Agenda - Council - 08/10/2021 - Laserfiche WebLink

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MINNESOTA LAWFUL GAMBLING LG214 Premises Permit Application 6/15 Page 1 of 2 Annual Fee $150 (NON—REFUNDABLE) REQUIRED ATTACHMENTS TO LG214 1. If the premises is leased, attach a copy of your lease. Use LG215 Lease for Lawful Gambling Activity. 2. $150 annual premises permit fee, for each permit (non-refundable). Make check payable to "State of Minnesota." Mail the application and required attachments to: Minnesota Gambling Control Board 1711 West County Road B, Suite 300 South Roseville, MN 55113 Questions? Call 651-539-1900 and ask for Licensing. ORGANIZATION _I'VFORMATION Organization Name: Chief Executive Officer (CEO) Gambling Manager: 3O35 a -532 -4 WV.2. Daytime PhoneW a/C7 License Number: Daytime Phone: GAMBLING PREMISES INFORMATION Current name of site where gambling will be conducted: List any previous names for this location: & / TaVe,v) Street address where premises is located: o not use a P.D. b+ n mber or mailing address. City: ti,e6 Seri-Yn s OR Township: County: 197261kat, Does your organization own the building where the gambling will be conducted? Yes No If no, attach LG215 Lease for Lawful Gambling Activity. A lease is not required if only a raffle will be conducted. Is any other organization conducting gambling at this site? EYes 1 Zip Code: No Don't know Note: Bar bingo can only be conducted at a site where another form of lawful gambling is being conducted by the applying organi- zation or another permitted organization. Electronic games can only be conducted at a site where paper pull -tabs are played. Has your organization previously conducted gambling at this site? [11Yes r..149 fk,A, riNo Don't know GAMBLING BANK ACCOUNT JNFORMATION; MUST BE IN MINNESOT Bank Name: DK Rie &wiz_ Bank Street Address: 116? //(.) City Bank Account Number: 64( ALL TEMPORARY AND PERMANENT OFF -SITE STORAGE SPACES 31p State: MN Zip Code: (a)3 Address (Do not use a P.G. box number): 6-64') City: State: Zip Code: MN 6-55,6_1 MN MN