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LG214 <br />(7/19/91) <br />Minnesota Lawful Gambling <br />Premises Permit Application Part 1 of 2 <br />eat <br />FOR BOARD USE ONLY <br />BASE # <br />PP # <br />FEE <br />CHECK <br />INITIALS <br />DATE <br />Renewal <br />Organization base license number .8 3L cx, <br />Premises permit number <br />New <br />h9QRon :IISforma1 <br />Class of premises permit <br />(check one) <br />A ($400) Pull -tabs, tipboards, paddlewheels, raffles, bingo <br />p;;KB ($250) Pull -tabs, tipboards, paddlewheels, raffles <br />❑ C ($200) Bingo only <br />D ($150) Raffles only <br />Name of Organization <br />Business Address of Organization - Street or P. 0 Box (Do not use the address of your gambling manager) <br />l?6-'• /mac= ,v S/c7/ <br />City State Zip Code County <br />���£ /7/(7 .5.S-0Z� <br />Name -- of chief executive officer (caann--11.---e----3 <br />be your gambling manager) Title <br />7 _ .SG �ti Y> -e -.-5e" 'z_— 6, C. 0, <br />Bingo Occasions <br />If applying for a class A or C permit. fill in days and beginning & ending hours of bingo occasions: <br />No more than seven bingo occasions may be conducted by your organization per week. <br />Day Beginning/Ending Hours Day Beginning/Ending Hours Day Beginning /Ending Hours <br />to to to <br />Daytime phone number <br />/Z) - 72zsf <br />Daytime phone number c� <br />(G/?)`/.3y <br />If bingo will not be conducted, check here <br />4i4 >I�g premises forntati+on <br />Name of establishment where gambling will be conducted • <br />to <br />Street Address (do not use a post office box number/1/ <br />� <br />/W. /•`-moo �cJ /1 <br />Is the premises located within city limits? XYes O No If no, is township n organized f— unorganized I-1 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 />1 <br />Name and address of legal owner of premises City <br />/ �/� T -I ,e___ ,8,-,.,./-1v-,,.:; ✓ :t c./ C-60 /749 ,s Sca . Z,' -- / G 4 r--•....>'" 3---c) /I/ <br />Does your organization own the building where the gambling will be conducted? 1 1 YES_ 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 />State <br />xy Code <br />Address of storage space of gambling equipment o not Use a PO box numb/ <br />Address City State Zip code <br />/K. <br />