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LG214 <br />(7%29191) <br />Minnesota Lawful Gambling <br />Premises Permit Application - Part 1 of 2 <br />.............................. <br />........................ <br />FOR BOARD USE ONLY <br />BASE # <br />PP # <br />FEE <br />CHECK <br />INITIALS <br />DATE <br />Renewal <br />Organization base license number, (9380c> <br />Premises permit number <br />New <br />::i:#:ki;''::ti::?;%moi;; :•t:':::::.::_:;:? <br />Class of premises permit <br />(check one) <br />n A ($400) Pull -tabs, tipboards, paddlewheels, raffles, bingo <br />%B ($250) Pull -tabs, tipboards, paddlewheels, raffles <br />C ($200) Bingo only <br />11 <br />D ($150) Raffles only <br />Name of Organization • <br />Business Address of Organization - Street or P. 0 Box (Do not use the address of your gambling manager) <br />/3r= ) Vc7/ <br />City State Zip Code County <br />5r% <br />Name of chief executive officer (carr be your gambling manager) Title <br />r72 ss�z5 <br />Daytime phone number <br />iz) ire % - 722.s� <br />Daytime phone number <br />7;;),--f—$G il. c� 77 /ti --vs< <z_— 6, r, O, (6/2) vs- - /7._.5-7" <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 <br />to to <br />to If bingo will not be conducted, check here <br />to <br />................................................... . <br />Name of establishment where gambling will be conducted Street Address (do not use a post office box number) <br />Is the premises located within city limits? p 'Yes EJ No If no, is township n organized n unorganized O 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 and address of legal owner of premises City State <br />Zi Code <br />err/ <br />Afc, l• 7 f3rc f} K,.; X% -r - 660r L Kt <br />Does your organization own the building where the gambling will be conducted? 1-1 YES cgi 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 City State Zip code <br />