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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 />12 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 Intemal Revenue Service) <br />1 `1(7 C>,e _ �� , o7-(5 OA <br />Name of chief executive officer (cannot be your gambling manager) <br />/34—T �y <br />Base license number <br />Daytime phone number <br />(67 ) 77v-33 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 />City & counttyre gambling <br />jpremises <br />/iiss located—OR—Township <br />14-ie,4tC1�b(�/�/G/( /�- <br />& county where gambling premises is located if outside city limits <br />Is the premises located within city limits?Yes No If No, is township: 1 1 Organized <br />n Unorganized <br />n Unincorporated <br />Does your organization own the building where the gambling will be conducted? <br />❑ Yes 17 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--M /}-S /14 o .f <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 LAC State/Zip <br />_c/ -cc `- r t/v /.3 413q ti,4,yl /, 1, "Ak_t 3 -51)`"I - <br />Questions? CaII 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 />