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Minnesota Lawful Gambling <br />Premises Permit Application - LG214 <br />FOR BOARD USE ONLY <br />Base # Check # <br />PP # Initials <br />Fee Date <br />Class of Permit <br />Check one: <br />❑ 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 />❑ 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 />A( 6> /A-X--eJ I .o (,_(5 ei6c <br />Name of chief executive officer (cannot be your gambling manager) <br />Base license number <br />Y. 4 e -6cP3 <br />Daytime phone number <br /><� 1 ? ?© -3 3-oz 7 <br />Gambling Premises Information <br />Name of establishment where gambling will be conducted Street address (do not use a P.O. box number) <br />/-1-1-1 . i . yy - i° e., (-- P s 7-5Z C 7 7 j / , lv6(0 4-1s 44;„,6 /41 <br />City & county where gambling premises is located —OR— <br />I C1(b A— e) 4—H O ti— <br />Township & county where gambling premises is located if outside city limits <br />Is Is the premises located within city limits? Yes No _ If No, is township: 1 I Organized <br />(-I Unorganized <br />_ Unincorporated <br />Does your organization own the building where the gambling will be conducted? <br />[l Yes [SCr 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 />6 /1-e% A-5 /14 0 v .� <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. (Attach an additional <br />sheet if necessary.) <br />Addres <br />.‘i /3 `13`1 4A_ <br />State/Zip <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 />