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Central ' STATE OF MINNESOTA IFOR BOARD USE ONLY <br /> GALLING CONTROL HOARD IAMT PAID <br /> PREMISES PERMIT RENEWAL APPLICATION ICHECK NO. <br /> L64PPR PRINTED:10/11/95 JDATE <br /> LICENSE NUMBER: B-02945-002 EFFECTIVE DATE: 04/01/• EXPIRATION DATE: 03/31 <br /> 40d- <br /> NAME OF ORGANIZATION: Sports St Anthony Boosters T <br /> GALLING 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 INFORMiTION <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 /> ORE FEET PER MONTH: 24 AMOUNT PAID FOR RENT PER MONTH: 800 <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 /> 251 5th St NW <br /> New Brighton MN 55112 <br /> BANK INFORMATION <br /> lot Bank <br /> 3928 Silver Lake Rd <br /> St Anthony MN 55418 <br /> GAMBLING BANK ACCOUNT NUMBER: 11654011860 <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 <br /> ORGANIZATION'S TREASURER MAY NOT HANDLE GAMBLING FUNDS. <br /> rerr`� -�{Aod' �ci90 Zan /K-"n Pdsfj4A,44ioA, mo ��/�8 I�fGY Arc,Jr,� <br /> (BE, SURE,TO COMPLETE-THE-,REVERSE,r SIDE OF THIS. APPLICATION) <br /> THIS FORM WILL BE MADE AVAILABLE IN ALTERNATIVE FORMAT (I.E. LARGE PRINT, BRAILLE) UPON REQUEST <br />