87-871 WHITE - CITV CIERK
PINK - FINANCE G I TY OF SA I NT PAU L Council /�
CANARV - DEPARTMENT /�
BLUE - MAVOR File NO. � " �J
Council Resol tion
Presented By �
Referred To Committee: Date
Out of Committee By Date
RESOLVED: That Application (I.D.#82625) for renewal of a Class C State Gambling
License by 5t. Aldabert Rosary Society at 1079 Rice Street be and the
same is hereby approved.
COUIVCILMEN
Yeas � Nays Requested by Department of:
�'�'"� /�j� �_ In Favor
�
sche�bei � __ Against By —
�r
Tedescu
W'��n JUN 17 1987 Form Appro d by ity rne
Adopted by Council: Date —
Certified Yasse C uncil Sec a BY
By
Approv Mavor: D _�,1��Ix L��� Approved by M or for Submission to Council
\
gy _ — By
Pll�.i�,��D ".;'! � 7 1987
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�µ6DVqp•, ��• Charitable Gambling Control Board �
-� Room N-475 Griggs-Midway Building FOR BOARD USE ONLY
1821 University Avenue uc��N�
- _ St. Paul, Minnesota 55104-3383 PAID
(612)642-0555 AMT
�:j868;'r•
�- : CHECK#
�� DATE
��': _�:
_� GAMBLING LICENSE APPUCATION
,
F�� ��, *t �-�' =
h � `:INSTRUCTIONS:
x�zt 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
,;w,.
copy and sends original to the above address with a check.
� ~�• C.._ Incomplete applications will be returned.
:;:;;., :'Type of Application:
`:�class A - Fee S 100.00(Bingo,Raffles,Paddlewheels,Tipboards,Pull-tabs)
,��Class B - Fee S 50.00 IRaffles,Paddlewheels,Tipboards,Pull-tabs) Makecheckapsyablsto:
� �Class C - Fee S 50.00(Bingo only) nntnnesocacx�eaw.�r�9co�eroteoa.d
s.�1Class D - Fee,S.25:OCT(Raffles onlK►..;,r;� _ :;,: ,,..r,:-_:a�u+ , _
_ : .. , _
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`�Yes❑No 1. Is this application for a renewal? If yes give complete license number � - %� �`; ��
x�k�Yes�No 2. If this is not an application for a renewal,has or anization been licensed by the Board before? If yes,give base
� license number�middle five digits) � '
Yes�No 3. Have Internal Controls been submitted previously?If no,please attach copy. . .
4. Applicant IOfficial,legal name of organization) 5. Business Address of Organization �/
-� '� : ,.y � f_ '� r ,..� '1 ,{ =n J J�/.�(j �� '�,,, � �C'_ - ,r'!� /`'�) 1'` L- �v .� � � (/ `-!
.. .. . .�; ir � � i .
6. City State Zip 7. County 8. Business Phone Number
v i. ;""`t .� ;;E•���j�r";�• .;•~ �• ,�[) � � '� !1�� •� i ( !; ) :- �
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:� 9. Type of organization: ❑Fraternal ❑Veterans �ieligious �.C�Other nonprofit'�
�`' `If organization is an"other nonprofit"organization,answer questions 1(7through 13.If not,go to quesiion 14."Other nonprofiY'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: rM Attach copy of certificate.
C7Yes ONo 11. Are articles filed with the Secretary of State?
SLYes❑No 12. Are articles filed with the County?
QYes�No 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�JNo 14. Has license ever been denied,suspended or revoked?If yes,check all that a ly:
� •
❑Denied ❑Suspended ❑Revoked Givedate:
15. Number of active members 16. Number of years in existence Note: If less than four years,attach
` , evidence r ars
of th ee ye
_ ___ . _ _ -_.:-- _ ' = r- � -. - - :existence. _. _..
a � .. :, _;, . ,
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17. Name of Chief Executive Officer . 18. Name of treasurer or person who accounts for other revenues
/��? ..-!� �%' of the ganization.
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Business Phone Number ne umber `� � �
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19. Name of establishment where gambling will be 20. Street address(not P.O.Box Number)
conducted
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' 21. City,Stste,Zip 22. County(where gambling premises is located)
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CG-0001-02(8/86) White Copy-Board Canary-Applicant Pink-Local Governing Body
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�ng Vc. ':A lication Page 2
of Ap , �o�pp[aClass A ❑Class B �Class C ❑Class D
�, ,�.
YeS�Na 23 Is gambling premises located within city limits?
qYes p�;':24. Are all 9ambling activities conducted at the premises listed in#19 of this application? If not, complete a separate
� lication for each remises(exce t rafftes)as a separate license is required for each premises.
;�' apP p p
�Yes o 25. Does organization own the gambling premises?If no,attach copy of the 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 Monthl Rent
., ;��'�=- the premises indicating what portion is being leased.A lease and sketch g
";`' is not required for Class D applications. � � " �
l�;y:..• eg pNo 2g. Do you plan on conducting bingo with this license?If yes,give days and times of bingo occasions:
.,t.2,{ Days..r _ . Timea
F�2:: _ . � . ' F.1 �I '� - � .t� .?; ' :;/�
,4f3��.. . .
��S}, . "� � e,f _ � '✓ - + '1 �
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, Yes�No 29. Has the 510,000 fidelity bond required by Minnesota Statutes 349.20 been obtained?Attach copy of bond.
:`�:%;�';;•��":•30. Insurance Company Name 31. Bond Number
'` � _ . -� i/q l - , ' . '� ��', � ,- :t
.�; �
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32. Lessor Name 33 Address 34 City State Z�
- � - - - _ _
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, 35. Gambling Manager Name :;1 ;' 36. Address = ;,�N�l 37. City,State,Zip
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s -
�.38. Gambling Manager Business Phone 39. Date gambling manager became
;: ( : � _ - � ,:� ,? member of organization: ;,� -:� . -
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.;
GAMBLING SITE AUTHORIZATION
� By my signature below,local law enforcement officers or agents of the Board are he�eby 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. ...�......... __,.... ,,..
�' � 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 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;
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;
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. Signature(must be signed by Chief Executive Officer)
. � � - ,:+',..`I �/f�-N}f %,,i"� , X !� � .-./ .-:.y.� �`,�
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Title of 'gper .. �" ' Date . _ -
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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 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(Local Goveming Body) If site is located within a township,item 43 must be completed,in
" ,� � addition to the county signature.
� �
� Signatur of p�rson receiving application 43. Name of Township
,� C
X� '� ;. � f r^ ' , �- ; }�,
Titl� Date received( 0 day period Signature of person receiving application
begins from this date)
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44. Name of Person deli4ering applicafion to Local Governing Body Title
__.? .
CG-0001-02 18/86) White Copy-Board Canary-Applicant Pink-Local Governing Body
�r=��, � ��7-�/
. �� City of Saint Paul
• Deparcment oi Finance and Management Services
Division of License and Permit Registration
iNFrRMATION REqUIRED wITH APPLiCATION FOR PERMIT TO CONDUCT CHARITABLE GAMBLING GAME IN
SAINT PAUL
� 1. Full and complete name of organization which is applying for license � -' 0 �i�b�"' �r
" '
2. Address where games will be held � p 2 � ��� . Q�,� �"��/�j
Number Streec City Zip
.. 3. Name of manager signing this application who will conduct, operate and manage
Gambling Games � � Date of Birth ��- �- / t�
(a) Length of time manager has been member ot applicant organizatioa ' � -
4. Address of Manager 3�7� � c.�y,.-z,L�l',�.e-���/ � ,,,�nz.�c-n"' u'��-// �
Number ' Street City Zfp
5. Day, dates, and hours this application is for � ,a � � S`�j. �-! •
6. Is the applicant or organization organized under the Iaws o: the State of �? r�
7. Date of incorporation
8. Date when registered with the State of �iinnesota
9. How long has organization been in existence? �.� ��
10. How Iong has organization been in exfstence in St. Paul":
11. What is the purpose of the organ:zation? C�cd�t.-c.�.�� ,Q�?����' .
12. Officers of applicant organization
Name���L� �C_.���.�� Va:ae ' ' .
Address ��d��/,C,r.c,P ,�����. Address ������r��� ��C�. .
Title DOB /O—�/-3v Title �- �hy_,��,�e,� DOB ,3
Name �`L�, Name -
r � 3 ' �,
Address Address
/ .
TYtle DOB �'!� �Q TitleJvJ �OB ��`7" �/3�
13. Give names of offfcers, or any othe- gersons ano pai3 tor se^�fces to cne or3an�:atfon.
Name vame
Address � �ddress
Title Ti�ie
(Attach separate sne�� '^- ac:�'__or.�: -:�_e�. '. ,
. � .
� �����i �
14. Attached hereto is a list of name� and addresses of all members of the organization
15. In whose custody will organization`s records be kept2
Name .�-.F.e� � � Address �7 S
-*=G�-�~' � /',�,.-� . GL�f
16. Persons who will be conducting, assisting in conducting, or operacing the games:
.,--_.
Name � g ^ Date of Birth �� ����.
e ,
Address 3 9� �-��� �
Name of Spouse Date of Birth ,����
Dates when such person will conduct, assist, or operate `"
/
Name Date of Birth
4ddress
Naae or Spouse Date of Birth
Dates when such person *ai?I condc:ct, ass:st, or ope:ate
17. Have you read ar.d do ;rou thoroughly uade:stand the provisions of all laws, ordinances,
and regulatior.s governing the operat:on o= Char�tab'e Gambl;n' games?
18. Attached hereto oa t?�e forr: �urzished bv the City of St. Paul is a Financial Report
whic:� itemizes a1� rece:pts, e_t�enses, ar.d disbursemencs of che applicant organization
as wel� as aiI orgar.izat:ons whc za�re rece:��ed =unds for t:�e precediag calendar year
which has been s:�ned, prepa_red, and ve�i*"_ed b,� ��-.d"'T-c-� � •
, �ame �
3 � ? �' �CG��G2�.f -- � � ,�-. � �.-►�- • �S'/t �
' Address
who is the _ .�yy���,,f��y�,.-d� • o` the aoplicant Organization.
' Vame Oi:=ce
19. Operator of premises whe-e �tames w�ll be heLd:
Name ��h.l% �`'�,�� � ` �
;
Business Address � 6 ? / ��-�C�. � .
--,�
Home Address y�� �, ni�� _ ��-;��� �hN,�, ��-��'
20. Amount of rent oaid by appy�csnt Organi�acion ror rent o� the na?1; specify amount
paid per 4-hou: se��:on ` � � S�• O-a ��a-�
-.� , ��7-P�/
. The p�oceeds ot the games will be disbursed after deduct:ng prize Iayout costs and
opera�ing expenses for the foll'owing purposes and uses:
/.� � / � ;
_ ,
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22. Has the premises where the games are to be held been certified for occupancy by the
City oE Saint Paul?
23. Has your organizat�on riled *'ederal form 990—T? ,(J Zf answer is yes, please attach
a copy with this applicacion. If answer is no, e:cplain why:
Any changes desired by the applicant �ssoc=at{on may be nade only with the consent of the
Citq Council.
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Organizac�o
Date Bv: � `
Manager i charge of game
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