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Minnesota Lawful Gambling <br />LG214 Premises Permit Application <br />Page 1 of 3 <br />7/01 <br />Check # <br />FOR BOARD USE ONLY <br />Amount <br />Expiratation <br />Organization Information <br />Organization name (as it appears on documentation filed with <br />Minnesota Secretary of State or Internal Revenue Service) <br />1-,;17/4., C0*r.aii .4itrackast, 1P4k lac. <br />Name of chief executive officer (cannot be your gambling manager) <br />5.ro_ A!B /sorz. <br />Organization license number <br />‘,y `rf .l 5za ---r/ <br />Daytime phone number, <br />including area code <br />F/ Virg <br />Class of Permit <br />Check one <br />Premises Permit Fee <br />Two years <br />During 2nd year of <br />organization license <br />1 1 ClassA Pull-tabs, <br />$400 <br />$200 <br />- tipboards, paddlewheels, raffles, bingo <br />lErer Class B - Pull -tabs, tipboards, paddlewheels, raffles <br />$250 <br />$125 <br />I I <br />$200 <br />$100 <br />Class C - Bingo only OR bingo and pull -tabs when total gross <br />receipts does not exceed $50,000 per year <br />1 1 <br />$150 <br />$ 75 <br />Class D - Raffles only <br />Organization Information <br />Organization name (as it appears on documentation filed with <br />Minnesota Secretary of State or Internal Revenue Service) <br />1-,;17/4., C0*r.aii .4itrackast, 1P4k lac. <br />Name of chief executive officer (cannot be your gambling manager) <br />5.ro_ A!B /sorz. <br />Organization license number <br />‘,y `rf .l 5za ---r/ <br />Daytime phone number, <br />including area code <br />F/ Virg <br />Address(es) of Storage Space of Gambling Equipment <br />List all locations where used and unused gambling product is stored. Do not use a P.O. box number. <br />(Attach an additional sheet if necessary.) <br />Address <br />I�t / City / ,T <br />a(V 14�' rem. /7zz `! ' 17/47/) ii .a-a <br />h',a,,.c.dw -�'i,z. y �'1 <br />y l7'.g.4.c��sckrnas. <br />G�iad� x m� s Brr &r S - fl'i 4t 51. <br />5 <br />State /Zip <br />4; fiYN- <br />Li77Yc Cg-.t sdt /Y , . 0- 07, ,/,s <br />Gambling Premises Information <br />Name of establishment where gambling will be conducted Street address (do not use a P.O. box number) <br />i <br />4 4.SPO 371c 4-7. <br />ity & co ty where gambling premises is located —OR— <br />4i,%, Car/air <br />Township & county where gambling premises is located if outside city limits. <br />% arnsey <br />Is the premises located within city limits? YesJ <br />No I 1 If No, is township: I I Organized <br />_ Unorganized <br />U Unincorporated <br />Does your organization own the building where the gambling will be conducted? <br />_ Yes riI No If no, attach (1) the appropriate lawful gambling lease form, and <br />(2) the sketch of all leased areas with dimensions and square footage clearly defined <br />A lease and sketch are not required for class D applications. <br />Name of legal owner of premises Address City State /Zip <br />"3 ►-Q 4 /44. 02 4/4 Aley 4. t• ron - 4 p".-/I. C@Le.cl/i, /tin as ;,2 <br />rJl <br />Address(es) of Storage Space of Gambling Equipment <br />List all locations where used and unused gambling product is stored. Do not use a P.O. box number. <br />(Attach an additional sheet if necessary.) <br />Address <br />I�t / City / ,T <br />a(V 14�' rem. /7zz `! ' 17/47/) ii .a-a <br />h',a,,.c.dw -�'i,z. y �'1 <br />y l7'.g.4.c��sckrnas. <br />G�iad� x m� s Brr &r S - fl'i 4t 51. <br />5 <br />State /Zip <br />4; fiYN- <br />Li77Yc Cg-.t sdt /Y , . 0- 07, ,/,s <br />