88-770 WHITE - CITY CLERK
PINK - FINANCE COUIICII
CANARV - DEPARTMENT GITY O SAINT PALTL
BLUE - MAVOR File NO. -�� -
Cou.nc l Resolution ,,j -���,
.�� , 3� ,
Presented By �
Referred To Committee: Date
Out of Committee By Date
RESOLVED: That Application (I.D. 61913) for a State of Minnesota Class A
Gambling License applie for by the Little Brothers of the Elderly
at 1079 Rice Street be nd the same is hereby approved/de�iie�.
, COUNCIL MEMBERS Requested by Department of:
Yeas Nays
Dimond
�� In Favor
���
Reccmao ctj/ B
Scheibel A gai n s t Y
Sonnen
I3GIsee-
MQY � 7 I�v� Form A roved by ity orney
Adopted by Council: Date
Certified Ya:- y uncil S re ar By , V
gy,
A►pproved y Mavor: Date ` MA 2.� � Approved by Mayor for Submission to Council
By
Pl�IiSNEO ir�;a�' � �s 1 .88.
. . ��-na
DIVISION OF LICENSE ANI) P�RMIT ADMINI TRATION DATE �/a� go/ � Z�O 0 �
INT�,RDF.PARTMENTAL REVIEW CHECKLIST Appn Proce sed/Received by
Lic Enf Aud
Applicaut �arce,llu,� � lr'u.�"h� Home Address ��Qg �• � 1"U�h.Q r'
Rusiness Name Ci'C71��f�'�I�L �iQIQ Home Phone � �� g3j~ �
�-F`�'1tt,. E)o�s r � "
Business Address /p�c� Qi� � Type of License(s) .�..�-�.'t�• C.�Q-SS �
Business Phone �qrn .b�tv�(,� � tGQ,✓�SQ� �--111UL5� �-Z�
Public Hearing Date �/Il 3 p License I.D. 4{ �0 ��/3
at 9:00 a.m. in the Council Chambers,
3rd floor City Hall and Courthouse State Tax I.D. �� /V�/-}
llate Notice Sen • Dealer �� �/�
to Applicant � � g g , 1 n
I�'ederal Firearms 4� rv 1/T
Public Hearing
DATE INSP CTIUN
REVIEW VERFIED (C UTER) CUMMENTS
Approved Not A roved
�
Bldg I & D N'�, I
Health Divn.
;
N�� �
�
Fire Dept. � �
f ��� �
I
I I
Police Dept. I
�
License Divn. ,
City Attorney �/�/��
i �
Date Received:
Site Plan N �
To Council Research 5 �2 �
as or Letter Date
f rom Landlord Z.� g�
. . . c,°� ��7��
,�`�,�,,
:.�o,�o�_.�•.. Charitable Gambling Control Bo rd FOR BOARD USE ONLY '
Room N-475 Griggs-Midway Bu Iding �
1821 University Avenue u`�°'.N�
_ St. Paul, Minnesota 55104-338 AMT
" " (612) 642-0555
'����' CHECK#
. DATE
� GAMBLING LICENSE APPLIC ION
INSTRUCTIONS:
A. Type or print in ink.
B. Take completed application to local governing body,ob ain signature and date on all copies,and leave 1 copy.Applicant keeps 1
copy and sends original to the above address with a ch ck.
C. Incomplete applications will be returned.
Txpe of Application:
. C�Class A— Fee S 100.00(Bingo,Raffles,Paddlewheels, ipboards,Pull-tabs)
❑Class B— Fee S 50.00(Raffles,Paddlewheels,Tipboar s,Pull-tabs) M��•p•Y���
❑ClassC — Fee S 50.00IBingoonly) MM"°s°t'p'°'tt'a'G�bi�C°"°'°�B°°'d
-" ❑Class D — Fee S 25.00(Raffles only) �` �
DYes C}No 1. Is this application for a renewal? If yes,gi e complete license number � - 0 - 0
dYes ONo 2. If this is not an application for a renewal,h s or anization been licensed by the Board before? If yes,give base
license number(middle five digits) � � � �
C�Yes ONo 3. Have Internal Controls been submitted pre iously?If no,please attach copy.
4. Ayiplicant(Official,legal name of organization) 5. Business Address of Organization
T G...... V� v
�L �,�-YLF.i�'JL ."L :.f�X. �c�:9��ct.. 5 ��J _✓1.i"�.ii -�'�.
6. City,State,Zip � � 7. County � 8. Business Phone Number
, ;;
� _��::,cc....�:*'-:c�1. :;�1.c.�.�•.s � S 5 ;''U 7 ''a=r-n�ic�Z.fl,i.r� ( �r�l�.1 �3/--(D� �
9. Type of organization: ❑Fraternal ❑Veterans ❑Reli ious C'�Other nonprafit'
'If organization is an"other nonprofiY'organization,answer qu stions 10 through 13.If not,go to question 14."Other nonprofit"organizations
- must dxument its tax-exempt status.
L'�Yes❑No 10. Is organization incor orated as a nonprofi organization?If yes,give number assigned to Articles or page and
book number: ' ' Atta h copy of certificate.
Yes�No 11. Are articles filed with the Secretary of Sta e?
�Yes❑No 12. Are articles filed with the Cou�ty?
DYes ONo 13. Is organization exempt from Minnesota or ederal income taxl If yes,please attach letter from IRS or Depariment of
Revenue declaring exemption or copy of 9 0 or 990T.
❑Yes�No 14. Has license ever been denied,suspended r revoked?If yes,check all that a ly:
❑Denied ❑Suspended ❑Revoked Give date: -
15. Number of active members 16. Number of years i existence Note: If less than four years,attach
-- , .. . , .w- evidence of three years
- . :. ,: , _
„ _ _ _ ,-
� ��, �� . - _. _ , _. - existence: . _ _
17. Name of Chief Executive Officer 18. Name of treasurer or person who accounts for other revenues
,, � of the�o,r anization. �,�. �� ;
�� !t�"%l � •�.Cf-,r�—%ri �l' �,`lC.f�.: /'�.,(1/�.t..ti-rv�"�a;�
Title+,/' Title
,� 7✓ y
� }
kr�' '� ' s
J�j �(4�.�1✓,(��Y/�' i/.���r-�G(�" � �f W�G7 O
Business Phone Number Business Phone NumlSer �
( �'�� 1 y�!- � � /� 1 .��`�- ) w �s=� s'i�-
19. Name of establishment where gambling will be 20. Street address(not P.O.Box Number)
cond�te� / , �J 7� 'q� /�. �
r ��
!/,;�'l"L11� .'�_.n�� ,i.r.�c"b�L`7�LfirW v' � !� J �� y�1 .�+i--�•� ��"' �
21. City,Stste,Zip � 22. County(where gambling premises is located)
� •, � �• � ="� '+% ./;'
/ �d .i % ;�17^.�Y�.'i
CG-0001-0218/86) Wfiite Copy-Board Canary-Appli�t Pink-Local Governing Body
; . ��. ,�d
Gaa��bling License Application Page.2
�, . Type of Application: OClass A OClass B O lass C �Class D
i;�'
I�Yes❑No 23. Is gambling premises located within city I mits?
GdYesONo 24. Are all gambling activities conducted ai e premises listed in#19 of this application? If not, complete a separate
'�'''� application for each p�emises lexcept raf les)as a separate license is required for each premises.
��R�" ❑Yes�No 25. Does organization own the gambling pre ises?If no,attach copy of the lease with terms of at least one year.
�� �Yes�No 26. Does the organization lease the entire pre ises?If no,attach a sketch of 27. Amount of Monthl Rent
`', the premises indicating what portion is b ing leased.A lease and sketch g K
�. is not required for Class D applications. )( -� f v . =%� =' �
- �Yes�No 28. Do you plan on conducting bingo with thi license?If yes,give days and times of bingo occasions:
;; Da ( -/ �r' / ,,.-Times
E,
� �:ii��'i!��s. ;��
i
y `�
K°
f,�Yes❑No 29. Has the S 10,000 fidelity bond required b Minnesota Statutes 349.20 been obtained?Attach copy of bond.
�� 30. Insurance Company Name 31. Bond Number
y.
J �
. �Z% � L"�.y.� � ,' , .� :"�.a.:.� � i . S o a 3
� '� �! �.. . ' � s � 34. CitY,�State,Zip , __.._ - __
32. Lessor Name ,� 33. ddres �
� _ .,..�.�1 "� ��rL`.�'i "�.,•H�::2..."""rs..�-'"»� �"' l-`I ���.� ✓�i �i `�/- � s
- 35. Gambling Manager Name 36. ddress , �-� 37. yCity,State�,JZip � �
�/%` �-" ¢•Y_• �avr��.'��yt-`� '�' ! � <%�li(.E%�`'sL .d�fi r ��LL�Ci� �LrtirL �S ��!
� 38. Gambling Manager Business Phone 39. Date gam ling manager became
( ) �� -� Sf 3 5� member o organization: ; j i-
;
GAMBLING ITE AUTHORIZATION
By my signature below,local law enforcement officers r agents of the Board are hereby authorized to enter upon the site,
` at any time, gambling is being conducted,to observe e gambling and to enforce the law for any unauthorized game or
�� practice.
r' . BANK REC RDS AUTHORIZATION
=' By my signature below,the Board is hereby authorized o inspect the bank records of the General Gambling Bank Account
�' whenever necessary to fulfill requirements of current ambling�ules and law.
�:{;_:" OATH
�:;>'° 1 hereby declare that: _
1. I have read this application and�all information sub itted to the Board; _
'' 2. All information submitted is true, accurate and co plete;
r 3. All other required information has been fully disclo ed
,
' 4. I am the chief executive officer of the organization
5. I assume full responsibility for the fai�and lawful o eration of all activities to be conducted;
6. I will familiarize myself with the laws of the State o Minnesota respecting gambling and rules of the Board and agree,
" if licensed,to abide b those laws and rules, inctu in amendments the�eto.
' 40. Official,Legal Name of Organization 41. Signature(must be signed by Chief Executive Officer)
. . �'e.r.�-f�.d VK�.r^.C�..��r-�[i :l'�� _�i':..�v �`9+�+' �,�.GSI X -r� .`� . .� .
_, i
�. Title of Signer _ • �° _ '_ Date _ _,�.%.. _- .- �-- - --- _- ,_- _.,1-- - -� — -
-- - . ___. _. . _ --• .-. - •. , ' 4
�' i i
� ACKNOWLEDGEMENT OF OTICE BY LOCAL GOVERNING BODY
: I hereby acknowledge receipt of a copy of this applica ion. By acknowledging receipt, I admit having been served with
notice that this application will be reviewed by the Cha itable Gambling Control Board and if approved by the board, will
� become effective 30 days from the date of receipt(note below),unless a resolution of the local governing body is passed
which specifically disallows such activity and a copy f that resolution is received by the Charitable Gambling Control
!= Board within 30 da s of the below noted date.
` 42. Name of City or County(Local Governing Body) If site is located within a township,item 43 must be completed,in
" __ addition to the county signature.
Signature of person receiving application 43. Name of Township
X - _ .. _ ;.,
Title Date received(30 day period Signature of person receiving application
� begins fr this d te4,�
_ . _ . _. ,. . _ . .i����- 1 �S X
44. N�ne of Person delivering application to Local Goveming y Title
„j� --
f � '��if� `��'_'�.''�r�.
, CG-OOQ1-02 (8/86) White Copy-Board Canary-Applicant Pink-Local Goveming Body
• C+ty of Saint Paul p/�`j/]�r ���
Depa�iment of Fi ance and Management Services �' °"
� ' Llcen e and Permit Division (P (C�!'
203 City Hall�
St. Paul Minnesota 55102-298-5056
� , ; , APPLIC TION FOR LICENSE
CASH CHECK � CLASS NO. New Renew
0 0 '.�- x 0 �- � ; �< �
Date i 19 —
Coda No. Title of License From � ° � 19�To y '` "a 19 �' �%y
S�C��-J I� �:a- �� � ., �� �
�_ � �� � � �1� �rU��-�(n�?5 �rt -in t:. c /.��:•l.
���.;•�j j�� ,��,� � '�V�','�. . �"'r Z 4• �/ �•J� App11CSnUComPany Nam�
`J 100 -� .
/�� 7G ��. ��.Z. =*1'�_p�
100 Buslneas Nsme
�
100 C-j . l� .�-C� j !'�''� 1 �% �� !
� �
Businass Address Phon�Na
100
100 Mail to Addrasa Phone Na
too '�'��Q /�• !� �� t�.� i�'J .' 7:!f' ,r-
ManapeNOwner-Nams ry� - -,
1� � , , y� t"'• `
1I � 's "..' . i,:JF� �, � �
100 htanagsHGwner•Home Addroas Phons No.
4098 Application Fes 2 Sp .-,.
Recefved the Sum of 100 `'�'1 . "d��i ��_ t �•���. i �� �� �
� L�' L� ManaqsHOwner•CJIy,Slate 3 ZID Cod� /
100 T tal 100 � �/J/�- ��,, �,�
i
License Inspector � � 8 : ���L St
y gnsture of Applieanl
Bond•
Company Name Policy No. Expintion Date
Insurance•
Company Name Policy No. Expiration Date
Mi�nesota State Identification No. " Sociai Security No.
Vehicle Information:
Ssrial Number at!Numbsr
Other.
THIS IS A RE E1PT FOR APPLlCATION
THIS IS NOT A LICENSE TO OPERATE.Your application for li ense will either be granted or rejected subject to the provisions of the zo�ing
o�dinanca and completion of the inspectiona by the Health, F re,Zoning andJor License Inspectora.
pll° an�z�.o,� —?�� 'loal�
�
� $15.00 CHARGE FO ALL RETURNED CHECKS
�n
, 0.�
\ `� � ' �
� � � z ��
�la�l�� �
j� City of Saint Paul
. - Department oE Fin nce and Management Services ��—77�
� �, Division of Lice se and Permit Registration
� • -
INFORMATION RE UIRED WITH APPLICATION FO PERMIT TO CONDUCT CHA.R.ITABLE GAMBLING GAME IN
SAINT PAUL
1. Full and complete name of organizat'on whfch is apnlying for license
' �,,.�.��� , ` �
2. Address where games will be held � � -s . .�
Number Streec ity Zip
3. Name of manager signing this applica ion who will conduct, operate and manage
Gambling Games Date of Birth .��•�(f��}
(a) Length of time manager has heen e�ber os app?{C3P_r organization � +
4. Address of Manager �/d� �l, ,,Q.'t' �� � i ,�.5�/1
Number Street City Zip
5. Day, dates, and hours this applicati n is for ?iL,/U�SQ���'=���� ,S
6. Is the applicant or organization org nized under the laws o= the State ot hIN? ��s
�( 7. Date of incorporati�n Z Z° g�
)C 8. Date when registered with the State f Mianesota Z�2O�F.�
9. How long has organization been in ex stence? /S" ��%Z,
_�
3C 10. How long has organi2ation been in ex stence in St. Paul? f� y�,a.rrs
X 11. What is the purpose of the organizat on? jo ,�,�� P N�-L a y� �r ,: "s rt-a c���•-r tv
PCVC�G G f.�/7 A 1i�4 R�C.? G/% � R - V G %S — i/ �.P KA i�/:�A i w' T.�t�'i
,.J�J ��C�,.�dLr.,r c F ,•J r�/c— e o.•s.y v,✓ j y
�, 12. Officers of applicant organizatioa
Name P•vrit ic�.a /1 e �ni Name iyi�� �as�E-..�.�o t Z
7 9 ti/ . rl c n��e c� s v , r� �.�o•s� �:.�1��+-� r o,:.✓S
Address Cyic.o�,o /c �O6o3 � Address �zc N. .�vie,�.�s:i, c.�iC�so iL b�^��
3iz-�9 - 9 goo `
Title ?�cs� a�r�� DOB Title T,,��s��9�R DOB o��- ���',S y
Name 7-0 � � Name v b ,q�r.�z�
P;9 c3 :�� 7 G 7 6: P�✓ � �P�'9 s c=r i"!c�a rc;.✓,—c•C
Address ci�r�ci� •o � �oe 90 addrass 6yo �,y�,rse.J , sr a�v��, rr•� •rSiol
Title �;cE' Pi', �S DOB Title Src�qr;.v•ty DOB _��
� 13. Give names of officers, or any other ersons who paid for services to the argani�atfon.
Name ,� •,; vame �--..�,�a �v a�..�;c z w�r
Address �m io ;,-� ?-u�.i" ,v�� s Address y/z.�// �� �c s � �.�c Y /1 v� s ,
�7�c 5, rt.�/ J.r��4b iy��5, H^� .1"S Y c:
Title �'Xc-cv,—�v� 'a��rc cTO "*iCle �r-✓�c.� PXE-ti'T a�•�e-cTv,�
(Attach separate snee� .`o- add+__:or.s: ,��es. �.
t
X 14. Attached hereto is a list of names and addresses of all members of the organiza[ibr�.
�
K 15. In whose custody will organization's records be kept?
Name �y��qV �✓�,�,� Address /pii,f ��', GAKE' S;
�
�yo<.S", /yi✓ .►rS Ye 7
16. Persons who will be conducting, assisting in conducting, or operating the games:
Name Date of Birth
Address
Name of Spouse Date of Birth
Dates when such person will conduct, assist, or operate
Name Date of Birth
Address
Name of Spouse Date of Birth
Dates when such person will conduct, ass:st, or operate �/,/c,�S[3A��f
��G L1 G��� /�'
17. Have you read and do vou thoroughly understand the provisions of alI laws, ordinances,
and regulatior,s �overning the operat:on of Chaz�table Gambling games? �dJ
18. Atta�hed hereto on the for� furr.fshed bv the City o� Sc. Paul fs a Financial Report
which ftemizes a11 receipcs, espenses, and disbursements of the applicant organizatfon
as weil as ai1 organ:zat'_ons who have :ece:��ed funds tor the orecediag calendar year
whfch has been signed, prepared, and verified by /�/�,
�Iame
Address
who is the of the aoplicant Organization.
:Iame o= Off=ce
19. Operator of premises where �ames ,rii� be hetd:
Name ,L, j iV!7/� �F�4__.��jrS
B�rsiness Address �0 �9 �t %� F S�'
Home Address y�v 0 (,�/���,���/
20. Amount of rent paid by appl:csnt Or3ani�acion ror renc of the hall; specify amount
paid per 4-hour se�sion 'r��,,7�,00
� .
, , ��--�o
1' 21.��� The proceeds oi the games will be d sbursed after deducting prize layout costs and
�. operating expenses for the followin purposes and uses:
To N�cP 6�.Dti�NA �rc ;it�r easT ._ .? O ,�?M t�cyc.✓Sr'S �ivcc vai.✓ Fo cJ i°�.(
.Soc�.�L �cri✓:7i�'s /�ra S o,✓so Cisi.d �- �c Tia�/ c� P iciv>cS �-0
?f+�c �-�c�fG
22. Has the premises where the games are to be held been certified for occupancy by the
City of Saint Paul? ��"
23. Has your organization tiled [ederal orm 990—T? ��$ If answer is yes, please attach
a copy with this application. If an wer is no, explain Why:
Any changes desired by the apnl:cant asso iation may be made only wich the consent of the
City Cc+uncil.
C
Organ' ation
Date �� � � —�_ gy;
Manager in charge of game
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Continued list of salarie officers of Little Brothers _
Jane Doser�agen
Social Team Supervisor
67� Viroinia
S�. PaUlr �'1 75��3
Susar. Makela
�dovoc�y Team Supervisar
2745 Aldrich Ave S
h9i nnea pol is, M.N 55408
P�fa�gie Mc�Jivitt
VolunteAr Director
1716 t�1 31 st.
�Iinneapolis, ivf� 55408
.,,... , _.. � . _�: . . ... .-� ,.. . �...DA7!NYf6► DA7! .. n �� � . . � .. . _� '�` �� .
. Jos� F. C'archedi ti71����.�� NE�; a 1��i.O
o� owECron wro�(ai i�sr�
�lY'�.St1Y1@ �3Zl�C i NUMeER i�r�owECroR �arv ar�c _
— , a oc�:i.1 �r�
: . � ,. �
Fi�"�n�oe & I�mt. Z�8-�056 _ c�aaeR: Z �,;,, �„
, �pplication for a State of Mi�nt�e�catd A _ Lic�n.�e. .
r�o►r�zc�zaN n�: 5/4/ss �: 5 17�ss �
, ,
•Moaw.tN«�l.a cR�► �� n�ro�rr: .
PLNIMi6 OOIAM6810N � CNIL�RVICE COMM�t18810N ..OATE.. ��y� � -AA- .. . .MUIY - Pf10NE N0. � . -
� aD/MKi COIi111BS1061 � 18D�b 8CNOOL BOARD . •��• � .. . . � � ,�/�/ � � -.
� SMFF� . . �f]URTER CAAMMSSNON . . � �. .. A6 IS �� � . ADDLlNFO. * � � RET9 TO CONTM�T. . a—�C0ld31Rld(f -.�. ..
_FOR A001 MFO. PE�lAdt 11DOED e
DISTRICT OOUiC< � . . . . � . . � - � ,
� &1rPOR'18 WINpi OOUNCL{JB��Ci1VE9 � . - � � -. . . . . . . . � . .. �
. � dC�l l��'- �lJ�JCCI�Fl� �t�►1't� _
_ : �R� � ���
M3lMNIO l�Ef�LlM,IMUE,OPVOIiTiN�FTY(Who.YYAat,VN�en��N�►e.yN�: '•' _.
r�aro�l�aa c�tnex, ori behal.f of t�t,e L�it�t].e 8a,^�the�s ' � Qf tt�e E�ly, �+ec,�est�s �ra].
of -t�ieir application for a State Class A ing ' � �t 1Q79 �i.c�e Street. Ge�liri�
_ sessic�s�.s wi].1 b� held' 7'4nirsc�ays fraar 1:00 .m: to 5: g.m. 'Proc�eeda �rom the g�].�g
s�.ans will be used`tro l�ieelp n�eedy eld�'�. people.
rmsnr�ea,�o�t+i�cx.ue.��.ar.�a.�F.�: ; , .: . :
All applicati.ons ar�d �ees Y�av�e beexi su�ii , Thp;re are currently 50 wec�l:y b�itygo �esaions
in Sai�t P�u7.. 402.03 {f) {2) ailcxas fcar 7 'Binc�o L3. �.n Saint Paul. •
.�tw�w�.w�ina��o rN,or+,1: : . : .
Tf Qauxa.l approval is. granted, the Little 1 be able fio hpLd a week].���1.�g
s�sion in Saint Paui. If Ca�u�cil �p i's r�ot gi , Little Srot,hers will be:�e to
�or�o�' a weekly ga�l�.rig sessic�ri� irY Saint . _ - , '
� ��u�: .- -. ,. . . cor�s . _
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