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• <br /> • <br /> FOR BOARD USE ONLY <br /> Base # Check # <br /> Minnesota Lawful Gambling pp # Initials <br /> Premises Permit Application - LG214 Fee Date <br /> Class of Permit Page 1 of 3 <br /> 1/99 <br /> Check one: <br /> ❑ Class A - $400 Pull -tabs, tipboards, paddlewheels, raffles, bingo <br /> El Class B - $250 Pull -tabs, tipboards, paddlewheels, raffles • <br /> ❑ Class C - $200 Bingo only OR bingo and pull -tabs when total gross receipts do not exceed $50,000 per year <br /> ❑ Class D - $150 Raffles only <br /> Organization Information <br /> Organization name (as it appears on documentation filed with Base license number <br /> Minnesota Secretary of State or Internal Revenue Service) <br /> 6 1)11 ,- e L rn L a y ' - ' Park a✓ fans' P rr' c) <br /> Naeof chl4f executive officer (cannot be your gambling manager) Daytime p phone number <br /> LC; j 6- ' S OA! <br /> (6 2) rift, `)7 <br /> L3. I fa1 1 t 4 <br /> Gambling Premises Information <br /> Name of establishment where gambling will be conducted Street address (do not use a P.O. box number) <br /> k €l►• .ur� <br /> Isis or 7elcz pn ter viflaw . • <br /> City & count/where gambling premises is located —OR— Township & county where gamb ing is located if outside city limits <br /> 0 0.yt IF PA I le _ <br /> Is the premises located within city limits ?Yes, No _ If No, is township: ® Organized <br /> ❑ Unorganized <br /> ❑ Unincorporated <br /> Does your organization own the building where the gambling will be conducted? <br /> ❑ Yes 24.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 D applications. <br /> Name of legal owner of premises Address �7 City State /Zip <br /> I / sec 707£r (� etii-r err',Ic am 'Roar/ C tee l' 1 3 <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. (Attach an additional <br /> sheet if necessary.) <br /> Addigaa City State/Zin <br /> g 93 (' ‹,,,vier Of; ve_ Si- v4 i rK' /7xl s.cxia <br /> 7C `% ( v v�, - e r1/ / ret4 -r ; lie 44X1 ri $e3 _ <br /> Questions? Call the Licensing Section of the Gambling Control Board at 651 - 639 -4000. If you use a TTY, you can <br /> call the Board by using the Minnesota Relay Service at 1 -800- 627 -3529 and ask to place a call to 651 - 639 -4000. This <br /> form will be made available in altemative format (i.e. large print, Braille) upon request. <br />