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<br /> <br />License No. <br />Receipt No. <br />Amount Paid <br />Date Recvd. <br />Ins. Ger!. <br />Total Fee Paid <br /> <br />~ <br /> <br />~ <br />.~~HILLS <br /> <br />Gity of Arden Hills <br />1245 West Highway 96 <br />Arden Hills, Minnesota 55112 <br />Phone: 651.634.5120 <br />Fax: 651.634.5137 <br />www.cLarden-hills.mn.us <br /> <br />v. <br />_3 -:: /~-v-'1' <br /> <br />I~'~ <br /> <br />2004 Premises Permit Application <br /> <br /> <br />Info rmatio n (all fields are required) <br /> <br />Business Name: _~ k + J2i:"..t..'}_t2.. A J'^- <- <br /> <br />Property Address: I I <br />/CJ-d( W c.OU-It-~ R.dF Avc1€'", H/lls,H,JS's]/Z. <br /> <br />Nature of Business: ~__E0c-.lL~?u_@ Me biAlY''' I ~_~v "*_6?",itL~__ <br />Local Contact:_Q-'2'00JC t-+~~'L1t~___~, <br />Business Phone: fc,~L:-. JD_3.1c:> =~LL':i2 Business Fax: ~ S- j~_G 3 :') :- / So I <br />Emajl Address: do" h PLV I t\-@ U Sol i.1. .JeVKe f. LOMWebsite Address: _ ~m.~______"~u <br /> <br />. <br /> <br />Federal ID#: <br /> <br />30_=~ -3Jf'D-Y-'?1 5 ~~".. <br /> <br />Investigation Fee <br /> <br />150.00 <br /> <br />2003 Income and Loss Statement ;.( <br />Projected 2004 ReceiptslPrizes .+- <br /> <br />(All organizations permitted to conduct lawful gambling within the City of Arden Hills shall contribute 10% (ten percent) of their <br />nct profits derived from gambling activities within the City to a special fund to be administered by the City Council for lawful <br />purposes. Payments to the fund shall be ealculated for quarterly periods ending on the last days of Mareh, June, September and <br />December, Quanerly installment payments shall be submitted together with verifiable supporting documentation not later than <br />the twentieth day of the month following the end of the quarterly period.) <br /> <br />Authorized Signature <br /> <br />~tttu)~~L_.__.~_ <br /> <br />Date .3 -/ E> -0 cJ <br />. ----------'.-". .-.--....----J- <br /> <br />. <br />