Laserfiche WebLink
State of Minnesota <br />Gambling Control Board <br />Premises Permit Renewal Application <br />0,G214PPR Printed: 3/1/2002 <br />License Number:B- 03800 -410 0 °5— Effective Date: 10/1/2000 <br />For Board Use Only <br />Amt. Pd <br />Check # <br />Expiration Date: 9/30/2002 <br />Name of Organization: Dead Broke Saddle Club <br />Gambling Premises Information <br />Name of the establishment where gambling will be conducted <br />Chage -Gity; MN- 55013 Aa© 7 /�cPy $4 1- <br />county: Chisago Leo 41c, /% 373�'.d <br />Note: Our records show the premises <br />is located within the city limits <br />Name of the property owner (If different): <br />dc. 157".-0,21 <br />c> <br />0E7 7 <br />,z,/,,w /G- 6'r. ,q1, 57-3297 <br />Lessor Information <br />Square footage leased per month: gtf <br />Rent paid per month: / © ®p <br />Square footage leased per bingo occasion: <br />Rent paid per bingo occasion: <br />Bingo Activity <br />Our records indicate that Bingo is not conducted on these premises. <br />Storage Information <br />19680 Harrow Ave N <br />Forest Lake, MN 55025 <br />5676 <br />1650 South Lake St <br />Forest Lake, MN 55025 <br />Bank Information <br />Gambling Bank <br />Account Number: 3011821 <br />On the lines provided below list the name, address and title of at least two persons authorized to sign checks and make deposits and <br />withdrawals for the gambling account. The organization's treasurer may not handle gambling funds. <br />Name <br />Address <br />City, State, Zip Code <br />Title <br />Michael Burress <br />9243 N 55th St <br />Lake Elmo, MN 55042 <br />Tom Schaffliusen <br />10010 240th St N <br />Scandia, MN 55073 <br />8118 181st Ave N <br />Forest Lake, MN 55025 <br />1 Dave €letter toff <br />(Be sure to complete the reverse side of this application) <br />This form will be made available in alternative format (ie. large print, braille) upon request. <br />Page 1 of 2 (Continued on Back) <br />