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MINNESOTA LAWFUL GAMBLING <br />LG214 Premises Permit Application <br />6/15 Page 1 of 2 <br />Annual Fee $150 (NON-REFUNDABLE) <br />REQUIRED ATTACHMENTS TO LG214 <br />1. If the premises is leased, attach a copy of your lease. Use LG215 Mail the application and required attachments to: <br />Lease for Lawful Gambling Activity. Minnesota Gambling Control Board <br />2. $150 annual premises permit fee, for each permit (non-refundable). 1711 West County Road B, Suite 300 South <br />Make check payable to "State of Minnesota." Roseville, MN 55113 <br />Questions? Call 651-539-1900 and ask for Licensing. <br />ORGANIZATION INFORMATION <br />Organization Name: ARAA License Number: 98049 <br />Chief Executive Officer (CEO) Dustin Reeder Daytime Phone: 612.366.0125 <br />Gambling Manager: Josh Jungling Daytime Phone: 612.860.5616 <br />GAMBLING PREMISES INFORMATION <br />Current name of site where gambling will be conducted: The Kitchen Table <br />List any previous names for this location: <br />Fountains of Ramsey <br />Street address where premises is located: 7533 Sunwood Dr <br />(Do not use a P.O. box number or mailing address.) <br />City: OR Township: <br />Anoka <br />County: Zip Code: <br />Anoka 55303 <br />Does your organization own the building where the gambling <br />will be conducted? <br />Lawful Gambling Activity. <br />Yes No If no, attach LG215 Lease for <br />A lease is not required if only a raffle will be conducted. <br />Is any other organization conducting gambling at this site? <br />Note: Bar bingo can only be conducted at a site where another <br />zation or another permitted organization. Electronic games <br />Has your organization previously conducted gambling at this <br />Yes No Don't know <br />form of lawful gambling is being conducted by the applying organi- <br />can only be conducted at a site where paper pull -tabs are played. <br />site? Yes No Don't know <br />GAMBLING BANK ACCOUNT INFORMATION; MUST BE IN MINNESOTA <br />Bank Name: Us Bank Bank Account Number: 104783931306 <br />Bank Street Address: 129 W Main St City: Anoka State: MN Zip Code: 55303 <br />ALL TEMPORARY AND PERMANENT OFF -SITE STORAGE SPACES <br />Address (Do not use a P.O. box number): City: State: Zip Code: <br />5997 Bunker Lake Road Anoka MN 55303 <br />MN <br />MN <br />