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Minnesota Lawful Gambling <br />• LG214 Premises Permit Application <br />• <br />• <br />Page 1 of 3 <br />7/01 <br />FOR BOARD USE ONLY <br />Check # Amount <br />Expiratation date <br />Class of Permit <br />Check one <br />❑ Class A - Pull -tabs, tipboards, paddlewheels, raffles, bingo <br />Premises Permit Fee <br />Two years <br />During 2nd year of <br />organization license <br />$400 . <br />, $200 <br />kli Class B - Pull -tabs, tipboards, paddlewheels, raffles ' <br />$250 <br />$125) <br />. <br />Class C Bingo OR bingo total <br />$200 <br />$100 <br />- only and pull -tabs when gross <br />receipts does not exceed $50,000 per year <br />❑ Class D - Raffles only <br />$150 <br />$ 75 <br />Organization Information <br />Organization name (as it'ppears documentation filed : th <br />Minnesota Secretary of State or lnternai Revenue Service) <br />eo,��cce_ <br />Or, gar.izati li:;ense number <br />Name ofchief executive officer (cannot be your gambling manager) <br />'(`n C.� ��� S � r r e S S <br />Daytime phone number, <br />including area code <br />6►Z- 34-n - 8 a2 <br />Gambling Premises Information <br />Name of establishmentwhere gambling will be conducted Street address (do not use a P.O. box number) <br />u q C` wb l9 0(D.--1 \-\ o ., b , Y ■ 'CZ da). <br />City & county where gambling premises is located —, a <br />L'c L,P►v_eS Aro .a I <br />Township & county where gambling premises is located if outside city limits. <br />Is the premises located within city limits? Yes 51 <br />No ❑ If No, is township: ❑ Organized <br />❑ Unorganized <br />❑ Unincorporated <br />Does your organization own the building where the gambling will be conducted? <br />❑ Yes rg No If no, attach (1) the appropriate lawful gambling lease form, and <br />(2) the sketch of all leased areas with dimensions and square footage clearly defined. <br />A lease and sketch are not required for class D applications. <br />Name of legal owner of premises Address City State/Zip <br />,'nom '...,(-0 _arc loon' Arzi&cocvN (2�aA_ Lrb La`c.es mw-. Sso∎L-1 <br />Address(es) of Storage Space of Gambling Equipment <br />List all locations where used and unused gambling product is stored. Do not use a P.O. box number. <br />(Attach an additional sheet if necessary.) <br />Address <br />City <br />S �- ova rd..e_ <br />m <br />State/Zip <br />.5 <br />my-N 5 5o3 8 <br />