87-637 M�HITE - CITV CIERK
PINK - FINAN�E C I TY OF SA I NT PAU L Council � R
CANARV - DEPARTMENT File NO. (, ���/
BLUE - MAVOR
Co c ' Res ut 'on
Presented By �� ��P
Referred To Committee: Date
Out of Committee By Date
RESOLVED: . That Application (I.D.#10519) for the renewal of a Class B
State Gambling License by Harding Area Hockey at 735 White Bear
Avenue (Minnehaha Tavern) be and the same is hereby approved.
COUNCILMEN Requested by Department of:
Yeas p�eW Nays �
Nicosia ln Favor
Rettman
Scheibel Q
Sonnen __ Ag3llist BY
•�sdeecu
Wilson �p
MQY 6 ^ ��v7 Form Appr e by Cit ttorne
Adopted by Council: Date
Certified P•s•e b Cou cil cr BY
By
A�ppro by Mavor: D
_��yY j -° � Appro ed y May for Submission to Council
- By
w!�:.�;s� !`A.=i7 �9V�
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,�p .� Cha�itable Gambling Control Board �. FOR BOARD USE ONLY
�'-R� . .Room N-475 Griggs-Midway Building: , -':+ �,,,N,�r .
` 1821 University Avenue ` `' ' � •
St. Paul, Minnesota 55104-3383 q�T :
- � (6121642-0555 ?
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1 A � . . DATF ;- ,.
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�. GAMBLING LICENSE APPLICATION � '' °�, ,
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INSTRUCTIONS: .
A. Type or print in ink.
8. 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. '
Type of Application:
�ClassA — Fee$100.00IBingo,Raffles,Paddlewheels,Tipboards,Pull-tabs) M�ecneckspeyab�eto:
I�Class B— Fee$ 50.00(Raffles,Paddlewheels,Tipboards;PUII-tebSl Minnesota CharitaWe Gemb6ng Control Boa►d
❑Class C— Fee$ 50.00(Bingo only)
OClass D - Fee S 25.00(Raffles only) : � _ ,_ - -
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' � �Ye�No� l Is this application for a renewal7 If yes give complete license number - -
❑Yes[�No 2. If this is not an application for a renewal,has or anization been licensed by the8oard before? ,;If yes,give base_ _
: ... • . . :
s license numti r(middle five digits) "`
OYesDNo 3. Have Internal;Controls been submitted previously7 If no,please attach copy.
t4,. Applicant(Official,legal�ame of organization) 5. Busine�Ad re_ of Org�'n`iz�oR .
' l�. �h � C�c�� = 5 C�'J I�73 U �C �1 f"' I D/� .a..
n A� 8. Business Phone Number
' 6. faity,State, ip r .r / 7 ounty`t,
i J , �AJ� /�/�Iti! .S ..`a J a C� � N�S � IG,I� 1 9
`9. Type of organization: ❑Fraternal ❑VetersitS';"OReligious Ce�ther nonprofit* � , ' �
` 'If organization is an"other nonprofit"organlzation,answer questions 10 through 13.If not,go to question 14."Other nonprofit' organizations
� must document its tax-exempt status.
E ❑YesONo 10. Is organization incor orated as a nonprofit organization?If yes,give number assigned to Articles or page and
book numbe�: H'33 t Attach copy of certificate.
(�,Yes ONo 11. Are articles filed with the Secretary of State?
� ❑Yes�No 12. Are articles filed with the County?
� [�Yes 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.
t
pYes�No 14. Has license ever been denied,suspended or revokedl If yes,check all that a ly:
L �Denied �Suspended ❑Revoked Givedate: - -
' 15. Number of active members 16. Number of years in existence Note: If less than four years,attach
� evidence of three years
� � � L ��� � :, ' existence.
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� 8'': ame of tr surer or pers�irr who accounts for other revenues
� ``" `T7. Name of Chief`�xecutive Officer � `� `� ' ' ', ` `' � "} �l. �
�. �:;;_ ��;"*- he organizatio
� 7� � �nrc.� l l� � L..,� ��tJl... � o l� G �15
(: itle Title
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' Business Phone Number Business Phone Number
�
F � �a� ► � J �� � �S ��1� ► 7� / .���9 '�
19. Name of establishment where gambling will be ' 20. Street address(n�� .�( .BPx Nuh�b�r) ;
�` i,., �'
� conducted } ` 7��J �1N� .!� C �� �' '� 1�� :
IV� �hl ,�1 t � /`� ! +R1�/r= , . '
� 21. City,State,Zip 22:-County(where gambling premises is located) '
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' CG-0001-02(8/86) - White Copy-Board ', Canary-Applicant Pink-Loc81 Goveming Body , ,�
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'��" �IC8t1011 . , � , -
ng License App'
� lication: C]Class A� �`. I�Class B;• F� OClass C. . .OClass D Fa '.: :.- �- .�
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YPe of ApP -
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es ONo 23. Is gambling premises located within city limits?
�:`' I�YeS.ONo 24..Are ali gambling activities 8�exce t afflespas e'seperate 1 cense is required fo eeach premises mp�ete a separate
,,, .,�. aPPliCation for each'��mis ( � ��
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' ❑Yes(�l0 25. Does organization own the gambling P�emises7 If no eattach a sketch of'ease 27 hAmount of Monthl Renf "
E ❑Yes�No 26. Does the organization lease the entire'r .� ...
i - `�- the premises indicating what portion is being leased A_lease and sketch $ . � . ._.
� is not required for Class D applications. �- �
Y. . ive days and times of bingo occasions:
❑Yes�o 28. Do you plan on conducting bingo with this lic�meS�f yes,g
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No 29. Has the S 10,000 fidelity bond required by Minnesota Statutes 349.20 31e�°ond Numbe�ach copy of bond.
�ego x� -- .�
� 30, Ir}sNr�Ce Com�any Name� � Q� 3 =
A � �� � 33. Ad�lress 34. City,State,Zip �
32. Lessor Nama-^ _ �� '`},a'�-� '°.. �!' -.` �
;,, �j. !.� � _,*�.+ _ ' : �r�.� `�� � � 37;,,Ci ,State,Zip . r. _.r. l .�
�i` _ > 36. Address ' '�.• , � /lJ C?.'�
f- � 35:, mbling Mana�jer Name . ,,. ,
y ja L� Y t � c�._ . .. �
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; 38. Gam b ling M a n a g e r B u s i n�s s P h o n e 39. membe oflorgani at9on became - ; y
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; � , si �� � � ` �� � �� � �
, , GAMBLING SITE AUTHORIZATION
� m si nature below,local law enforcement officers or agambi nf t and to enforce the law forrany unauthor ied game or �
,t. By Y 9 �
at any time,gambling is being conducted,to observe the g 9 � �
' practice. �•����•� gANK RECORDS AUTHORIZATION �r ,
ure below,the Board is hereby authorized to inspect the bank records of the General Gambling Bank Account �
. gy my signat �
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;
2.' All information submitted is true,accu�ate and complete; �
3. All other required information has been fully disclosed . `�
4i 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�o�fiM�amendments there oambling and rules of the Board and agree,
if licensed,to abide b those laws and rules, inc w
40. Official,Legal Name of Organization .,,, 41. Si n (must be signed b Chis#-�x utiv O icer)
�� �{� . S5oc.it t�o X
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�� � Date j
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�' Tit e�of Signer \ : , , . •
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� ACKNOWLEDGEMENT OF NOTICE BY LOCAL GOVERNING BODY
g recei t of a copy of this application: By acknowledging receipt, 1 admit h o ed by the board,Nwt'h
I hereby acknowledg P, ;,
� notice that this application wdl be reviewed by the Charitable Gambling Control Board and if app
j
become effective 30 days from the date of receipt I�not�d bh°e�solut on is rece ved by the�Char'table�Gambling Cont ol
which specifically disallows such activity and a c py
BOard within 30 da s of the below noted date. �f site is located within a townsfiipi item 43 must be completed in �
42. Name of,City or County(Local Governing Body) addition to the county signature. ;
� - �: � ,��� -�-�("_,R,_..._.�: :, ;;
�- ��- 43. Name of Township .;
� ••;Signaturabf p, on receiving application ry
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' �, ; `•�, � .x1 r_^ ` t.�_ct. .'?t. t.`.�ti ti.. .. , . .�:
k � `^' -�° eriod ! Signature of person receiving app��cation ;
( Date receiv�d.(30 d y p :
; Title begins fr m t is�te) �
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�:. a lication to Local Goveming BodY � Title . "� ;
, , e of Person 9 ` ;�
! Canary-Applicant � Pink-Local Goveming Body,�
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` CG-d 01-02 (8/86) `, :.
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City of Saint Paul
Department oE Finance and Management Services
Division of License and Yermit Registration
V INFORMATION RE UIRED WITH APPLICATION FOR
pER�'(IT TO CONDUCT CHAR_ITABLE GAMBLING GAME IN
SAIN� 1 ing for license
1, Full and complete name of organization which is apP Y
r--,
� . � ��'_l � n�' �
� �/� � � J�
� � � i,.. , ,�� �^/�/�/� Zip
ames will be held � �-`� Cit
Number Street
Z, Address where g .
er signing this application who will conduct, operate and manage
g, Name of manag Date of Birth ' � � �7 —`�
.—� �'�� ' _—
Gambling Games � � r� 'Z '� �� r��—
ime manager has been member of aPPlicant organization y "
th of t �' "� '��
(a) Leng � ^ �L -
;� 7.^ I ' Zip
4, Address of Manager Number Street
C ity
, ..
dates, and hours this application is for ' ���_
5, Day, � the State ot MN• i �
6, Is the applicant or organization organized under the laws o-
. � c , ��
oration
7, Date of incorp �� �r
g, Date when registered with the State of Minnesoca j
•C �
How long has organization been in e:tistence? �' c ct
9. -�
p, How long has organization heen in exiszence in St.rPaul"•. f
1 �� �, "' �
�� at is the purpose of the organiaation?
�.� 11. �►
1y�,i
!�0
•i�
, �t: .
` Officers of applicant orgar.ization . � ,�
,,; -� �� �� 7,�,i
• ,,x I2. �-, � �`� :Varse ,� �L. �
� �.�. �%�U� `
in a Name 1 �" �Il l�n�C.K � � �-'��l�t�'t oi,► ��
^� Address
�.�:���
A�' Address ��''� `� � ��N DOB
;:� Title ��. ��
Tit1e��5 �,�iv ! DOB �Ac>� �` C.�� L> ;
� ' � Name
' � n W�I ��
� �i Name 1 �. r' N
�"�' Address 1.5 � � ML- �'
-{ '' �/y, � i
�� Address � I � � �L,� DOB
�. ' � T�tie / /Cy�
�� DOB anizat'on.
:� :� Title` � �._ �
13. Give names
of officers, or any ot:�er persons wno paid for ser'rices to the or3
�ame
�:':
� � Name
Address
Address
T��ie
',:. .-_or.s' .�-:'�• '
Title (,�ttach sepzYate sR2"" �'` '3"�
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14. Attached hereto is a list ot names and addresses of all members of the organiZ,
' �
15. In whose custody will organization's reco�ds be kept? �
Name �'J��,�v S !"r�,� Address )�7.ti L91�7i 2 1Jhi�,ti� 1� � x�
16. �Persons. who will be conducting, assisting in conducting, or operating the �ames:
�
Name Sr J^�' �t S � Date of Birth
Address
Name of Spouse Date of Birth
Dates when such person will conduct, assist, or operate 7 �t�y S q �v,�E k
Name Date of Birth
Address
Nane of Spouse Date of Birth
Dates when such person aill conduct, ass'st, or ope-ate
17. Have you read and do ;�ou thoroughly understand the provisions of all laws, ordinances,
and regulations governing ttte operat`_on or Cha:�tab�e Gambiing €ames? �/C S
18. Attached hereto on the form fur^ished bv the City o� St. Paul is a Financial Report
which �temizes a11 receipts, e_cpenses, and d:sbursemezts a= [?�e applicant organization
zs well as a'i orgar,iza�:ons who na��e receive� `unds *or tae preceding calendar year
whfch has beez s:g�:e�, prepared, and ve�i�;ed by ��
Name
� � 7.'� �7 j --, � � •� �
� �
:�dd ess
who is the _�. �� � �'.� q�„`�1,�,N(,?_ j�,�AN ��-C� ��o` the applicant Organization.
Vame �' Off�ce �
„19. Operator of premises wnere �ar�es a�l; oe he1d:
� �,., �' �^
Name �h.L_�,.� � /�:c� �v�.-�SZ___;.____
Business Address � 3 J �/�//-� [ I � 'JT' ;�� ��//�
Home Address o� y � �'{r NiV�1�, �J j
20. Amount of rent paid by apo�?can� Orgar.i�ac±on ror rent of che ha1Z; specify amount
paid per 4-hour se�sion �
' ��� b, o C� r� /v�c��, 1 1�`'
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Y ' � . _. .:� � � !
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21. The proceeds of the games wiil be disbursed after deducting p�ize layout costs ana
operating expenses for the following purposes and uses:
� [�c.1- r' !� E.- �� r ��C � _
22. Has the premises where the games arz to be held �een certified for occupancy by the
City of Saint Paul? �/�� C; _
23. Has your organization riled tederal form 990—T? x_� If answer is yes, please attach I'
a copy with this application. I: answzr is no,�e:cplain why: �
Any changes desired 'od the apolicant �ssociation may be �.ade only with the consent of the
City Council.
Organization
Date By�
Manager in charge of game
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