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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 />THoHflS' (3, CDS:> f'r<:.t< ,3833 1..EX1N5TON AVE! If, ARDE'N 1f1U-S SSICL ( 011:. ) </-'S3-0000 .
<br />Name of Lessor Street Address City Zip DayTIme Phone
<br />(If same as legal owner, write in "SAME")
<br /> ::7AME ( )
<br />Name of Leased Premises Street Address City Zip Daytime Phone
<br />l3LUE: FOX 3'633 LeX/iJoTDN AVE IV, AK:Df=fJ HILLS MN 55 Ii Z- ( biZ- ) '-1-83 - ioD:JO
<br />Name of Lessee (name of organization leasing the premises) GCB license no. of organization Daytime Phone
<br />L-16HT f3f?I<JAOETNC o'Z. '0 '-/-7 ( (011-- ) 1<>7&-0> I(
<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 $ I) MO,_':!!
<br /> (If no 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,,",,,,\,)":,::'<:/':'T::\.""';",(,'
<br /> F6~.f'~~Ti~.~.,g~mJi~~.7r17~I..f':PPI.\c~.~?~~PP!Y':i!f9g;;
<br />of gambling and storage of gambling product at this ~l)apgesl)avebeen 'maile ai the slt9.you dOI'1()th~ve fil"1
<br />premises, attach a sketch (drawing) showing: (1) the .,',':__'.',..".--"",,,.,___',-',,-':'; >'C,,',__,-",''',' "",,,',.,," ... ;.-, ';',' ._--:".' ,,',-, ,,' """,--."",--",.",:;",,',>.,.,.",.,"",.
<br /> complete thIs secti"n}lr,proyide a ~~elch""f,\ii!i):~iil!
<br />leased area(s), and (2) the dimensions, .' ,: ",,'n,1
<br />Dimensions .
<br />The leased areas are: feet by feet for a total of square feet.
<br /> feet by feet for a total of square feet.
<br /> , feet by feet for a total of square feet.
<br /> Storage feet by feet for a total of square feet.
<br /> Storage feet by feet for a total of square feet
<br /> Combined total square feet
<br />Lawful Gambling Activity"... .,..
<br />Type of gambling activity that will be conducted at this gambling premises, Check all that apply,
<br /> Paddlewheels ~ . Pull-T~bs Raffles 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 />premises permit issued by the Gambling Control Board, ing the term of the current premises permit, write in the'
<br />unless terminated sooner by mutual consent ofthe lessor date that the changes will be effective _'---1_,
<br />and lessee. Both parties that signed the lease must initial and date all
<br /> changes, ..
<br /> '~F
<br />Questions on this form should be directed to the Licensl~g .'. -- .'.,' . . ".'" .,..'..<~""
<br /> The inf6rmation requested on this form will be used by thE{,""
<br />Section of the Gambling Control Board at (612) 639-4000. Gambling Control Board (Board) to determine your compliance'.}::
<br />This publication will be made available in alternative format with Minnesota statutes and rules governing lawful gambling'::.
<br />(I.e. large print, Braille) upon request. Hearing impaired activities. All of the information that you supply on this fonmj' .
<br />individuals using a TTY may call the Minnesota Relay Service will become public information when received by the Boardj:, .
<br />,at 1-800-627,3529 and ask to place a, call to (612) 6~9.-4000, except, if required , your Social Security number, which r~l11~iD~;:l;;
<br /> private. ." " ,:.".:,.:;,,:,,~..,..,~~:.t..'~.
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