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MINNES07A LAWFUL GAMBLING 5/15 Page 1 of 2 <br /> LG214 Premises Permit Application 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 attachmerrts 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 /> Questions7 Call 651-539-1900 and ask for Licensing. <br /> ORGANIZATION INFORMATION <br /> Organization Name: Norther Lakes Youth Hockey Assoc. Inc. License Number: 02055 <br /> Chief Executive Officer(CEO) Matt Balmer Daytime Phone: 218-831-0831 <br /> Gambling Manager: �ohn Engstrom Daytime Phone: 218-820-4636 <br /> GAMBLtNG PREMISES INFORMA'RON <br /> Current name of site where gambling wili be conducted: Barajas Mexican Grill <br /> List any previous names for this locatlon: <br /> Pestel lo's <br /> Street address where premises is located: 31094 Front Street <br /> (Do not use a P.O.box number or mailing address.) <br /> �- City: pR Township: County: Zip Code: <br /> Pequot Lakes Crow Wing 56472 <br /> Does your organization own the building where the gambling will be conducted? <br /> �Yes �No It no,attach LG215 Lease for Lawful Gambling Activity. <br /> A lease is not required if only a rafFle wilt be conducted. <br /> Is any other organization conducting gambling at this site? �Yes �No �Don't know <br /> Note: Bar bingo can only be rnnducted at a site where another form of lawful gambling is being conducted by the applying organi- <br /> zation or another permitted organization. Electronic games can only be conducted at a site where paper pull-tabs are played. <br /> Has your organization previously conducted gambling at this site? �Yes �No �Don't know <br /> GAMBLtN6 BANK ACCOUNT INF�RMATION; MUST BE IN MINNESOTA <br /> Bank IVame: First National Bank Bank Account Number: 551754 <br /> Bank Street Address: 35197 County Rd. 3 ��ty; Crosslake State: MN Zip Code: 56442 <br /> ALL TEMPORARY AND PERMANENT�FF-SITE STORAGE SPACES <br /> Address(Do not use a P.O. 6ox number): City: State: Zip Code: <br /> County Rd. 3 Crosslake MN 556442 <br /> � <br /> MN <br /> MN <br />