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Minnesota Lawful Gambling Lease for Pull-Tab, Paddlewheel, Tipboard, and/or Raffle Activity - LG221 • Name of Legal Owner of Premises Street Address City Zip Daytime Phone City of St. Anthony 3301 Silver Lake Rd. , St. Anthony 55418 (612 )789-8881 Name of Lessor Street Address City Zip Daytime Phone (If same as legal owner,write in"SAME") Same as above ( ) Name of Leased Premises Street Address City Zip Daytime Phone Stonehouse 2700 Hwy. 88, St. Anthony 55418 (612 )789-8881 Name of Lessee(name of organization leasing the premises) GCB license no.of organization Daytime Phone St. Anthony Village Sports Boosters, Inc. , B-02945-001 (612 )788=4597 Rent Information • Total rent cannot exceed $1,000 per month for all An organization may not pay rent to itself or to non-bingo activity for this premises. any of its affiliates for space used for the conduct • For bingo activity, use lease form LG222. of lawful gambling. • For pull-tab dispensing machines, use lease form LG223. ` Rent to be paid per month $ 010 D-00 (If no rent is to be paid,indicate-0-) Sketch and Dimensions of Leased Area Sketch: For all areas being leased for the conduct For Premises Permit Renewal Applications Only: If no of gambling and storage of gambling product at this changes have been made at the site,you do not have to premises, attach a sketch (drawing) showing: (1)the complete this section or provide a sketch. • leased area(s), and (2) the dimensions. Dimensions The leased areas are: feet by feet for a total of square feet. feet by feet for a total of square feet. feet by feet for a total of square feet. Storage feet by feet for a total of square feet. Storage feet by feet for a total of square feet. Combined total square feet. Lawful Gambling Activity Type of gambling activity that will be conducted at this gambling premises. Check all that apply. Paddlewheels X Pull-Tabs Raffles Tipboards Term of Lease Amended Lease Only The term of this lease agreement will be concurrent with the If this is an amended lease showing changes occurring dur- premises permit issued by the Gambling Control Board, ing the term of the current premises permit, write in the unless terminated sooner by mutual consent of the lessor date that the changes will be effective and lessee. Both parties that signed the lease must initial and date all changes. Questions on this form should be directed to the Licensing The information requested on this form will be used by the Section of the Gambling Control Board at (612) 639-4000. Gambling Control Board(Board)to determine your compliance This publication will be made available in alternative format with Minnesota statutes and rules governing lawful gambling • (i.e. large print, Braille) upon request. Hearing impaired activities. All of the information that you supply on this form individuals using a TTY may call the Minnesota Relay Service will become public information when received by the Board at 1-800-627-3529 and ask to place a call to(612)639-4000. except,if required,your Social Security number,which remains private. Page 1 of 2 Rev. 8/97