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MINNESOTA LAWFUL GAMBLING 6/15 Pagel of 2 <br /> LG214 Premises Permit Application Annual Fee $150 (NON-REFUNDABLE) <br /> REQUIRED ATTACHMENTS TO LG214 <br /> 1. If the premises is leased, attach a copy of your lease. Use LG215 Mail the application and required attachments to: <br /> Lease for Lawful Gambling Activity. Minnesota Gambling Control Board <br /> 2. $150 annual premises permit fee, for each permit(non-refundable). 1711 West County Road B, Suite 300 South <br /> Make check payable to "State of Minnesota." Roseville, MN 55113 <br /> Questions? Call 651-539-1900 and ask for Licensing. <br /> ORGANIZATION INFORMATION <br /> Organization Name: Forest Lake Area Athletic Assciation License Number: 04354 <br /> Chief Executive Officer(CEO) Allan Hauge Daytime Phone: 651-270-1229 <br /> Gambling Manager: Dana Arntzen Daytime Phone: 651-895-5015 <br /> GAMBLING PREMISES INFORMATION <br /> Current name of site where gambling will be conducted: Fiesta Mexican Grill and Bar <br /> List any previous names for this location: <br /> Street address where premises is located: 7090 21st Ave N <br /> (Do not use a P.O.box number or mailing address.; <br /> City: OR Township: ( aunty: Zip Code: <br /> Lino Lakes Ramsey 55038 <br /> Does your organization own the building where the gambling will be conducted? <br /> Yes n No If no, attach LG215 Lease for Lawful Gambling Activity. <br /> A lease is not required if only a raffle will be conducted.Is any other organization conducting gambling at this site? nYes I n I No n Don't know <br /> Note: Bar bingo can only be conducted at a site where another form of lawful gambling is being conducted by the applying organi- <br /> zation or another permitted organization. Electronic games can only be conducted at a site where paper pull-tabs are played. <br /> Has your organization previously conducted gambling at this site? nYes fNo nDon't know <br /> GAMBLING BANK ACCOUNT INFORMATION; MUST BE IN MINNESOTA <br /> Bank Name: MidWestOne Bank Account Number: 4137741 <br /> Bank Street Address: 1650 Lake St S City: Forest Lake State: MN Zip Code: 55025 <br /> ALL TEMPORARY AND PERMANENT OFF-SITE STORAGE SPACES <br /> Address (Do not use a P.O. box number): City: State: Zip Code: <br /> Hallberg Mini Storage 682 Lake St N Forest Lake MN 55025 <br /> MN <br /> MN <br />