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<br />. <br /> <br />Minnesota Lawful Gambling <br /> <br />Lease for Pull~Tab, Paddlewheel, Ti <br /> <br />Name of Legal OWner of Premises Street Addre.. <br /> <br />Goldie K Siedow 3873 114th Ln.N.E. <br />Name of Lessor Street Address <br />(1lsame aolegal owner, write In 'SAME" <br /> <br />Pot O' Gold 3776 Connell Ave. <br />Name of Leased Premises Street Address <br />3776 Co elly Ave, <br /> <br />Name of Lessee (name of organization leasing the premises) <br />Earthstar project, Inc. <br /> <br />Rent Information <br /> <br />~~\B'"l C <br /> <br />board, and/or Raffle Activi <br />City Zip Deytlme Phone <br />Blaine MN 55449 (612) 783-1840 <br />City Zip Daytime Phone <br />612 783-1840 <br />(651 ) 631 1724 <br />Daytime Phone <br />( 651 ) 631-1724 <br />Daytime Phone <br />( 651 ) H~:d~9i <br /> <br />y'2- <br />- LG221 <br /> <br />Arden Hills <br />City <br />Arden Hills <br /> <br />55112 <br />Zip <br />55112 <br /> <br />MN <br /> <br />MN <br /> <br />GCB license no. of organization <br />A-04711 <br /> <br />. Total rent cannot exceed $1,000 per month for all <br />non-bingo. activity for this premises. <br /> <br />. For bingo activity, use lease form LG222. <br /> <br />. For pull-tab dispensing machines, use lease form <br />LG223. <br /> <br />. An organization may not pay rent to itself or to <br />any of its affiliates for space used for the conduct <br />of lawful gambling. <br /> <br /> <br />Rent to be paid per month $ 0 <br />(If no rent Is to be paid. indicate-o-) <br /> <br />Lawful Gambling Activity <br /> <br />Type of gambling activity that will be conducted at this gambling premises. Check all that apply. <br /> <br />,...> Paddlewheels .X Pull.Tabs _Raffles _Tlpboards <br /> <br />Term of Lease Amended Lease Only <br /> <br />The termaf this lease agreement will be concurrent with If this is an amended lease showing changes occur- <br />the premises permit issued by the Gambling Control ring during the term of the current premises permit, <br />Board, unless terminated sooner by mutual consent of write in the date that the changes will be effective <br />the lessor and lessee. ---1---1-. Both parties that signed the lease <br />~"".~~ must initial and date. all changes. ,.'\ <br /> <br />,.' . <br /> <br />Questions 6" this form should be directed to the licensing <br />Section of the Gambling Control Board (Board) at 651-639- <br />4000, This publication will be made available in altemative <br />format (Le. large print, Braille) upon request. Hearing impaired <br />individuals'using a TrY may call the Minnesota Relay Service <br />at 1-80~:i7~3529 and ask to place a call to 651-639-4000. <br /> <br />. <br /> <br />Sketch and Dimensions of Leased Area <br /> <br />Sketch: For all areas being leased for the conduct <br />of gambling and storage of gambling product at this <br />premises, attach a sketch (drawing) showing: (1) the <br />leased area(s), and (2) the dimensions. <br /> <br />Dimensions <br />The leased areas are: <br /> <br />Storage <br />Storage <br /> <br />feet by <br />feet by <br />feet by <br />feet by <br />feet by <br /> <br />. <br /> <br />''1~~t,:;::~.. <br />,"r:;.',I._,_t::,_';E' <br />. ~"iohm: ie(' <br /> <br /> <br />:':'::!:;;:!';};!;~i <br /> <br />feet for a total of <br />feet for a total of <br />feet for a total of <br />feet for a total of <br />feet for a total of <br />Combined total <br /> <br />square feet. <br /> <br /> <br />square feet. <br /> <br /> <br />square feet. <br /> <br /> <br />square feet. <br /> <br /> <br />square feet. , <br /> <br /> <br />square feet. <br /> <br />The information requested on this form will become public " <br />information when received by the Board, and will be used to' I <br />determine your compliance with Minnesota statutes and rules <br />governing lawful gambling activities. . <br /> <br />'. <br /> <br />Page'10f2 <br />1/99 <br />