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87-466 WNITE - CITV CLERK PINK - FINANCE G I TY O F SA I NT PA U L Council . CANARV - DEPARTMENT BLUE - MAVOR File NO. 7 ,.-,� Cou i so ution - Presented By . �� Referred To Committee: Date Out of Committee By Date RESOLVED: That Application (I.D.#19470) for a new Class A 5tate Gambling License by the Humane Society of Ramsey County at 1324 E. Rose be and the same is hereby approved. COUNCILMEN Requested by Department of: Yeas orew Nays � Nicosia [n Favor Rettman Scheibel ,�/ Sonnen _ Agei[ls� BY ?�ac�s- Wilson /�p 7 /�1�R � — ��81 Form Approved City Attorn Adopted by Council: Date Certified P s Council Se ry BY sy� Approved by avor Da �� / pj�'ip �' `" .�'�f Approved b ayor for Submission to Council gy � — gy .^� Pl�RLR°az�':' :_ _ i:�� , .,�,� � �,;,� ,'�9 Charitable Gambling Control Board FOR BOARD USE ONLY �; ' •:P, Room N-475 Griggs-Midway Building " �82� Uf11V@fSlt�//4V611U2 LlcenseNumber :� � �:` St. Paul, Minnesota 55104-3383 =�' " (612) 642-0555 _ AMT •••�....�;�' CHECK# �„��,n . - DATF _ GAMBLING LICENSE APPUCATION _ INSTRUCTIONS: �' ;. , q. Type or print in ink. g. Take completed application to local goveming body,obtein signature and date on all copies,and leave 1 copy.Applicant keeps 1 ;� copy and sends original to the above address with a check.` - _ � s C. Incomplete applications will be retumed. �? Ty pe of Application: ' � �Class A - Fee$100.00(Bingo,Raffles,Paddlewheels,Tipboards,Pull-tabs) i �Class B- Fee S 50.00(Raffles,Paddlewheels,TIpb08�dS,PUII-tebS) Makecheckspayableto: ❑Class C - Fee S SO.00(B111g0 Of11y) Minneaote Charitable Gambling Control Board ; ❑Class D - Fee S 25.00(Raffles only) `t OYes I�No 1. Is this application for a renewal? If yes,give complete license number 0 - � - 0 � [�IYes ONo 2. �f this is not an application for a renewal,has or anization been licensed by the Board before7 If yes,give base � , license number(middle five digits) � f ��' es�No 3. Have I�ternal Controls been submitted previously?If no,please attach copy. � :, 4. Applicant(0fficial,legal name of organization) 5. Business Address of Organization � _,..r... ��c�r�E,w� SvR�cTy r�r= �� ,m5�,Y CoUNTy I � 1 5 F3 �=u. LA N L_ R� � � 6. City,State,Zip 7. County 8. Business Phone Number � r,l`• �A U t� M !J 5 5 1 O S T� A Nt'��' � (� I �. 1 !�h+,s'- l�t.,,_S ; 9. Type of organization: ❑Fraternal ❑Veterans ❑Religious I�Other nonprofit* � � . rd:'�� 'If organization is an"other nonprofit"organization,answer question§10 through 13.)f not,go to question 14."Other nonprofit"organizations �; � must document its tax-exempt status. � Yes�No 10. Is organization incor orated as a nonprofit organization?If yes,give number assigned to Articles or page and ' , book number: � 1' � A Attach copy of certificate. � f�Yes O No 11. Are articles filed with the Secretary of State? ' 4 Yes�No` 12. Are articles filed with the Countyl � �Yes ONo 13. Is organization exempt from Minnesota or Federal income tax7 If yes,please attach letter from IRS or Department of Revenue declaring exemption or copy of 990 or 990T. ;<� OYes�No 14. Has license ever been denied,suspended or revoked7 If yes,check all that a ly: ODenied ❑Suspended ❑Revoked Give date: - 15. Number of active members 16. Numbe�of years in existence Note: If less than four years,attach evidence of three years - '� � � { Z 5 �jE�A !� 5 existence. '� 17. Name of Chief Executive Officer 18. Name of treasurer or person who accounts for other rexenues �+ �O 11 G.,l (Q �'J. � �#lie organizatio�n :�.��.'��A � �� "fi4' � i' �3.e �. � � ., . p �jir Title Title �:� ' , � �, =� {' ' ul� �X L� G tl., � � ��1'�'" C. 0� � Business Phone Number � Business Phone Number , �C> 1 � (��t �-- �3�-7 i b l�� Co� � - `7 � 19. Name of establishment where gambling will be 20. Street address(not P.O.Box Number) � qonducted �/ +, /�_ rr�� ] ��jj `` � . .��I�!L G� '��,1-1 16�^ � I-I��'��...�.....� ., R L� �J' ��. �� ✓ �aR+ ! ��i.� r �.� \G�,S �-`�.: ' �.` � . ,� � ,�21. City,State,Zip " 22 .County(where gambling premises is located) ; � �r. .��j ��t�j� .:��"-��.�.1�� m.. �� MT�� `�..�,��, .��4�:� . �4? CG-0001-02($/86) '� WhiYe GopytBo�rd �� ° r i;Cane�Applicantt = �� Plnk Lbcal GovQ�n�ng Body' 1 ' �`i£ k� � �' ;'�� ,�t,� �', ;�t � � r�:.�` ;` ;�.d°� �� '�� , �'` � a )'Y .'4 � M .1 B � � r' �i i � . } �4° �� e td t ,-,r .. 'b i 4 . A . w�,�' �� . . . , . F :*� a��t+S^r :� �''a � �� ' �C+ t ^fi� F }^d '�.,-t"5�, �;�,�' '�b I ,rs.�� ;. . - . �'i�J �'"- �� Y "rl' s��Fe;'1"�s�r !� ,��`xT, i,� 1 . � ' 7" �j J �4� �'1:' . • � a��; � ��„5.i� .y��E' Y' ..�� '� r�,¢K'�t'�y�'. y��t�a :, .+ ' .: " r ; . . q i.t,:?� - �.. xa:, � . �s. �.: . . .. . . ,�, . ..�.Xr�h.,�/m`�l,i�.n�aY�i�'..�'.te�-�at�#i3�6�'a-'..MS'L i��r_�� ,k.�i_ E.y:sLw'S.�� :;� s '�� . . , �_.i>.�...$�3�tta�.�i�'t`'. . . . . . , .:.. , � �/�' ��- �� ,`.;, I License Appli tion Page 2 p plication: �Class A ❑Class B �Class C ❑Class D No 23. Is gambiing premises located within city limits? No 24. Are all gambling activities conducted at the premises listed in #19 of this application? If not,complete a separate application for each premises(except raffles)as a separate license is required for each premises. �; 8�No 25. Does organization own tNe gambling premises?If no,attach copy of the lease with terms of at least one year. � I Yes�tNo 26. Does the organization lease the entire premises?If no,attach a sketch of 27. Amount of Monthl Rent ;� the premises indicating what portion is being feased.A lease and sketch S, t^��. Q� � is not required for Class D applications. �? es�No 28. Do you plan on conducting bingo with this license?If yes,give days and times of bingo occasions: - t� Days Times � � F(�, �U A v � a M . :� �� L�lfes�No 29. Has the S 10,000 fidelity bond required by Minnesota Statutes 349.20 been obtainedTAttach copy of bond. �F; ' 30. lnsurance Company Name 31. Bond Number '� ; ST • i'AU�. � RE' � N1 � � lNE GO � Grd � lV � � 7 � f�' " .=; 34 Ci Sta ,Zip . � 32. Lessor Name 33. Ad ress �('� ,) �� O � � � r ' �'.'S h �� 1 e�� bSi4r F'1 ,�• � � !ll ; 35. Gam ng Manager Name 36. Address 37. City,State,Zip : ,, ; • �i r� O S M A L S K i 1 ! t � 13 Ev t. A t-� t-a r� E' S�'. ►�� c.� M N .�.��t�s�' :, 38. Gambling Manager Business Phone 39. Date gambling manager became , ( G. 1 � 1 (w�l 5 - 1��'7 S member of organization: � . . ; . ,, ,, : GAMBLING SITE AUTHORIZATION ' By my signature below,local law enforcement officers or agents of the Board are hereby authorized to enter upon the site, � at any time,gambling is being conducted,to observe the gambling and to enforce the law for any unauthorized game or � practice. _.,, „z. ..:, �.. ::. . . _ °.. , _��;,,�„��,v � � BANK RECORDS AUTHORIZATION ,,By my signature belc:v,the Board is hereby authorized to inspect the bank records of the General Gambling Bank Account s� ;`�whenever necessary to fulfill requirements of current gambling rules and law: - � OATH , i ` I hereby declare that:' � ; - - ,' 1.� I#rave read this application and all info�mation submitted to the Board; � ' 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. 1 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 licensed,to abide b those laws and rules, includin amendments thereto. x � � 4 . Official,Leg Name of rganizati c � � 4X Si ature(must be si ned ief xe u e fficer} - � � , � � � j � . Title of Signer Date 5 � a ."n � ." .. . .� � � ; J�. ' t � .� ACKNOWLEDGEMENT OF NOTICE BY LOCAL GOVERNING BODY ;; I hereby acknowledge receipt of a copy of this application. By acknowledging receipt, I admit,�having been served with � notice that this application will 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 belowl,unless a resolution of the loc�l governing body is passed ,� which specifically disallows such actiyity and a copy of that resolution is rece�ved by the Charitable Gambling Control � Board withirr 30 da s of the below noted date. �� ' � 42. Name of City or County(L I Governing Body) If site is(ocated witfiin a township,'item 43 must be completed,in .� a addition to the county signature. ' 4, C�� -�• �� Si nature o erso ceiving application 43. Name of Township �. r.-• t _ � F X ; _ � �. � �. �t'fS�. - :� Title Date received( 0 d y period ' Signature of person receiving epplication � , y, begins fro this et I ;� � � y � �, . � �� ; � X .- � s� � � .t' r. k � ', �, z ,.. ,iw �+ " a r �sx,�� 3 �� t . .: � . � '� ': - �y,� �` F. j ,� +'". � f��yJf 4i r a'�.'. �t } '�-�,S„�3yeEa',n. z '(�'S��S��,° 44r ; 8fT1@ Of P@�SOI'I SI8 1� I�}!V ��y7�,"�'9 x F( � "fik g J§ F 'N`d ?' �>„# w.y x� a, �r�- � .$ ,�,`+x e� .�.Y s -:X "a�� t� � r �a 'i F�'"'8��'"'q !� �^',�r„ �'. '� , �:^.. �� ; x c r' . . .. ' �. � '� �� '� ` ` � � . E`� '+ � Fj ��'nk Cpl! o�vbr'�i�l�gBo y� �L� �;y, � ��«��'OZ �8�8�.. ,� ��It� � �� 5 � �� .n � �� „� 3�x r:. � n �r�,a" �."" ,�- ° �:- � r :t- y �`'' '�,t� ��r ; Ys� _. -�'y�4,.,x'tµ:.�`�x + .�r,ct�cst �s 1 + � �a ,�, �i -�', ��,{ , t ��gt t a 9` t�, �'j�„;' xs� '; 's�: `�� i�"�`+��Y � .S � � �F � �� v}�� r�' ��x �`�R ��{ ��{L": ��;:�y'�� _-,��£��#c�r�. '"`i` * i{�a"��. *n� s��? .�, ° ` ' � { ,r�t, � �� ✓� e��,.�'` „�''"'` " .� � �t` r„ _ + i�`�:�'� �' �bs w;{4 CtLF�� rs�i� �5� �.�� Y 1 11 �Yar W�.Y��.4 _.ii&.'�v}��Ga.�...L�$t.cds;oki�., x��.�. _.A . �t '�#. ,�� .. . t . �,.�i.��.+�7n.� .