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Northwest <br />LG214PPR PRINTED: <br />STATE OF MINNESOTA <br />GAMBLING CONTROL BOARD <br />PREMISES PERMIT RENEWAL APPLICATION <br />(FOR BOARD USE ONLY <br />AMT PAID <br />CHECK NO. <br />DATE <br />LICENSE NUMBER: B-03800-005 <br />EFFECTIVE DATE: 09/01/95 EXPIRATION DATE: 09/30/96 <br />NAME OF ORGANIZATION: Saddle Stillwater Dead Broke Club <br />GAMBLING PREMISES INFORMATION <br />NAME OF ESTABLISHMENT WHERE GAMBLING WILL BE CONDUCTED <br />49 Club <br />6007 Hodgeson Rd <br />Lino Lakes 55014 <br />COUNTY <br />!70104� IS THE PREMISES LOCATED WITHIN THE CITY LIMITS?: Y <br />DOES YOUR ORGANIZATION OWN THIS SITE?: No <br />IF NO, LIST THE LESSOR: <br />David Nathe <br />6007 Hodgeson Rd <br />Lino Lakes MN 55014 <br />NAME OF PROPERTY OWNER (WHEN NOT LESSOR): <br />Nathe Brothers Inc <br />SQUARE FEET PER MONTH: <br />SQUARE FEET PERTOCCASION:' <br />204 <br />LESSOR INFORMATION <br />AMOUNT PAID -FOR RENT PER MONTH: 1000 <br />AMOUNT PAID PER OCCASION:'= 0 <br />BINGO ` ACTIVITY :0' <br />BINGO IS CONDUCTED ON THIS PREMISES: No IF YES, REFER TO INSTRUCTIONS FOR REQUIRED ATTACHMENT <br />STORAGE ADDRESS` <br />11,680 Harrow Ave N <br />Forest Lake MN 55025 <br />BANE INFORMATION <br />st y gee & <br />/6.5-0s -c A4 sf. <br />t- Je kc At• -.I• 3 -3 -oz <br />GAMBLING BANK ACCOUNT NUMBER: <br />30 -//8Z-/ <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.=1 <br />MCg,p - - -t .(/, T(:-"-eS.F' / ez 33-ozcc <br />✓i c <br />/4/.‘ �E'c l/y ,-Z4'/Qi v:s ; ... s)4 t,i / fl 4 t A"fr 5s//o Awsi e," -- <br />(BE SURE TO COMPLETE THE REVERSE SIDE OF THIS APPLICATION) <br />THIS FORM WILL BE MADE AVAILABLE IN ALTERNATIVE FORMAT (I.E. LARGE PRINT, BRAILLE) UPON REQUEST <br />