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Minnesota Lawful Gambling <br />Premises Permit Application - LG214 <br />Page 1 of 3 <br />1199 <br />FOR BOARD USE ONLY <br />Check# Fee <br />Class of Permit <br />C,�e�k 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 <br />Minnesota Secretary of State or internal Revenue Service) <br />Base license number <br />Name of chief executive officer (cannot be your gambling manager) Daytime phone number <br />R. Robert Matson � f51 � 63 R-4CM <br />Gambling Premises Information <br />Name of establishment where gambling will be conducted Street address (do not use a P.O. box number) <br />�ity & county where gambling premises is located-OR-Township 8, county where gambling premises is located if outside city limit <br />Roseville Ramsey � <br />Is the premises located within city limits?Yes� No � If No, is township <br />LJ Organized <br />❑ Unorganized <br />V 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 cleariy 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 />Capital City Investments, LLP � y� S, R 1 L..,'E S�', . Sr. P'"' � W� W� t� a, <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_yt StatelZip <br />�ruu�o� ��M�w��wuua�mur.nr.� <br />738 Thomas Ave., St. Paul, <br />Questions? Call the Licensing Section of the Gambling Control Board at 651-639-4000. If you use a TfY, 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 alternative format (i.e. large print, Braille) upon request. <br />