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-- - <br /> STATE OF MINNESOTA FOR BOARD USE ONLY <br /> GAMBLING CONTROL BOARD AMT PAID <br /> `-^ PREMISES PERMIT-RENEWAL APPLICATION ' -' CHECK NO <br /> LG214PPR 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 Moundsview 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 /> -4 .•••• , •••'• -,•;'• • ' ; . <br /> COUNTY--ItalaSeir IS THE- PREMISES---LOCATED -WITHIN THE-CITY-LIM-ITS?:Y <br /> LESSOR INFORMATION <br /> DOES YOUR ORGANIZATION OWN THIS. SITE?: No - <br /> IF NO,- LIST THE LESSOR: -- - <br /> Daniel Hall 84O8'Groveland I4 . ,• , <br /> , • - 4-1 , <br /> `, t <br /> Mounds View MN 55112 . - _ <br /> NAME OF PROPERTYOWNER (WHEN NOT LESSOR): <br /> - , <br /> SQUARE FEET PER MONTH:_ . 37 AMOUNTPAID'FORRENT PER MONTH: 1000 <br /> SQUARE FEET PEROCCASION: 'AMOUNT'PAID PER OCCASION: • ' _ 0 ' <br /> • <br /> ; • 'r ' * ; ; •••,• <br /> - BINGO ACTIVITY <br /> BINGO IS CONDUCTED ON THIS PREMISES: No .- IF :YES, REFER TO INSTRUCTIONS FOR' REQUIRED'ATTACHMENT <br /> r <br /> ' • . <br /> ' ‘ ;, . <br /> _ - • STORAGE ADDRESS <br /> • <br /> 7462 Spring Lake Rd ' ' E-063 = <br /> Mounds view MN 55112,, 7807' Hwy, 65 NE " <br /> Spring Lake Park, MN '55/132 <br /> • ' ? - . • ' - - <br /> Firstar' New Brighton Bank .; 2 <br /> 7r <br /> 2299 act , ' o• •14,,,*iCEIXIMIDEQX_: <br /> NN, 55112, on; <br /> -•"` • = •`' •":" :•1,:; <br /> GAMBLING BANK ACCOUNT NUMBER 909732 & i00605is;- •• • <br /> ' -." ,4•• '' - • • <br /> ON THE LINES PROVIDED BELOW LIST THE NAME, ADDRESS AND TITLE OF AT LEAST. TWO PERSONS <br /> AUTHORIZED TO SIGN. CHECKS itkWAT.S.".FOR THE GAMBLING ACCOUNi,._ <br /> j. <br /> THE ORGANIZATION'S TREASURER MAY NOT HANDLE GAMBLING FUNDS; <br /> Raymond N..Long 2604 Ridge .Lane iloundsz-View, MN 55112 Tites <br /> .,-.-r:-,Lffe,,,Irtxre, - <br /> -John' R-'161hartan‘ :Spri.ng-.L&Ites'Road View;r MN '55112 C..0,0Aft,i44.4. IMG-R <br /> David,,14.6.as" 5225- Stinnys i de' Dr.- iize!,I.;14,1oundst7Viewv-i:IvIN 55112 041. <br /> . e A t4 Tel,"vzt, - • •-•• - <br /> (BE SURE TO COMPLETE THE REVERSE SIDE OF THIS APPLICATION) <br /> • = . •• . ' ;.f - - ' <br /> THIS FORM WILL BE MADE AVAILABLE IN ALTERNATIVE,FORWAT, (I.E.-LARGE PRINT, BRAILLE) UPON REQUEST <br /> - _ <br /> • ' . - <br />