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LG2 t4PPR Printed:l2l3/Z00 I <br />License Number: B-02069-Q45 <br />Name of Organization: TSE <br />State of Minnesota Far Board Use Only <br />Gambli�g Control Board <br />Premises Permit Renewal Application A�- � <br />C#�ck !l <br />Effe��ive Date: 7/1/ZtiWl Expirarion Date: 6138/24U2 <br />G�m�li�qg Premises Information <br />Name of the establishment where gambling will be conducted <br />Ol Mexico <br />1754 Lexington Ave <br />Roseville, MN 55113 <br />county: Ramsey <br />Name of the properry owner (If different): <br />Note: Our records show thep�e�iSCs <br />is bcatcd within du city limits <br />Lessor Information <br />Square footage leased per month: �}-$ <br />Rent paid per month: 9 Q� � <br />Square footage leased per bingo occasion: p <br />Rent paid per bingo occasion: (� <br />Bingo Activity <br />Our records indicate that Bingo is not conducted on these premises. <br />�h, �r����a. ���n:,,- S�a...� <br />SSECoRdB <br />Little Canada, MN 55117 <br />Community National Bank <br />1501 W County Rd C <br />Roseville, MN 55113 <br />Storage Information <br />Bank Information <br />Gambling Bank <br />Account Number: 2009181 <br />On �e 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 />Phillip C Saari 3374 Owasso St Shoreview, MN 55126 �_ �` �) �� <br />Ci'� <br />Daniel William Rietz 4333 Braddock Tr Eagan, MN 55123 U��j�,� l�,,,�(��_ �r, <br />�� •---� l71 �� V� a�!gN�'i:�@iY99 �tliilna*anLn MI►i CC2A5 `Z . `' C�l t l/' <br />�l 1 �f .� S T.» WC. <br />(Be sure to complete the reverse side of this application) <br />Thls form will be made available in alternative format (ie. large print, braille) upon request. Page l of2 (Continued on Back) <br />