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<br />Minnesota Lawful Gambling <br /> <br />Lease for Pull-Tab, Paddlewheel, Tipboard, and/or Raffle Activity - LG221 ~ <br />Name of Legal Owner 01 Premises Street Address City Zip Daytime Phone <br />THOMAS <S. COSSJ'lC:1( ~~3'U)(/~TON AVE. N. A~t>elJ H'''''S $Sf/Z- ( 6>51 )~5-tPo <br />Name of Lessor Street Address City Zip Daytime Phone <br />(If same as legal owne" write in "SAME") <br />"SI\ME' <br /> <br />feet by feet for a total of square feel <br />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 />feet by feet for a total of square feet. <br /> Combined total square feet. <br /> <br />Name of Leased Premises Street Address <br />BLUE FLlX 7S3~ LE)ON.:Tt>rJ Av~. N. <br />Name of Lessee (name of organization leasing the premises) <br />t..1<>1f, @RI<SADl<::DJC <br /> <br />Rent Information <br /> <br />. Total rent cannot exceed $1,000 per month for all <br />non-bingo activity for this premises. <br /> <br />. For bingo actlvity, use lease form LG222.' <br /> <br />. For pull-tab dispensing machines, use lease form <br />LG223. <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 (dr';wilng) 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 /> <br />( ) <br />City Zip Daytime Phone <br />A'ii'..DE'A;H/I.L> J1JJ >5/1Z- ((,5'1 ) </.83-bOtX> <br />Gce license no, of organization Daytime Phone <br />02-8"1-7 ( 6>5/ ) c..:!b-DS/I <br /> <br />. An organization may not pay rent to Itself or to <br />any of ijs affiliates for space used for the conduct <br />of lawful gambling. <br /> <br />',''1 <br /> <br />(>-0 <br />Rentto be paid per month $ / tJ 00 - <br />(II no rent is to be paid, Indicate-O-) <br /> <br /> <br />Lawful Gambling Activity <br />Type of gambling activity that will be conducted at this gambling premises. Check all that apply. <br /> <br />Paddlewheels Y Pull-Tabs Raffles Tipboards <br /> <br />Term of Lease <br /> <br />The term of this lease agreement will be concurrent with <br />the premises permij issued by the Gambling Control <br />Board, unless terminated sooner by mutual consent of <br />the lessor and lessee. <br /> <br />Amended Lease Onlv <br /> <br />If this is an amended lease showing changes occur- <br />ring during the term of the current premises permit, <br />write In the date that the changes will be effective <br />--1--1_. Both parties that signed the lease <br />must initial and date all changes. <br /> <br />Questions on 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 (I.e. large plint, Braille) upon request. Healing impaired <br />individuals using a TTY may call the Minnesota Relay SeNlce <br />at 1-800-627-3529 and ask to place a call to 651-639-4000. <br /> <br />The information requested on this form will become public <br />Information when received by the Board. and will be used toA <br />determine your compliance with Minnesota statutes and rulesW' <br />governing lawful gambling activities. <br />Page 1 of2 <br />1/99 <br />