Agenda - Council - 01/11/2022 - 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 TT'A T .:TO L0, `::... 1. If the premises is leased, attach a copy of your lease. Use LG21.5 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, ORGAN IZATION Iri4FORMATION Organization Name: Chief Executive Officer (CEO) Gambling Manager: 21N:1 Current name of site where gambling will be conducted: List any previous names for this location: Street address where premises is located: License Number: Daytime Phone: Daytime Phone: 1// -7) fi-stqf\/ 116) (Do not use a P,0, box number or mailing cidress.) g0 4/7 2_, -X6 AC City: OR Township: County: Yie() Zip Code: .5.530 Does your organization own the building where the gambling will be conducted? Yes ri 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? Yes 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? Yes VI No Don't know GAMBLING BANK ACCOLINTINFORMATION"` N KINNESOTIA Bank Name: V� Bank Street Address: kl /ton J1-- Bank Account Number: /Oil )15 q3)306 City: VI6/ Ct State: MN Zip Code: 553613 Address (Do not use a P.O. box number): 0 t t /Mid 11; 12_0, City: State: Zip Code: rfrt 51e-7 MN ,I-5,5_30 MN MN