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Northwest STATE OF MINNESOTA <br />GAMBLING CONTROL BOARD <br />PREMISES PERMIT RENEWAL APPLICATION <br />LG214PPR PRINTED:O1/02/96 <br />IFOR BOARD USE ONLY <br />AMT PAID <br />CHECK NO. <br />DATE <br />LICENSE NUMBER: B-03017-003 EFFECTIVE DATE: 05/01/95 EXPIRATION DATE: 06/30/96 <br />NAME OF ORGANIZATION: <br />ian�snniw) Firs .Ss . <br />GAMBLING PREMISES INFORMATION <br />NAME OF ESTABLISHMENT WHERE GAMBLING WILL BE CONDUCTED <br />Millers on Main <br />8001 Lake Dr <br />Lino Lakes 55014 <br />COUNTY Anoka IS THE PREMISES LOCATED WITHIN THE CITY LIMITS?: Y <br />LESSOR INFORMATION <br />•"bOES YOUR ORGANIZATION OWN THIS SITE?: No <br />IE NO, LIST THE LESSOR: <br />James Miller <br />7851 Knoll Dr <br />Lino Lakes MN 55014 <br />NAME OF PROPERTY OWNER (WHEN NOT LESSOR): <br />/00 0 <br />SQUARE FEET PER MONTH: 36 AMOUNT PAID FOR RENT PER MONTH: Ag59- <br />SQUARE FEET PER OCCASION: 0 AMOUNT PAID PER OCCASION: 0 <br />BINGO ACTIVITY <br />BINGO IS CONDUCTED ON THIS PREMISES: No IF YES, REFER TO INSTRUCTIONS FOR REQUIRED ATTACHMENT <br />STORAGE ADDRESS <br />14042 Lake Dr <br />Forest Lake MN 55025 <br />Firstar -:Centennial <br />1 Commercial St <br />Circle Pines MN 55014 <br />BANK INFORMATION <br />GAMBLING BANK ACCOUNT NUMBER: 1016989 <br />ON THE LINES PROVIDED BELOW LIST THE NAME;..' ADDRESS AND, TITLE OF AT.LEAST TWO PERSONS:,; <br />AUTHORIZED TO SIGN CHECKS AND MAKE -:DEPOSITS AND -WITHDRAWALS -FOR -THE GAMBLING - ACCOUNT. <br />THE -ORGANIZATION'S TREASURER MAY NOT:.HANDLE-: GAMBLING' FUNDS. <br />/1-40, im7!bP <br />/74% PeWier <br />1�K a iee• <br />mi /U j 1S4nr7 e r r <br />696/ Glrnvi <br />LHServ114i )n V �So3R <br />f�/�f0 f.a•KoS� hIA% ' <br />grICnadVa..-N. i 7/417 ?r 'lt., Ltday <br />Zen'iCI// �,... ,S'5 _._03: 8' <br />/Irr,v7�`iy `At I / /1375- G ue1ec. /1en1 •tryi /k rim/ - 503? <br />(BE SURE TO COMPLETE THE REVERSESIDE OF THIS APPLICATION) <br />THIS FORM WILL BE MADE AVAILABLE IN ALTERNATIVE FORMAT (I.E.::LARGE PRINT, BRAILLE) UPON REQUEST <br />