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<br />State of Minnesota <br />Gambling Control Board <br />Premises Permit Renewal Application <br /> <br />For Board Use Only <br />Amt Pd <br />Check # <br />Date <br />Initials <br /> <br />LG214PPR Printed: 11/15/1999 <br /> <br />License Number: B-02847-004 <br /> <br />Effective Date: 4/1/1998 <br /> <br />Expilation Date: 3/3112000 <br /> <br />Name of Organization: Light Brigade Roseville Arden Hills <br />Gamblin2 Premises Information <br />Name of the establishment where gambling will be conducted <br /> <br />Blue Fox <br />3833 Lexington Ave N <br />Arden Hills, MN 55112 <br />County: Ramsey <br /> <br />Note: Our records show the premises <br />is located wi1hin the city limits <br /> <br />Lessor Information <br /> <br />Thomas Cossack <br />3833 N Lexington. Ave <br />Arden Hills; MN 55112 <br /> <br />Name of the property owner (If different): <br /> <br />, ., <br /> <br />Square footage leased per month: <br />Rent paid per month: <br />Square footage leased per bingo occasion: <br />Rent paid per bingo occasion: <br /> <br />Bin20 Activity <br />Our records indicate that Bingo is not conducted on these premises. <br /> <br />49.00 <br />1,000.00 <br /> <br />e <br /> <br />Stora2e Information <br />C. ~LlJE'" R>x 'St'TE: 3~ ~ 3 /....E"t(J N6Tt>N /'Nt: N AI< DE7J rj-,I..LS II-tJJ !>sm:.. (PlU./J\S 13""71't <br />~ '5T"a..~e-- Is-O\f w. 1-f.:vY. qt, AttDe1-.lI-f/l..l.<; 1l-1.'-l '5~//~ <br />~ ~Z-MIW' STOI~1\6F Zt;/ 5~'5T N/AJ NfiWgel6fYTO).J WI! 5:r"1lZ-.- <br />Bank Information <br /> <br />Firstar Bank <br />4061 Lexington Ave N <br />Arden HiUs, MN 55126 <br /> <br />Gambling Bank <br />Account Number: 244643601 <br /> <br />On the lines provided below list the name, address and title of at least two persons authorized to sign checks and make deposits and <br />withdrawals fur the gambling account The organi21llion's tre...urer may not handle gambling funds. <br /> <br />Name <br /> <br />Address <br /> <br />MMLe' l.JJ <br />(, <br /> <br />City, State, Zip Code <br />(Jsevlu~ J.1}J5S113 <br /> <br />Title <br /> <br />DoNA<...1) W.I~nr <br />~j(J3Gl\r E. 1(0'1'6 <br /> <br /> <br />Cf?O <br /> <br />NlPr;}I IU.S "'1J~J{ 6~M6(j~E. 141r)JA-6aL <br /> <br />(Be sure to complete the reverse side of this application) <br /> <br />This fonn will be made available in alternative fonnat (ie.large print, braille) upon request. <br /> <br />Page I of2 (Continued on Back) <br />