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STATE OF MINNESOTA FOR BOARD USE ONLYI <br />GAMBLING CONTROL BOARD ANT PAID <br />PREMISES PERMIT RENEWAL APPLICATION CHECK NO. <br />LG214PPR PRINTED:08/13/93 DATE <br />LICENSE NUMBER: B-01816-005 EFFECTIVE DATE: 02/01/92 EXPIRATION DATE: 01/31/94 <br />NAME OF ORGANIZATION: Lions Moundsview Club <br />GAMBLING PREMISES INFORMATION <br />NAME OF ESTABLISHMENT WHERE GAMBLING WILL BE CONDUCTED <br />Donatelles Supper Club <br />2400 Hwy 10 <br />Noundsview 55112 <br />COUNTY RANSEY IS THE PREMISES LOCATED WITHIN THE CITY LIMITS?: Y <br />DOES YOUR ORGANIZATION OWN THIS SITE?: No <br />IF NO, LIST THE LESSOR: <br />Ed Donatelle <br />5269 Jeffery Dr <br />New Brighton MN 55112 <br />NAME OF PROPERTY OWNER (WHEN NOT LESSOR): <br />SQUARE FEET PER MONTH: 30 <br />SQUARE FEET PER OCCASION: 0 <br />LESSOR INFORMATION <br />AMOUNT PAID FOR RENT PER MONTH: 600 <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 />Mounds View MN 55112 7807 Hwy 65 NE <br />BANK INFORMATION <br />Firstar Now Brighton Bank <br />2299 Palmer Drive <br />{rdaaa(xi}( Mx 55112 New Brighton <br />GAMBLING BANK ACCOUNT NUMBER: 701333 <br />ON THE LINES PROVIDED BELOW LIST THE NAME, ADDRESS AND TITLE OF AT LEAST TWO PERSONS <br />AUTHORIZED TO SIGN CHECKS AND MAKE DEPOSITS AND WITHDRAWALS FOR THE GA1'.3LING ACCOUNT. <br />THE ORGANIZATION'S TREASURER MAY NOT HANDLE GAMBLING FUNDS. r� <br />Raymond A Long 2604 RidRe Lane M6unds View MN 55112 MLeSLbe..r <br />John R Wharton 7462 Spring. Lake Road Munds View MN 55112 �—ArM6Lv.,` WG2 <br />David Maas 5225 Sunnyside Drive Mounds View, MN 55112 (�ssr. wd-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 />