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<br />,i <br /> <br />. <br /> <br />Minnesota Lawful Gambling <br />Lease for Pull-Tab, Paddlewheel, Tipboard, and/or Raffle Activity - LG221 <br /> <br />Name of Legal Owner of Premises Street Address Coy Slate Zip Daytime Phone <br />n / !-fort /4.<-'-,"" {;S7r.? Ce~,t:./--J/c ..f'J L_~ L>!'-.tc",> /7V 3305$ ?51-fZ627 - <br />/"'-./. 7 <br />Name of Lessor Street Address COy State Zip Daytime Phone <br />(If same as legal owner, write in "SAME'1 I <br />.-5~;41. .e- <br />Name of Leased Premises Street Address COy Zip Daytime Phone <br />-;r,b Z/1 r'-- 70$7. c:e...h..-v//lc ,R-e c'cA.A:vv;/I /YP::JO:;,3 05/-lIu -Z'T .5 <br />Name of Lessee (name of organization leasing the premises) GeB license no. of organization Daytime Phone <br />17-c"<~ 13"'-0 .lee ~A/k chd !.l-OJ80,p C:;-7-/- 5/( $' 72Z':: f- <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 />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 />~ <br />~ <br /> <br />8 <br /> <br />feet by <br />feet by <br />feet by <br />feet by <br />feet by <br /> <br />Storage <br />Storage <br /> <br />(: <br /> <br />c:: <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-O-) <br /> <br />'100 <br /> <br />For Premises Permit Renewal Applications Only: If no <br />changes have been made at the site, you do not have to <br />complete this section or provide a sketch. <br /> <br />feet for a total of <br />feet for a total of <br />feet for a total of <br />feet for a total of <br />feet for a total of <br />Combined total <br /> <br />Y!o <br /> <br />square feet. <br /> <br /> <br />square feet. <br /> <br />square feet. <br /> <br /> <br />square feet. <br /> <br /> <br />square feet. <br /> <br /> <br />square feet. <br /> <br />LfO <br /> <br />Lawful Gambling Activity <br />Type of gambling activity that will be conducted at this gambling premises. Check all that apply. <br />o Paddlewheels IX] Pull-Tabs 0 Raffles [XI Tipboards <br />Term of Lease Amended Lease Only <br /> <br />The term of this lease agreement will be concurrent with <br />the premises permit issued by the Gambling Control <br />Board, unless terminated sooner by mutual consent of <br />the lessor and lessee. <br /> <br />If this is an amended lease showing changes occur- <br />ring during the term of the current premises permit, <br />write in the date that the changes will be effective <br />--1--1_. Both parties that signed the lease <br />must initial and date all changes. <br /> <br />Questions on this form should be directed to the Licensing <br />Section of the Gambling Control Board (Board) at 651-639- <br />4000. This publication will be made available in aiternative <br />format (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 651-639-4000. <br /> <br />The information requested on this form will become public <br />information when received by the Board, and will be used to <br />determine your compliance with Minnesota statutes and rules <br />governing lawful gambling activities. <br /> <br />Page 1 of 2 <br />1/99 <br />