Laserfiche WebLink
<br />.. <br /> <br />, <br /> <br /> FOR BOARD USE ONLY <br />Minnesota Lawful Gambling Base # Check # <br />pp# Initials <br />Premises Permit Application - LG214 Fee Date <br />Class of Permit Page 1 013 <br />Check one: 1199 <br />~ Class A . $400 Pull.tabs. tipboards, paddlewheels, raffles, bingo ./ <br />Class B . $250 Pull-tabs, tipboards, paddlewheels, raffles <br />D Class C . $200 Bingo only OR bingo and pull.tabs when total gross receipts do not exceed $50,000 per year <br />D Class 0 ... $150 Raffles only <br /> <br />e <br /> <br />J <br /> <br />Organization Information <br />Organization name (as it appears on documentation filed with <br />Minnesota Secretary of State or Intemal Revenue Service) <br /> <br />Base license number <br /> <br /> <br />I' <br />Name of chief executive officer (cannot be your gambling manager) <br /> <br />I( ~7 . <br />I I < <br /> <br />Daytime phone number <br />(t,. S-I ) t4q-CJ2 'ZZ <br /> <br /> <br />Gambling Premises Information <br />Name of establishment where gambling will be conducted <br /> <br />Street address (do not use a P.O. box number) <br /> <br /> <br />",--r 0 (f;oLD Go snc. CoM.../(.r! It) S,WL <br />City & county where gambling premises is located-OR- Township & county where gam ling premises is located if outside city limits <br /> <br />e <br /> <br />y \ )" <br />Is the premises located within city limits? Yes ~ No 0 <br /> <br />If No, is township: 0 Organized <br />o Unorganized <br />o Unincorporated <br /> <br />Does your organization own the building where the gambling will be conducted? <br />o Yes ~NO If no, attach (1) the appropriate lawful gambling lease form, and <br />(2) the sketch of all leased areas with dimensions and square footage clearly defined <br />A lease and sketch are not required for class D applications. <br /> <br />Name of legal owner of premises Address City StateJZip <br /> <br /> <br />717J <br /> <br />(,-/'t L I'f <br /> <br />;.I"CI~ <br /> <br />pfj/ <)\~tf <br /> <br />Address(es) of Storage Space of Gambling Equipment <br /> <br />List all locations where used and unused gambling pro!luct is stored. Do not use-a P.O. box number. (Attach an additional <br />sheet if necessary.) <br />Address ~ StatelZio <br /> <br />'3 7(. G9 <br /> <br /> <br />Ii{ IU 5"5';("2... <br /> <br />Questions? Call the Licensing Section of the Gambling Control Board at 651-639-4000. If you use a TTY, you can <br />call the Board by using the Minnesota Relay Service at 1-800-627-3529 and ask to place a call to 651-639-4000. This <br />form will be made available in alternative format (i.e. large print, Braille) upon request <br /> <br />e <br />