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<br />.(~ <br />Minnesota Lawful Gambling '- <br />Lease for Pull-Tab, Paddlewheel, Tipboard, and/or Raffle Activity - LG221 <br /> <br />Name of Legal Owner of Premises Street Address City Stale Zip Daytime Phone <br />1HOHlrS e. ~o5SAe K 'Y,35~/,,,-ro.Jltvf. N. AR Dfi/J HILL.-$ MN 5',,1.(. ~"I-'lS3-btJOO <br />Name of Lessor Street Address City Stale Zip Daytime Phone <br />(ij same as legal owner, write in "SAME') 1I5AME " <br />Name of Leased Premises Street Address City Zip Daytime Phone <br />BLUE r: ox e,...1l." Q RILJ. Jf3$ IEIVNtSTDN A'IE. N. fl~ve,v HIU.5 5'~/U. ~S'I-Ij.G3-'OOO <br />Name <:i Lessee (name of organization leasing the premises) GCB license no. of organization Daytime Phone <br />L.J&Hr 8I?J<jAlJe,$JoI<!.. OZ3J7.1 '-51- '~t.-J/4' <br /> <br />e <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 activity, use lease form LG222. <br /> <br />. For pull-tab dispensing machines, use lease form <br />LG223. <br /> <br />. An organization may not pay rent to itself or to <br />any of its affiliates for space used for the conduct <br />of lawful gambling. <br /> <br />Rent to be paid per month $ / tJt)(). !! <br />m no rent is to be paid, indicate.l)-) <br /> <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 /> - <br />feet by feet for a total of square feet. <br /> Combined total square feet. <br /> <br />e <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 (drawing) 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 />For Premises Pennit Renewal Applications Only: If no <br />changes have been made at the site, you do not have to <br />complete this section or provide a sketch. <br /> <br />Lawful Gambling Activity <br /> <br />Type of gambling activity that will be conducted at this gambling premises. Check all that apply. <br /> <br />.0 Paddlewheels '. . G2]pulI-Tabs ... .0 Raffles . 0 Tipboards. <br /> <br />Term of Lease Amended Lease Only . <br /> <br />The term of this lease agreement will be concurrent with If this is an amended lease showing changes occur- <br />the premises permit issued by the Gambling Control ring during the term of the current premises permit, <br />Board, unless terminated sooner by mutual consent of write in the date that the changes will be effective <br />the lessor and lessee. ~~_' Both parties that signed the lease <br />J...eHor- "'0.'1 ,...;-......,,,...fe le"~" j,J~#,<fo must initial and date all changes. <br /> <br />() ~),)e I-ke... a", I (Jo'3 <br /> <br />e <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. Thi$ pUblication will be made available In alternative <br />formal (i.e..large print, B~IIe>"upon request. Hearing impaired <br />individuaJs using a TTY may call the Minnesota Relay Service <br />at 1-600-627-3529 and ask to place a call to 651-639-4000. <br /> <br />The information req uested on this form will become public <br />infannation when received by the Board, and wUl be used to <br />determine your compliance wilh Minnesota statutes and rules <br />governing lawful gambling activilies. <br /> <br />Page 1 of2 <br />1199 <br />