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Check applicable item: <br />1. Lease for new application. <br />Submit with new premises permit <br />premises permit renewal. <br />_ / Submit new or amended <br />application. <br />name <br />of the <br />- <br />lease within 10 days <br />Booth /bar <br />'after new lessor <br />_Activity change <br />assumes ownership. <br />Other <br />tlt. Renewed lease. Submit with <br />New owner. Effective date <br />_ 3. <br />4. Amended lease <br />the lease: Rent <br />• Check the change(s) in <br />• Date that changes will <br />• Both parties must initial <br />• Submit changes at least <br />_ Premises <br />be effective /_/ <br />change. <br />and date all changes. <br />10 days before the effective date <br />Organization name <br />f k <br />�' ! && t'` V <br />License number <br />��c '— L/ <br />Daytime phone <br />/ q c?' ' 7 <br />rem <br />Name ofleased premises <br />ry S Z� <br />Street address <br />" aAk <br />City <br />, A SEY <br />State <br />m <br />Zip . <br />r53 <br />Daytime p <br />#9 �- <br />Name of legal owner of premises <br />y�` lr LLB <br />Business / address <br />/ M X l <br />City <br />N�� it s <br />State <br />r <br />Zip <br />�53& <br />ime phone <br />' �✓ <br />Name of lessor (if same as legal <br />owner, write in "SAME ") <br />OrM <br />Business /street address <br />City <br />State <br />Zip <br />Daytime phone <br />Check (4) all activities that will be conducted • <br />/ Bar <br />Pull -tabs _Pull -tabs with dispensing device Tipboards %/Paddlewheel _Paddlewheel with <br />table <br />i! bingo <br />_Bingo <br />Pull -tab, Tipboard, and Paddlewheel Rent (No lease required for raffles.) <br />Booth operation - sales of gambling <br />(or volunteer) of a licensed organization <br />that is distinct from areas where food <br />r Does <br />from <br />L <br />If you answered yes to the question <br />based on the following combinations <br />- Booth operation <br />- Booth operation and pull -tab <br />- Booth operation and bar operation <br />- Booth operation, bar operation, <br />The maximum rent allowed <br />per month for all organizations <br />COMPLETE ONE OPTION: <br />Option A: 0 to 10% of the gross <br />Percentage to be paid <br />equipment by an employee Bar operation - sales <br />within a separate enclosure premises by an employee <br />and beverages are sold. food and beverages are <br />your organization OR ant other orgarnz Lion conduct <br />of gambling <br />of the lessor <br />also sold. <br />gambling <br />No <br />equipment <br />from a common <br />above, rent <br />of operation: <br />device <br />not exceed <br />at this premises. <br />profits per <br />% <br />within a leased <br />area where <br />7 <br />J <br />limits are <br />$2,500 in total <br />month. <br />less per month, $0 <br />be paid $ . <br />a booth operation at this location? <br />above, rent limits are <br />of operation: <br />dispensing device <br />and pull -tab dispensing device <br />may not exceed $1,750 in total <br />at this premises. <br />profits per month. <br />°/u <br />If you <br />based <br />- Bar <br />- Bar <br />- Pull <br />The <br />per <br />COMPLETE <br />Option <br />Percentage <br />Option <br />to $200 <br />Option <br />profits. <br />Plus, <br />gross <br />9 <br />Yes <br />answered no to the question <br />on the following combinations <br />operation <br />operation with pull -tab dispensing <br />-tab dispensing device only <br />maximum rent allowed may <br />month for all organizations <br />ONE OPTION: <br />A: 0 to 20% of the gross <br />to be paid <br />B: When gross <br />per month may <br />C: $0 to $200 per <br />Amount to be paid <br />o%r <br />0% t over $1,000. <br />profits <br />profits are $1,000 or <br />be paid. Amount to <br />month on the first <br />$ <br />Option B: When gross profits are <br />$400 per month may be paid. Amount <br />Option C: $0 to $400 per month <br />profit. Amount to be paid $ � <br />$4,000 or less per month, $0 to <br />to be paid $ . <br />$1,000 of gross <br />paid n <br />paid per month on <br />pn he first $4,000 of gross <br />tU/ . <br />gross profits may be <br />to be <br />Plus, 0% to 10% of the gross profits may be paid per ontho n <br />gross profits over $4,000. Percentage to be paid / /0 <br />Bingo Rent ` <br />Bar B Rent <br />be <br />to <br />the <br />option <br />F: No rent may be paid for bingo <br />conducted in a bar. <br />Option D: 0 to 10% of the gross profits per month from all lawful <br />gambling activities held during bingo occasions, excluding bar bingo. <br />Percentage to be paid <br />Option E: A rate based on a cost <br />110% of a comparable cost per <br />approved by the director of the <br />paid for bar bingo. Rate to be <br />The lessor must attach documentation, <br />confirm the comparable rate and <br />organization to the lessor. <br />per square foot, not to exceed <br />square foot for leased space, as <br />Gambling Control Board. No rent may <br />paid $ per square foot. <br />New Bingo Activity <br />not previousl <br />For any new bingo activity previously <br />For a <br />included in a bi ac t activity not a Pm Permit paper listing t he <br />t <br />days a and e reate sheet es bingo will er conducted. <br />verified by the organization, <br />all applicable costs to be paid by <br />Minnesota Lawful Gambling <br />LG215 Lease for Lawful Gamblin Act <br />6/07 <br />Page 1 of 2 <br />—61- <br />