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<br />Minnesota Lawful Gambling
<br />Lease for Pull-Tab, Paddlewheel, Tipboard, and/or Raffle Activity - LG221
<br />Name of Legal OWner of Premises Street Address City Zip Daytime Phone
<br />John J. Welsch 2058 Jefferson St. Paul 55705 ( 612 ) 699:7235 .
<br />Name of Lessor Street Address City Zip Daytime Phone
<br />(If same as legal owner, write j~_~SAME")
<br />John J. Welsch 2058 Jefferson St. Paul 55705 ( 612 ) 733-7255
<br />Name of Leased Premises Street Address City Zip Daytime Phone
<br />Big Ten Super Club 4703 N. Highway 10 Arden Hills 5511? ( 612 ) 633-7253
<br />Name of Lessee (name of organization leasing the premises) GCBlicense no. of organization Daytime Phone
<br />North Suburban Youth Association A-01485 ( 612 ) 638-4600
<br />Rent Information
<br />. Total rent cannot exceed $1,000 per month for all . An organization may not pay rent to itself or to
<br />non-bingo activity for this premises. any of its affiliates for space used for the conduct
<br />. For bingo activity, use lease form LG222. of lawful gambling.
<br />. For pull-tab dispensing machines, use lease form
<br />LG223. Rent to be paid per month $ 1 ,000.
<br /> (lfno rent is to be paid, indicate-O-)
<br />Sketch and Dimensions of Leased Area
<br />Sketch: For all areas being leased for the conduct ::....;;::;.,;,"'::.y;::';--''.",:;::':';,..,-,:',:::,~.,,-c:',--:-,,;;;_,,::::-;r'.'T-:;':'_(-:;;'.'-:;-;<':i':'!f'it":)',,:::";';
<br /> fO~l'remi~"" Permit Rene.;...al.Applications' Cln1yi"lfn<t'
<br />of gambling and storage of gambling product at this " .......",."...'....,.'.;...-..;"!"'.,.,. .... ',f"" -.,-",-"".,-,.<-" '.:--.,... :.,-,.,":':,..";."....,<,;.,,.::.,...,.:. -<:"::',,</'-,"."'.','-',
<br /> p rapg~,hav~~~ep'rTla~~~.: ,':he sl~;'yi:>'v- d 9P~tr~~~,~?i'
<br />premises, attach a sketch (drawing) showing: (1) the col11plete this. section orprovide'asl(etch, .' ,i.::.!:;,,; i~:i'
<br />leased area(s), and (2) the dimensions. ".. c,_._...." ,--"" ," --'. .. -;~~:-/::;.-;i _..C,;' ': ,,;;;<:"'; ';:_':{-':::~~:,:::::[;~, :H)::::::i
<br />Dimensions 6 8 48 .
<br />The leased areas are: . feet by feet for a total of square feet.
<br /> "/,..-.-
<br /> feet by feet for a total of square, feet.
<br /> . -0", feet by ,"1" .. ~ f .. ',.-, f"
<br /> . feet for a total of Hsquare feet.
<br /> ..,"". .-'.... ",,'. , f~etfora total of '-".'_,,0,"': ..'
<br /> .' Storage feet by . ; square feet.
<br /> -", . -".":' ,.,~ ..
<br /> Storage . . feet by feet for a total of sg ua~~ feet.
<br /> .. 48
<br /> Combined total
<br />Lawful Gambling Activity . .. .,
<br />Type of gambling a?tiVity)hat will be conducted at this gambling premises. Checl( all that applY:
<br /> X . ' '. Pacfdlewheeis X.Pull-Tabs X Raffles X Tipboards
<br />Term of Lease ' Amended Lease Only
<br />The term of this lease agreement will be concurrent with the If this is an amended lease showing changes occurring dur- "
<br /> .,,'
<br />premises permit issued by the Gambling Control Board, ing the term ot'the current premises permit, write in the' /f.-'
<br />unless terminated sooner by mutual consent of the lessor date that the changes will be effecUve ~--1_,
<br />and lessee, Both parties that signed the lease muslinitial and date.all
<br /> .changes. " H " . "-", '... . ~,
<br /> -;..;~'~ ..
<br /> .... ,___" ",' .'.. "j"., _.',' -":"""._." : "<'-.. :~'--", "" " _:'",""~,'!J~:\\
<br />Questions on this fonm should be directed to the Licensing :The info'rmation requested on this form'will be used bythe;'5\'
<br />. Section of the Gambling Control Board at (612) 639-4000, . Gambling Control Board (Board) to determine your compliance }~:J'
<br />This publication will be made available in alternative format with Minnesota statutes and rules governing lawful gamb!ing>.::
<br />(Le, large print. Braille) upon request. Hearing Impaired activities. All of the infonmatlon that you supply on this fonm.':/,
<br />Individuals using a TTY may call the Minnesota Relay Service will become public infonmation when received by the Board, /-'. .
<br />at 1-800-627-3529 and ask to place a call to (612) 639:4000, - except, if required, your Social Security number, which remain~ -:;:,'_
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