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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 />Make check payable to "State of Minnesota." Roseville, MN 55113 <br />Questions? Call 651-539-1900 and ask for Licensing. <br />ORGANIZATION INFORMATION <br />Organization Name: Lake Region Hockey Association License Number: 01837 <br />Chief Executive Officer (CEO) Ted Koeppl Daytime Phone: 612-202-2842 <br />Gambling Manager: Robert ]ahnke Daytime Phone: 551-592-9901 <br />GAMBLING PREMISES INFORMATION <br />Current name of site where gambling will be conducted: Mermaid <br />List any previous names for this location: <br />r <br />Street address where premises is located: 2200 Mounds View Blvd <br />Do not use a P.O. box number or mailing address.) <br />City: OR Township: County: Zip Code: <br />Mounds View Ramsey 55112 <br />Does your organization own the building where the gambling will be conducted? <br />Yes E No If LG215 Lease For Lawful Gambling Activity. no, attach <br />A lease is not required [f only a raffle will be conducted. <br />Is organization at this Eyes 11 No Don't knowanyotherconductinggamblingsite? <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 conducted at this site? Oyes ENODon't knowyourorganizationpreviouslygambling <br />GAMBLING BANK ACCOUNT INFORMATION; MUST BE IN MINNESOTA <br />Bank Name: Premier Bank Bank Account Number: <br />Bank Street Address: 1875 W Highway 36 City. Roseville State: MN Zip Code: 55113 <br />ALL TEMPORARY AND PERMANENT OFF -SITE STORAGE SPACES <br />Address (Do not use a P.D. box number): City: State: Zip Code: <br />North Star Mini -Storage Shoreview MN 55126 <br />MN <br />MH