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ff1-4y v <br /> 4- ( Kinn e '3Pfs:: <br /> a/,f-&a 2--1P/ <br /> MINNESOTA LAWFUL GAMBLING 7/12 Page 1 of 2 <br /> LG214 Premises Permit Application Annual Fee $150 <br /> Required Attachments to LG214 <br /> 1. If the premises is leased, attach a copy of your lease. Mail the application and required attachments to: <br /> Use LG215 Lease for Lawful Gambling Activity. Gambling Control Board <br /> 2. $150 annual premises permit fee, for each permit. 1711 West County Road B, Suite 300 South <br /> Make check payable to "State of Minnesota." Roseville, MN 55113 <br /> Questions? Call 651-639-4000 and ask for Licensing. <br /> Organization Information <br /> 1. Organization name BY`e,e2i Pox License number 1,:,1A <br /> y�J CA b 18 ��8 <br /> 2. Chief executive officer(CEO) F(r Lci�ems) /�L�,� �l� Daytime phone <br /> 3. Gambling manager /r7/ K Inn G r.1 Daytime phone ;.2/Q'-ga0 <br /> Gambling Premises Information <br /> 4. Current name of site where gambling will be conducted Lacey 'S 7.71 vern <br /> 5. List any previous names for this location Nlsy sow s S;bley S*Ztfion //�� ,t_ <br /> 6. Street address where premises is located ;1& 0 t_';F�iI"r�m en* b h " f'P (�,�i G L4ss <br /> Do not use a P.O. box number or mailing address. <br /> 7. City OR Township County Zip code <br /> 'Nu of IA keS Crow ITV ✓tq 54.1.t72. <br /> 8. Does your organization own the building where the gambling will be conducted? •1 <br /> Yes X No If no, attach LG215 Lease for Lawful Gambling Activity. <br /> A lease is not required if only a raffle will be conducted. ��// <br /> 9. Is any other organization conducting gambling at this site? /\ Yes No _ Don't know <br /> 10. Has your organization previously conducted gambling at this site? Yes )(,_ No Don't know <br /> Gambling Bank Account Information. Must be in Minnesota. <br /> 11. Bank name Bank account number <br /> Lake S Sfeite n /J//-1- t <br /> 12. Bank street address City State Zip de <br /> 3P g( - �' S-t- ?eta°f 'S MN <br /> All Temporary and Permanent Off-site Storage Spaces <br /> 13. Address (Do not use a P.O. box number) City State Zip code <br /> MN <br /> 14. Address (Do not use a P.O. box number) City State Zip code <br /> MN <br />