, MN 55113 <br />1---- Township of (if applicable) <br />Organization owns this site: N <br />Does your organization conduct bingo at this site. <br />Is the resolution of approval attached? Y <br />J Check this box if this site has been discontinued or will not be renewed. <br />Site number 012 <br />Ramsey County <br />Gambling account # 18002394 <br />North American Banking Co <br />N 2230 N Albert, Roseville, MN 55113 <br />Board Use Only <br />If yes, the attached list of the days and beginning and ending hours of your • <br />bingo occasions must be updated and returned. <br />Check this box if this site has been discontinued or will not be renewed. <br />Big Ten Supper Club <br />4703 N Hwy 10, Arden Hills, MN 55112 <br />Township of (if applicable) <br />Organization owns this site: N <br />Does your organization conduct bingo at this site <br />Is the resolution of approval attached? Y /0 <br />• <br />Ramsey County <br />Gambling account # 18002394 <br />North American Banking Co <br />N 2230 N Albert, Roseville, MN 55113 <br />Board Use Only <br />If yes, the attached list of the days and beginning and ending hours of your • <br />bingo occasions must be updated and returned. <br />Site number 013 <br />J Check this box if this site has been discontinued or will not be renewed. 1 <br />Willards Bar <br />738 Thomas Ave, St. Paul, MN 55104 <br />Township of (if applicable) <br />Organization owns this site: N <br />Does your organization conduct bingo at this site? Y <br />Is the resolution of approval attached? Y <br />Ramsey County <br />Gambling account # 18002394 <br />North American Banking Co <br />2230 N Albert, Roseville, MN 55113 <br />Board Use Only <br />If yes, the attached list of the days and beginning and ending hours of your <br />bingo occasions must be updated and returned. <br />