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Minnesota Lawful Gambling <br />Premise Permit Application - Part 1 <br />Qrgamzation Irtfarri:tat n <br />FOR BOARD USE ONLY <br />FEE <br />CHECK <br />INITIALS <br />DATE <br />Legal Name of Organization <br />Little canada Volunteer Fire Department <br />Business Address of Organization - Street or P. 0 Box (Do not use address of gambling manager) 't <br />440 East Little Canada Road <br />State Zip Code . County Business phone number <br />MN 55117 Ramsey 612) 484 -2722 <br />Title Business phone number <br />Fire Chief 612) 484 -9346 <br />City <br />Little Canada <br />Name of chief executive officer (cannot be gambling manager) <br />Frank Serry traczyk <br />Address of chief executive officer - Street or P. 0. Box <br />13 West Demont <br />b <br />Little Canada <br />are <br />MN <br />p ode <br />55117 <br />ounty <br />Ramsey <br />Type o-, f'Appiteattar; <br />Class of Premise Permit Fee <br />EZI Class A— Bingo, Raffles, Paddlewheels, Tipboards, Pull -tabs $200 <br />❑ Class B — Raffles, Paddlewheels, Tipboards, Pull -tabs $125 <br />❑ Class C— Bingo only $100 <br />❑ Class D — Raffles only • $75, <br />The class of premise permit <br />must be reflected by class of <br />the organization license. <br />Bingo Occasions <br />If class A or C, fill in days and beginning and ending hours of bingo occasions: <br />No more than seven bingo occasions may be conducted by an organization per week. <br />Day Beginning/Ending Hours Day Beginning/Ending Hours Day Beginning /Ending Hours <br />to <br />to <br />to <br />to <br />to <br />* *SEE ATTACHED SCHEDULE ** <br />to <br />to <br />Status of Premise Permit - check one: <br />❑ New premise — All in base organization premise permit number <br />Renewalot existing premise permit — Fill in comolete premise permit number A- 00864 -002 <br />❑ Previously expired premise permit — Fill in complete premise permit number <br />Page 16 <br />