87-631 M�MITE - CITV CLERK
PINK - FINANCE G I TY O F SA I NT PA LT L Council
C4NARV - OE�AFTMENT File NO• �" _��I
BLUE - MAVOR
Council e u 'o ,=
,
Presented By /�
Referred To Commit Date
, Out of Committee By Date
RESOLVED: That Application (I.D.# 79195) for a renewal of a Class A State
Gambling License by Como Area Hockey at 1079 Rice Street be
and the same is hereby approved.
COUNC[LMEN Requested by Department of:
Yeas p�eW Nays �
Nicosia lR FBVO[
Rettman
Scheibel
Sonnen a __ Against BY
i�laaaa
Wilson
Adopted by Council: Date
MAY �.�i — 1�� Form Approve y City Attorney
Certified Ya s d ouncil Se ar BY
sy
Appr by \�tavor: Date _� �AY 7 — ��t7� Approved y ayor for Submission to Council
By — By
P�������� M AY 1 5 198T
"W'qW'�' '�"'�. ' . .�,,f 'j 's' c� v � n"�t ; HR au waa
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ys'r %
s �. �s � "�" ••. :� Charitable Gambling Cont�ol Board, �'��7 r�' :;'FOR BOARD USE�ONLY `:c "' ' `"'�` '
;�;���' Room N-475 Griggs NAidway Building �
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�" k St.Paul Minnesota 551043383 ' ,,�^�,�,
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t}��.«��r'- � � ; T, GAMBLING UCENSE APPLICATION #����,F,..ri���.A ,��� t�� �_�� ,���;;y_�',� ' ;i �,����F , r�
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.� INSTRUCTIONS .�.w_,�� ���..,�r�,�:',,a�,�� y p' t� ,� � �- ���
__A.Y.:TYPe or print in ink:-__ � .__._ ;_ :.- -=-� -- . _- __ r �,� ��--y,_y
� -- - �- �>--- •. ��� r x, � ;�. , .T �_ : . , ,
, B Take completed application to local goveming body,obtain signature'and dai��on ell coples,��and leave 1 copy Applicant keeps 1 A� �i
k, copy and sends original to the above address with a check. f��.r ?.� � `� F�� .: y g r; r c � , �i:
: C �..Incomplete applications will be returned ' ,��,. � �� ��� �K �� " ." i�
� N 5 . €' A �•Z �1 A � � �y�y,C�3r � 'r �2�9s ,r:
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� - T pe of Application. ,; � 4} •�,
�Class A— Fee S 100.0016ingo,Raffles,Paddlewheels,Tipboards,Puli-tabs) ;"
��� ❑Class B ,..,.Fee��:50.00(Raffles,Paddlew�eels,Tipboards,Pull tabs),,; �� � � M,��ns��spe y�abl,6p.to� �, °3�s� �Y kx
�l�Class C Fee S '�O.00(Bingo only) �fi x f , i'�"'arnbpn9 ;
. ; . Control 8oa►d
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�,, .;,.�Yes C7N„ „ 1 ,Is„ 's applicatio�for a renewal� �If yes,give complete license number �'`- -�' � 'A _ O��
" OYes ONo 2 If this is not an application for a renewal,has or enization been Jice �,b It�Bo� forel�,,Jf yesr give base 1
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`��j licen,ge number(middle five digitsj '_� �;_ ,.� _, , h � �.�K� � ,, '` �r h ;. r� .
. Yes C7No 3. Havg Internal Controls been subm�tted previously7 If no,please atta `copy .` �.,�'��� �
4. Applicant(Official,legal ame of organization) 5. Business Address of Or �anization�
_ . � , � � ���� ,� ; .� . � , :. � ,
6. City,State,Zip 7. C unty 8. Business Phone Number °�
� l?') 5�ios :; �,� � � � / ► �88�:�`G�� ��
� �` ;-:
9. Type of organization: ❑Fraternal �C]Veterans"���']Relig�ous��` ther nonprofit* �' ''
� _. A;. . ` �- s
If organization is an'bther nonprofiY'orgarnzation,'answer questions"10 through 13.I�not,go to question 14."Other nonprofit"organizations
must documenf its tax-exempt status. ° ' `� • � ' � f-':
Yes�No 10. Is organization incor orated as a nonprofit organizationZ If yes,give number assigned to Articles or page and
book number. '�Q� Attach copy of certificate. ° '
'�Yes ONo 11. Are articles filed with the Secretary of State? .�
�Yes ONo 12. Are articles filed with the County7 ;�'
�Yes uNO 7.3. Is orgarnzation exempt from Minnesota or Fede�al income tax7 If yes,please attach letter from IRS or Department of
Revenue declaring exemption or copy of 990 pr 990T. , . , ;;4
,[�Yes ONo 14: Has license ever been denied,suspended or revoked?If yes check all that a ly: . `}
enied OSuspended ❑Revoked ' Give date: •: - _ � �
�. :;
15. Number of acUve members 16. Numbe�of years in existence : . ' Note: If less than four yea'rs,attach "
<_ ': _ " � _ '�,��5> -s-=;<, ; --. ,�. �� ',�'- ` _ � . vidence of th °.
��.�.
� : e re�years
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. . . _ -,- -°: .. •�,.. ��_� ry .: ;r,-��'�,"�"� �. "'��xlstence >��.�.r-x� -
. 17. Name of Chief Executive Officer . 18 Naine of tre�surer or person who accounts#or other revenues .
�V, a J�� of the organization -� �''� ';
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Title Title +;.
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Business Phone Number Business"Phone Number.`_„ ' ,•�;
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19. Name of establishment where gambling will be � , � 20 Strest address(not P 0 Box Number) ^
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'��Type of Applicationpp"'�,�lass A ❑Class B qClass C {]Class D �,� � � �,� '� �;`� ' Page 2`� �
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- `#�No ,��3 =1s:gambling premises(ocate wi�h�n Ci�X�limits� ` �,„^���;.. ; s � £�:�"�� �<"����'�,�,�,� ,� �,y
���'�YesC3No��24��Are all gamtif�rig activitiesTc�'�ndu�fe�l,at'the premises listed�n"�P1�of:this''apphc8tion?{f �;��Qmpl��e�separate 4~�
P�
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,k�3 ; . � , application for each premises(ekcept�'8�fles)as a separ'ate license is tequ�red fo�each pre�ises �? , � k � �
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:L7Yes No:.-25.-Does orgarnzation own the gambbng p�iemisest if n+�,etfech�opy of t;t�e Le.ase with ter`��o et leas#"ort��'ear:`, � > P:: `
,: �Yes�110 ;;26, 'Does�the organization lease the�ntire pt m�ses7 If no,:�ttach a sketch�qf�; ~27. Am�iun`t,'�Mon'h(� Rert't,s '�'� �' ;=
y
� � ��` � the premises indicatmg what pd�tfo�i�'J3'eing leased A.leas�aiid sketC,h �'+� � r q I�-�� `' ��'�°�" ��
'�� is not required�for Class D appiicet�ons,� . � ' +��«�����1� a� y
� � �Yes ONo .28. Do you,plan on conducti�g bingo wit�hi�Iicensel I�y�s�give days and times of bingo oc�asions--��'��,-�� ��
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j Yea�No 29: Has the S 10,000 fidelity bond required by Minnesota Statutes 349.20 tieen obtained�Attach copy of bond:� '4
i . 30. Insurance Company Name �` 31. �Bond Number ' .
Sr�Y� S � b�s �"�'s �, �a.rA - �i �? ?. �l� �' �;: �:_ -:
•�} ;�p�';�L�essor Name' �°.'".. : a ' 33'^Address '��,"�w'' ;�;� r��. ;� 34 Git��`Sf;:e�Z�p'°'� �,�, � � '+:
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35. G bling M nager Name 36. 'Address ; :�` < 37 Gity,' ate Zip',°" u'„�
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;�` 38.-`Garp'bling Mana er$usiness Phone ; � 39 Date gambUng managerbecame > ,. � �.� :� �,� £�,�,,,�
�: �'-(�(i��,�.);��� �`��i7 S :. ,��. member of orgarnzation.�_ , �: �. ,: - ..� ; �;��� �,,..,;;�.� ���.�. .
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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 �r
practice. _ , ; � �
� � � ' " �"•. '•'"> BA�IVK I#�C0��5'AC1TN.d'R��i�►TION �� � �� � � '"�� ��� � �:��
By my signature below,the Board is he'reby authorized to inspect the bank records of the General C�a�.�,ng B��KAccount �� �
whenever necessary to fulfill requirements of current gambling rules ahd law.'`}'�• �''�' `` ' "�"'"'` �"`�" �
f . �
� OATH r�
I hereby declare that: . ' " °; �. � °
1. I have read this application and all information su6mitted t the Board; • �
° .c . ;j
f 2. All information submitted is true,accurate and complete; � �_{,
�F 3. All other required information has been fully disclosed
� 4. I am the chief executive officer of the organization; •!�
r 5. I assume full responsibility for the fair and lawful opera ion of all activities to be conducted; �
� 6. I will familiarize myself with the laws of the State of Mir�nesota�especting gambling and�ules of the Boa�d and agree, �_
, ,�
' if licensed,to abide b those laws and rules,'includin amendments thereto. ' --
,:�
40 Officia,Legal Name of.Or nization 41 „ igna ure(m t.be i e y ief Executive Officer) : ���
�or»o REA odr� �ocK�►/ -�ssociA�' a,n! X ;: :� � ,
_ Title of Signer Dat �,�,�
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J � � '"ACKNOWLED��MENT OF 1�OTICE BYLbCAL GOVERNINGBODY-
. I hereby acknowledge receipt of a copy of,this gpplication, By acknowledging receipt,i admit liaving been served with
nofice that this application will be reviewed by the Charitable Gambling Control Board and if approved by tlie board,'will ;;
become effective 30 days from the date of receipt(noted below),unless a resolution of the local governing body is passed �
" which specifically disatlows such activity and,a copy of tFiat resolution is received.by the Gharitable Gambling Control_ x�
. Board within 30 da s of the below noted date. � �• � : � � ' ' � �:�, . . �
' 42 Name of Cit or Count (Lo 1 Governin Bod � If site is'located within a townshi -:�
Y Y 9 Y p,item 43 must be completed,in
� / s � addition to the county signature ,. �'�
N ��� j ' i�• •Y f�
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, Signature f person receiving application ' � ' ° 43. Name ofTowriship �� �:, �'.� ti. ;r� g
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,,_� 44. Name of Pers dehvering�pplicefion to Loca� iivemiri�`Body Title �'� �'� ���.� �`�� '�z�� `{ �;� , �� ��3� ��� ,,�;,�;�'
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. � City of Saint Paul
• ` � Department of Finance and Management Services
Division of License and' Permit Registration
INFORMATION REQUIRED WITH APPLICATION FOR PERMIT TO CONDUCT CHAR.ITABLE GAMBLING GAME IN
SAINT PAUL
1. Full and complete name of organization which is applying for license
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o�n� H�E't=� r�����! �oc.�E�' /-�s�3c�c.i�Tio�l
2. Address where games will be held ��7� ��:,E S;'. ST• 1'A�L �'�y-5�/% �7
Number Street City Zip
3. Name of manager signing this application who will conduct, operate and manage
Gambling Games �iGi,i ��-�rn �'a Date of Birth �'�>'I7'y ]
(a) Length of time manager has been member or applicant organization ��`y
4. Address of Manager �Q',,2(,� �.j�r►�v /�` - �� • /!� �J` � ���3
Number Street City Zip
5. Day, dates, and hours this application is for �Pi hR � hJ�c;�-iT 5 � `- O��' " /�� UC:r ..
6. Is the applicant or organization organized under the Iaws o= the State of MIr? � �v.S_�
7. Date of incorporation -� ✓�`l� � � %�c`��:J
� —
.�, g ,
8. Date when registered with the State of Minnesota -, v�'Y o2 ; 1�J �i) ���^
9. How long has organization been in esistence? / � ��� � yl:� �
10. How long has organization been in existence in St. Paul? 7 �Y�'-5
11. What is the purpose of the organization? j'� �Lte� yC�1 'Tf! / v �L/� }�
�oc ��� ��1 �'�i (./�CyF�n91 zF1� L�Af�t�F c.,���v D�'(1./�n!!z��� Tr�I r✓► S
12. Officers of applicant organization
Name �pJl�. �Nt,�2�c11 Name �on1 �2�n/G,S
Address ��g� �-O/�j�i,/S,E.� Address �a �7 �On'Jo �L ,
Title ri:E.-S DOB �-��' �� Tit?e �iCE ��.ES DOB s' vZv " ���
Name �►1�i E --�o I�ti�,Un� Name �/�n1 �/11C,�
Address �(i�i0 N • 1�An'►�I�JE Address l0/") �.�O�n� ��,
Title �EL DOB 7'/g'��� Title /��6AS- DOB g '�Q �`��
13. Give names of officers, or any othe: oersons who paid for services to tne organization.
Name Vame
Address �,ddre�s
Title Ti�le
(Attach separate snee� :.�_ acdi�:or.�_ ::a�es. '.
- , � . � al .
. . . �� . ,;,
�
14. Attached hereto is a list of names and addresses of all members of the organization, z;��
,'�
15. In whose custody will organization's records be kept? ;
Name /� �
�\CI-1 �UU�►'� �S Address _�Qa?� �,,,�p 1r`t,.
— �
,,
16. •Persons who will be conducting, assisting in conducting, or operating the games•
• .'k
Name �:��I (�oo.�►� �S Date of Birth _1 -S � `�7 _
1 [1
Address f Q�� C,C�ry,C� T''� .
Name o f Spouse _�i GN Ld o�n�.S Date of Birth %a -/�7- � �7
Dates when such person will conduct, assist, or operate
Name Date of Bi*th
Address
Name of Spouse Date of Birth
Dates when such person will con�uct, ass�st, or operate
17. flave you read a^.d do you thoroughly unde:stand the orovisions of all laws, ordinances,
and regulations �overning the operation of Cha��tab�e Gamblin� �ames? ��S
18. Attached hereto on the form �urn�shed bv the City o� St. Paul is a Financial Report
which itemizes a11 receipts, e_tpenses, and disbursements ot the applicant organization
as well as a1i organ�iat'ons who have received `unds tor the preceding calendar year
which has beea s:$ned, prepared, and veritied by _�1C1� �oOy»iS
. Name
) c
/0�� � Q i�✓i�� �L . J i. �✓4 ,�'.�/ 1J =3
Address
who is the CjAr✓�1SL�.�IG ///�nlAGE� o� the applicant Organization.
Vame oL Of«ce "
19. Operator of premises where �ames aill be held:
Name /V6f'T}� �+�� �►'►'"+Pe�j�6/✓►,�ni�T �LcJ1S
B�rsiness Address �� 7 y ��GE J,'—
Home Address
20. Amount of rent oaid by app�ican� Organi�acion ror rent o� the ha11; specify amount
paid per 4-hour seGsion �13s.0(7
� --�---- � ,...m�w+�newas+as+vam�aw..aMnAta�.CaTn�.�V`�^H..T-�:•.!a:, k,'�,.:.u.t,.,•y�r,:x.:�.-
. �-�--���� � .
.. . .�
21. The proceeds of the games will be disbursed after deducting prize layout costs and
operating expenses for the following purposes and uses:
.�c� /i�� /��L� VN/FoPmS �02. IO�Ti1 /-loc1�E� /ERM5
22. Has the premises where the games are to be held been certified for occupancy by the �z
City of Saint Paul? �E �
23. Has your organization filed [ederal form 990—T? �o If answer is yes, please attach
a copy with this application. IE answer is no, explain why:
t<<� �Pin �90 �CO"r'Y H�'RGj-lE�>
Any changes desired by the appl�cant �,ssociation may be �ade only with the consent of Che
City Council.
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,o,�� �rtA `lo�-►-� �ec�E� 1����c..
Organization
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Date y.' !�" �' '� By: 'ya?—�
Manage i charge of game
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