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<br />State of Minnesota <br />Gambling Control Board <br />Premises Permit Renewal Application <br /> <br />For Board Use Only <br />Am!. Pd <br /> <br />roO<) i, <br />'\ ,. <br />L 'fL <br /> <br />Check # <br /> <br />eG214PPR Printed: 9/5/2001 <br /> <br />z-o"z..-- <br />Effective Date: 4/100% <br /> <br />Z.OO<f- <br />Expiration Date: 3/31/J \1112 <br /> <br />License Nurnber:B-02847-004 <br /> <br />Name of Organization: Light Brigade Roseville Arden Hills <br />GamblinK Premises Information <br />Name of the establishment where gambling will be conducted <br /> <br />Blue Fox 81tfZ;' tit/. /L/.,.. <br />3833 Lexington Ave N <br />Arden Hills, MN 55112 <br />County: Ramsey <br /> <br />Note: Our records show the premises <br />is located within the city limits <br /> <br />Lessor Information <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 />Bin~o Activity <br />Our records indicate that Bingo is not conducted on these premises. <br /> <br />e <br /> <br />Stora~e Information <br /> <br />251 5th St NW EZ Mini Sto <br />New Brighton, MN 55112 <br /> <br />Bank Information <br /> <br />SI{EHel? SANK <br />F;~.!.tAI BAlik <br />4061 Lexington Ave N <br />Arden Hills, MN 55126 <br /> <br />Gambling Bank <br />Account Number: 0244643601 <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 />wifudrawals for the gambling account. The organization's treasurer may not handle gambling funds. <br /> <br />Name <br /> <br />Address <br /> <br />City, State, Zip Code <br />Roseville, MN 55113 <br /> <br />Title <br /> <br />Donald W Hewitt <br /> <br />1794 W Maple Ln <br /> <br />G~""'t.IP6 I'tAloJlo,&li/l., <br /> <br />Herbert Eugene King <br /> <br />1504 W Hwy 96 <br /> <br />Arden Hills, MN 55112 <br /> <br />PIIUi'C't' 0 II--- <br /> <br /> <br />00rfN {,. Ct.AS~I1AtJ t.f'l1o E. T"p'''/fbtJE St/tJ1{e-Vll~l<INN 55/!' ';HIEft:F;>(f'Cu~Orw: <br /> <br />(Be sure to complete the reverse side of this application) <br /> <br />This form will be made available in alternative fonnat (ie.large print, braille) upon request. <br /> <br />Page 1 of 2 (Continued on Back) <br />