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LG214 <br />(72991) <br />Minnesota Lawful Gambling <br />Premises Permit Application - Part 1 of 2 <br />Renewal <br />Organization base license numbe Pi /p7r <br />New <br />Premises permit number <br />Organization ?Trtfonnati <br />NNmeooif/.GOfr//g (an//i�[zDaationsi C- <br />usiness Address of Organization - Street or P. 0 Box (Do not use the address of your gambling manager) <br />c.,4 /703/ Ad,, 6—S7 / 7 <br />-0/� try -o4/ <br />FOR BOARD USE ONLY <br />BASE # <br />PP # <br />FEE <br />CHECK <br />INITIALS <br />DATE <br />Class of premises permit <br />(check one) <br />❑ A ($400) Pull -tabs, tipboards, paddlewheels, raffles, bingo <br />❑ B ($250) Pull -tabs, tipboards, paddlewheels, raffles <br />❑ C ($200) Bingo only <br />t4 D ($150) Raffles only <br />City <br />State Zip Code County Daytime phone number, <br />ST Pa," /t4 -�. cs l/7 / ?a wi. ( ) ‘3 r /iilk, <br />Name of chief executive officer (cannot be your gambling manager) Title Daytime phone number <br />� ! t (aft-> e 1�. ( ) 63SLLtfr.. <br />B o sions <br />If applying for a class A or permit, fill in days and beginning & ending hours of bingo occasions: <br />No more than seven bin: . occasions may be conducted by your organization, per week. <br />Day Beginning/Ending Hours Day Begtnnt g/Endthg Hours Day Beginning /Ending Hours <br />to <br />to <br />to to <br />If bingo will not be conducted. check here <br />loavraiticrowiieratorm <br />Name of establishment re garbling will be conducted Street Address (do not use a post offi box number) <br />?8 /h' fl, ems,,... -.4. <br />If no, is township I= organized n unorganized n unincorporated <br />to <br />to <br />C,l <br />Is the premises located within city limits? f Yes O No <br />City �an�d�C�o"unty where gambling premises is located OR Township and County where gambling premises is located if outside of city limits <br />04-� eed-we.l. 711-„ <br />Name and address of legal owner of premises City State Zip Code <br />/,a e 3 a'Q& &,,,--= n,t '.nd ,&y -•, s—.57 o p <br />s your organization own the building where the gambling will be conducted? O YES p NO <br />If no, attach the following: <br />• a copy of the lease (form LG202) with terms for at least one year. <br />• a copy of a sketch of the Moor plan with danendons, showing what portion Is being leased <br />A lease and sketch are not required for Class D applications.... <br />Page 7 <br />