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State of Minnesota <br />Gambling Control Board <br />Premises Permit Renewal Application <br />3214PPR Printed: 12/3/2001 <br />For Board Use Only <br />Amt Pd <br />Check # <br />License Number: B-03017-003 <br />Effective Date: 7/1/2000 Expiration Date: 6/30/2002 <br />Name of Organization: Centennial Fire Relief Assoc <br />Gambling Premises Information <br />Name of the establishment where gambling will be conducted <br />Millers on Main <br />8001 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 />Name of the property owner (If different): <br />Lessor Information <br />Square footage leased per month: <br />Rent paid per month: 1 000 • C) <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 />-18 Quebec-S't - <br />-Centerville; . N-550 - <br />Firstar Centennial <br />1 Commercial St <br />Circle Pines, MN 55014 <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 />Bank Information <br />Gambling Bank <br />Account Number: <br />1016989 <br />ame <br />Address <br />City, State, Zip Code <br />Title <br />Timothy Mathias Thell <br />1875 Quebec St <br />Centerville, MN 55038 <br />Glkin\7111‘b M%k• <br />Arthur Mohler <br />1756 Peltier Lake Dr <br />Centerville, MN 55038 <br />\I f i ci S)'1-cr <br />Milo Bennett <br />L <br />6961 Glenview Ln <br />Lino Lakes, MN 55014 <br />C.-\'‘ l Z. p> <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 />