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LG214 <br />(7,29/91) <br />Minnesota Lawful Gambling <br />Premises Permit Application - Part 1 of 2 <br />TSype of, App ea <br />FOR BOARD USE ONLY <br />BASE # <br />PP # <br />FEE <br />CHECK <br />INITIALS <br />DATE <br />Renewal <br />Organization base license number <br />Premises permit number <br />New <br />Organization Irk formation <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 />D ($150) Raffles only <br />11 <br />Name of Organization <br />je-C>/- /6!"'VY* ('te r ' ,a� �, ,< e �C' ,* �_',� �/i . <br />Business Address of Organization - Street or P. 0 Box (Do not use the address of your gambling manager) <br />City State Zi Code County <br />Daytime phone number <br />Gni! pie . nre-S ,i//• 6/4 7g4f-747Z_ <br />Name of chief executive officer (cannot be your gambling manager) Title Daytime phone number <br />& f/4-", iv� G.,,d.D f✓i2��5�1i�'o�/�' (6/2)i79-5lizi <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 <br />to <br />to <br />to If bingo will not be conducted, check here, <br />Gambling Premises Information <br />Name of establishment where gambling will be conducted Street Address (do not use a post office box number) <br />•GLS; O.t/ /24'i/ - 8900 / L.4ke %•e• Ciivb L./lice) ,Td. <br />Is the premises located within city limits? j74t Yes E] No If no, is township n organized n unorganized I I unincorporated <br />to <br />to <br />City and County where gambling premises is located OR Township and County where gambling premises is located if outside of city limits <br />/A729 Ke S Aivz7k,4 1 <br />Name and address of legal owfier of premises City State Zip Code <br />414•2.-5_, 114 L7 YSi vpioeL G L in/0Pity <br />Does your organization own the building where the gambling will be conducted? 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 0 applications_ <br />Address of storage S ace of gambling equipment - Do not use a PO box number <br />Address City State Zip code <br />