87-633 M�HITE - C�TV CLERK
PINK - FINANCE G I TY O F SA I NT PA LT L Council ���111,�` b3�
CANARV - DEPARTMENT �I'
BLUE - MAVOR File NO. Q
Counc " R l ti
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Presented By � �
Referred To Com tee: Date
Out of Committee By Date
RESOLVED: That Application (I.D.#79250) for the renewal of a Class A State
Gambling License applied for by Merrick Companies, Inc. at
1060 University Avenue be and the same is hereby approved.
COUNCILMEN Requested by Department of:
Yeas � Nays
�-�'' ���,vran� In Favor
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sc,,,:. <. - -- Against BY —
Sonr.�:��.
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Wiison �qy E: - 1987 Form Approved':by Cit Attor y
Adopted by Council: Date —
Certified V• -- ouncil S et BY
By � '
Appr ve by Ylayor: Dat —
� �H� j ��OI Approved,�'Mayor for Submission to Council
_ By
1 �J'z':uY4d� �„�`.l' 1 � ��V 1
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�;�� :�° Charita6le Gambling Control Board R BOARD.USE ONLY '
� �, �''•Q� Room N-475 Griggs-Midway Building • � ���,�,N,,,nn,. .:
" - 1821 University Avenue � .;
St. Paul, Minnesota 55104-3383 AANT �'
(6121642-0555 ' `'
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� GAMBLING LICENSE APPLICATtON
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_ INSTRUCTIONS: _ -, _ _ _
A. Type or print in ink.
B. Take completed application to local governing body,obtain signature and date on all copies,and leave 1 copy.Applicant keeps 1 �
copy and sends original to the above address with a check.
C. Incomplete applications will be returned. �
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Type of Application: y,
[�Class A — Fee S100.O0(Bingo,Raffles,Paddlewheels,Tipboards,Pull-tabs) Makecheckspayableto: <�
❑Class B — Fee S 50.00(Raffles,Paddlewheels,Tipboards,PUII-tebS) Minnesota Charitable GambGng Control Board '.,
❑Class C — Fee S 50.00(Bingo only) ;
❑Class D — Fee S 25.00.(Raffles only) �d 2 b� 0,0�
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-. .. ' _.L�IYes O No .: 1_: .Is this application for a renev�al2_.� If yes,,;give complete license nurpber . :
❑Yes�No 2. If this;is not an application for a renewal,has or anization been licensed by the Board before7 If es,give base- /
Y 1
�+� license number(middle five digits)
"" �Yes ONo 3. Have Internal Controls been submitted previously?If no,please attach copy. �
4. Applicant(Official,legal name of organization) 5. Business Address of Organization �
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iif:l'i"a��::: �.UITi al's�t.::.= �1:t:. 17�3 GE::�VF31S z,VCf1LlC
" 6. City,State,
Zip 7. County ' 8. Business Phone Number ;
T�;a lc�;�t��ci MI3 5�wu9
Rat�t�e. ( G?_� 1 7p—G��J
9. Type of organization: �Fraternal ❑Veterans �Religious �IOther nonprofit*
� •If organization is an"other nonprofiY'organization,answer questions 10 through 13.If 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: � i t�J..S Attach copy of certificate.
{M �1Yes�No 11. Are articles filed with the Secretary of State?
❑Yes G3No 12. Are articles filed with the County?
G�-lfes ONo 13. Is organization exempt from Minnesota or Federal income tax?If yes,please attach letter from IRS or Department of
Revenue declaring exemption or copy of 990 or 990T.
❑Yes[�No 14. Has license ever been denied,suspended or revoked7 If yes,check all that a ly:
' ❑Denied ❑Suspended ❑Revoked Give date: - -
! 15. Number of active members 16. Number of years in existence Note: If less than four years,attach
evidence of three years
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17. Name of Chief Executive Officer 18. Name of trea'surer or person who accounts for other revenues
� of the organization.
' C�.:���al�:; Glars� Chrl Fall.o�asl�i
� Title~ Title
Pzesident 'Ir�aaurEi
Business Phone Number Business Phone Number
� u12 � �i�l—UG4i ( F�1� 1 22'1—��56
19. Name of establishment where gambling will be 20. Street address(not P.O.Box Number)
ConduCted : �`. ,t ', ,
I�ilit�ry 4rder af Fu� I.� Hear� :Ha7.l _`106t� t�riiV�a�:sit �'�v�riv�� d,
21. City,State,Zip 22. County(where gambling premises is located) ;z
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�t. P�ul, 2�� 55103 , RAinsey - -
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• - _ . licant 'Pi -
nk Local Gove�rnng Bo
CG-0001-02(8/86) White Copy-Board �-: � ,. CanarY APP . - -, .,. : 54�
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' lication 4.=. . � , Page 2 '�i
;� ,.,on PP�Class A ❑Class B ❑Class C `OClass D . ���p� � � �y •
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,,�� �3, Is gambling premises located within�city limits? � •
��` 24. Are all gambiing activifies conducted at�the premises listed in#19 of t�iis application? If not,complete a separate �
� No
~`.a� application for each premises(except raff�es)as a,separate license is required for each premises.
No 25. Does organization own th�gat9�blin�'•pYehiises?I��►d;atta�h'copy of�fie'tease With terms of at Ie�sYon�a`year:'""'
�ONo 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 leased.A lease and sketch S 125/S�SS' 017
is not required for Class D applications. ''
r_' (�Yes ONo - 28. Do you plan on conducting bingo with thislicense�If yes,give days and times of bingo occasions: -- - • � '
Y`� Days Tlmes
��� ,. Sunci�iy;; b:OQ Fm — 1�• Ob pm
�' ' 61Yes�No 29. Has the S 10,000 fidelity bond required by Minnesota Statutes 349.20 been obtained?Attach copy of bond. '
� 30. Insura�ce Company Name 31. Bond Number
F C�c���u �.ii:��s��: :c�: C:Ci11�FiIi I�U J7 6� ss ri
` 32. Lessor Name 33. Address 34. City,State,Zip ;
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riil.�t�:� Orde:: uf� �l.�� �'Zi� le Hear� G0� V�t. �ei'v. Blci ;�i:. Pau.�, .�.lv �:il��
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� . f _. 35. Gambling Manager Na�me '; y� 36� Addr'ess = i - 37. City,State,Zip
� Fxa;:i:�iic: t:u�ii'�::cl�ei� . ` - 776C `�.src� :�t: 'ca w.� - Lar:� E'�.1�t�, t�i� `��v4i
� � 38. Gambling Manager Business Phone 39. Date gambling manager became '
`�.=-�" ( G.�2 1 7 7 0-�T�E 3 •' member of organization: 6/8 5
� GAMBLING SITE AUTHORI2ATION
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By my signature below,local law enforcement officers or agents of the Board are hereby authorized to enter upon the site,
" at eny time, gambling is being conducted;to observe the gambling and to enforce the law for any unauthorized game or . ^�
practice. �
� BANK RECORDS AUTHORIZATION
By my signature below,the Board is hereby authorized to inspect the bank records of the General Gambling Bank Account �
whenever necessary to fulfill requirements of current gambling rules and law. "�
. � ' OATH _ s�
I hereby declare that: ;
" 1. I have read this application and all information submitted to the Board; :
2. All information submitted is true,accurate and complete;, j
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. 1 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. �
40. Official,Legal Name of Organization 41. Signature(must be signed by Chief Executive Officer) �
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l...: ;_c't� C�ra��ur���:�, �ticvl��oyatec:i x i;.?.c-� r��. 1 /` ,' ,�•
Title of Signer Date
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ACKNOWLEDGEMENT OF NOTICE BY LOCAL GOVERNING BODY
( 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 s
become effective 30 days from the date of receipt(noted below),unless a resolution of the local governing body is passed �
which specifically disallows such activity and a copy of 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 ILocal Governing Body) If site is located within a township,item 43 must be completed,in
addition to the county signature. . �
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' Signatur o erson receiv'ng appl�cation 43. Name of Township `�
x�. � �... '"� � :,c � � ' .� , �
. Titl 1, Date received(30 ay period Signature of person receiving application � • `�
. _ l , '�%'� begins fr i 's ate :a
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q { 4�N ' "'fPerson deliv ring application to Local Goveming Body Title r �. , s
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� ��� CG-0001 2 (8/86) White Copy-Board - Canary-Applicant Pink-Local Governing Body; _
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. ' . City of Saint Paul
' Department of Finance and Management Services
Division of License and Yermit 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 Merrick
Companies, Tnc.
2. Addresa where games will be held 1060 Unive�:'sity Ave. St. Paul, Mn 55103
Number Street City Zip
3. Name of manager signing this application who will conduct, operate and manage
'�
Gambling Games Francine Kubitschek Date of Birth 5-27-63
(a) Length of time manager has been member of applicant organization 3 vears
;' 4. Address of Manager 7760 53rd St. N. Lake Elmo, Mn 55042
Number Street City Zip
5. Day, dates, and hours this applicatien is for Sundays year round 6 : 00 PM to 10 : 00PM
6. Is the applicant or organization organized under the laws oi the State of �? y e s
7. Date of incorporati�n 3-8-72
8. Date when registered with the State of Minnesota 3-8-7 2
9. How long has organization been in existence? 2 3 years
10. How long has organization heen in existence in St. Paul? 2 3 years
11. What is the purpose of the organization? To provide habilitation programs for
persons who are developmentally disabled
12. Officers of applicant organization
Name Gerald Glomb Name Jean Bell
Address 1365 Englewood St. #201 1706 Margaret
St. Paui . Mn 5 104 Address St_ Paul ' Mn �,51f1ti
Title President DOB Title Secretary DOB
Name Stephanie Mann Name Carl Falkowski
868 Cobb Rd. 364 Charles
Address St. Paul, Minn 55112 Address St. Paul, Minn 55103
Title Vice-Presideni�OB Ticle Treasurer DOB
13. Give names of officers, or any ot?�er persons who pa{d Eor services to the organization.
Name N/A �ame
Address Addre�s
Title T��ie
(,Attach separate she��� 'a- 3C::1��_o;:s_ ;:��:z�. '
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d hereto is a list of names and addresses of all members of [he organization.
,se custody will organization's records be kept?
Kevin Mari:ineau Address 1728 Gervais Ave. Maplewood,Mn
55 9
8one who will be conducting, assisting in conducting, or operating the games•
;me Francine Kubitschek Date oE Birth 5-27-63
,ddress 7760 53rd St. N Lake Elmo, Minn 55042
Name of Spouse Rick Kubitschek Date of Birth
. Dates when such person will conduct, assist, or operate �11 occasions
Name Carl Falkowski Date of Bi*th 3-7-23
Address 364 Charles , St. Paul, Minn 55103
Name of Spouse Betty Jean Falkowski Date of Birth �-9-29
Dates� when such person �aill conduct, assist , or ope=ate When Francine Kubitschek
is not available to conduct the bingo session
1,7. Have �you read and do ;�ou thoroughly unde:stand the orovisions of all laws, ordinances,
� ,
and regulations governing the operat;on of Char�table Gamblino €ames? y es
J;.B. Attathed hereto on the form furnished bv the Cit� o� St. Paul is a Financial Report
which itemizes all recei�ts, expenses, and disbursements of the applicant organization
as well as all organizat?ons who have :ece=��ed `unds ror the nr�ceding calendar year
which has been s�3ned, prepared, and Vt'L'{Lied by Kevin Martineau
Name
1728 Gervais Ave. Maplewood, Minn 55109
Addrzss
who is the Chief Executive Officer of the aoplicant Organization.
`lame uE Off�ce �
19�. Operator of premises whe*e �tames �rili be held:
Name Military Order of the Purple Hearts , Chapter #5
Business Address 208 Veterans Service Bldg, St. Paul, Minn 55155
Home Address N/A
2.Q.. Amount oE rent paid b.� applicsnc Organi�acion ror rent oL the hall; speciEy amount
paid per 4-hour se��±on $125 . 00 per session
. , y � � � � � . �������
ames will be disbursed after deducting prize layout coets and
eeds of the � ur oses and usea: �
,g expenses for the following p P
archase e ui ment events and or ro rams for the mentall d
arded adults who attend the day habilitation programs provide
Merrick Companies , Inc.
s the premises where the games are to be held been cettified for occupancy by the
,ity of Saint Paul? yes
� If answer ia yes, please attach
Ras your organizatiolicationfedifaansuer isOno, e plain why:
a copy with this app
�An changes desired by the applicant association may be made only With the consent of the
y
� City Council.
Merrick Com anies , Inc . _,
, Organization
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Uate By� Manager in charge of gane .
Francine Kubitschek
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