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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:10/13/93 DATE <br /> 1110ENSE NUMBER: B-02945-002 EFFECTIVE DATE: 04/01/92 EXPIRATION DATE: 03/31/94 <br /> NAME OF ORGANIZATION: Sports St Anthony Boosters <br /> GAMBLING PREMISES INFORMATION <br /> NAME OF ESTABLISHMENT WHERE GAMBLING WILL BE CONDUCTED <br /> Apache Wells <br /> 3800 Silver Lake Rd <br /> St Anthony 55418 <br /> COUNTY Ramsey IS THE PREMISES LOCATED WITHIN THE CITY LIMITS?: Y <br /> LESSOR INFORMATION <br /> DOES YOUR ORGANIZATION OWN THIS SITE?: No <br /> IF NO, LIST THE LESSOR: <br /> City of St Anthony <br /> 3301 Silver Lake Rd <br /> St Anthony MN 55418 <br /> NAME OF PROPERTY OWNER (WHEN NOT LESSOR) : <br /> SQUARE FEET PER MONTH: 24 AMOUNT PAID FOR RENT PER MONTH: 800 r <br /> AMARE 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 /> 251 5th St NW <br /> New Brighton MN 55112 <br /> BANK INFORMATION <br /> irs St Anthony Ba Fl;c,4- <br /> 40 L r Av <br /> t Ant y MN 55418 <br /> GAMBLING BANK ACCOUNT NUMBER: 4 / <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 GAMBLING ACCOUNT. <br /> THE ORGANIZATION'S TREASURER MAY NOT HANDLE GAMBLING FUNDS. <br /> r .-s/c2 ���3 2a N ,`.- S �•An:° ,1; SSI i� 5 r 222 - : epp j �s <br /> lJ� � f�' �•r� � 1 D°) Ec� � i ' � r r � • 1 � <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 />