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-I • <br />LG214 <br />(7/29/91) <br />Minnesota Lawful Gambling <br />Premises Permit Application- Part 1 of 2 <br />pe of Applcatiorz <br />Renewal <br />Organization base license number <br />Premises permit number <br />New <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, dpboards, paddlewheels, raffles, bingo <br />• B ($250) Pull -tabs, tipboards, paddlewheels, raffles <br />❑ C ($200) Bingo only <br />❑ D ($150) Raffles only <br />Organization': or/ nation <br />Name of Organization <br />Mf f <br />Busin ss Address of Organization I- Street or P. 0 (Do not use <br />• 4-77 City State <br />the address of your gambling manager) <br />// 7n�� <br />Zip Code County <br />Name of chief / ut'i ie officer (cannot gambling manager Title <br />-x/77 <br />Daytime phone number <br />(tc /A) 'AZZ -t co <br />Daytime phone number <br />( ) <br />Bingo Occasions <br />If applying for a class A or C permit, fill in days and beginning & ending hsurs of bingo occasions: <br />No more than seven bingo occasions may be conducted by your organization, per week. <br />Day Beginning/Ending Hours Day Begtnning/Endtng Hours Day Beginning /Ending Hours <br />to to <br />to to <br />to If bingo will not be conducted, check here <br />Gambi;ng prenaes Information , <br />Name of establishment where gambling will be conducted Street Address (do not use a post office box number) <br />�t/ o kie$ k(le SST <br />to <br />to <br />U(J) 7i4t) /A/ , /L' . <br />Is the premises located within city limits? CYes O No • If no, is township = organized = unorganized = unincorporated <br />City and County where gambling premises is located OR Township and County where gambling premises is located if outside of city limits <br />Name Aid address of legal owner of premises State (� '_� Zip Code <br />1e % l/r �ec.ee -a 7422 &�.z_4t :� -6 O _, t.r °d ctitn, ST52 /7 <br />Does your organization own the building where the gambling will be conducted? ED YES r0t/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 floor plan with dimensions, showing what portion is being leased. <br />A lease and sketch are not required for Class D applications. <br />Address of storage space of gau bling equipment -co not use PO box number' <br />Address City State Zip code <br />Page 1 <br />