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<br />Bas t STATB OP MINNESOTA
<br />GAMBLING CONTROL BOARD
<br />PRBMISBS PBRMIT RBNBWAL APPLICATION
<br />LG214PPR PRINTED:Ol/02/96
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<br />IpOR SOARP USH
<br />IAMT PAID
<br />I CHECK NO.
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<br />LICENSE NUMBER: B-01837-003
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<br />EFFECTIVE DATE: 07/0l/9~
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<br />
<br />NAME OF ORGANIZATION: Hockey New Brighton Lake Region Assoe
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<br />EXPIRATION DATE: 06/3o/9ig
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<br />GAMBLING PREMISBS INFORMATION
<br />
<br />NAME OF ESTABLISHMENT WHERE GAMBLING WILL BE CONDUCTED
<br />Champps
<br />2397 Palmer Dr
<br />New Brighton 55112
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<br />COUNTY Ramsey
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<br />IS THE PREMISES LOCATED WITHIN THE CITY LIMITS?: Y
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<br />LBSSOR INFORMATION
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<br />DOES YOUR ORGANIZATION OWN THIS SITE?: No
<br />IF NO, LIST THE LESSOR:
<br />Arthur Pew III
<br />Manitou Island
<br />White Bear Lake MN 55110
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<br />NAME OF PROPERTY OWNER (WHEN NOT LESSOR) :
<br />
<br />o
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<br />AMOUNT PAID FOR RENT PER MONTH: 1000
<br />AMOUNT PAID PER OCCASION: 0
<br />
<br />SQUARE FEET PER MONTH:
<br />SQUARE FEET PER OCCASION:
<br />
<br />48
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<br />'BINGO ACTIVITY
<br />BINGO IS CONDUCTED ON THIS PREMISES: No IF YES, REFER TO INSTRUCTIONS FOR REQUIRED ATTACHMENT
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<br />STORAGB ADDRESS
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<br />251 5th St NW EZ Mini
<br />New Brighton MN 55112
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<br />BANK INFORMATION
<br />
<br />Norwest Bank
<br />401 2nd Ave S
<br />Minneapolis MN 55407
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<br />GAMBLING BANK ACCOUNT NUMBER: 6521134
<br />
<br />ON THB LINES PROVIDED BELaWLIST THE NAME , ADDRESS AND TITLE OF AT LEAST TWO PERSONS
<br />AUTHORIZED TO SIGN-CHECKS ANDMAKE,.DEPOSITS,AND WITHDRAWALS. FOR-THE. GAMBLING.ACCOUNT..,-,
<br />THE ORGANIZATIONISTREAStmER.MAY _NOTHAND~GAMBLING FUNDS. '.. ..'_:;~:: ~'~'!/~~Y";jl!~)"
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<br />THIS FORM WILL BE MADE AVAILABLBIN ,ALTERNATIVE
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<br />FORMAT (l.E.LARGE PRINT, BRAILLE) UPON REQUEST
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