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i' <br />Ii �� <br />�� <br />Page 1 of 3 <br />1 /99 <br />Minnesota Lawful Gambling FOR BOARD USE ONLY <br />Premises Permit Application. LG214 Check# Fee <br />Class of Permit <br />C,he�ck one: <br />�J Class A-$400 Pull-tabs, tipboards. paddlewheels, rafFles, bingo <br />�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 />MIDWAY SPEEDSKATING CLUB, INC. A-00070-005 <br />Name of chief executive officer (cannot be your gambling manager) Daytime phone number <br />KENNETH HARASYN� PRESIDENT ( 612 ) 617-3254 <br />Gambling Premises Information <br />Name of establishment where gambling will be conducted Street address (do not use a P.O. box number) <br />ROSEVILLE BINGO 2525 N. Snelling Ave., Roseville, MN 55113 <br />(;ity & county where gambling premises is located-OR-Township & county where gambling premises is located if outside city limit! <br />Roeville, MN Ramsey <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 � 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 definec <br />A lease and sketch are not required for class D applications. <br />Name of legal owner of premises Address City State/Zip <br />Capitol City Investments, LLP, 246 S. Albert St., St. Paul, MN 55105 <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 City 5 ate/Zi <br />Park Place, Inc., 2617 Park St., Little Canada, MN 55117 <br />Roseville Bingo 2525 N. Snelling Ave., Roseville, � 55113 <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 I-800-627-3529 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 />