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<br />#bX-- <br /> <br />&P( <br /> <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: 4/112002 <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 />. Gamblin~ Premises Information <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 />k'Cfl<tl-( r f/Cz.n4.:r t1c&.I <br />~ B? c. C -cu,.c.,yv//'~ If../! <br />Ccu-h-u,/I-c /7/1/ sso38 <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 />Bin~o Activity <br />Our records indicate that Bingo is not conducted on these premises. . <br /> <br />, <br /> <br />Storage Information <br /> <br />s-C: r";- <br />ffi.-Ct" 0 <br /> <br />.-:- <br />/70 .,;.,L- Y <br />/7",(/ S-S--o 38 <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 deposi~s and <br />withdrawals for the gambling account. The organization's treasurer may not handle gambling funds. ' <br /> <br />Name <br /> <br />Address <br />9243 N 55th St <br /> <br />City, State, Zip Code <br />Lake Elmo, MN 55042 <br /> <br />Title <br /> <br />Michael Burress <br /> <br />Tom Scharn:tisen <br /> <br />&(!;J <br /> <br />10010 240th St N <br /> <br />Soandia, MN 55073 <br /> <br />~....P' h:c:-p5--- <br /> <br /> <br />8118 181st Ave N <br /> <br />Forest Lake, MN 55025 <br /> <br />f/c'<-zo //<"J <br /> <br />(Be sure to complete the reverse side of this application) <br /> <br />This fonn will be made available in alternative fonnat (ie. large print, braille) upon request. <br /> <br />Page I of2 (Continued on Back) <br />