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<br />~ast STATE OF MINNESOTA I FOR BOARD USE ONLY I
<br />rlltMBLING CONTROL BOARD I AMT PAID I
<br />PREMISES PERMIT RENEWAL APPLICATION I CRECK NO. I
<br />LG214PPR PRINTED: I DATE .
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<br />GICENSE NUMBER: B-02847-004 EFFECTIVE DATE: 04/01/96 EXPIRATION DATE: 03/31/98
<br />~AME OF ORGANIZATION: Light Brigade Roseville Arden Hills
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<br />GAMBLING PREMISES INFORMATION
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<br />~AME OF ESTABLISHMENT WHERE GAMBLING WILL BE CONDUCTED
<br />alue Fox
<br />3833 Lexington Ave N
<br />i\.rden Hills 55112
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<br />:OUNTY Ramsey IS THE PREMISES LOCATED WITHIN THE CITY LIMITS?: Y
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<br />LESSOR INFORMATION
<br />JOES YOUR ORGANIZATION OWN THIS SITE?: No
<br />IF NO, LIST THE LESSOR:
<br />rhomas Cossack
<br />3833 N Lexington Ave
<br />Arden Hills MN 55112
<br />
<br />~AME OF PROPERTY OWNER (WHEN NOT LESSOR) :
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<br />3QUARE FEET PER MONTH: 49 AMOUNT PAID FOR RENT PER MONTH:, 1000 A
<br />3QUARE FEET PER OCCASION: 0 AMOUNT PAID. PER OCCASION: .~ 0_
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<br />.:BINGO ACTIVITY._.,,~... ..~.' ).~~,~'.. .... "(:~~':'i'",,, .:~~j>._
<br />3INGO IS CONDUCTED ON THIS .PREMISES: No IF YES, REFER TO .INSTRUCTIONS FOR REQUIRED ATTACHMENT
<br />.... - '. . .,' \ .
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<br />. '. . 'STORAGE ADDRESS,;'. . "/";" ','.
<br />251 5th St NW EZ Mini Sto' ./-"
<br />~ew Brighton MN 55112
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<br />:~~~t~:x~::~onAve~' ',." . BANK INFORMATION .:~';<i':c,:: .....H;~;i~':~h.
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<br />Arden Hills MN 55112 c.,.,..
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<br />3AMBLING BANK ACCOUNT NUMBER: 244643601
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<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 ORGANIZATION'S TREASURER MAY NOT HANDLE GAMBLING FUNDS,' ); "
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<br />DONALD 'A./.Heu.:,ITl 1/'14- MHCE LI-J KOS-EV/Ll.f? 111J 'S'S 113;':;CEO
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<br />\ ':~":','o::,:', ,:~~'>":'i""T:FJ~', .'" .,c',:,,: '..' .
<br />. . (BE SURE .TOCOMPLETE.,THE 'REVERSE"SIDEOF THIS APPLICATION)
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<br />THIS FORM WILL BE .MADE AVAILABLE IN 'ALTERNATIVE' FORMATX\ I::E >: LARGE . PRINT ;,BRAILLEJ'.::tiPON'REQUEST
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