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87-876 WHITE - CITV CLERK PINK - FINANCE 7F �7 COUnC1I �j a / CANARV - DEPARTMENT G I TY OF SA I NT 1,A l� L �( /� /� BLUE - MAVOR File NO. V �—u �✓� Counc �l e oluti n Presented By Referred To Committee: Date Out of Committee By Date RESOLVED: That Application (I.D.# 1gg62) for a Class B State Gambling License by Brunette's Youth Boxing at 1091 Rice Street be and the same is hereby approved. COUNCILMEN Requested by Department of: Yeas Nays fllrew�. as�_ /'c2�'�i✓ In Favor �,`�'� u scr,e�t�� _ __ Against BY -- .:�.:�:� Tedesa? 'N'� �' JUN 1 � 1�87 Form Approv by ity Att ey Adopted by �ouncil: Date Certified Pa.se Council , et BY B5� Appro by ;Nayor: Date JU19 L � ��p Appcoved y ayor for Submission to Council _ By P,lte�tSl�D ����� � 7 1987_ F' � . �Euu.n4 0 �`71 �� f � k ' •"'�"'�� Charitable Gambling Control Board FOR BOARD USE ONLY F.... �•'�ol1iDUMp1�•. '�� Room N-475 Griggs-Midway Building � � r . 1821 University Avenue uoe�s.N�,ner � �:' St. Paul, Minnesota 55104-3383 (612) 642-0555 AMT � �:i�:�':. � CHECK# `� DATE �. GAMBLING LICENSE APPLICATION �. E � 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 C. Incomplete applications will be retumed. Type of Application: - OClass A - Fee S 100.00(Bingo,Raffles,Paddlewheels,Tipboards,Pull-tabs) �` �lass B - Fee S 50.00(Rafftes,Paddlewheels,Tipboards,Pull-tabs) Makecheckspayableto: k Minnesota q�xitable Gambing Convol Board E Class C - Fee S 50.00(Bingo only► > ❑Class D - Fee S 25.00(Raffles only) ❑Yes�No 1. Is this application for a renewal? If yes,give complete license number � - 0 - 0 ; ❑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 F license number(middle five digits) �' ❑Yes No 3. Have Internal Controls been submitted previously?If no,please attach copy. �. 4. Applicant(Official,leg I name of or anization) 5. Business Address of Org ization ► • � 6. City,State,Zip 7. County 8. Business Phone Number �'y 1 1 4 9. Type of organization: ❑Fraternal ❑Veterans ❑Religious Other nonprofit �` •If organization is an"other nonprofit"organization,answer questions through 13.If not,go to question 14."Other nonprofit"organizations k must document its tax-exempt status. I . ±' ❑Yes�No 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. r` ❑Yes No 11. Are articles filed with the Secretary of State? ❑Yes No 12. Are articles filed with the County? `` ,❑Yes�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�No 14. Has license ever been denied,suspended or revoked?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 ;,;.. existence. r . 17. Name of Chief Executive Officer 18. Name of treasurer or perso�who accounts fo�other revenues of the o aniza ion. � � �/t n e r Title Title . _ 'i' ' ,e C , S. P, Business Phone Number Business Phone N mber- 1 �p I 1 - � � ( (0 1 - � - 19. Name af establishment where gambling will be 20. Street address(not P.O.Box Number) cond'ucted }. � � •c � 21. City,Stste,Zip 22. County(where gambling premises is located) �� , ,� �.. s � � i CG-0001-02 18/86) White Copy-Board Canary-Applicant Pink-Local Goveming Body � , , g�—��� � Gamt�iing License Application Page 2 Type of Application: ❑Ciass A �lass B ❑Class C ❑Class D Y sONo 23. Is gambling premises located within city limits? es�No 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 rafflesl as a separate license is required for each premises. ❑Ye No 25. Does organization own the gambling premises?If no,attach copy of the lease with terms of at least one year. ❑Yes�INo 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. ❑Yes No 28. Do you plan on conducting bingo with this license?If yes,give days and times of bingo occasions: Days Times M� Yes❑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 32. Lessor Name 33. Address 34. Cit State,Zip e �e �c�. 5-t- �� �' 3 Gambling Manager N me 36. Addres �7� Cty,Sta ,Zip Va �ve 3� � t ve �C n 38. Gambling Manager Business one 39. Date gambling manager became • (�t� � �� _ member of organization: ,`,� Q � ;. 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 or p�actice. 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 faw. �: �' 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 Nam of Or anizati � 41. Si t ru e(must be sigc�ed b�liref'�xecutive O ficer) � Y' � ` L X .'�/�'��.r.�.. �^�j l,�� �i�?'�. ��°� Title of Si Date � ` � S � $ � 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 f�om 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 Governing Body) If site is located within a township,item 43 must be completed,in �°, y.�` �- addition to the county signature. �� . `k� . j �.i.i.i.�' . Signatur person r ceiving application � 43. Name of Township � � pE ,� ;'.I �� 6;���- A _ �i'� � ��� �� Titl� Date received(30 day period Signature of person receiving application . � begins�m �$�S X c ',' . - ; , . 44. Name of Person.delivering application to Local Governing Body Title �; . '':i-i u::�. :; . �''` , ,% �`-: CG0001-02 (8/86) � White Copy-Board Canary-Applicant Pink-local Governing Body �.