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Minnesota Lawful Gambling <br />Lease for Pull -Tab, Paddlewheel, Tipboard, and/or Raffle Activity - LG221 <br />Name of Legal Owner of Premises Street Address City Zip Daytime Phone <br />(...4-1-q o- E L it k- Cou a 15 c &R Ln'c n J& ysl c 7 ( 51 ) { <br />8 <br />q -� i 7 7 <br />Nam of Lessor SetAddre wCity Zip Daytime Phone <br />(0 same as legal owner, write in "SAME) <br />( ) <br />Snme, Zip Daytime Phone <br />Name of Leased Premises Street Address City <br />5rooner Park L}oo i 11 go( L -I+I& CAnO24.- 551(7 (le5l )404-2417 <br />Name af Lessee (narne af organizatiOn leasing the premises) GCB license no. of organization Daytime Phone <br />Li+e &1J4 CAnakdiT 5-01-z1g - 002_ i05/ )4g4-5l0y <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 />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 feet by <br />The leased areas are: <br />Storage <br />Storage <br />Lawful Gambling Activity <br />IType of gambling activity that will be conducted at this gambling premises. Check all that apply. <br />^ Pull-Tabs <br />feet by <br />feet by <br />feet by <br />feet by <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 $ _ D — AJb ne <br />(If no rent is to be paid, indicate -0-) <br />For,Premises Permit Renewal Applications Only: If no <br />changes have beenmadeatthe site, yotxdo nothave to <br />complete this section orprovide a sketch <br />feet for a total of <br />feet for a total of <br />feet fora total of <br />feet fora total of <br />feet for a total of <br />Combined total <br />4 square feet. <br />square feet. <br />square feet. <br />square feet. <br />square feet. <br />square feet. <br />Paddlewheels <br />Term of Lease <br />The term of this lease agreement will be concurrent with <br />the premises permit issued by the Gambling Control <br />Board, unless terminated sooner by mutual consent of <br />the lessor and lessee. <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 altemative <br />format (i.e. large print, Braille) upon request. Hearing impaired <br />individuals using a TTY may call the at 1-800-627-3529 and ask Minnesota <br />to place a t call 651 9-40008 <br />Raffles <br />Amended Lease Only <br />Tipboards <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 />i <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 17 <br />Page 1 of 2 <br />1/99 <br />