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State of Minnesota For Board Use 2-Rix <br /> Gambling Control Board Amy_ Pd <br /> Premises Permit Renewal Application Check# <br /> Date <br /> lnitials <br /> LG214PFR Printed: 11/15/1999 <br /> License Number: A-01485-009 Effective Date; 4/1/1998 Expiration Date: 3/31/2000 <br /> Name of Organization: North Suburban Youth Roseville Amm L�*4 <br /> Gambling Premises Information <br /> Name of the establishment where gambling will be conducted <br /> K of C Council 4021 Note: our rexrds show the premises <br /> 2555 Snelling Ave N is located%ki t1i1 n the Mgr 1hits <br /> Roseville, MN 55113 <br /> county: Ramsey <br /> Lessor Information <br /> Nazareth Bldg Assoc <br /> 2555 Snelling Ave N <br /> Roseville, MN 55113 <br /> Name of the property owner (If different): Square footage leased per month: <br /> Rent paid per month: <br /> Square footage leased per bingo occasion: 7,260.00 <br /> Rent paid per bingo occasion: 300.00 <br /> Bingo Activity <br /> Our records indicate that Bingo is not conducted on these premises. <br /> Storage Information <br /> 55 E. County Road B, Little Canada - 2555 Snelling Ave. Roseville . 2900 N. Rice St., Little Canada <br /> 1183 University Ave., St. Paul m 4703 N. Hwy 10, Arden Hills - 738 Thomas Ave., St. Paul <br /> Bank Information <br /> Roseville Community Bank Gambling Bank <br /> 1501 W Co Rd C Account Number: 096005624 <br /> Rosevilie, MN 55113 <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 /> Name Address City, State, Zip Code Title <br /> R. Robert Matson 2774 Kellwood Roseville., MN 5511 CEO <br /> Drake Anderson 1436 Ryan Ave. W. Roseville., MN 55 1 1 Member <br /> Gale Pederson 929 W. oSelawn-Tv e. okviUe., A ember <br /> (Be sure to complete the reverse side of this application) <br /> This form will be made available in alternative format (ie. large print, braille) upon request. Page 1 of 2 (Continued Uri Hack) <br />