87-635 WHITE - CITV CIERK
PINK - FINANCE G I TY O F SA I NT PA LT L Council ///►►►
C4NARV - OEPARTMENT �7 ��
BLUE - MAVOR File NO. �
Counci � t '
Presented By /
Referred To Co ttee: Date
Out of Committee By Date
RESOLVED: That Application (I.D.#16909) for the renewal of a Class B
State Gambling License by Shop Pond Gang, Inc. at 991 N.
Lexington Parkway (Gabe's By The Park) be and the same is
hereby approved.
COUNCILMEN Requested by Department of:
Yeas p�eW Nays �
Nicosia [n Favor
Rettman
Scheibel �
Sonnen __ AgBinst BY
�edeseo+
Wilson
Adopted by Council: Date MAY E — ��T Form Approv d y City Atto y
Certified Pa•• Council Se a BY
sy�
� �' ��l/ 7 _ �qS7 Approve b Mayor for Submission to Council
Appr e by lilavor: Dat
— BY
P1����€D ����'�Y 1 5 1g87
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City of Saint Paul
_ • Department of Fi�ance and�Management Services
Division of License and Permit Registration
INFORMATION REQUIRED WITH APPLICATION FOR PERMIT TO CONDUCT CHARITABLE GAMBLIh(' GAME Iv
SAINT PAUL
1 . Full and complete name of or�anization which is applying for license
ff��° �o�r'I) ���✓' /Nc
2. Address where games will be held ,L p V . � uL �1J d
Number Street ity Zip
3. Name of manager signing this application who will conduct, operate and manage
Gambling Games Q E �J,� Date of Birth 6 p
(a) Lengt`� o: tiae manager has been member of applicant organization p ,/
4. Address of Manager �L�/� �����G-$������ �- �./0�
a!/_ ST!'�vG
Number Street
City Zip
5. Day, dates, ar,d hou:s th?s aoplication is for p S W'�, _��,
, ,'61p�'{i�,.
6. Is the applica:�t or organ��ation organized under the laws oi the State of MN? �
��
7. Date oi incorpora�?on ��' �
8. Date whe^. reg'_;tzred ait:� the State or Kinnesota f/�j/�E � /
9. How long nas c:�anizatio:: been in e:cistence?
10. How :on� has cr;an;zat?on been ±n e:cistence in St. Paul? � ` ��...Q� �
[l. TN�l2r is tZe pu��ose o= t`ie organization? d/�/ J� � —v�
� a rs°►� � ��TTc o � / �-
/1 �D �I1 C�g(�I� PLA- J�u 1.+�/�� ��E,` ��R.(G� L� SC,I'Ci (� , L �O� �/l �T��'l
� _ � , ' f1 77 V'r Tr�S a,� vanlG H N� d�A D ,�oN�4r�
Ofricers o� app�'_caa� or�an�zation �vC�1'� �s"rIDE,Qoas-rERcL�ogs,
Name �CIY/�le� �� __O_��� Name ds�U '
Address �U �j9 D l � C
( � � ..57��M/1r Ad d r e s s �vZ 70 �15�,�/fP,PF�r 7'E'v2 ��r�'7
Title �� '��/t''7� DOB l� f � Tit1e �ln�6o��i�11-7�1�9
� ��f� vrPEl'�' DOB __s3//f2�
Name /G/�f��'D �/Y� �l�SO� �"
�ame �fi�/�/� C/�S5 FC.L/U,.>
Address �T��°,�,�k��,�w_ s�T������, �ddress
vR6��'S�-. s'r,P��L Hr�v, �
Title �j�G E 1 DOB �N �l �Dv� �
O Title �E,�SuRE� DOB � a. 3,S �
{. Give names or o�='_ce�s, or ar.f ot�er persons who paid for services to the organization.
Name
Name �
Address
Address
Title '
Title '
(=t=aca S27dC3C2 sheet �or add�tic::�� aames. )
�. -� - . � � �����s
,4. Attached hereto is a list of names and addresses of all members of the organization.
15. In whose custody will organization's records be kept?
�� .
Name � � ' 0.'�J� Address �a°J� �!/�, L,�RPEn��'�R �a0'�
�P�v ,tii«rn�', ,r•s� 3
16. Persons who will be conducting, assistin� in conducting, or operating che games:
ivame E/e� tJ,STE Date of Birth (�0
A d d r e s s �� E$T�.%.Si�l-/6?(/I�E '���f — .�j, r�{v� /�/!(M'/�/', .���Ot�
tiame ot Spouse ���¢f�f �v ����/l� Daee of Birth (� �o�j
Dates wher. such person will conduct, assist, or operate (1� �p '��� �/�E
�l�oM ��o P�. T 9-� PNt•
�ame Date of Birth
�dd:ess
Name �� Spouse Date of Birth
Dates �.:ilen sucl oerson wi11 conduct, assist, or operate
I7. Have ;�ou read and do you thoroughly understand the provisions of all laws, ordinances,
ar.d reg�1?3L'_OL15 gove-ning the operation of Charitable Gambling games? �
13. :��taczed `�e-e�e on t;�e form furnished by the City of St. Paul is a Financial Report
�n'_cc! ���m;zes a?'_ receipts, expenses, and disbursements of the applicant organization
as Ne' = as a�: oroan�za�:ons who ha�re received funds for the preceding calendar year
«�.?cn zas �ee^ s'_sned, prepared, and verified by � ` � � U✓E�G�✓✓1���
Name
j��� Inl� ��P�n�T-�vi� '��o�� .���/��L ��r�r�/, .s'",�l13
Address
�^o '_s �7e �(/✓�L� �/ ���' � /`t� / �1 �/�✓�v/P�/� of the applicant Organization.
Name of OfEice
!9. Qoe�a��� oL �r�m:s�� ahere games will be held: �/�,8�✓� /.g T�� / ��'\ �U���G�
- - � r
`i a�e ���,��R �, �v�LL�.
�us�,ess :�ddr�ss �9� ��xr�'�To.� P��1N Y• sr�/¢V�s; fY�lt�/�. .�,��t>3
:cme �de�ess (�� /��/1��`�R �Y�� /" y�-P,��� ���,�.v. ��/O(o
�0. :L:,ou^� o� renc �a� d b;� applicant Orftan{.zation for rent of the hall; specify amount
� Mo�-�K �
�a:-_ :z- � .T � ._ _ �.3.3
�R �f��oR S�ssi�N
. . '' . . � ������
�'1 . The proceeds of the games will be disbursed after deducting prize layout costs and
operating e:cpenses for the following purposes and uses:
�� ,50 ��G � ��iv r� �� ���° S o � r�f'��rc c> �� �r.s
?�l��v'�S `�,+2 �i�c'GS �i� 7�h�� Cv.�•�a F'�P `��'/�F� - ���' ��� Y',��P�avs
�^ / } � ��li.7 � CJ(J r W/ '��C[l�/\� L � �Ll�/-� l.. �/Y /� /►�
C/�� ��Ov`�,c CL (J/3.Ci�
22. Has ttie p emises where the games are to be held been certified for occupancy by the
City of Saint Paul? ,� ,�
23. Has your organization filed federal form 990—T? � If answer is yes, please actach
a copy with this application. If answer is no, explain why:
�/�� ����/`/Y �(�• �F_y����l'.� �/',���/\/ '7i�/�� L/� / / `� !//T�bJr �VIU�S��,r��p l:J r
��- L o�h2 0 � o� Sc�� F RrG f" ,ev r� r // �6 m�r� ,198�6
Any cha:�ges desired by the applicant Association may be made only wich the consent of �he
City Counc{L,
�r�O��o�'.,� �.��/'G. /�c.
Organization
D a t e � i (o I �7 BY� ��.�� � - ��CR��1G`�b'��
Manager in charge of game
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� '� Chantable�Gambling Control Board
� Room N-475 Griggs-Midway Building . FOR BOARD USE ONLY ��
_ 1821 University Avenue x
_ _ -_ St. Paul, Minnesota 55104-3383 ��censeNumber
`�•. . ' ;' (612) 642-0555 AMT
lZ't';;1�'+'''�� . .
CHECK# �
GAMBLING UCENSE APPLICATION ' DATE 'h
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 co ,q
copy and sends original to the above address with a check. PY Ppltcant keeps 1
C. Incomplete applications will be returned.
Type of Application:
❑Class A — Fee S 100.00(Bingo,Raffles, Paddlewheels,Tipboards,Pull-tabs)
�JClass B — Fee S 50.00(Raffles,Paddlewheels,Tipboards,Pull-tabs) Makecheckspayableto:
�OClass C — Fee S 50.00(Bingo only)
OCIasS D — Fee$ 25.00(Raffles only) Minnesota Charitable Gambling Control Board
,[�Yes ONo 1. Is this application for a renewal? If yes,give complete license number � _ ;: �;,� ; �---�
OYes ONo 2. If this is not an application for a renewal,has or anization been licensed by the Board before? If yes,give base t
_ <<, ;.-=J
license number(middle five digits) �
�]Yes�No 3. Have Internal Controls been submitted previously?If no,please attach copy. �
4. Applicant(Official,legal name of organization) �
� . 5. Business Address of Organization —�
. c�, � .
6. City,State,Zip =. : ", _ ,. .
. . . 7. County .. . �.�
� - :: • � 8. Business Phone Number
9. Type of organization• ❑Fraternal ❑Veterans ❑Reli ious '1 �+ « ( /��� � � `"� ' °.�-.,
'If organization is an"other nonprofiY'organization,answer questions 1�0 tOhrough�13PIf ot,go to question 14."Other nonprofit"or
must document its tax-exempt sfatus.
ganizations
QYes�No 10. Is organization incor orated as a nonprofit organizationl If yes,give number assigned to Articles or a s and
book number. ' � °�/ Attach co p g �
OYes DNo 11. Are articles filed with the Secretary of State? pY of certificate. ¢
�Yes ONo 12. Are articles filed with the Countyl �
OYes�No 13. Is organization exempt from Minnesota or Federal income tax?If yes,please attach lette.r from IR � .
Revenue declaring exemption or co S or Department of
❑Yes�1No 14. Has license ever been denied,suspen ed o90rev kedl If yes,check all that a I :
❑Denied OSuspended ❑Revoked Give date: Y
15. Number of active members 16. Number of years in existence
, Note: If less than four years,attach
�_ evidence of three yea�s
17. Name of Chief Executive Officer t� existence.
18. Name of treasurer or person who accounts for other revenues
of the organization.
' ', r7 . -
Title � ' _ - . .
Title
- � ;. 7_
.... � , ; ,
Business Phone Number � ' ``'�• °� � % � - -.�". � �
Business Phone Number '
( � '--, ) " '' .- % .-r _� l
19. Name of establishment where gambling will be ( � ~~ , � ^ ^' �1��
conducted 20. Street address(not P.O.Box Number)
j;. ' ' ,: .� -F�'� � .:� : i �- c� , �
21. City,State,Zip _ � ,:' � �� �� ��( _ ,ri '(, _�_ ;= ,t� ,
t 22. County(where gambling premises is located)
` �, f� :, � ; ,�- �-r
cc-000�-os�aiss� �� �� 4' ` `;r f� ,.�1 t�= � ".4 :�f"�,f
White Copy-Board Canary-Applica
Pink-Local Governing Body -
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,ling License Application � Page 2
_ a of Appiication: ❑Class A f�Class B_��°= OClass C' ❑Class D �.�
rYes ONo 23. Is gambling premises located within city Iimitsl T'
�.Yes ONo 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.
❑Yes No 25. Does organization own the gambling premises?If no,attach copy of tlie lease with terms of at least one year.
�Yes�No 26. Does the organization lease the entire premises?If no,attach a sketch of 27. Amount of Monthly Rent .
the premises indicating what portion is being leased.A lease and sketch S t�.3�,�� �
_�� is not required for Class D applications. `
-- _._ . .
' ❑Yes I�INo 28. Do you plan on conducting bingo with this license?If yes,give"days and times of bingo occasions: ;
Days Timea . '
�.Ye��No 29. Has the S 10,000 fidelity bond required by Minnesota Statutes 349.20 been obtained?Attach copy of bond.
30. Insurance Company Name 31. Bond Number -0
,A�' ;c - c.. iR,i�JC "� I�/Sdr� �G��/C�" (�r; 1f�..�" U�(c�a�..t� D _ �
_� .....
33. Address 34. City,State,Zip �
32. Lessor Name ;i
Gr>>. -r�,_A. �..• �I'�IlI.LE c.o--r,.'� �I�/� F/GLIy F �!�. F ��"F�lG� �rr�•!� �..�_��� .
35. G �nbling Manager ame 36. Address .�- ' 37. City,State,Zip ry � ;
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38. Gambling Manager usiness Phone 39. Date gambling manager became
( ��4� � � r � �� member of organizatiorr: �� f, �
�
•�
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 ar i
practice. 4
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
<
I he�eby declare that: : °
1. I have read this application and all information 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. I assume full responsibility for the fair and lawful operation of all activities to be conducted; y
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. �
40. Official,legal Name of Organization 41. Sign�ture Fnust be gned�y Chief,�x'ecutwe,Officer) i
{{�,�" f� �✓ G,�!J C 1 C. X �.... ,, �'' _ ,
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Title of Signer ' , � � Date / 'G
`,;: a.-C_--<'�_.�-s�7/t. i ! r�� <} � 'i
3
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
becoci�e 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. va
42. Name of City or County(Local Governing Body) If site is located within a township,item 43 must be completed,in �
� b� ,, / , Q� 1 addition to the county signature. � ' '
'��t� � s
Signature of perso receiving a plication ' 43. Name of Township �
�:
X' . , : ' �
T e . Date received(3 da erio� , Signature of person receiving application� ' �. y � -
begins from this date) 1 �
�� _ ����� X :�
4. .Name o P� 'Vering applic8tion to Local GoveMmg Body Title�' � " ' # ��`'"�'�r '� �"; �
`i-f%iw��•',{�� � �G�/J l Y, �` � �
CG-0001-02 (8/86) . " � White Copy-Board : . -� 7 ,�Canary-Applicant ��t� ning Body_ s
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�-Pink Local Gover
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