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<br />, <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 />214PPR Printed: 3/112002 <br /> <br />License Number:B-03800-008 <br /> <br />Effective Date: 10/112000 <br /> <br />Expiration Date: 9/3012002 <br /> <br />Name of Organization: Dead Broke Saddle Club <br />Gambling Premises Information <br />Name of the establishment where gambling will be conducted <br /> <br />Trio Inn <br />7082 Centerville Rd <br />Centerville, MN 55038 <br />County: Anoka <br /> <br />Note: Our records show the premises <br />is located within the city limits <br /> <br />Lessor Information <br /> <br />L /~,C' ) ",-.{.~ <br /> <br />H,v' ,,-;s-03B <br /> <br />Square footage leased per month: {/O <br />Rent paid per month: ya? <br />Square footage leased per bingo occasion: <br />Rent paid per bingo occasion: p <br /> <br />(2J/ <br /> <br />Name of the property owner (If different): <br /> <br />Vr:ev/ /tOri- 1-",,/><-- <br />C:-Io Ccw/",/(j,/lc,f'cJ2 <br /> <br />Bingo Activity <br />Our records indicate that Bingo is not conducted on these premises. <br /> <br />l.f~yo:rc~ <br /> <br />Storage Information <br /> <br />st 7C <br /> <br />/76.) ..-( 5"<'- <br /> <br />19680 Hen-9ft Ave <br />Forest Lake, MN 55025 <br /> <br />hi,",:)"', H"l/ S-..5-0 38 <br /> <br />/1",)->(.. fr""--,,,- r- $",.,... 4...- <br />Tile Ct"lD~ B..llA <br />1650 South Lake St <br />Forest Lake, MN 55025 <br /> <br />Bank Information. <br /> <br />Gambling Bank <br />Account Number: 3011821 <br /> <br />On dIe lines provided below list the name, address and title of at least two persons apthorized to sign checks and make deposits and <br />withdrawals for the gambling account. The organizatjon'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 />"- <br />Tom Schaffheusen <br /> <br />10010 240th St N <br /> <br />Scandia, MN 55073 <br /> <br />CG"C' <br />13&~/.e M l--.~ <br /> <br />Clettef'ttln <br />/A....#Z'.-/-c....-_ <br /> <br />8118 181st Ave N' <br /> <br />Forest Lake, MN 55025 <br /> <br />-fv. <br />L/.,;c.."'C <br /> <br />NeS <br /> <br />(Be sure to complete the reverse side oftbis application) <br /> <br />This form will be made available in alternative fonnat (ie: large print, braille) upon request. <br /> <br />Page 1 of2 (Continued on B/JiOk) <br />