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<br />~ <br />~~HILLS <br />. <br /> <br />City 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.ci.arden-hills.mn.us <br /> <br /> <br />License No. <br />Receipt No. <br />Amount Paid <br />Date Recvd. <br />Ins. Cert. <br />Total Fee Paid <br /> <br />2006 Charitable Gambling Premise Permit- <br /> <br />Application Form <br />(Terms of the License: 2 Year Agreement) <br /> <br /> <br />{QUOD <br /> <br /> <br />Information (allfields are required) <br /> <br />Business Name: <br /> <br />North Suburban Youth Foundation <br /> <br />Property Address: <br /> <br />Big Ten Supper Club, 4703 N. Highway 10, Arden Hills 55112 <br /> <br />Nature of Business: <br /> <br />Local Contact: <br /> <br />Business Phone: <br /> <br />Email Address: <br /> <br />. <br /> <br />FederallD#: <br /> <br />Lawful Charitable Gambling <br /> <br />R. Robert Matson <br /> <br />651-638-4600 <br /> <br />Business Fax: <br /> <br />bmat,80ri{~;nS\-f.Il~ <br /> <br />Wcbsite Address: <br /> <br />0363323380 <br /> <br />651-636-3070 <br /> <br />v,-wv,'.ns\'fnet. <br /> <br />Premise Permit and Investigation Fee <br /> <br />$1(10.00 <br /> <br />*2005 Income and Loss Statement <br />*Projected 2006 Receipts/Prizes <br />*Copy of Lease Agreement <br /> <br />(All organizations permitted to conduct lawful gambling within the City of Arden Hills shall contribute 10% (ten percent) of their <br />net 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 calculated for quarterly periods ending on the last days of March, June, September and <br />December. Quarterly installment payments shall be submitted together with verifiable supporting documentation not later than <br />the twentieth day of the month follow.ing the end of the quarterly period.) <br /> <br />, <br />t---, <br />i~, <br />U,,",.,.,,'''-->~ <br /> <br />Authorized Signahlre <br /> <br />. <br /> <br />'/( '.' -0-.. <br />1- l J'---.I\, <br /> <br />Date /1 / (J& <br />