Agenda - Council - 08/28/2001 - Laserfiche WebLink

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Page 1 of 3 7101 Minnesota Lawful Gambling I FOR BOARD USEONLY LG2t4 Premises PermitApplication I Check # Amount Expiratation date Class of Permit .... Pr~mises P~:~it Fee During 2nd year of Check one Two years organization license [] Class A - Pull-tabs, tipboards, paddlewheels, raffles, bingo $400 $200 ~] Class B - Pull-tabs, tipboards, paddlewheels, raffles $250 $125 [] Class C - Bingo only OR bingo and pull-tabs when total gross $200 ,$100 receipts does not exceed $50,000 per year F--J Class D - Raffles only $150 $ 75 Organization Information Organization name (as it appears on documentation filed with Minnesota Secretaryof State or Internal Revenue Service) Name of chief executive officer (cannotbe your gambling manager) Organization license number Daytime phone number, including area code I I I IGambling Premises Information Name of establishment where gambling will be conducted 'Street address (do not use a P.O. box number) ICity & county where gambling premises is located-OR~-Township & county where gambling premises is located if outside city lira Is the premises located within city limits? Yes [] No E~ If No, is township: [] Organized [] Unorganized [] Unincorporated Does your Organization own the building where thegambling will be conducted? ~'~es [] No If no, attach (1) the appropriate lawful gambling lease form, and (2) the sketch of all leased areas with dimensions and square footage clearly defined A lease and sketch are not required for class D applications. Name of legal owner of premises Address City State/Zip tS. I I I I I I Address(es) of Storage Space of Gambling Equipment List all locations where used and unused gambling product is storeid.' Do not use a P.O. box number. (Attach an addition~ sheet if necessary.) Address : _~ State/Zip I I I -136-