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Minnesota Lawful Gambling <br />Premises PermitApplication-LG214 <br />Page 1 of 3 <br />1/99 <br />FOR BOARD USE ONLY <br />Check# Fee <br />Class of Permit <br />Cp�,ck one: <br />V 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 />IMinnesota Secretary of State or Internal Revenue Service) <br />Base license number <br />�.. �, h� �� I P p� 14 C' �a�pr� a L��� ,� - O 31 �� <br />Name of chief executive officer (cannot be your gambling manager) Daytime phone number <br />`�1 F� � y G o e..,-t� ((� s r) ys�-a 6%,� <br />Gambling Premises Information <br />Name of establishment where gambling will be conducted Street address (do not use a P.O. box number) <br />�1 b52 V�� 1'� �i/ i n y0 � J� o� ,� N o� /1e.1 �� � <br />City & county where gambling premises is located-OR-Township & county where gambling premises is located <br />�o5ev � i �e �0.mse,y <br />Is the premises located within city Ilmlts?Yes � No ❑ If No, is township: <br />U Organized <br />❑ Unorganized <br />❑ Unincorporated <br />city limits <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 Address City State/Zip <br />� mPQ,p , <br />GPp:7-o � L' rT� �.nJes'fiw►e�f"5 L1.1° 3�y� h1�K�n(ey S7: 1�1�� ss4�ff <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 />��,.,.� ;F � arY ) � . <br />� __ S; 7'�e k�; �i,,C� � � 3 state�z� <br />�"`' �S� s /U Sn �l: „A ,d.,,.o �i�se� /1�IR ) s s [/ 3 <br />�7Q. - <br />,�a. � /�o k �` - I'; ►� e �y mti <br />}'Y)N Y??�,V, S�vraAe S5 �.�ty�� �.%�Tl� �� IrnlUss'ii� <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 />