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Minnesota Lawful Gambling <br />Premises Permit Application <br />Page 1 of 3 <br />1/99 <br />FOR BOARD USE ONLY <br />Check# Fg@ <br />Class of Permit <br />Check one: <br />� Class A W$400 Pull-tabs, tipbaards, p8ddlewheels, raffles, bingo <br />❑ Class B•$250 Pull-tabs, tipboards, pa�lewheels, 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 <br />Minnesota Secretary of State or Internal Revenue Service) <br />/l ��� l_�����; T-Y <br />Gambling Premises Information <br />Name of establishment where gambling will be conducted <br />located-0R—Township <br />Is the premises located within city limits?Y�s <br />Base license number <br />Daytime phone number <br />(f � � )�.3J-���7 <br />Street address (do not use a P.O. box number) <br />If No, is township: <br />U Organized <br />❑ Unorganized <br />❑ Unincorporated <br />Does your organization own the building where the gambling will be conducted? <br />❑ Yes�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 <br />/��y,,� <br />:�) I-i-n- l�� � �'1 <br />City , State/Zip <br />3�y7 �'Yl��.irvt�� n.� . <br />►/%'1 � � � %�l ,v ��t � <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 />Address C��it ( St8t�/Zlp <br />� , � <br />Pn-- o ° , .(`a s-�+ � e,M �v <br />� — �-Sa-S SNt,u.�n�y A'�- � . 5�S11" <br />Questions? Call the Licensing Section of the Gambling Control Board at 651-639-4000. If you use a TTY, you can i <br />call the Board by using the Minnesota Relay Service ''�t 1-800-G27-3529 and ask to place a call to 651-639-4000. This� <br />form will be made available in alternative format (i.e. large print, Braille) upon request. <br />