87-872 M�HITE - CITV CLERK
PINK - FINANCE G I TY OF SA I NT PAU L COUIICII
CANARV - DEPARTMENT
BLUE - MAVOR File NO. �� ��
Cou c ' e l ion
Presented By
:
Referred To Committee: Date
Out of Committee By Date
RESOLVED: That Application (I.D.#13781) for renewal of a Class C State Gambling
License (Bingo Only) by Juan Diego Club Our Lady of Guadalupe Church
at 408 P�Iain be and the same is hereby approved.
CQUNCILMEN
Yeas Nays Requested by Department of:
�e►�
dv�acaA� ���� [n F a vo r
�
scne�bei � __ Against BY —
se�reFl
Tedesco
W�ISOn JUN 1 7 1987 Form Appro ed by C' rney
Adopted by Council: Date
Certified Pa s � cou cil re BY
By�
I��ti f
App by Mayor: Date Approved by yor for Submission to Council
By
Pt18�iSlt�D ��ia 2 7 198�.
�.'.�tID��iiirrqii�� /,/,_ G�J_�j�r)
''�~, �� Charitable Gambling Control Board
• �.`SpILLDONp��1� i/� e � a e.
�` ' Room N-475 Griggs-Midway Building FOR BOARD USE ONLY
, -�:--.;� 1821 University Avenue .. ��ruomne.
� �_: _ _ _ St. Paul, Minnesota 55104-3383
(612) 642-0555 PAID
�+i�a+��.• AMT
�
CHECK#
f GAMBLING LICENSE APPLICATION DATE ;
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. fncomplete 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(Raffles,Paddlewheels,Tipboards,Pull-tabs) Makscheckspayablsto:
6d�Class C — Fee S 50.00(Bingo only)
❑Class D — Fee S 25.001Raffles only) M�^^°s°t°CharitableGamb�ngControlBoard
� @�Yes ONo 1. fs this application for a renewal? If es,
Y give complete license number � - ��
€; ❑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)
, es�No 3. Have Internal Controls been submitted previously?If no,please attach copy.
`'�;4. Applicant(Official,legal nam of organizatinn)
v'�A tE r,�r� ����B d u R �H p y a+ 5. Business Address of Organization
6. City,State,Zip 6� f�✓ S� u Re�t- R��o E -S .�)U�
'� 7. County 8. Business Phone Number
S � E ( � d
9. Typeoforganization: OFraternal ❑Veterans eligious ❑Othernonpro it`
'If organization is an"other nonprofiY'organization,answer questions 10 through 13.If not,go to question 14."Other nonprofiY'organizations
must document its tax-exempt status.
❑Yes ONo 10. Is organization incor orated as a nonprofit organization?If yes,give number assigned to Articles or page and
book number: Attach copy of certificate.
❑Yes❑No 11. Are articles filed with the Secretary of State?
OYespNo 12. Are articles filed with the County?
❑Yes 0 No 13. Is organization exempt from Minnesota o�Federal income tax?If yes,please attach letter from IRS or Department of
Revenue declaring exemption or copy of 990 or 990T.
❑Yes G�No 14. Has license ever been denied,suspended or revoked?If yes,check all that a ly:
❑Denied ❑Suspended ORevoked Givedate: _
15. Number of active members 16. Number of years in existence
Note: If less than four years,attach
• �Q • evidence of three years
17. Name of Chief Executive Officer existence.
18. Name of treasurer or person who accounts for other revenues
L� ��� oftheorganization. �E�/, Hr7CK,�`NyuE,�[.E�4, f��'� c�
LL � Al.�c N�T ��afiTS of 7N� ORg-q/VIzATiOn/, ��r� �
Title _
, Tt�e M ARC�A �P ET G, Ko E�I i 6 �
� : VT TREASUR��'
Business Phone Number
Business Phone Number
� 6�a , - o oh � 6� ,
19. Name of establishment where gambling will be +
conducted 20. Street address(not P.O.Box Number)
21. City,Stste,Zip O " , .
22. County(where gambling premises is located)
CG-0001-02(8/86) � White Copy-Board
Canary-Applicant Pink-Local Gaverning Body
------'-�-.�...
� ����
�bUng License Application
pe of Application: C1CIass A OClass B . � Page 2
[�lass C ❑Class D
;
Yes�No 23. Is gambling premises located within city limits?
Yes�No 24. Are all gambling activities conducted at the premises listed in#19 of this application? If not, com let
application for each premises(except raffles)as a separate license is required for each premises, p e a separate
❑Yes Gr�No 25. Does organization own the gambfing premises?If no,attach copy of the lease with terms of at leasi one year.
❑Yes No 26. Does the organization lease the entire premises7 If no,attach a sketch of
the premises indicating what portion is being leased.A lease and sketch 27' Amount of Monthl Rent
is not required for Class D applications.
�YeS�No 28• Do you plan on conducting bingo with this IicenseT If yes,give da s an $ /O�r �EE (( L
oa s y d times of bingo occasions:
�UESDAV AF1"ERNn��l,s' /:,��pM_S.3o
,
' P M,
$Yes�No 29. Has the 510,000 fidelity bond required by Minnesota Statutes 349.20 been obtained?Attach co
30. Insurance Company Name f{ j_�x� N oE R ,� PY of bond.
�+�E/tT N(E R � ��-�XA NflF R�I�c, 31• Bond Number
32. Lessor Name ^���R A N � 5
L� �LEXaNpER t 33. AddresstldtRrEf
• CfiNT� �A R K 34. City,State,Zip :
35. Gambling Manager Name ' ��' �x � �.$, S
F�.ORCNC 36. Address i 37. City,State,Zip�
38. Gambling Manager Business Phon� 39. Date gambling manager became �T
� ,5S/�6
( �� � 7�J member of organization: � I : •
By my signature below,local law enforceme n off c'ers orlagentsTof t�e'Board are hereb authori '
at any time, gambling is being conducted, to observe the gambling and to enforce the law for any unauthorized am �
practice. Y zed to enter upon the site,
g e or
By my signature below,the Board is hereb au hoRz d�o i�nspe�Ct h�bankTe�ords of the General Ga
whenever necessary to fulfill requirements of current gambling rules and law, mbling Bank Account
-:�
I hereby declare that: OATH -
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 res
if licensed,to abide b those laws and rules, includin amendmen s ihere oambling and rules of the Board and agree,
��. Official,Legal Name of Or anization l,(AN � `
�,. -Q � G a l�(;O 41. 3ignature(must be signed by Chief Executive Officer)
Title of Sign E �lR H X t� '�, � -�%-% _a. ,
/ �+�.. ././ .
Fsl�F �{r — Date ' `. .'`;: -
A ��, , -
, ,,: _ ; :�.
. , .: � , ,
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 Cha�itable Gambling Control Board and if a
become effective 30 days from the date of receipt(noted below►,unless a resolution of the local governing body-is assed
which specifically disallows such activity and a co Pp�oved by the board, will
Board within 30 da s of the below noted date. pY of that resolution is received by the Charitable Gambling Control
42. Name of City or County(Local Governing Body) - �
If site is located within a township,iterri 43 must be completed,in
Ci ty of St, Pau1 addition to the county signature.
Signature of person receiving application
�OS� h 43. Name of Township
x P Carchedl J � _
Title i'`^ t � ��
Date received(�day period Signature of person receiving application
License Inspector beginsfrsr�rt,fi���te)
44. Narqe of Person delivering,applicat,'on to Local Governing Body Title
^�� �'�LCG- �. (G r,r-�n�
CG-0001-02 (8/86) White Co
py-Board Canary-qpplicant
Pink-Local Governing Body
�� �C�'7_�'70�-
� ��"'' City of Saint Paul
� Department of Finance and Management Services
Division of License and Permit Registration
INFORMATION REQUIRED WZTH APPLICATION FOR PERMIT TO CONDUCT CHARITABLE GAMBLING GAME IN
SAINT F'AUL
1. Full and complete name of organization which is applying for license ��,q�/
..�i��E%'�/3 �6�� � - /� i'C � //�C'/ �'�' ��� � /��� /�,�,c ��/Ci�,e cr
2. Address where games will be held � l'� �� ''
. r. ."7 . � Cc �- ,�r/C E
vumber Screec City Zip
3. Name of manager signing this application wno will conduct, operate and manage
Gambling Games �/,/_'/f��y�� �, �p/,�f G P��n/ Date o f Birth ,� ��'1-.-���
(a) Length of time manager has been �ember ot appl±cant organization ,:�_5' �/,E /�!Z_j
4. Address of Manager /� lf � �j,E7��-t s j ,�7� �y� � � J /G �
.�`��
Number Street �it� Zfp
i
5. Day, dates, and hours this application is ior �� '�'S�A�� �FTE�'!✓vd�/-S-j,',��� f?�'�1 -S.'.��t'iy
-sLLt ./ / / 3 1'% �T!° NF '� /� }'-1i
6. Is the applicant or organization organized under the laws o: ;the State of �IlV? !i�r S '
_7"�—
7. Date of incorporation _ � �.7- �,� �, n����.,� �r� � �y3�
, �iC�fN.t/ �H`7/fa�,�/C Nk 2CI-{�
8. Date when registered with the State of Kfr.nesota �./tL �.�/ J�'� /yrJ� �
�
9. How long has organization been in esfstence? �,$' y�,c.f� 5
10. How long has organization been in e:cistence in St. Pau1? � � �/��� c I
11. What is the purpose of the organization? _%G �f}/,S� ��NE Y -��c � � � ' �
-� �A�T''h%{-�ti
�u-t��l;F_ <. 'c' r C /,( r c� � f n� c'►l �tir�r7A u P� � �f Rc ff '
�
I2. Officers of applicant organization
Name �<;;r�cN '��,��NG" ht A�.�(�,v'��it/f' ;;�r�� Vame �� J��f,���T fT: e ' i�
- ff` , _ , /F.ti/i C,°-
Address _��/' ��� fj�E 1 L� 9ddrzss � �
�a��-/ ��,�,r;� � ��-
� ir
Title �F•;/ni�iT-�-/�,��T.�'.\DOB rf--- �- /��' Title �,7-i°,E�i�ra 1�,�i` DOB f- ;3-'/G
a -
Name /� �f� �/ ,/ � '� '� �
�!,!I 7Th�F..l!� � �( Name �i 6 �.i✓G� �
�. � :G" F.�
r
�
�' i
Address _;1�� �, �L�,,�,r-�,�r address ji���
.�i�T��2
� . � /J
TYtle �'i�,E- lh(�.Si�D�kT DOB ,�-� �'31 Tit�e !'/��/ff�=E1Z DOB �/��--�,;
�;
13. Give r.ames of officers, or any ot^er �ersa::s ano ^;a:d =o� ser�;.ces to t^e orgaaizatfon.
Name Vame �
Address �� '� Addre�s / j
�
Title ?_`:2 '
(Attach separate szee- :. - ac�'_�_or.�_ -:�_es. '
;.:
. ���-�7�
14. ALtached hereto is a list of names and addresses of all members of the organi
15. In whose custody wili organization`s records be kept?
Name ��C�,��Cf � � �LGC �f}�/ Address l//�5� ��r Tfl�
,
Ib. Persons who will be conducting, assisting in conducting, or operating the �ames:
Name ��G /�ENL',� _ G�C_'C��`}'/� Date �f Birth J�'-/�/-�j
Address /��s` �j,ET�j�. , �
Name of Spouse /vG T �0�,����A���,.,,E Date of Birth r-----
Dates when such persan wfll conduct, assist, or operate
_ � � / �.. �- /�r^ '
Name /��}-j��°�1J3'�� �ENi C= Date of Birth ��- 3 f1G
Address 7�'/ ,�, �d T J`"/�- !�-,E '
Name of Spouse /t��� 7 � f�',� /��j �.( /"_ Date of Birth -'�
Dates when such person wi1l con�uct, ass:st, or ope=ate
l C�i�( � /(l C� T
17. Have �ou read ar.c do pou thar�ughly unde:staad the provisions of ali laws, ordinances,
aad regulatior.s ;overning che operat:on or C�a�itab_e Gambiing games? S
18. Attached hereto oa t:�e for� �ur.^.ished bv the Cit� oi St. Paul is a Financial Report
which itemizes a1'_ Z2Cfl_�CS, e:c�enses, aad d{sbursemeats o= che applicant organization
a; we?1 as a?i o�ganizat'_ons wao nave :e�ei��ed =unds �or t:�e precedfng ca?endar year
whfch has been s:3zed, prepa_Ted, ar.d ve_i��ed �y -�i(,�R��t/C: � �. ���C�C��'r�;��
. vame
— �� �� /F�,�� �% .�1, �� u � , /`��- , �r.�ic�
�ddress . .
who is the ��i3�� �E 2 �
o� tne applicant. Organization.
Vame o� Oi�=ce '
I9. Operator of prem=ses where ¢ames �rii1 be held:
Name �Ci �T� ,��i�- %`t� �� / �C /JiNls-
��.7J�� /!'�TIO�/
Business Address /Q a� /��, �� ,j �,
Home Address
20. Amount of rent paid by a�plicsnc Orzaai�ac=on ror ze^c o� the ha11; specify amount
paid per 4-hour se�s:cr. ��(jJ ��� R L� � �, ,jc55id��
����T u>� s �N � � � � s E n �� � ��' �,� �° e /� � . c �v
f�.�cJ��r ,t;.0 i? i, 19��� , �(. C7'T� !� �4-;?iy. c = �
�� �.
���y�� :
,9�eeds oz che games will be disbursed after deducting prize layout costs and
,�ing e;cpenses for the following purposes and uses: '
� u. _f�} :�v N !� L 'i- i�C YO✓`F< .� �H f ' ' ' % r.�/ o�t-
- �f/� � �'/• � �b * �ll f�TJf}iC�r P,c ��u���'ff
I
i `Z_ Has the premises where the games are to be held been certified for occupancy by the
City or Saint Paul? S � :
23, Ras your orgar.izat:on �iled :ederal tor:n 990-T'. � IL answer is yes, please attacn � ;�
a copy W�C:'l this applicac�on. I: answer is no , e:cplain why: �`
w
,(�.� 7' lq" F'1',c, l ��'f��c �
I
i
'; .
Any changes desired b•: �ae appl�c�zc �ssoc=acion ma� �e �ade on1;r with the consent oi the
City Counc?1. Q�l/: /�./-�O c�f CvkHl7rJ/,,�i'.r ��/��i/T�� '
G ! l
�G�.-AN / iE�;� C� crr
Organ_zac:on
Date � ��� �r�/ / / 0 � By: �,-
'�—� Manage: in charge or game
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