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<br />State of Mioncsota <br />Gambling Control Board <br />Premises Permit Renewal Application <br /> <br />For Board Use Only <br />AmL Pd <br /> <br />Check # <br /> <br />. LG214PPR Printed: 1212/1999 <br />License Number:B-01485-012 <br /> <br />Date <br /> <br />Effective Date: 4/111998 <br /> <br />Expiration Date: 3/3112000 <br /> <br />Name of Organization: North Suburban Youth Roseville Assoe <br />Gamblinlt Premises Information <br />Name of the establishment where gambling will be conducted <br /> <br />Big Ten Supper Club <br />4703 N Hwy 10 ' <br />Arden Hills, MN 55112 <br />County: Ramsey <br /> <br />Note: Our records show the premises <br />is located wi1l1in 1I1e city limits <br /> <br />Lessor Information <br /> <br />John Welsch <br />2058 Jefferson <br />St. Paul, MN 55105 <br /> <br />Name of the property owner (If different): <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 />48.00 <br />1,000.00 <br /> <br />e <br /> <br />Binlto Activity <br />Our records indicate 1I1at Bingo is not conducted on these premises. <br /> <br />Storalte Information <br /> <br />55 E. County Road B, Little Canada - 2555 Snelling Ave. Rosevi11e - 2900 N. Rice St., Little Canada <br />1183 University Ave., St. Paul- 4703 N. Hwy. 10, Arden Hi11s - 738 Thomas Ave., St. Paul <br /> <br />Bank Information <br /> <br />l\lid A....11FifallaBIl N~";~ A~C;'~4"''' O~",k.:.....'1 Cdf....f.."'t <br />lHII N Faiprioffi An' ;n.10 f.J. A I but s-t. <br />Roseville, MN 55113 <br /> <br />GamblingBank I~OO~] r't<t <br />Account Number: 111231111111 <br /> <br />On the lines provided below list 1I1e name, address and title of at least two persons authorized to sign checks and make deposits <br />and withdrawals for the gambling account. The organization's treasurer may not handle gambling funds. <br /> <br />Name <br />R. Robert Matson <br /> <br />Address <br />2774 Dellwood <br /> <br /> <br />Title <br /> <br />. <br /> <br />Drake Anderson <br />Gale Pederson <br /> <br />1436 Ryan Ave. W. <br /> <br />Rosevi11e., MN 551 3 <br /> <br />Member <br /> <br /> <br /> <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 priot, braille) upon request. <br /> <br />Page I of2 (Continued on Back) <br />