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MINNESOTA LAWFUL GAM BLING <br />LG214 Premises Permit Application <br />6lLS Page 1 of 2 <br />Annua! Fee $15O (tot-nEFUNDAaT-r) <br />REQUTRED ATTACHMENTS TO Lc2,^4 <br />1. If the premises is leased, attach a copy of your lease. Use LG2l5 <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 />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 />ORGANIZATION IN FORMATION <br />License Number: 00584Organization Name:Spring Lake Park Lions <br />Chief Executive Officer (CEO)Deborah Roberge Daytime phone: 612-483-3962 <br />Gambling Manag "r. <br />Amanda Jackson Dayti me phone: 763-784-9t79 <br />GAMBLING PREMISES INFORMATION <br />Street address where premises is located: <br />(Do not use a P.O. box number or mailing address.) <br />4703 Highw ay 10 <br />Current name of site where gambling will be conducted. Welsch's Big Ten Tavern <br />List any previous names for this location: <br />City: <br />Arden Hills <br />OR Township County: <br />Ramsey <br />Zip Code: <br />551 12 <br />Does your organization own the building where the gambling will be conducted? <br />r' <br />./ <br />Note: Bar bingo can only be conducted at a site where another form of lawful gambling is being conducted by the applying organi-zation or another permitted organization. Electronlc games can only be conducted at Jslte whire paper pultitabs are itayid. <br />- <br />r'Yes No Don't know <br />Yes No <br />Has your organization previously conducted gambling at this site? <br />Yes <br />Don't know <br />A lease is not required if only a raffle will be conducted. <br />Is any other organization conducting gambling at this site? <br />No If no, attach LG215 Lease for Lawful Gambling Activity <br />GAMBLING BANK ACCOUNT INFORMATION; MUST BE IN MINNESOTA <br />Bank Nams; Northeast Bank <br />Bank Street Address: 200 Coon Rapids Blvd City State: MN Zip Code: 55433 <br />Bank Account Number. 10012805 <br />Coon Rapids <br />ALL TEMPORARY AND PERMANENT OFF-SITE STORAGE SPACES <br />Address (Do not use a P.O. box number): <br />MN <br />IrlN <br />City State: Zip Code: <br />MN