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(,. -.?,s <br />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 L6214 <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: Merrick, Inc. License Number: 00264 <br />Chief Executive Officer (CEO) John W. Barker Daytime Phone: 651_ 789-6200 <br />Gambling Manager: Wendy L• Busch - - Daytime Phone: 651-23876871 <br />GAMBLING PREMISES INFORMATION - - - <br />Current name of site where gambling will be conducted: __" J i .Ii`'.r' i Cct- i !r —i' = l 01,1 A 1, � � 2-0 <br />List any previous names for this location: <br />r — <br />Street address where premises is located: <br />(Do not use a P.O_ box number or mailing address.) <br />City: OR Township: County: Zip Code: <br />Does your organization own the building where the gambling will be conducted? <br />F]Yes El No If no, attach L6215 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 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 <br />;[are <br />± played. <br />Has your organization previously conducted gambling at this site? �-s ❑No Don't know Orr6i" <br />GAMBLING BANK ACCOUNT INFORMATION; MUST BE IN MINNESOTA <br />Bank Name: TCF/ P pk 5 C n k N i dkyn' Bank Account Number: 2865541070/3163526 <br />0 <br />Bank Street Address; 8Tamarack Village 3S� "�� Woodbu � f s. 01" .F 110 <br />City: rY State: MN Zip Code: 55125 <br />ALL TEMPORARY AND PERMANENT OFF -SITE STORAGE SPACES <br />Address (Do not use a P.O. box number): City: State: Zip Code: <br />3210 Labore Road Vadnais Heights MN 55110 <br />3700 Highway 61 N. White Hear Lake MN 55110 <br />MN <br />