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• LG214PPR Printed: 9282000 <br />State of Minnesota <br />Gambling Control Board <br />Premises Permit Renewal Application <br />For Board Use Only <br />Amt. Pd <br />Check # <br />Date <br />License Number: B- 03934 -003 <br />Effective Date: 4/1/1999 <br />Expiration Date: 3/31/2001 <br />Name of Organization: Hockey Circle Pines Centennial Youth Assoc <br />Gambling Premises Information <br />Name of the establishment where gambling will be conducted <br />Shirley Kayes <br />6810 Lake Dr <br />Lino Lakes, MN 55014 <br />County: Anoka <br />Note: Our records show the premises <br />is located within the city limits <br />Shirley Moore <br />6810 Lake Dr <br />Lino Lakes, MN 55014 <br />Name of the property owner (If different): <br />Lessor Information <br />Square footage leased per month: <br />Rent paid per month: <br />Square footage leased per bingo occasion: <br />Rent paid per bingo occasion: <br />30 <br />1,000 <br />Bingo Activity <br />Our records indicate that Bingo is not conducted on these premises. <br />CARE: 'Roe CT GL - <br />Storage Information <br />9yA 3Srj <br />/3/, / )7/`' , 527k19 <br />Twin City Federal <br />1059 Meadowlands Dr <br />White Bear Lake, MN 55127 <br />On the lines provided below list the name, address and title of at least two persons authorized to sign checks and make deposits <br />and withdrawals for the gambling account. The organization's treasurer may not handle gambling funds. <br />Bank Information <br />Gambling Bank <br />Account Number: <br />5851499148 <br />Name <br />Address <br />City, State, Zip Code <br />Title <br />/‘ 64\(do< <br />isl ( 1C'AvIet,ll tie- <br />1,1)° tel,A. 40/11 <br />Sm4Ah C o <br />C4 i_ SA141 /UN <br />aio �,f� -ulih �. <br />2,rc.& Pines— sCOly <br />s-i�,tJn MIA_ <br />`mmt LIRSL) <br />l� � <br />s3q Love LJ . <br />Lrio 14 5CU,y <br />o <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 />