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<br />State of Minnesota <br />Gambling Control Board <br />Premises Permit Renewal Application <br /> <br />For Board Use Only <br />Amt. Pd <br /> <br />Check # <br /> <br />LG214PPR Printed: 3/5/2001 <br /> <br />Date <br /> <br />License Number:B-00584-010 <br /> <br />Effective Date: 5/1/2000 <br /> <br />Expiration Date: 7/31/2001 <br /> <br />Name of Organization: Lions Spring Lake Park Club <br />Gambling Premises Information <br /> <br />Name of the establishment where gambling will be conducted <br /> <br />Kellys Korner <br />7098 Centerville Rd <br />Centerville, MN 55038 <br />County: Anoka <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 />W; HiA."'- Ii? i:se ~ <br /> <br />Square footage leased per month: I ;3 7 <br />Rent paid per month: . ~ ~(!) 0 · C C:1 <br />Square footage leased per bingo occasion: - c::J <br />Rent paid per bingo occasion: -c <br /> <br />Bingo Activity <br />Our records indicate that Bingo is not conducted on these premises. <br /> <br />~Y'A~e 5~'t'"e <br />'T'I 3'8 c:::..."","t""C! r D...; lie <br />s p .LoU". Pc, $ $''18 2- <br /> <br />Storage Information <br /> <br />Bank Information <br /> <br />~.~~fE~s 0 :B 6..Vl-lC <br />8455 NE Plaza Blvd <br />Spring Lake Park, MN 55434 <br /> <br />Gambling Bank <br />Account Number: 1080034913 <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 <br />and withdrawals 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 Title <br /> <br />Spring Lake Park, MN Employee <br />55432 <br /> <br />Dean Harold Keller <br /> <br />528 79th Ave NE <br /> <br /> <br />Chief Executive Officer <br /> <br />(Be sure to complete the reverse side of this application) <br /> <br />This form will be made available in alternative format (ie. large print, braille) upon request. <br /> <br />Page I of 2 (Continued on Back) <br />