Laserfiche WebLink
<br />Minr;esota Lawful Gambling <br />Lease for Pull-Tab, Paddlewheel, Tipboard, and/or Raffle Activity - LG221 <br />Name of L gal Owner of Premises Street Address City Zi~ Daytime Phone <br />t · v (/." /l'}cJ/'JrA>';AJ -/0 CP~ It. ~ ~7) ~ 2C:- <br />Name of Lessor Street Address City Zip p.9ytime Phone ,/ :] ~ <br />(If same as legal owner, write in "SAME") S5(:):j'6 <br /> <br />~& ( ) <br />Name of Leased Premises Street Address .~, : ; ~: City Zip Daytime Phone <br />,;. rr,~ f,/VV 7&aZ-ce#"lervl1/~~ e."f~/v,11 63-038 ( ,'s-I ) ~ifl6 -Z>,~-Z~ <br />Name of Lessee (name of organization leasing the premises) Gee license no. of organization Daytime Phone <br />- !t 17" cc:: oR ,8 ro.l-e ~cR'fi c- c4-.5 /3 -0 3 ~ (c;#- ) f"e, F - rz i.. , <br /> <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 $ <br />(If no rent is to be paid, indicate -0-) <br /> <br />00 <br />300. -~ <br /> <br />feet by ~ feet for a total of ~O 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 />feet by feet for a total of square feet. <br /> Combined total square feet. <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 />8 <br /> <br />Storage <br />Storage <br /> <br />~pr,~~;ii~~~~rm~j'~~~~~al'..\pplicationSOnIY: If no <br />i!~~~~II~~jil!~~i~1;;;~~~~~~~not have to <br /> <br />Lawful Gambling Activity. <br />Type of gambling activity that will be conducted at this gambling premises. Check all that apply. <br /> <br />L Paddlewheels <br />Term of Lease <br /> <br />LPull-Tabs ~Raffles _Tipboards <br />Amended Lease Only <br /> <br />The term of this lease agreement will be concurrent with the' If this is an amended lease showing changes occurring dur- <br />premises permit issued by the Gambling Control Board, ing the term of the current premises permit, write in the <br />unless terminated sooner by mutual consent of the lessor date that the changes will be effective _1_1_. <br />and lessee. Both parties that signed the lease must initial and date all <br />changes. <br /> <br />Questions on this form should be directed to the Licensing <br />Section of the Gambling Control Board at (612) 639-4000. <br />This publication will be made available in alternative format <br />(Le. large print, Braille) upon request. Hearing impaired <br />individuals using a TTY may call the Minnesota Relay Service <br />at 1-800-627-3529 and ask to place a call to (612) 639-4000. <br /> <br />The information requested on this form will be used by the <br />Gambling Control Board (Board) to determine your compliance <br />with Minnesota statutes and rules governing lawful gambling <br />activities. All of the information that you supply on this form <br />will become public information when received by the Board <br />except, if required, your Social Security number, which remains <br />private. <br /> <br />Page 1 of 2 <br />Rev. 8/97 <br />