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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: 41112002 <br /> <br />License Number: B-03800-012 <br /> <br />Effective Date: 4/112002 <br /> <br />Expiration Date: 9/3012002 <br /> <br />Name of Organization: Dead Broke Saddle Club <br /> <br />Gambling Premises Information <br /> <br />Name of the establishment where gambling will be conducted <br /> <br />Wiseguys Pizza & Pub <br />7095 20th Ave S <br />Centerville, MN 55987 <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 />;(/cl1'ir( r rren.l",/ ~c...[ <br />tB'l L C-o<f"v'-'i~~ ,ifJ? <br />[c<<-k---u' /I..:. /7 Ji/ 5-'50 3 B <br /> <br />Square footage leased per month: <br />Rent paid per month: <br />Square footage leased per bingo occasion: <br />Rent paid per bingo occasion: <br /> <br />Bingo Activity <br />Our records indicate that Bingo is not conducted on these premises. <br /> <br />Storage Information <br /> <br />S-?7C /7io-li- .s;';:- Y <br />~yo H,U .>"503& <br /> <br />19680 Harrow Ave N <br />Forest Lake, MN 55025 <br /> <br />Bank Information <br /> <br />Mainstreet Bank <br />1650 SLake St <br />Forest Lake, MN 55025 <br /> <br />Gambling Bank <br />Account Number: 3011821 <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 and <br />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 <br /> <br />Title <br /> <br />Michael Burress 9243 N 55th St Lake Elmo, MN 55042 1-.&0 <br />Tom Scha~sen 10010 240th St N Scandia, MN 55073 ~"...P' Hc-P5.,....- <br />. <br />Dave ~llI~e._~: 8118 181st Ave N Forest Lake, MN 55025 t"e.... e. //e--> <br />/'t:..~ ~.....-/o~ <br /> <br />(Be sure to complete the reverse side of this application) <br /> <br />This fonn will be made available in alternative format (ie. large print, braille) upon request. <br /> <br />Page 1 of 2 (Continued on Back) <br />