89-1167 WHITE - GTV CLERK
PINK - FINANCE C�OUflCIl
BIUERV - MAVORTMENT GITY OF INT PAUL F�le NO. ���`�7
Cou cil esolution
a..q
Presented By ����"G -_...
Referred To Committee: Date
Out of Committee By �ate
RESOLVED: That application (ID #949 1) for a State Class B Gambling License
by DEAF Inc. At Mr. Pato 's Saloon, 995 W. 7th .Street, be and the
same is hereby approved/
COUNCIL MEMBERS Requested by Department of:
Yeas Nays
Dimond
�� [n Favor
coswitz
Rettman 0
s�he;n�� _ Against BY
Sonnen
Wilson
�JUN � � 198� Form Approved by Ci�ty ttor
Adopted by Council: Date - • '�
Certified Ya_ d Council , etar By G �/�_�
By I
A►pprov 1Aavor: D � 2 8 Approved by Mayor fpr Submission to Council
By
PUBLIStEE� J U L ' 8198
' ' ��f'" d 7'
• � L��07
DEPARTMENT/OFFICE/COUNqI DATE INITI D
Fi nance/�i cense GREEN SHE T No. 4����
CONTACT PERSON 6 PHONE DEPARTMENT DIRECTOR �CITY COUNCIL
Chri sti ne Rozek/298-5056 N� CITY ATTORNEY L3]cm c�a�c
MUBT BE ON COUNCIL AQENDA BY(DAT� AOUTINO BUDOET DIRECTOR �FIN.Q MOT.SERVICES DIR.
6-27-89 MAYOR(ORAS818T p (:ni�nri 1 R
TOTAL#�OF 81GNATURE PAQES (CLIP AL L ATIONS FOR SIGNATUR�
ACfION RE�UESTED:
Approval of an application for a ta e Class B Gambling License.
Notification Date: 6-9-89 Hearing Date: 6- 7-89
RECOMMENDATIONS:Approw(l y a Reject(R) COUNqI M ITTEE/RE8EARCN REPORT OPTI NAL
_PLANNINQ COMMISSION _GVIL SERVICE COMMIS810N ��Y� PF�NE NO.
_qB COMMITTEE —
� COMME
_STAFF _
_DISTRICT COURT _
SUPPORTS WHICH CaINqL OBJECTIVE?
INfT1AT1Nfi PROBLEM,18SUE,OPPORTUNITY(Who,Whet,When,Whsre,Why):
Neil Johnson on behalf of DEAF, I c. requests City Caun il approval of
his application for a State Class B ambling License at r. Patom's Saloon,
995 W. 7th Street. Proceeds from th pulltab sales will be used to promote
understanding of the needs and ri ht of deaf individual and to improve
their educational , socia1 and eco on c status in the Sta e of Minnesota.
All fees and applications have be n ubmitted.
ADVANTAOES IF APPROVED:
If Council approval is given, DEA , nc. will operate a ulltab booth at
Mr. Patom's Saloon.
D18ADVANTAOEB IF APPHOVED:
OISADVANTAOES IF NOT APPROVED:
Co:: .�;9 (�es��rch Center
,�Ji'a 16 ���;u�
TOTAL AMOUNT OF TRANSACTION COST/REVENUE BUDOETED( RCLE ONE) YES NO
FUNDINO SOURCE ACTIVITY NUMBER
FlNANCIAL INFORMA710N:(EXPLAIN) .
/ �
. ♦ �
NOTE: COMPLETE DIRECTIONS ARE INCLUDED IN THE GIREEN SHEET INSTRUCTIONAL
MANUAL AVAILABLE IN THE PURCHASING OFFICE(PHONE NO. 298-4225).
ROUTING ORDER:
Below are preferred routings for the five most frequent rypes of documents:
CONTRACTS (assumes authorized COUNGL RESOWTION (Amend, Bdgts./
budget exists) Accept.Grants)
1. Outside Agency 1. Department Director
2. Initiating DepaRment 2. Budget Director
3. City Attorney 3. Gry Attomey
4. Mayor 4. MayodAsaistant
5. Finance&Mgmt Svcs. Director 5. City Council
6. Flnance Accounting 6. Chief AcoouMant, Fin&Mgmt Svcs.
ADMINISTRATIVE ORDER (Budget COUNCIL RESOLUTION (all others
Revision) and ORDINANCE
1. Activity Manager 1. Initiatlng Department Director
2. DepartmeM Accountant 2. Ciry Attomey
3. Department Director 3. MayodAsaistaM
4. Budget Director 4. Ciry Council
5. Gty Clerk
6. Chief Accountant, Fin &Mgmt Svcs.
ADMINISTRATIVE ORDERS (all others)
1. Initiating Department
2. City Attorney
3. MayoNAssistant
4. City Clerk
TOTAL NUMBER OF SIGNATURE PAGES
Indicate the#of pages on which signatures are required and reli
each of these pages.
ACTION REDUESTED
Deacribe what the projecUrequest seeks to accompiish in either chronologi-
cal order or order of importance,whichever is most appropriate for the
issue. Do not write complete aentences. Begin�ch item in your list wfth
a verb.
RECOMMENDATIONS
Complete if the issne in question has been presented before any body, public
or private.
SUPPORTS WHICH COUNCIL OBJECTIVE?
Indicate which Council objective(s)your project/request supports by Ilsting
the key word(s)(HOUSING, RECREATION, NEIGHBORHOODS, ECONOMIC DEVEIOPMENT,
BUDGET, SEWER SEPARATION).(SEE COMPLETE LIST IN INSTRUCTIONAL MANUAL.)
COUNCIL COMMITTEEIRESEAACH HEPORT-OPTIONAL AS REGfUESTED BY COUNCIL
INITIATING PROBLEM, ISSUE,OPPORTUNITY
Explain the situation or conditions that created a need for your project
or request.
ADVANTAGES IF APPROVED
Indicate whether this is simpy an annual budget procedure required by law/
charter or whether there are speciflc ways in which the City of Saint Paul
and its cltizens will benefit from this projecUaction.
DISADVANTAGES IF APPROVED
What negative effects or major changes to existing or past processes might
this projecUrequeat produce if it is passed(e.g.,treffic delays, noise,
tax increases or assessments)?To Whom?When? For how long?
DISADVANTAGES IF NOT APPROVED
What will be the negative consequences if the promised action is not
approved?Inability to deliver aervice?Continued high traffic, noise,
accident rate? Loss of revenue7
FINANGAL IMPACT
Although you must tailor the information you provide here to the issue you
are addressing, in general you must answer two queations: How much is it
going to cost?Who is going to pay?
.' • ���--/ff�,�
DIVISION OF I.ICENSE AND P�RMIT ADMINI T TION llATE ' � �� / � �• �5
• , '�
INTF.RDF.PARTMFI�TAL REVIEW CHECKLIST A,�pn Processed/Received y
, Lic Enf Aud
Applicant �I� �I �)D�1!'15�/'1 O�{��v Home Address �� I �I �, „�.��r f ����
17C A r Z n�� ' " � c�
Rusiness Iv'ame � Om5 SC� pY Home Phone �' v� a �-I'J {j(�3
,T
�
Business Address y5 (� ' � Type of License(��) ���� �
,
Business Phone �G m blt�'1G� ',(� � � (�/1 5�
Public Hearing Date (;� 7 License I.D. 4� I ` y ���
at 9:00 a.m. in the Council hambers, � fV I�
3rd floor City Ha11 and Courthouse State Tax I.D. ��
llate N�tice Sent; Dealer 41 N'q-
to Applicant �p— � ,
I'ederal I'irearms �� /v
Public Hearing
DATE INSP CT N I
REVIEW VEKFIED (C FR) I CUMMENTS
A roved N t roved � i
�
Bldg I & D + i
I�l /�- , �'
Health Divn. ' �
�
�U �
i
Fire Dept. � �
i
I U � i
! S�n � f � �
Police Dept. I
s���.J o ,�
,
License Divn. '
(� �� �; � �
,
City �ttorney �
� t� �' � ,�
i
Date Received: I
�
Site Plan N �' �
To Council Resea�ch � �. �
Lease or Letter � D te
f rom Landlord �� .�' �
�
, . .. ...:��: .
• • ��
Charitable Gambling Controi B ard �'�'' *`"' FOR BOARD USE ONLY
Room IV-475 Griggs-Midw�y B ildi g ��N�
1821 University Avenue
St. Paul,Minnesota 5510433 3 PAID
(6121642-0555 14MT
` -- ' CHECK#
pATE
GAMBLING LICENSE APPLIC TI N
INSTRUCTIONS:
A. Type or print in ink.
B. Take completed application to local governing body,o tai signature and date on all copies,and leave 1 copy.Applicant keeps 1
copy and sends original to the above address with a c eck.
C. Incomplete applications may be returned.
D. Enclose lice�se fee with application.
Type of Application:
❑Class A— Fee S 100.00(Bingo,Raffles,Paddlewheels, ip ards,Pull-tabs)
�Class B— Fee S 50.00(Raffles,Paddlewheels,Tipbo ds, ull-tabs) M"k"�p"v"�"�°
❑Class C— Fee S 50.00(Bingo only) �/°°"'°�'���0"�BOB'�
�Class D — Fee S 25.00(Raffles only)
Check one: :�.11 A. Organization has never been licensed.
�1 B. New site—Give base license number. �
❑1 C. Renewal of existing license—Give co plet license number. � - � - 0
❑1 D. Change in class of an existing license— ive omplete license number. � - 0 - 0
❑Yes�7No 2. Has organization ever received a Lawful m ing Exemption Permit from the Board? If yes,give complete
permit number
❑Yes No 3. Have Internal Controls been submitted pr vio ly on a form provided by the'Board?If no,please attach copy.
4. Applicant(Official,legal name of organization) 5. Business Address of O�ganization
:> - ' `' � / �� 7 'i� ` t /'�,�
rc:i��,�sS r �i M ���' �.., ��..��� ,�r� .�.�• '! 9 vllr� C
6. City,State,Zip / 7.,,County 8. Business Phone Number
:;: , v� �� '� ��S1�r �'S�.�S< � .,� � t.��y—�'��3
9. Typeof rganization: ❑Fraternal O.Veterans ❑Re gio s ,QlOther. onprofit'
•If organization is an"other nonprofiY'organization,answer q esti ns 10 through 12.If not,go to question 13."Other nonprofiY'organizations
must document its tax-exempt status.
�lYes�No 10. I�Qrgectization incor orated as a nonpro t or anization?If yes,give number assigned to Articles or page and
book number: �1.�—•2-� A ch opy of certificate.
�Yes ONo 11. Are articles filed with the Secretary of St te? •
�Yes❑No 12. Is organization exempt from Minnesota o Fed ral income tax?If yes,pleaseiattach leiter from IRS or Department of
Revenue declaring exemptio�.
❑Yes.�INo 13. Has license ever been denied,suspended r r oked7 If yes,check all that ly:
❑Denied ❑Suspended ORevoke Give date: -
14. Number of active members 15. Number of year in e istence N te: Attach evidence of
G l three years existence.
s{� O�'2 4 Sv ti� � C.Z�`r.�
16. Name of Chief Executive Officer(Cannot be 17. Name of treasureror p�rson who accounts for other revenues
Gambling Manager) of the organization(C�nnot be Gambling Manager)
✓lJH� � -C 1��.�/r�t►� � t.%�w • H I% :� !V/� /�i7�4•1f( ✓1
rtie rtie '
Ii i�si ����`� j��'��rJv�r/" I'
Business Phone Number Business Phone Numb�r
3 �`�.3 ( r�,�-c /Tl,a )
� c i,��G /,?J %2.� `/— �
(/-�) li �. ► 757 —/b� 6 /�i0/J nl. , ,4-)1 1 � S / — 717 �?i�U ;,�� l.
18. Name of establishment where gambling will be 19. Street address(not P.O�.Box Number)
conducted r � � � � �/
� �,�,.,� � � , -
i �i!! City,State,Zip 21. County(where gamblirtg premises is located)
!�_ .- � ,� r-�-
:-; �R'i// �, ,,n L- /�'��.., .- /-
CG-0001-0318188) White Copy-Board Canary-App' ant , Pink-Local Governing Body
ge 1 of 2
�����--���7
Gambling License Application -/ �� '�'
Type of Application: �Class A �Class B ❑ as C O Class D
�Yes�No 22. Is gambling premises located within city li its
DYes ONo 23. Are ali gambling activities conducted at t e pr mises listed in#18 of this application? If not,complete a separate
application for each premises(except raffl s)a a separate license is required fo�each premises.
❑Yes.C9No 24. Does organizatio�own the gambling pre ses If no,attach copy of the lease with terms of at least one year,and
attach a sketch of the premises indicatin w t portion is being leased. A lease and sketch are not required for
Class D applications.
25. Amount of Rent Per 26. Do you plan on conducting bing with this license7 If yes,give days and times of bingo occasions. �J
Month or Bin o Occasion Day Ti �e Day Time Day Time
S ""� .
, , � =�
/ ✓ �-'� � ;.f. :,C.[�7., .
QYes ONo 27. Has the S 10,000 fidelity bond required by Mi nes ta Statutes 349.20 been obtaihed?
28. Insurance Company Name(not agency name) 29. Bond Number
/� i: _� S �: ( � y �. 3 �' '_ �%r�!J(G.
30. Lessor,Name 31. A dres � ., 32. City,State,Zip
vI r J� -''t .1 �: r ��::•-i �'f • 7 � � '�•. .�T i'- ; ��,f/. r �!�.<
:
33. Gambling Manager Name 34. A dres �. 35. City,State,Zip
�- � ,1,� � ,�ay - `' <� . ,�✓. ' �x,,. � �-;•1 ss 'r�y
36. Gambling Manager Business Phone 37. Date gambl g nager became ' '
( � �Z � � � � ._:� S; member of rga ization: Month�',,,;,- Year��
OYes�No 38. Has the license termination form been compl ed? ttach copy.
C�Yes�No 39. Has the compensation schedule been approv by he organizatio�?Attach copy.'
40. List the day and time of the regular meeting of the organizat n. ay- >1- � :''-' •- 7� -"'-� ':: • Time
41. Bank Name 42. Bank A res 43. Bank Account Number
','� ' _1= J J �.i f . /
�\j� 1/ �v� L'� . ,_ ��r.�, '✓� �! J r .
GAMBLING IT AUTHORIZATION
By my signature below,local law enforcement officers or en s of the Board are hereby authorized to enter upon the site at any
time gambling is being conducted to observe the gamblin an to enforce the law for any unauthorized game or practice.
� BANK REC D AUTHORIZATION '
By my signature below, the Board is hereby authorized t ins ect the bank records of the gambling bank account whenever
necessary to fulfill requirements of current gambling rules nd aw.
I hereby declare that: O TH
1. I have read this application and all information submit ed t the Board;
2. All informatio�submitted is true,accurate and compl te; ',
3. All other required information has been fully disclose
4. I am the chief executive officer of the organization;
5. I assume full responsibility for the fair and lawful oper tio of all activities to be conducted;
6. I will familiarize myself with the laws of the State of in esota respecting gambling and rules of the Board and agree, if
licensed,to abide by those laws and rules,including a en ments thereto; '
7. Membershi list of the or anization will be available ithi seve�da s after it is re ue ted b the board.
44. Official,Legal Name of Organization 45. ' nature Imust be sig�hed by Chief Executive Officer)
- -'� �- .c�r..G„�- � �' ,< f:, .., i�Y:�., �i,� i1;�" x �-i � / �
Titlq of Signer Date,, , U
.i �, : -;,�,�`�, �<.� '�� � �,� --- ,���
ACKNOWLEDGEMENT OF OTI E BY LOCAL GOVERNING BODY
I hereby acknowledge receipt of a copy of this application. y a nowledging receipt,I admit having been served with notice that
this application will be reviewed by the Charitable Gambli g C ntrol Board and if approved by the board,will become effective
60 days from the date of receipt (noted below) unless a es ution of the local governing body is passed which specifically
disallows such activity and a copy of that resolution is rec ive by the Cheritable Gambli�g!Control Board within 60 days of the
below noted date.
46. Name of City or County(Local Governing Body) If site is located within a township,item 47 must be completed,in
+ � . � � f�` addition to the county sig ature. If township is not organized,
% {'1ti ��- '�.:--'t i"'�r�(-�•�-�' county must sign.
Signature of person�eceiving application 47. Name of Township �
� „' ,
X . t' ( � ,i:. i'_�
. Title Date received(60 day period Signature of person receivin application
__�,X:, . begins from is at j
..� .. X
48. Name of persort delivering application t Loc I 6 veming y Title
CG-0001-03 l8/88) White Copy-Board Canary-Applicant Pink-Local Governing Body
ge of 2
� � � , Cicy : ainc Paul ' ``��
..�'` Deparcment oE Fina ce and Management Services ���
Division of Licen e nd Yermit Registration
INFORMATION RE UIRED WITH APPLICATION FOR PE IT TO CONDUCT CHARtTABLE GAMBLI:�G CAME I*1
SAINT PAUL
1. Full and complete name of organizati n hich is applying for lfcense ����_
�`
� u h ut ., vc� : .
2. Address where games will be held ��/ — �' d� . -Sf�d
�u er Screec City Zip
3. Name of manager signing this application who will conduct, cperate and manage
Gambling Games ���� 1�0 vinSu•� Datc of Birth ��,� ��/.Z
(a) Length of time manager has been m mb r oi applicant organization �Titcrv s'
4. Address of Ma�ager �D y �- 6 fi�` �/�F', a; /��- :.S�.S �/
Number tree[ Ci�ty Zip
5. Day, dates, and hours this applicatio i for �(Yl ,n�)r�i — ���A� ��m ' ��y5/�h
6. Is the applicant or organization orga iz d under the laws oilthe State of I�1? �
7. Date of incorporati�n � I
8. Date when registered with the State o :i nnesoca � 1v '' /g� U
J
�
9. How long has organization been in exi ce ce? ���. �^S
10. How long hae organization been in exi te ce ia St. Paul? �/2 y�.a�s
-�
11. What is the purpose of the otganizati n? �d ,Or>�z��e. ��e.�c�'a�d•�;� ,- �� 7�e n`�-ds'
�} �
�'/Z��h 1's 0 �� e/aa,iz :n.d�`►ri dun l.t 4� o :�•s�pv.�� Tke.;r ��Ca�.'.�,. I� s�sc�:oclt fL
(�'L'✓Hr An•'C: 1���5 � 7, ��22 ,Y +I�G f'� �-[i�•
12. Officers of applicant organization , _ ,,�
Name d N a �r►e. l"l� o��. —lJo h r y "Iame �7�vt✓�� !� G�L
Address /O�/� —(, � f. -�. [7I�n'.` AddressYB'�� �rr7'�oh �"e- �, ���5
Title ��s.���� DOB � ��' Title �/T�rs`� � DOB �p� 7—so�-
Name i �v � olr Name /yo� � �Q�H.�a t-�
Address l , �v/ y�e. y- � �ddress `S21 ' .l�l- ✓:, .`i�/�d.�r �r�'a���>,
Title ��re�y�y DOB 6�S Ticle Jver►,s�✓G�/ DOB �6 /y s
13. Give names of officers� or any other p rs ns who paid far servtces to the organf�ation.
NaIDe af � C� h�� t� VSme �On c���:
Address d �. .� � �d Address �y�. �yD_ Hs�� � �7� J��u�
� / .� 7�,r.�
Title t v : � �i�cLT�� Ti��e ��-,"f` /�1C�. /edS�`'.CG � rr .!
c.
(Atcach separate he `^.r acd'___or.s: �s:. s. �
/� ()� �d �( e� - � y y� G..�G * T.�~� �7. �urras`�L�L (
VHi/ �f'✓'. -'//-/./s�S�'�'��Y l/�� � .SBI�vi G t -- /"/'�S .SJ a �� �J� 7J �' ,/ ✓�'
\
' � (���"��
14. Actached hereto is a Iist of names n addresses of all m�mbers of che organiza�lor..
r
15. In whose custody will organization' r cords be kept? �.
Name �d�G f' � Address �J'. ' .�c / y.Z
fJ; � vl, /�2w-sS/d/ -.
16. Persone who Will be conducting� ass st ng in conducting, or oper�ting the �ames:
Name•- � - /VN��� �',� �� Date of Birth `��l��-
Address �� �,v v .�,,r, — _ ,��1 0
Name of Spouse /U�vl �,_._ Dat! of Birth '—'—
Dates when such person will conduct, as ist, or operate /t[,�rlo�o, v ^sq�
Name /r/�; G�lK �, Date of Birth � Z
Address — � .� i �-1' ,v ,^ �S 3 �
Name of Spouse ` /�c,�o Date of Birth �1�3 �j/ �
Dates when such person will conduct. assist, or ope�ate �.�Y1 Q�v� -� ,�qfJ� � �
,
17. v � I
Ha e you read and do �ou thcroughly u de stand the prov�si�c�s or' -ti11 �aws, or::.':nances,
and regulations governing the operati n f Cha::table GambZ�ng games? �S
�
18. Attached hereto on the Eorm �nrzished bv che C1ty o: Sc. Paul is a Financial Report
which itemizes al'_ recei�cs, e:cpenses a d d±sbursements of the applicant organization
as well as aii organ±zat'_ons who have :e eived funds =or che, creceding calendar year
... . , . .
which has been signed, prapared� and er'�_ed by /U�/�
�ame
,
dd ess
who is the of cha applicant Organization.
vame oc Off ce
19. Operator of pre���es where Aames .ril: e eld:
Name --�--�--�=�-� �'e uT
B�siness Address 7��. . ,�'�.,� �
Home Address �,s�� �� o%. �"�-, q�, /�fti.�,,
20. Amount of rent paid by aop::cant Or3ani ac on cor renc oE thel'hall; specify amounc
paid per 4-hour seaston U �
. . . ������
21. The ptoceeds of the games will be d sb sed after deducting prize layout costs and
operating expenses for the followin p poses and uses:
� /
o��-o-�= ✓�7 Qw►�d:Y.K �-S - cl' ,` ![.��n ,` '' '�
�G� � �GbV! ' C +�.
22. Has the premises where the games are to be held been ceTtiFied for occupancy by the
�
City of Sainc Paul? - '
23. Has your organization filed iederal or 990-T? '�,� If a�nswer is yes, please atcach
a copy with this application. If an we is no, `�xplain whyl:
,
Any changes desired by the applicanc asso ia '_on may be made only with the consent of the
City Council. i
� � �
f; l�,�� .L.-i�,,,. :
Organization
Da t e - . By: �'W
na in harge of game
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- Ci of ' int Paul
Department of Finan e a d Ma�agement Services �� "��
License a d ermit Division
2 3 Ci y Hall
St. Paul, M1n eso 55102-298-5056
APPUCATI N FOR LICENSE '
CASH CHECK CLASS N Ne enew
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Code No. Title of License ��� 19 r�2o 19�
From sr�r�
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�� ��. ApplfcanUCompany Wame
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1 eusiness Name
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Buslness Address Phon�No.
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10 Maii Io Address Phone No.� _
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-� ManaperlOwner•Name
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10 1� � c� , r�o ��t" �"I y�
10 Atanafle�lGwner•Ho e Addresa Phone No.
4098 APPIiCation Fee g ` 1, J\ f �f , � � ��Z
Received the Sum ot 1 5 J � 'rG�l ( , J 1 � �
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��a pZ ManaflerlOwner-City,State 3 Zip Code
100 Total 1
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LiCBnS@ InSp@CtOr � v By: / ignature of Applieant
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Bond: -^ —
Company Name Policy No. ExpiraHon Date
Insurance:
Company Name Policy No. Ezpiration Date
Minnesota State Identificat(on No. Social Security No. �� -
Vehicle information:
Serfal Number I Plats NumDer
Oth@r
THIS IS A RECEI T OR APPLICATION j
• THIS IS NOT A LICENSE TO OPERATE.Your application for Iicens will eithe�be granted or rejected slubject to the provisions ot the zoning
ordinanee and compleNon ot the inspectiona by the Health, Fire, oni and/or License Inapectoro.
,
$15.00 CHARGE FOR A L ETURNED CHECKS
�.�p�� ��'-�' � 7 � ��
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� ' ' TO E OI�LETED BY
ORGANIZATION P SI ENT AND GAMBLING MAIAAGER
�
I understand and will uphold S int Paul Ordinance 409, Sectione 409.21
and 409.22 relating to pulltab a tipboarda in bare�
Further. I underetand that my j rb r muat meet city sdsndards; that lOx
of the net profit from pulltab al e muet be returned �to the City-Wida
Youth Athlatic Pund on a monthl b eis; that monthly financial etate-
mente muat be filed With the ci y; and that all procedds from pulltab
sales muat be uaed for youth at le ics.
: �, �
�ignature' a ager
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gnature - Organizatio Pre de t. ,
�f/��'.�•�' � / , � , .
.��_,�-.h_KS v� �� yr �/'Ol�vCaC t� o�(�y
0�'ganiz ion Name �
i ,
,[r• f O�U�.. ,1 Sa IULy �
��s �.. ��= s� ��
Gambling Location ,
/,� � _ �
Date '
i
Pleaae retain the attac ed ordinance for your records. �