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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-01816-004 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 /> Roberts Off 10 <br /> 2400 Co Rd H2 . <br /> Mounds View 55112 <br /> • <br /> COTU**T-Y--- RAMSE-Y I-S THE PREM-IS-ES-LOCATED WITHI-N THE- CITY- LIMITS?• Y <br /> LESSOR INFORMATION <br /> DOES YOUR ORGANIZATION OWN THIS SITE?: No <br /> IF NO, LIST THE LESSOR: <br /> Robert Waste <br /> 2345 <br /> MoundsoView82MN 55112 =�> _ :.:� ,= <br /> :.. . .__. <br /> NAME OF PROPERTY OWNER (WHEN NOT LESSOR) : <br /> • <br /> SQUARE FEET PER MONTH: . 40 AMOUNT PAID FOR RENT PER MONTH: 1000 <br /> SQUARE FEET 'PER'OCCASION: 0 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 /> MoundsviewMN 55112 7807 Hwy 65 NE <br /> Spring Lakc' Park, MN 55432 <br /> BANK INFORMATION <br /> Firstar New Brighton Bank <br /> 2299 _Palmer rDrive <br /> MN 55112 New Brighton <br /> is rLfi — . -:::�:.-E,� c. yn.. .y ..>.. �.� + --�, -. ... r.ir .. } <br /> GAMBLING BANK ACCOUNT NUMBER: 700592 ` `z <br /> c , <br /> ON THE LINES PROVIDED BELOW LIST THE NAME,-ADDRESS AND TITLE OF AT LEAST TWO PERSONS <br /> AUTHORIZED,TO SIGN CHECKS AND MAKE DEPOSIT-8 AND WITHDRAWALS FOR--THE GAMBLING ACCOUNT <br /> THE.ORGANIZATION'S TREASURER MAY NOT'HANDLE"GAMBLING FUNDS. <br /> Raymond A- Long 2604-Ridge Lane, Mounds View, MN 55112 • Restpeau-r <br /> - e. ;Y;Ty 4Y+f$.," ; J r i5 _.tom s r.. �`st Fr;s n :r` ,. ..r-t - t'c—. __ .. •,•:i . . <br /> John R: Wharton" :7462 Spring Lake " Road, ` Mounds View, riN 55112 „v,6u,t,� �,tt <br /> David511aas • 5225- Sunnyside Drive','`Mounds View, rte. 55112 ASsr 1440.2 <br /> £ (BE SURE TO COMPLETE THE REVERSE SIDE OF THIS APPLICATION) <br /> THIS FORM WILL BE MADE AVAILABLE IN ALTERNATIVE;FORMAT (I.E. LARGE PRINT, BRAILLE) UPON REQUEST <br />