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MINNESOTA LAWFUL GAMBLING <br />LG214 Premises Permit Application <br />6/15 Page 1 of 2 <br />Annual Fee $150 (NON—REFUNDABLE) <br />REQUIRED ATTACHMENTS TO LG214 <br />1. If the premises is leased, attach a copy of your lease. Use LG215 Mail the application and required attachments to: <br />Lease for Lawful Gambling Activity. Minnesota Gambling Control Board <br />2. $150 annual premises permit fee, for each permit (non-refundable). 1711 West County Road B, Suite 300 South <br />"State Roseville, MN 55113 <br />Make check payable to of Minnesota." <br />Questions? Call 651-539-1900 and ask for Licensing. <br />ORGANIZATION INFORMATION <br />Organization Name: hamcY F oO la L I ASSOC 1j 'O4;kLicense Number: 31obss <br />Chief Executive Officer (CEO) J 0,Son 5+r6LS5e4- Daytime Phone: 9-0707 <br />Gambling Manager: Marcie e— f r iGt fo Daytime Phone: 4P3 "a(9 7 /( 00 <br />GAMBLING PREMISES INFORMATION <br />Current name of site where gambling will be conducted: M ey- aid n I e, kaIn me,yA F t Um-L <br />List any previous names for this location: <br />CA �>,fK)al,d Sw ppef ClL) <br />Street address where premises is located: DIN) 11 tiOUAL V N) U� MOQVVi5 U i W MA E51lo� <br />(Do not use a P.O. box number or mailing address.) <br />City: OR Township: <br />County: Zip <br />\ <br />lCode: <br />q <br />J 155 L <br />Does your organization own the building where the gambling will be conducted? <br />Yes 1XNo If no, attach LG215 Lease for Lawful Gambling Activity. <br />A lease is not required if only a raffle will be conducted. <br />Is at this site? "Yes ONO Don't know <br />any other organization conducting gambling <br />Note: Bar bingo can only be conducted at a site where another form of lawful gambling is being conducted by the applying organi- <br />zation or another permitted organization. Electronic games can only be conducted at a site where paper pull -tabs are played. <br />Has this Yes "No EDon't know <br />your organization previously conducted gambling at site? <br />GAMBLING BANK ACCOUNT INFORMATION; MUST BE IN MINNESOTA <br />ALL TEMPORARY AND PERMANENT OFF -SITE STORAGE SPACES <br />Address (Do not use a P.O. box number): City: State: Zip Code: <br />37U /agt" Lace Na) Coon 2apids MN SSy33 <br />1 y 6 of ("r V-O use S�_ Nub MN S 30y <br />7a) IA4 g �h 1-a "e Nw 6h D uev ,SS30y <br />13(0a q 40 nsorn Blvd A�j d o ve✓ MN s�530q <br />