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STATE OF MINNESOTA FOR BOARD USE ONLY <br />GAMBLING CONTROL BOARD ANT PAID <br />PREMISES PERMIT RENEWAL APPLICATION CHECK NO. <br />LC214PPR PRINTED:08/13/93 DATE <br />LICENSE NUMBER: B-01816-003 EFFECTIVE DATE: 02/01/92 EXPIRATION DATE: 01/31/94 <br />NAME OF ORGANIZATION: Lions Moundsviaw Club <br />GAMBLING PREMISES INFORMATION <br />NAME OF ESTABLISHMENT WHERE GAMBLING WILL BE CONDUCTED <br />Mermaid Supper Club <br />2200 Hwy 10 <br />Mounds View 55112 <br />COUNTY Ramsey IS THE PREMISES LOCATED WITHIN THE CITY LIMITS?: Y <br />DOES YOUR ORGANIZATION OWN THIS SITE?: No <br />IF NO, LIST THE LESSOR: <br />Daniel Hall <br />8408 Groveland Rd <br />Mounds View MN S5112 <br />NAME OF PROPERTY OWNER (WHEN NOT LESSOR): <br />SQUARE FEET PER MONTH: 37 <br />SQUARE FEET PER OCCASION: 0 <br />LESSOR INFORMATION <br />AMOUNT PAID FOR RENT PER MONTH: 1000 <br />AMOUNT PAID PER OCCASION: 0 <br />BINGO ACTIVITY <br />BINGO IS CONDUCTED ON THIS PREMISES: No IF YES, REFER TO INSTRUCTIONS FOR REQUIRED ATTACHMENT <br />STORAGE ADDRESS <br />7462 Spring Lake Rd Unit E-063 <br />Hounds View MN 55112 7807 Hwy 65 NE <br />Spring Lake Park, 55132 <br />BANK INFORMATION <br />Firstar New Brighton Bank <br />x?VVjtKf=X 2299 Palmer Drive <br />KdWI�C XJ' jW MN 55112 New Brighton <br />GAMBLING BANK ACCOUNT NUMBER: 909732 700605 <br />ON THE LINES PROVIDED BELOW LIST THE NAME, ADDRESS AND TITLE OF AT LEAST TWO PERSONS <br />AUTHORIZED TO SIGN CHECKS AND HAKE DEPOSITS AND WITHDRAWALS FOR THE GAMBLING ACCOUNT. <br />THE ORGANIZATION'S TREASURER MAY NOT HANDLE GAMBLING FUNDS. <br />Raymond A Long 2604 Ridge Lane, t;ounds View, MN 55112 (iles1q(N7- <br />John R Wharton 7462 Spring Lhke Road, Mounds View, MN 55112 6AMAjL14,a N&R <br />David Maas 5225 Sunnyside Drive, Mounds View, MN 55112 ACS7% Wo-a <br />(BE SURE TO COMPLETE THE REVERSE SIDE OF THIS APPLICATION) <br />THIS FORK WILL BE MADE AVAILABLE IN ALTERNATIVE FORMAT (I.E. LARGE PRINT, BRAILLE) UPON REQUEST <br />