Laserfiche WebLink
MINNESOTA LAWFUL GAMBLING <br />LG214 Premises Permit Application <br />REQUIRED ATTACHMENTS TO LG214 <br />1. If the premises is leased, attach a copy of your lease. Use L6215 <br />Lease for Lawful Gambling Activity. <br />2. $150 annual premises permit fee, for each permit (non-refundable). <br />Make check payable to "State of Minnesota." <br />ORGANIZATION INFORMATION <br />Organization Name: Merrick, Inc. <br />Chief Executive Officer (CEO) John W. Barker <br />Gambling Manager: Wendy L. Busch <br />GAMBLING PREMISES INFORMATION <br />6/15 Page 1 of 2 <br />Annual Fee $150 (NON—REFUNDABLE) <br />Mail the application and required attachments to: <br />Minnesota Gambling Control Board <br />1711 West County Road B, Suite 300 South <br />Roseville, MN 55113 <br />Questions? Call 651-539-1900 and ask for Licensing. <br />License Number: 00264 <br />Daytime Phone: 651-789-6200 <br />Daytime Phone: 651-238-6871 <br />Current name of site where gambling will be conducted: 14Q lln(- (..(,tom i on Pu ` 7_0 <br />r <br />List any previous names for this location: <br />` I .{. <br />Street address where premises is located: 3 /'1 D l�i✓ !.. . <br />(Do not use a P.O. box number or mailing address.) <br />City: OR Township: County: <br />i <br />Zip Code: <br />S-b3 8' . <br />Does yours,?rganization own the building where the gambling will be conducted? <br />Yes a No If no, attach LG215 Lease for Lawful Gambling Activity. <br />A lease is not required if only a raffle will be conducted. <br />Is any other organization conducting gambling at this site? Yes El No Don't know <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 your organization previously conducted gambling at this site? ❑Yes ENODon't know <br />GAMBLING BANK ACCOUNT INFORMATION; MUST BE IN MINNESOTA I <br />TCF Lake Area Bank , �,M1 F yh' i'G�A�1.Ct.fcfYr°,j �110 <br />Bank Name: �/ s ���' f� 1 t[• $ank Account Number: 2865541070/3163526 <br />Bank Street Address 8432 Tamarack Village City: Woodbury State: MN Zip Code: 55125 <br />ALL TEMPORARY AND PERMANENT OFF -SITE STORAGE SPACES <br />Address (Do not use a P.O. box number): <br />3210 Labore Road <br />City: <br />Vadnais Heights <br />3700 Highway 61 N. White Bear Lake <br />State: Zip Code: <br />MN 55110 <br />MN 55110 <br />MN <br />