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Minnesota Lawful Gambling <br />Premises Permit Application - LG214 <br />FOR BOARD USE ONLY <br />Base # Cnecn n <br />PP tt initials <br />Fee Date <br />Page 1 of 3 <br />Class of Permit 1 /99 <br />Check one: , <br />1 Class A - $400 Pull -tabs. Upboards, paddlewheels, raffles, bingo <br />ri Class B - $250 Pull -tabs. Upboards, paddlewheels, raffles <br />Class C - $200 Bingo only OR bingo and pull -tabs when total gross receipts do not exceed $50,000 per year <br />I Class D - $150 Raffles only <br />Organization Information <br />Organization name (as it appears on documentation filed with Base license number <br />Minnesota Secretary of State or Internal Revenue Service) <br />LITTLE CANADA CANADIAN DAYS INC B04219 <br />Name of chief executive officer (cannot be your gambling manager) Daytime pnone number <br />SUE NELSON \651 483 4541 <br />Gambling Premises Information <br />Name of establishment where gambling will be conducted Street address (do not use a P 0 box number) <br />SAXON BOWLING LANES 61 LITTLE CANADA RD <br />City & county where gambling premises is located –OR– <br />LITTLE CANADA RAMSEY <br />Township & county where gambling premises is located if outside city limits <br />β€” <br />Is the premises located within city limits? Yes 71- No IJ If No, is township Organized <br />Unorganized <br />_ Unincorporated <br />Does your organization own the building where the gambling will be conducted? <br />JI Yes 'r 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 />AMF BOWLING LANES 8100 AMF DR, MECHANICSVILLE, VA 23111 <br />Address(es) of Storage Space of Gambling Equipment <br />List all locations where used and unused gambling product is stored. Do not usea P.O. box number. (Attach an additional <br />sheet if necessary.) State/ZiQ <br />Address UNUSED. 61 LITTLE CANADA RD LITTLE CAIA MN 55117 <br />USED 440 LITTLE CANADA RD LITTLE CANADA MN 55117 <br />Questions? Call the Licensing Section of the Gambling Control Board at 651 - 639 -4000. If you use a I I Y, you can <br />call the Board by using the Minnesota Relay Service at 1- 800 - 627 -3529 and ask to place a call to 651- 639 -4000 This <br />form will be mane available in alternative format (i.e. large print, Braille) uoon request <br />Page 32 <br />