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I <br /> I <br /> I <br /> I <br /> I <br /> I <br />I <br /> I <br /> ! <br /> I <br /> I <br /> I <br /> <br />LG214PPR Printed: 3/5/2001 <br /> <br /> State of Minnesota <br /> Gambling Control Board <br />Premises Permit Renewal Application <br /> <br />For Board Use Only <br /> <br />AmL Pd <br /> <br />Check # <br />Date <br /> <br />License Number'.B-01203-004 Effective Date: 8/1/1999 Expiration Date: 7/31/2001 <br /> <br />Name of Organization: Ramsey Lions Club <br /> <br /> Gambling Premises Information <br /> <br />Name of the establishment where gambling will be conducted <br /> <br />Super Bowl <br />6720 Riverdale Dr NW <br />Ramsey, MN 55303 <br />County: Anoka <br /> <br />Note: Our records show the premises <br /> is located within the city limits <br /> <br />Timothy Holm <br />9620 180th Ave <br />Becker, MN 55308 <br />Name of the property owner (If different): <br /> <br />Lessor Information <br /> <br />Square footage leased per month: 57 <br />Rent paid per month: 1,000 <br />Square footage leased per bingo occasion: <br />Rent paid per bingo occasion: <br /> <br /> Bingo Activity <br />Our records indicate that Bingo is not conducted on these premises. <br /> <br />Storage Information <br /> <br />Bank Information <br /> <br />l~,~ankAaoka ~A ~4~JL Gambling Bank ~S re /~d,~- <br />Hwy"4~ & 167th Ave NW <br />Ramsey~N 55303 <br /> ~5'30 <br />On the lines p~vided below list ~e name, address ~d title of at least ~o persons authori~d to si~ chee~ ~d make deposits <br />and with&awals ~r the g~bling accost. The o~a~z~ion's't~u~r may not handle gambl~g ~nds. <br /> <br /> Name ~ Address Ci~, State, Zip Code Title <br /> <br />(Be sure to complete the reverse side of this application) <br /> <br />This form will be made available in alternative format (ie. large print, braille) upon request. <br /> <br />Page 1 of 2 (Continued on Back) <br /> -[17- <br /> <br /> <br />