88-1626 WHITE - CITV CLERK
PINK - FINANCE COIIRCII / /n
BLUERV - MAVORTMENT G TY OF SA I NT PAU L File NO. � `�a1`
i esolution (�
, \ _`-�.��
Presented By
Referr d To Committee: Date
Out Committee By Date � --
;
RESOLVED: That application (ID #31029) for renewal of a State Class A
Gambling License by the North End Boxing Association at
1079 Rice Street, be and the same is hereby approved�._
COUNCIL MEMBERS Requested by Department of:
Yeas Nays
�Lo�� (n Favor
Goswitz �/
Rettman
s�he;ne� __ A gai n s t BY
-�enx�. �
Wilson �+
��+T ^ � ��� Form Ap oved by City Attorney
Adopted by Council: Date
� 2Z �
Certified Pas y ouncil Sec ry� By
gy.
Appr by iVlavor: Da �_ ,��"�_�p�. APP�oved by Mayor for Submission to Council
r�vv
By
p1�B1.ISN� ►�i�'% � 5 1988
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� �'� � 1�, CRY ATTpWEY � � . . � .
Applicatic�a for renewal af $ Class A Gambling l:icense. �
: Noti�ication Date: 9-27-88� Hearin� Date: 14-6-88 . :
_ . �►t�ou�t�vonwe t�f ar R+Isc�(a)) cS�N�cw�nna+Re+�Ortt: : :
.�, -. . �� PLMRINO OOMMIS810N � � �CIVIL BERVICE COMMI3SION OA7E IM-� MTE OUC ' MULYST � . �� �RIONE Fp. � � . . .
- �WMMI�WN �6�i�8f:Fi00L BOARD . . . � . . � .- . �
�_ . ..$fAFF,� .. . � � . CFNRTER C031M138tON � �.COMPLETE AS IS � � ��J1pD'L M1�0.AOD�*. _ AODL� _�fEEDBAq(ADD@• � . ..
.. DIBTNK.T OOI��L . +`D�LANI1TqN: -. . . . � .� . .. . ..
- � BIIP►EIRTB MM1MCM OOUNCL DB�IFCTIVE? ... . � . . . .. . � . � - . . - . . .
. . Mt1�1�10 MO�L�r I�i O�lORRNwTV(Who.WNet.VNIMI.YM1Nr.1NhY): , .. . .
Frart� M�rawski , on behaTf of North End Boxing Association, requests..Cour�cil
appraval of his appiication for renewal of �iis State .C1ass., � Gam6ling t,ice�ts�-.
North End Boxing sponsars a weekly bingo sessior� on W�dne�day evenings,
between the hours of 8:00 PM and 12:00 Midnight. Bingo is played a�: ip79 R�� 5t.
Praceeds from the gambling sessions are used to train boxers for e�mpetition.T':
.;�urnr+a►��+�..�w.�.ai.s:s+.�,�r. _ _ . . . . � . ._ `
. _ . . ,� ,. >=-
�111� fees ,and appl i cations have-aeen submitted, COt1CtCI� ResearCh Cetltet' .
. : S tP �8�9$$
� � .��w��,a�.,�,�: _.. . : . . . ;
� If Council approval is given, the North End Boxing Associat�on wi:�1 continue
. to sponsor a weekly gambling session. .
: ar.�:.. ar+os ; , , ca�s � . . � :
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wst�+Ytv�s:
u�iu.�s: .
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' UiVISION OF LICENSE AND PERMIT AI)MINISTRATION DATE 3a �� � ��
INTERDF.PARTMFNTAL REVIEW CHECKLIST A.ppn roce sed/Recei ed by
Lic Enf Aud
r �1 L
Applicant �j�hK �,( yq w�� Home Address � � � � l. (,�I�,p�r�Qn�
Rusiness lvame NQ�•� �N� �py�trlq Home Phone
4
Bu�iness Address �� �� ,��GLS"� Type of License(s) ��,n �(,V � .r„���
Business Phone ��ss A �(,t W►,b�tYtt 1,,.� ��,l�Sj,.,
Public Hearing Date � O License I.D. 41 ;3 � fl2q
at 9:00 a.m. in the Council Ch uib •rs,
3rd floor City Hall and Courthouse State Tax I.D. �� �� f/�
llate ATUtice Sent; Dealer 4� ��/q'
to Applicant �
� Pedera2 Firearms �6 N A
Public Hearing —�T
DATE INSPECTIUN
REVIEW VERFIED (C,OMPUTER) CUMMENTS
A proved Not A roved
�
Bldg I & D �
N �,� ;
Health Divn. 1
--
N �� '
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Fire Dept. � �
' N�A� �
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; A s
Yolice Dept. �h•` I'I�ZD'�p
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License Divn. /� '
_�,� �� ; �
' D
City Attorney �
�� Z'' � O�S
Date Received:
Site Plan N il�
—T To Council P.esearch � a-1` �
Lease or Letter p �' Date
f rom Landlord �3��� � ��
�r...lh. �•, ,�r�,_„�y�,�,�.+�+t.�,•7-s�':t: _ - - -- - . ;..y...,-4�+wi'.,r.�:;lPw'•.--7's.?� �-- —+ ±7�
'. ' '.� � ,.. ir" �� . � _ ' .. . �w ' City ot Saint Paul . . , � . . . .. . . .. , . ;��I0�9 �,
` '' ' � _ Department of Financs and Management Services �
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� : '� License and Pennit Division �i''/ ��j�
; r•� _ �• . Z03 City H811 • ;�'Q7 '�/��Y/ :
. `'° ° ,c.y ,,.. - St.Paul.Minnesota 5510't-298-5056
� .: �-���� _ � '��• �. =`<� ` ` APPLiCATION FOR UCENSE .
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� ' CASH .�CHECK CIASS NO � „ d, : , y�� New �qA11ew ,;�Y - :�
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1 ,w►�'- � ���. • ti..�:- ... . : :« f , ..,i , r . Date � V 19
i 7, Code No. �'-Title of License , . ✓x ..From . � 3� I 1�To � 3 L� ' 190�
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i �1�7.SU • ApplleanUCompany Nam� , ,
I = . - . , - . ,_. �� �O�llh �na ZmDrO�JPi)lOv� C' �
100 Busln�ss Nam� ��
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�oo l o�1 ��c� S�e.e'� j
� � - B s n�ss Address Phon�Na
; ,00 � • (�A.�` I
i � • 100 Addroea Phone No.
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� ManapsHOwnsr•Name -
� 100 (��CI-O(OS�
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i � ;.. � 100 � htanaqenGwn�r•Hom�Addross Plron�Na ,
� �. 40g8 Application Fee ` . 2. � .
I _` Recelved the Sum,of pppQ . � _].5 ��7
� - .:� . . . � .. ,. '�v�' �v 'y .Mana�eNOwner•City,State 3 Ztp Cod� - -
• . , 2r.;.. .,�^: : �K#�}l;•2:aPyti' . .�iA�..t�OO . :-E:�'SlTO�YI ..�OO �'riR +-u�±-.r .L ��*s:�' ?w���' �,�.._, �`:.. �" �S.-,f �I;.',�:. .
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� �' '" - ����� - � Gyy�`��� -' - _
� ' l(cenae Inspector L dy: . Stgnaturo of App�ieant
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��� Bond• .�. ;: . �,-'` �. - . . - :: �__ .:
I -. • Company Name - _ Paliey No. Expiratlon OaM . . ...
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; :.I�surance•
! - .Compa�y Nam� Pdicy Na Expl►atbn Oat�
! "���Minnesota State Identificatlon No. � ' Social Security No. �
t .; �, - - .. , . - .
� Vehicle Information: � . . -_ '
. S�NaI Number at�Number
Other
THIS IS A RECEIPT FOR APPLICATION
i THIS IS NOT A LICENSE TO OPERATE.Your application for license will either be pranted or rejected sub�ect to the provisions ot the zo�ing
oMlnanee and completion o(the inspections by the Health, Fire,Zoniny andlo►Ucsnse Inspectoro.
i
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$15.00 CHARGE FOR ALL RETURNED CHECKS
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;; Charitable Gambling Control Board
Rm N-475 Griggs-Midway Bidg. For Board Uae Only
� 1821 University Ave. P��
�� St. Paul, MN 55104-3383 Check No.
, •:.....:� (612)642-0555 Date:
'� GAMBLING LICENSE RENEWAL APPLICATION
;�, ,
��� ' LICENSE NUMBER: /EFF.DATE: /AMOUNT OF FEE:
A-1 �l - 1 11 15 81 5119.1i
- 1.Applicant-Legal Name of Organization 2. Street Address
T 0 1i18 tu.berland Street
3.Ciry,State,Zip 4.County 5. Business Phone
p NN 5 1 Raase 612 184-1651 -
6. Name of Chief Executive Officer 7.Busi�Phone
av' larson �
8. Name of Treasurer or Person Who Accounts for Revenues 9. Busi�ss Phone �. ,.
��II
10. IYame of Gambling Manager 11. Bond Number 12. Busir�esa Phone .
. nk Nuraus � 219/32
' 13.Name of Establishme�t Where Gambling Will Take Place 14.County 15. No.�Aative Members
,„:" N th fnd I�a rovement ClD St Paul Raese 3l
16. Lessor Name 17.Monthy Rent:
~ Morth end !a rovx�ent clu� 5135
18. If Bingo will be conducted with this license,please specify days and times of Bingo.
DaYs Times Days Times DaL Times
W@C�II@9C�8 8 m - IIl
r .
=� 19. Has license ever been: ❑ Revoked Date: ❑ Suspended Date: ❑ Denied Date:
_� ,
20. Have internal controls been submitted previously? f�Yes ❑ No(If"No,"attach copy)
21. Has current lease been filed with the board? �Yes . ❑ No(If"No,".attach copy) �
22.Has current sketch been filed with the board? . C�Yes ❑ No(If"No,"attach copy)
��„a�. .� ... ,., , . .,. , , . _ ., _.,. ..... ..... ..... _.� . �v . .. - - _. , t
��� ;y , GAMBLING SITE AUTHORIZATION ' '
�,� By my signature below, local law enforcement officers or agents of the Board aze hereby authorized to enter upon the site,at any time,gambling is
- being conducted,to observe the gambling and to enforce the 1aw for any unauthorized'game or practice.
BANK RECORDS AUTHORIZATION
�;�. _ By my signature below,the Board is hereby suthorized to inspect the bank records of the General Gambling Bank Account whenever necessary to
" fulfill requirements of current gambling rules and law.
OATH •
_-�_; I hereby declare that:
�==: 1. I have read this application and all information submitted to the Board;
.��s:..:" 2. All information submitted is true,accurate and complete;
3. All other required information has been fully disclosed;
4. I am the chief executive officer of the organization;
5. I assume full responsibility for the fair and lawful operation of all activities to be conducted;
6. I will familiarize myself with the laws of the State of Minnesota respecting gambling and rules of the board and agree,if lic�r►sed,to abide by those
_ iaws and rules, including amendments thereto.
23.Official Legal Name of Organization Sig ture(Chief Executive Officer) Date Title
.. �'`b�Z,'� �
� North'Ead Bo Asaocia ion ''� •
ACKNOWLEDGEMENT OF NOTICE BY LOCAL GOVERNING BODY �
I hereby acknowledge receipt of a copy of this appiication. By acknowledging receipt, I admit having been served with notice that this applieatiorrwill
be reviewed by the Charitable Gambling Control Board and if approved by the Board,will become effective 30 days from the date of receipt(noted
�: ' below), unless a resolution of the local goveming body is passed which specifically disaliows such activiry and a copy of that resolutiorr is received by.
�z� the Charitable Gambting Control Board within 30 days of the below noted date. •
24. + ounty Name(�al Gov.erning Body) Township: If site is located within a township,please complete items 24
� ` � q,4.c.�� and 25:
Signature of erson Receiving Application: 25.Signature of Person Receiving Application
('� • I
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_ �{ l, �1-..'_'{�!\-R..G�-l.. � jv
Title � Date Received(this date h�e i�s 30��.P��iod) Title:
��.:? __,--�J �....��,_-..-� _ !��U '��S
Na of Person eli rin Appl�cation to Lxal,�ovAming Body: Township Name
,
CG-00022-01 (5/ � White Copy-Board Canary-Applicant Pink-Local Governing Ba'
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`` .�'• -' City of Saint Paul p�CJ �" S� ��°
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�. . Department of Finance and Management Services ��r �O J���
'�" Division of License and Permit Registration %
INFORMATION REQUIRED WITH APPLICATION FOR PERMIT TO CONDUCT CHARITABLE GAMBLING GAME__IN
SAINT PAUL
1. Full and complete name of organization which is applying for license
lyd7s.T1i � N � ' 07t/ JG /}S30CJ /; T� GN l �6.�f /�/��• �i' �`� H'1
2. Address where games will be held �� 3 S� /Z/G� `�i� -s'?• PAGL -�-��� �7
Number Screec City Zip
3. Name of manager signing this application who will coaduct, operate and manage
Gambling Games �2� IJk �• h'IU2 �u: .SfTii Date of Birth �'/-�-I- �l
(a) Length of time manager has been member o= applicant organization ', �J/L� ;
4. Address of Manager % )/ � C_ L'm �i>n.l ��vc� 5 f= PAc. �--� SSI / 7
Number Street City Zip
5. Day, dates, and hours this applicatien is for
6. Is the applicant or organization organfzed under the laws o� the State of �1? �y ES
7—
7. Date of incorporation 9 - � $�' $ �
8. Date when registered with the State of Minnesota g •1 S- g�S
9. How long has organization been in e:cistence? J '� y 2 S
10. How long has organization been in existence in St. Pau�^ � 'Z � /LS
11. What is the purpose of the organization? �-� �h, p „t} �3 ex�/LS !-"o.z. �c �� �'�7'.T�a.v
L°p ^1 al / T� d N i nI'G- Q-T i�.aGh / N Cr T h rt .�►1 Th ¢� !'Z uhGS a w j h � S{�n 2T
I2. Officers of applicant organiza[ion
Name ,� F'1 U I 1� L a 2 S n .� N�e q,1- V/�/ /� �-2 O e 13 N �2
Address ) y� � /v�c �,A,jIE:� Addrzss Jt�7/ i�rurz.�e,� Si'
Title f1-�t�s .dE.vi DOB 9 - 3 "3 �} TitTe T�zc3�15vrtn^rL DOB �'��=
Name /�,a.u L. ��� ,� � C L Name
Address �7�O � 7 7h A v Z � �os,-•PA�L �ddress
Title �lce. 2R�s.d�,�OB �— !c�-S�Y T�tle DOB
13. Give names of officers, or any otzer person5 aho ?a:d �or serrices co �ne o:ganizatfon.
Name Vame
Address address
Title T=�:e
(Attach saparace snz�_ -_ - ac:.-__o^_- -__zs. �
ti
� �� '. � � � � ��/G-��
21. The proceeds o: the �ames will be disbursed after deducting prize layout costs and
operating e:cpe�ses for the following purposes and uses:
T o F v n.c6 A-•���u E� �3 0�r.',u ti
2Z. Has the premises where the games ar� to Se held been certified for occupanc}• by the
City oE Sainc Paul? t/ ,ss
23. Has your orgar.izac:on �i1ed cederal �orm 990-T'. IL answer is yes, please attacn
a copy with t;,;s applicacioa. Ic answar is ao, explain why:
�,v Przoc�ss _
Any changes desired bJ tae appl�cazc �ssociacion ma� be �ade only wich t;;e consent �i the
City Councii.
/Vo�;S �iv d !3 a s�.N�-- � c�'.v f
Organ_zacLon
Date �" �' �' �� By: .1r,� �/ )
Man e: �n charg� of game
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' �' Deparm�ae of Fiaaaca and Hanag�aant S�rvices /��r' �C�
• Diviaion o! Lieana� and P�rsit Adsinistratioa ��
• . UMlOII4 CBARIrAELE C�AlmLINC lIIUNCIAL RLFO�T �►/�.�/��
� Date
X. � � "' �� � r
1. Nas. ot or;anizaeson r X i�' SS�
2. Addr��� vhsre Chasieabi� Gablinf is eonduetad ����'T�j �.�C`� -��Kf�ra�-°MC�'►v�c�t,(,�
3. �port tor p�riod cc►�sias 19�7 thronsh�tL�.Q, 19��
4. Total nwbar oE da�� pL��d ��
�� S. Gro�s r�eeipu lor abo�� period ; ���� / � �• ��
r .. 6. Gros• peiz• pa�oats for abo�a pertod (iaalnd� ea�h short) i �� ��'O • a�
� 7. N�t r�c�ipu - liae S dau� lia� 6 ; . �-�
8. Fspens�s incnsred in eooductin; aad op�ratia; ;ak:
A. Gros� va;as paid. Attuh wrkar lise vith ����y��
nawa. adds�sa and jso�s va;s�. ; Q
8. x�at fos 7( vab ; ��'W V�
C. Lieans• fee ; CO�Q. �
. D. Lnsuranes � ��Q� �/
E. Hond : i oo vo
P. Dishonored ehsciu oot r�eo�ersd //f �O/QSS �u-�j�;
c. Acaouacin; Ezpsas. i
N. Employ�ss T.I.C.A. l.�1,,, ��� ;
� I. Pulltab T� Yaid to Departseat of R�vsau� ; ��5�^ �
� J. Kina. Q.C. ?az 2^ LIJ� Q� ;
R. F�d�ral Fscis� Tas i Sta�p i �
' L. State Gublias Taz : a a-o�9.�
M. tilse.ilaa.ous e:p.a..,. ia.aesty eh. moune
� md to vha� paid.
1. ��rt�wa�'�i -�Pl;e!', a�
Z. �,�,e,�ri� : / '79�. S�
. 3. i
4. ;
9. zo�u �.A... � s a l�a�-a-aq
' 10. H�t. Iaco�a - lia� 7 ainu� lias 9 i / / �/O. �.(c�
11. C!►�ckbook balanee be;iaoins ot psriod i � ���
12. Totil. ot li� !0 and 11 , i �� f C ��
13. Total contri6aciona fso� lia� 17 f ��� C� ��/ / 7
. .
14. Chacicbook balane� ead ot r�porting p�riod - �/, � � �• ��
� Iias 12 INS lin� 13 i ``� �
I3. Speeif� uss �ad� of aoaat on lin� 13: l��� �=''`-''�
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Addreas CK,., � �6 � Address Ci�.tf-�O�� C���/��T
" Dacs lae`d ���J��� f Dae� lae'd 7�9/O 7
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Purpas. l��lfLGI'Q..�cce r �o�c�t6 Purpos. l�Q.c��.i Sc1?°�%� -�• �c+�eJ�S
Si;nacurs - Sisnacare
oQ A�eipiant - at A�eipianc
. rmouac _�00 tiouae FS�•�o�
✓Nas� /`!(�e S�Q� Ut�/YI �Nma !CC S UICi/7'1
Addrus l�K� /O � Addru� C� �p��
Qaca �i�e'd 7 Oae� B�e'd 7///�7
?urpas� 6lX�c� /•-�Xi A.� �4.� Purpo�a �� //�GL✓f:Y ��. T'c�✓ �dJC2J�S
Slgnacuri ~ Slgnat�re
oE 4�eipianc � oE R�eipi�ec
Asount ��3•�l> �woune `Jd-G�
✓ Name /1�CP ��!'�P�Y `��-1�? ✓Naoa �('P_ ��P!a,',^ C..�[//Yl
Addraes �Q �'� Addn�s C�� �O ��
Daca Rec'd � 9/�7 Dac� ttec'd �//d/��
Purpos� � fa1�l�pClJ',S Purpos�
.Signseur• 516na�ur�
oC �aeipianc o! R�elpisae
AmounC � Aoiounc �• b 0
/ Nama �;r� ��PP�7 �tw/l�l NaN �i�P S/I P ' l�u�
1/ Aads�ss .� ��p , /Addre�s ��� ����f
v Q
�` Dac� �ee'd /D�p? Date Ree'd ��p�/� �
' ?arpoa� Pvtpose
Slgracure Si;naeure
ot daeipiene of taeipiene
Amoune / ��C� Amcane �J^��
L7. Tocal Olabursmancs
'1�iI5 3E'ORS �RTST 3E eILI.�•L� CO2�LETELY ?0 QUALIF7 APPLIG2ION FaR CHAAI?ADLE G�LIYG
LICIIiSE. .
r�y,�
BFIIIp.EY 8AC111AAN
� � ? -1 A �'� Iq�AAAY PII�Ni-I�IESOTIIr C � A a tn � �1
�o e 7 O �ION OOIMIY �O � � > oi � .'.
� �o .�i ., „�y �t �MY COIML EP�/xllY 30.
� ., -� � � A N
-� IoV � o •s e •e � < a a -� �
� O � O w �
� O w y n a� �w O >
\ � � � Q � _ � ^ � ^ Q � _ � �
� � ^ � w n. A '+
7 r� 0� � ' .�1 9 �t 7� � 2 ,�,� .
�� •+ a .. eyw v�i •r � � w ai a C
(�� a � � o � �►C
oc. 2 n s X� ^ � � N � r q � n ! 2 1
A ! ( O A tl� � � O .,, 0 w � � O f7
t� � A \ � f �1 '�
V ^ ^ S A vvv .ni � � r3f wvv � 7
W � ' , ' I
�{ n a O M L n 7 9 `\ �s �1
A A V ..� ^ �r �t � 7� 1
� 7 � 0 C = �
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� � a � � � � L _
n O a� r
O. y ^ = . n n .+� �
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_ � O J \) � .
1 � , C �
�� • C ..� t � � .
I� l '� � i 3 O i, CCC i �
� ` T \. 7s
I —� I � (� a �
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r
' :5., .•s:_:saae�cs .:am laouac 1z ilaa 12: ��
. � :laot NaID� f�/� _ V// � � /�j'!
� Address L�c..�f(� 9 Addreas �,�u �/��', � .. /��
c ����/V
D:ce �ae'd ��1�� ✓ Dau Rae'd ����6�
?urposa Purpoa•
Sl�naeura Sisnaeuse
oE ��eipisnc o! R�eipiant
��4� S ,�.o�,� /7�•9�--
H,v. �, G ✓H.s. ;
'� a►ad=.s� C�tt �/ naa:.., C� /�9�--
ffac� ��e'd �//(�L2 Oaca It�c'd ��0/6 /
°urpasa Purpats •
Slanacnr� Signaesre
ot A�etpi�ac ot R�eipiane
� . ,�o�n� ar�.cb �o��� /�So" �
N�.. �:a. S�
Addrsas � �� �9U Address (�,C ,ci �/0�
Oata Bsc'd 9����a7 Data Rec'd —I�1�j�?
Purposa Purpos�
Si�natur• Sl;nacur�
o! RaeipianC ot Reeipiene
�A� 3�-� �� gS� 7S!
�Nama Naa /y(
�d=.0 C,�� jgnta �d=.,s GK� l9 3l ,
. . Dsc• �se'd ��}S f0� Date Ree'd �0�%)/p 7
. ?urpea� Purpose 17t�M �S — G��I��
51�nacure Si;aacure
ot d�cipisat oE teeipiene
Amouac _Q 1 o w Amc���c ��� 7.5_
17. ?ocal Olabursesancs
THIS �OA? MJST 8E elLb�•Z� COi�LETILY TO QUALIF7 APPLICA?IO[1 E0� CHARI2ADL� C.H�LIYG
ucrosE. .
.. �_.�� . s���r aaa+MnN z
� .� v' �-1 t'f r,��� dOTAiM PUBLIC-�IAINNESOTA c -�I tt a m ��
�O n S Oc.. WASHINGTON COUNTY � •�• � C > w �±
r.. � A C'
` � M1A1��OMM EXPIRES JULY�. t:"�I� n o --rc � e. i�+
� � ... •Z► t�7-- �
� � A ^ '� 3 �.�_n�y'��^/1/N/V`/NVNPl�.'N�'.r.,,.
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y 1� 0� �1 V O 't � '
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r�.. � S � : 7 > 2
s I � w �S � . o .qi .� r Z x ;;� ..
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/� s x � � o n .�. e � a � 1 A O
S 1�J 2 � � �� ^ � N � a � .. ! 2 -r
u C w � n � c � ^ � n � (�� 7 � � w 7
u � r. o 'J _ ....... A a
y A v v v � � .1 � 9
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W n �. � C u ^ ^' � -�
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n a a� a
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i n = n n w i
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I � , � \ a, i
l. � � �e i os
7 s p�
I I i °` aIt a I l;y
• . :5�. ,•ss�:seaea_s .:am aaoua: :a i:ae l2: ��
' � � :�a.. �7` ��'� I !'y1 rsm. /�� �
� p � �� � ('��'/��1�
✓ Addresa C[�,�` // 7� ! � Addrasa �_�� �! 7�
Oaca �ae'd ����—O / Dae� tae'd /� ���b �
.�� , ,
/ // '"'` ,,;
Purpoa� ��iUi'�?� � Pur9es� �CG�P�'��'^�i+��;!J,r v�=�G�
Si;eacur� Sigaaenra j •
ot (t�eipiaac o� A�eipiaete
��p� a�/ � � a-s�
Nas� Nas�
,/ �d=.:� ClG�/973 '��d=... L� /h�4�
Oac� tl�e'd ����o'O 7 Oac� R�a'd ���(o�o�
Purpaas ���e �4_,e,,;,d Purposa �/D 7/1 i�2 �/ �GY2�//� �
Sl�nacura �— Signsctire %
of �aeipiant ot R�eipieee
. Amounc � o�•� .lwount O`0 tp•�U
/ Name �/� � �PJ �t�ry} � ,llasa 2/(�� S P�7 vC�/yf
V Addreas (..�C� �/7� �Addr�ss l �L� / �`7� `
Oaca �ee'd ����6�O � Data Ree'd / �"�v �
Purpos. JO.'te��-► (�.1''f't'�r�afC� Purpos. �U � 1/CIZ -�Or �'�'C�i it.%�y ���E
� Si�naeur• Siseacuea �
of R�eipiant oE A�eipisae
Aaaune �Do�'-(� Asount s'�a.9�
✓ Nsma �f� � � 6C�/p� Has� /\I CQ. ����yY�
Aadr�sa ��� / i�.'1l Addr�ss ���d�� �t�
�� Data �tet'd ��"6'�O Date Ree'd �/7—�$
' 7�rpoa� GI�Y'��i I� Gw'4J� Purpose /'��,�1i✓ I AR`!� ���/�
Signacura Signaeura—T
ot tseipisat of teeipiene
Amounc �7'��G,� Aac+inc oc3��0
17. Toeal Diabursoanes
THSS dEPOx? IiUST aE eILL�•I:1 COl�LEfELY TO QV/1I.IFT aPPLZGTION EOA CFUAI?JIdLb C.120LING
LICEZISE. ,
.. 2: � SHIRLEY BAppiAAN '
� �o e S O N(IOTARY PUBII�-M�SOTA � `.� � � � i "� � �
-� � C > WA8l9NBTaN COUr(TY � n C > a �7 ••
v o Z •� �Cpi�l OWIi�$,�ILY 30. 1 ti .. -=i n�i n 7�y
\ w � � o -~i � n , ^ � '� a � '� a
,.. I�'�' .. o
n O +� n C +f 1
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tY\ A `t � �+ � '+ � R � �► r 1 � 9
r�. S 7 > 2 � i � 0� � 2 :�1 G
n
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r. ^ � ,� r o � s S 1 �
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r S n O 9 r� v v..► . �� 9
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C. � �` n = n n :w >
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a a.
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• ;5'., :'s:_:se;e.^._s .:om aaun: 'z i:ae L2: � � �
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I � , ^ - ��µ/�z�
Addsaaa �1�[�'T� ��� Addze�a \ _� �V �� ,
Daca �ac'd �` � T�� Daea Rae'd �'—/�—��
Purpase �I.vrC�Q.QP �4lrt l�� P+srpos. U..l�2 YaS eXS
Si�nacura Signacura �
ot 0.�eipi�ac o! R�eipiane
. Aaouae ��,t�p Aso e �O •d
Nas� �' Na� �
Addr�sa ���.��� Addzus �„(G��O���
. -
Oacs �t�e'd ��T— O�es Rsc'd (���3 O
Purpos��U.��l�e � �t��/'�t��yfL�►r1��� Pueposa �/�i � _ _ '��
SiQnacur� � Signacsr� 1.
of Raeipi�nt oE B�cipiane
• A�une Aaouet �V•w
Name N+� Naoa _��Q J p�►�
Addr�as � '.{j1f1 Addreas �I�t dV4�
.
Osca Ree'd L—I T Ab Daca ltec'd �� ��O 0
Puspasa � �✓ i �`J��'�� , Yarpose ��
Si�nacnr� Sisnaenr�
of Rseipiane o[ R�elpi�ne
,,.o,a�� ��.�o ��� I b I��
Bama fC2 S�Ps� bGn� Na.. `i ►1'`
Aadr�as C�..��� Addr�ss ` �iC� d� 16
� Dace �ts 'd 1"'r�—� Daee Rec'd '���p—g a
• ��e�. �l — r �� : �,�o�.�c.l�l�e �a�c,i� Q..� �j�„w�
sibn,acur. ss;nacu�.
ot �i�eipieae oE �eeipiene
Aaounc �•�� Amenne ► q i•SO
17. tocal Olabursmancs
TftIS �LE?ORT M1SS BE iILI.�•1� COl�LE'TELY TO QQALIFT APlLIGTIOH FOR CHAAI2MLE G.1�LII1C
LI@ISE.
��..r.. SF�LFY BIICHMAW Z
:
� �e ,i S O ' aNOTARY PU&JC-�NNNESOTA � � � e� � a m �
� o � _ � � �' WASi11t�TON COUNiY �O` .°, ,'s C > ai �:,
� � ^ � � - I n COM�A. p(PIRES JULY 30. 1^"�C. ^ ^ ,� � � �y
^ � �j n ^ � O ..,�. ..A.M'.nl�.,..N,',,."�:::,:. IvC.i A ' ,{ Q p� 1 y
� 9 I n a� +�i � S T � a�i +�i � O >
,�w � o = •e o �s - o _
��.� n v .. � .+ .+ � �s � _ -�
� .. T � > n a i � z �
s .� 0� S � o n � 0� �
r i N f�l �1 � `t �1 N A � :�1
� 7� S 7 � O e r e i . J � O ,+�1 !
4 � 2 �+ a � v � • � w C 9 a � a
n � � O � I� ^ � � � Q A � = } �1 �
�� � O �+ O • � O f!
t/ A '� C
` A � � A � � a 'w '�
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� �J ! J ] 9 3. 7 .� � A
� 7 V n tl� O x \ A L n ! � � s !1
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N) L '1� � � fl � O • O S ���F.111'� 7� �
I� �. O u � A 3 •+ u � O =
A � a v t
i �
a ' ^ � � �� +�i- � _r
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I� C � � � � G s� �
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I� � i � � � IG
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:6: :'.:�:seae.^.cs .:o� aaua: ia iLze l2:
� � � �' �r � � ����a�
, ,��. e � ��. ��. �, l
Address C`s .���!_ �►ddraaa t�C--L� ��(� j
, Dacs Rse'd 3 r i�-p � -� Dsca Rae'd 3-rb-��
Purp�sa UI+(C+��F.t�! I fb��r'�J��l'� �r,Q Pnspos. l.l��. � �COK?�i�t- � �"""��
Sl�naeur� Sl;nsensa
ot &�eipisae of RsCipiant
Aoouae ' � A�enae / TO
Nso� - o Nasa
Jlddrasa ��C��Jt� � Adds�as [�G.�-af� �
Dac• R�c'd 3-�(7-O o Oau Rse' 3-/(�-��
°urpoa� (y(� l r'G�� �C���G Parpo�a 1.lX e %11 �q l.C.l��
Signacuc• Signaeaca �
of �aeipianc ot R�eipiane
�unc �38��J1J Awounc d • .
Nama o Naaa
Address G�µ- ��Jj Addr�ss 'v![_.•�"�i �y
Daca �ee'd 3 �-fS O Dau Rec'd �-����
Purpoa� �� Yurpase �G�t .. 1'�C1.�C..3[ �d�
Sianaenr• Sl;natur�
ot d�eipisnc ot R�eipiene
unc ��• 3 Anovac 1�.9 �
N� r,n N,.. �c�_ S e,�6� vr�
�ad=.�� r�ILtt �� ' ,�dr.,. �IC�# a-e�S�b
� Dat� �tse'd �- -�� Date Ree'd
' Tarpas� 1T. J' Purpoa� ��(Q�� LCJfldr3J 1�-�-+I�S�►�"�'
Si�nacurs Signsevre �
ot �seipisac of �t�cipient
Amouac �b.o�, Aeeunc ���r�
17. tocal Olabursa'�ncs
TIiIS SE30R2 ttUS? bE FILIaD• �I COt�LFiELY ?0 Q(TALIFY ABPLICAtION FOIt CIIARI?Aai.L� G�OLAtG
LICENSE. ,
.. ' �
SHIRIEY BACHb1AN �
� � ,� n y �AAY PUBI.IC-MINNESOTA � ;
s �o o T o WASMMIGTON COUNTY �a • � � 7 "�� N ��'+ '�-'
°�IY COAiMiI.E7�IES JULY 30. 1 ` .• n � > ai � ..
� �j I p � Z �I � O � 3 O y
� � � .� rl Y A A
� � ' � � � � � i r
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r� r. A i n � � � �
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e�. s Z � s O � !. e a � 7 � O �f �
y (� = n s a� -1 • ' a C 3 d y � �T
,y �•• y � i I �. > a �. a is � > = a �
if � O A '�' w Q r�. 0 r' � '�J O f7
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. ;:T:' i'l.:�:S!^t.^.�3 .:OtA 1�Otiit: �1 i�.'S! �2: �j—
?o
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addrssa (�� a"�� �ddr�aa � Gt�� � �0� /���
Oua �a 'd ���rTp O Dae� Rac'd �'�(D��
n �/� � � p �(`
?urposs 1�1� � 104�Pnrpas� l )OZ�'^� �^- ��1� 1��'�-J
Sianacura Sigaacusa
ot 0.�eipianC at R�eipi�ae
. uae •7� A� �
Naw� 2
IK Nasa
Jlddrasa � ��� Adds��s �� �'�j'�
Qaca R�e'd ��'Lp�T Oac• R�e'd —��o�o
°urpas� \..�YtQf �iJIC�d���� ��pucposa ��'�'+�1�
Slgnacur� Signse�r�
oE qeciplant of R�eipi�nt
• Amouae �� Aa�oune �10.��
Nama � Nasa �(�, � P��c,.l (�y�
Addreaa _r�� �q , Addr�sa (�'�.� �9 �—
Dsca Nee'd �Sp Oaca Rae'd � � �'��
Purposa 1 � Pnspose ( �
Stanaeur� Signacnsa
o! A�elpisnc o[ a�eipisae
Mwune � �� ,►ewunc �O•�
N�• w� N�. � tcA S�r� rn
��r.'� � � � �d=.�. CIC-��4
�� Dac� �ee'd 3'I�— g OaCe Ree'd ��p��
' Parpos� / Puspos� �s � O��
Signacur� Si;�atuss
oE t�eipisae aE tseipiene
Amouac �'�'•l�C� • �mc,�ne � �
t�. total Olabursas�ncs
THIS �CR2 MJST dE eILLT�•L� COlQLE?EL7 TO Qti/1I.I�Y 11PTLIGTION FGR CHARI7A�LL' C.t20LIYC
LICIIiSE.
..�.�.�_. �
a
a
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,%. -, � C M��TON COUNTY � � > a '� ••
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r a N. �1 •i � � °! 1 N PI � .^1
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