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<br />..sota Lawful Gambling <br />...G214 Premises Permit Application <br /> <br />Page 1 of 3 <br />7/01 <br /> <br />Check # <br /> <br />FOR BOARD USE ONLY <br /> <br />Amount <br /> <br />Class of Permit Premises Permit'Fee <br /> During ::<r1d year of <br />Check one Two years organization license <br />0 Class A . PulHabs, tipboards, paddlewheels, raffles, bingo $400 $200 <br />~ Class B - Pull-tabs, tipboards, paddlewheels, raffles $250 ( $125) <br />0 Class C - Bingo only OR bingo and pull-tabs when total gross $200 $100 <br /> receipts does not exceed $50,000 per year <br />0 Class 0 - Raffles on Iy $150 $ 75 <br /> <br />Expiratation date <br /> <br />Organization Information <br />Organization name (as it appears on documentation filed with <br />Minnesota Secretary of State or Internal Revenue Service) <br /> <br />Pc"" J: /lrcl-c:: Ji../'./k C/<../6 <br />Name of chief executive officer (cannot beyourgambling manager) <br /> <br />Organization license number <br /> <br />/I/c J.... I J /3<///'.:-s..; <br /> <br />8-' 0 S c9o<'"~ <br />Daytime phone number, <br />including area code <br />CIl 3'st7 8c.oL- <br /> <br />Gambling Premises Information <br />Name of establishment where gambling will be conducted Street address (do not use a PO. box number) <br /> <br />14/.'s",-<"o<; ;2:.;:'<... <i- ,/'~6 7075- Zc/) ..c S <br />City & county where gambling premises is located-DR-Township & county where gambling premises is located if outside city limns <br /> <br />[..-.{frrv. /Ie /a,d "'-- <br />Is the premises located within city limits? Yes.~ No 0 <br /> <br />If No, is township: 0 Organized <br />o Unorganized <br />o Unincorporated <br /> <br />Does you~anization own the building where ttie gambling will be conducted? <br />DYes l<:\J No If no, attach (1 ) the appropriate lawful gambling lease form, and <br />(2) the sketch of all leased areas with dimensions and square footage clearly defined <br />A lease and sketch are not required for class 0 applications. <br /> <br />Name of legal owner of premises Address City State/Zip <br /> <br /> <br />of <br /> <br />~t' LT' <br />2~. '7....~ <br /> <br />~.~"" h L", <br /> <br />/1'.(./ <br /> <br />----- <br />./:> <':J <br /> <br />Address(es) of Storage Space of Gambling Equipment <br />List all locations where used and unused gambling product is stored. Do not use a P.O. box number. <br />(Attach an additional sheet if necessa'Y.) <br />Address City state/Zip <br />/'1'tik # ,-j.-e;#,;' H'... z- #' hr'.",J/- /'~ " <=- //',/f/ 55"oz:'/ <br />r,,'7c. /70 -4~/- #<./"0 /7),/ E-oJ'$ <br />