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410 Minnesota Lawful Gambling <br />Premises Permit Application - LG214 <br />• <br />• <br />FOR BOARD USE ONLY <br />Base # Check # <br />PP # Initials <br />Fee Date <br />Class of Permit <br />Check one: <br />n Class A - $400 Pull -tabs, tipboards, paddlewheels, raffles, bingo <br />Class B - $250 Pull -tabs, tipboards, paddlewheels, raffles <br />❑ Class C - $200 Bingo only OR bingo and pull -tabs when total gross receipts do not exceed $50,000 per year <br />n Class D - $150 Raffles only <br />Page 1 of 3 <br />1/99 <br />Organization Information <br />Organization name (as it appears on documentation filed with <br />Minnesota Secretary of State or Internal Revenue Service) <br />M ihheSo -'G 7 u,SK4 Mr -es-fl )) I c <br />Name of chief executive officer (cannot be you rambling manager) <br />W� I1ic i. 1-11- tic I� y <br />Base license number <br />Daytime phone number <br />(ooJ ) $S`1.7yCy <br />X 6'i 4 I <br />Gambling Premises Information <br />Name of establishment where gambling will be conducted Street address (do not use a P.O. box number) <br />7e 99 C(I 6001 /404550K 'Rd <br />City & county where gambling premises is located —OR— <br />1 -1hoL.c,Kes 11 -nokc, <br />Township & county where gambling premises is located if outside city limits <br />1 <br />Is the premises located within city limits ?Yes 0,5 <br />No ❑ If No, is township: ❑ Organized <br />E Unorganized <br />❑ Unincorporated <br />Does your organization own the building where the gambling will be conducted? <br />_ Yes .7)‘. 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 />NGfliefBrod- ir,erS (nc a1 14o4 t Rd LrNo Las P N 55o/ / <br />Address(es) of Storage Space of Gambling Equipment <br />List all locations where used and unused gambling product is stored. Do not usea P.O. box number. (Attach an additional <br />sheet if necessary.) <br />Address City State/Zip <br />o0.1 140dc Sof 1oc1d L I`►io Lc, I<J2 s YYl ry SSOi Lt <br />3321 Hehheoly Au t. S, Whois hiN SS�1vk <br />So m <br />S�oS S. Cedar ii� �� � L ��S r c. ! <br />Questions? Call the Licensing Section of the Gambling Control Board at 651- 639 -4000. If you use a TTY, you can <br />call the Board by using the Minnesota Relay Service at 1- 800 -627 -3529 and ask to place a call to 651 - 639 -4000. This <br />form will be made available in altemative format (i.e. large print, Braille) upon request. <br />