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Minnesota Lawful Gambling <br />-Tab, Paddlewheel, Ti board and/or Raffle Activity - LG221 <br />Name of Leeggal Owner of Premises Street Address City �p, rPaytime Phone <br />HOGGSBREATH ENTERPRISES, INC. 2504 Rice St. LittS� C7pg ,`o i -484 -706 <br />Name of Lessor Street Address <br />Of same as legal owner, write in "SAME ") <br />SAME <br />City State <br />Zip Daytime Phone <br />Name of Leased Premises Street Address <br />2504 <br />Hoggsbreath Bar &Restaurant <br />City Zip <br />R <br />LittleToanada,55113 <br />Daytime Phone <br />651 -484 -7067 <br />Name of Lessee (name of organization leasing the premises) GCS license no. of organization <br />Little Canada Volunteer Fire Dept. B- 00864 -003 651- <br />Daytime Phone <br />766 -5057 <br />Rent Information <br />• Total rent cannot exceed $1,000 per month for all <br />non -bingo activity for this premises. <br />• For bingo activity, use lease form LG222. <br />• For pull -tab dispensing machines, use lease form <br />LG223. <br />• An organization may•not pay rent to itself or to <br />any of its affiliates for space used for the conduct <br />of lawful gambling. <br />Rent to be paid per month $ 1000.00 <br />(If no rent is to be paid. indicate -0-) <br />Sketch and Dimensions of Leased Area <br />Sketch: For all areas being leased for the conduct <br />of gambling and storage of gambling product at this <br />premises, attach a sketch (drawing) showing: (1) the <br />leased area(s), and (2) the dimensions. <br />Dimensions 4 <br />The leased areas are: <br />Storage <br />Storage <br />feet by <br />feet by <br />feet by <br />feet by <br />feet by <br />6 <br />For Premises Permit Renewal Applications Only: If no <br />changes have been made at the site, you do not have to <br />complete this section or provide a sketch. <br />feet for a total of <br />feet for a total of <br />feet for a total of <br />feet for a total of <br />feet for a total of <br />Combined total <br />24 <br />24 <br />square feet. <br />square feet. <br />square feet. <br />square feet. <br />square feet. <br />square feet. <br />Lawful Gambling Activity <br />Type of gambling activity that will be conducted at this gambling premises. Check all that apply. <br />Paddlewheels <br />Pull -Tabs <br />Raffles <br />X <br />Tipboards <br />Term of Lease <br />Amended Lease Only <br />The term of this lease agreement will be concurrent <br />with the premises permit issued by the Gambling Control <br />Board, unless terminated sooner by mutual consent of <br />the lessor and lessee. <br />If this is an amended lease showing changes occur- <br />ring during the term of the current premises permit, <br />write in the date that the changes will be effective <br />. Both parties that signed the lease <br />must initial and date all changes. <br />Questions on this form should be directed to the Licensing <br />Section of the Gambling Control Board (Board) at 651 -639- <br />4000, This publication will be made available in alternative <br />format (i.e. large print, Braille) upon request. Hearing impaired <br />individuals using a TTY may call the Minnesota Relay Service <br />at 1 -800- 627 -3529 and ask to place a call to 651-639-4000. <br />The information requested on this form will become public <br />information when received by the Board, and will be used to <br />determine your compliance with Minnesota statutes and rules <br />governing lawful gambling activities. <br />Page 1 of 2 <br />1/99 <br />Page 66 <br />