87-970 WHITE - CITV CLERK
PINK - FIN�ANCE G I TY O F SA I NT 1 A ll L COIIIICII AA� w��
BLUERV - MAVORTMENT File NO. Q / `�
� Cou ci es lution
Presented By � ' � -�'`�
Referred To Committee: Date
Out of Committee By Date
RESOLVED: That Application (I.D.#39333) for the renewal of a Class A State
Gambling License (Bingo, Raffles, Paddlewheels, Tipboards, and
Pulltabs) by Mary, P�Iother of Mercy �, Good Hope Shelter Inc. at
1494 North Dale be and the same is hereby approved.
CQUNCILMEN
Yeas Nays Requested by Department of:
Drew
-masa�- /i�,l��'rtl�r� In Favor
t�licos:,
_ � __ Against BY
Sch ei b, --
$p!1l1Pr'
�
y�At� �'�=- —' � �7 Form Appr d by City Attorn y
Adopted by Council: Date
Certified Pass d by C,�ec ry BY
sy� .
A y Mayor: Date J L °'� �7 Approve by Mayor for Submission to Council
_ _ By
Pt��lisl�ED J�J L 1 1 1.98�
� . � ��� ���
, ; ,- s � � � • Cicy of Saint Paul
'. Department of Finance and Management Services
Division of License and Permit Registzation
INFORMATION REQUIRED WITH APPLICATION FOR PERMIT TO CONDUCT CHAR.ITABLE GAMBLING GAME IN
SAINT PAUL , , . ,
I. Full and complete'name of o�ganization which 'is applying for license
i�L�Y, i�AT��B. OF :'�.0� �c GOOD HfJP:. SiiELTEP�, Il�LC.
2. Address where games will be held 1l�9�. PTorth D21e 5�... St.Paul� I•�1. 5�117
Number Street City Zip
3. Name of manager signing this application who will conduct, operate and manage
Gambling Games a,� �'� �1�?, Date of Birth 7�7��3
(a) Length of time manager has been member ot applicant organization 1.1. ye2Ss
4. Address of Manager �25� :^lest ELdxidg� �lve., St. Paul� 2-��? 57113
Number Stree.t , Cit,y Zip
5. Day, dates, and hours this application is for i�,lednesday �fternoons 1 to 5
6. , Is the applicant or organization organized under the ].aws o= t:�e State of 1Rd? �FS
7. Date of incorporati�n 11/25/81
8. Date when registered with the State of �i�naesota 11�25�81
9. How long has organization been in existence? � years
10. 8ow long has organization been in esistence in St. Pau1? 11�25�81
• 11. What is the purpose of the organization? To �rovide the basic necessitiss of food,
clothin� & snelter to its residents. To insure the '^_ealth of the residents -� tr.at of
their un�oYn. crild. �o offer �rog�^a^�s �,o t�s �esiden�s to iielp ths� develon maturelf.
12. Officers of applicant organizatiorc -
Name Crer�ll Trombley :tame John �tel
Address 920 Qhio �t., :T. St. Paul 5K118 Address 1188 Seninole �ive., St. Pau]. 55�18
Title president DOB 1/7/56 Title Vice Presidsnt DOB o/$/31
Name Jean 2�.nning `tame Stella I,undquist
Address 3�9 Ottzwa Ave., St. Paul 55�07 �ddress 1360 Ih�esdan Ct., Eag2n, I�I. 55�23
Title Secretar.y DOB $/� 3��,Q , Ti��e Treasurer DOB 9/�5/29
13. Give names of officers, ar any ot�:er persoas uho pai3 �or serfices to tne organizat�on.
�vame none � Vame
Address ' ddd_e�s �
Title --�?e
(Arcach sepa-ate sne� '..- �cc__`_or.�_ ..-�_as• �
� _ � . �-�.�_�,d
. . . .
2I. The proceeds oi the gacaes will be disbursed after deducting prize layout costs and
operating e:cpenses for the following purposes and uses:
N�, 2���tl�.�r of Mercy � Good u.ope ahelter, Inc. To provide the basic nece�sities
of foad, clotivng and shel�er to its residents. 2b insure t�e .zea.].t>i o� tze resi-
dents and trat of tr��r vnborn c?�ild. To offer �ro�rams to t�ie resident� to hel�
th�rs C�GPBIOT� :�ature?�. '
2T. Nas the prem�ses where the games are to be held been certified for occupanc}• by the
City of Saint Paul? v�
23. Iias your orgar.ization riled cedera' �or:n 990-T' s �^ If answer is yes, please attacn
a copy wit;� this epplicacLon. I: answar is no, e:cplain why:
Any changes desired b•r tae ap�l�canc �ssoc�ac�on ma� be made onlr with t;;e consent o� the
City Counczl.
1�LaRY, PZOT_::�.� OF P�LRCi' �: G00� :'iOPE SF-�.T�, i�:C
Or az_zation
Date G"'K-~�. �• .
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' :.�o;��o��??�;a� Charitable Gambling Control Board FOR BOARD USE ONLY
'-� Room N-475 Griggs-Midway Building �
- :'� 1821 University Avenue LicenseNumber
_ St. Paul, Minnesota 55104-3383 �p
(6121642-0555
�`j�' .. CHECK#
DATE
GAMBLING LICENSE APPLICATION
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. Incomplete applications will be returned.
Type of Application:
I s — Fee 5100.00(Bingo,Raffles,Paddlewheels,Tipboa�ds,Pull-tabs)
lass B — Fee S 50.00(Raffles,Paddlewheels,Tipboards,Pull-tabs) �����Y�ta=
qClass C — Fee S 50.00(Bingo only) Minnesota Charitabls GamWing Control Board
�Class D — Fee S 25.00(Raffles only)
. �Yes❑No 1. Is this application for a renewal? If yes,give complete license number � - } �{�"L _ 0 U 1
❑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. pplicant(Off�ial legal name of organization) 5. Business Address of Organization
�:Mary,M�oth�r oL l�erc�u(�aod riop� ;.z�lter , I �c. 1�OGB �akd�le Ave.
F',� 6. City State.Zip 7. County 8. Business Phone Number
�'`
sb,�t ,P�ul, i�in. 5511II Dr�kota ( bI2 ) 457-SSr39
L��:� 9. Type of organization: ❑Fraternal ❑Veterans OReligious DOther nonprofit"
��'` 'If organization is an"other nonprofit"organization,answer questions 10 through 13.If not,go to question 14."Other nonprofit"organizations <-
€''� .
`�= must document its tax-exempt status.
�1`�', �Yes�No 10. Is organization incor orated as a nonprofit organizationl If yes,give number assigned to Articles or page and
��':`':. book number: U-353 Attach copy of certificate.
ti`r,'
QYesONo 11. Are articles filed with the Secretary of State?
'~ �YesONo 12. Are articles filed with the County?
Y'
�Yes❑No 13. Is organization exempt from Minnesota or Federal income taxl If yes,please attach letter from IRS or Department of
� Revenue declaring exemption or copy of 990 or 990T.
- DYes C�No 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
f. evidence of three years
33 five and on�-;�alr yrars existence.
17. Name of Chief Executive Officer 18. Name of treasurer or person who accounts for other revenues
- of the organization.
;�:
Cher;1 Trorble f Stella Lun:iqtiist
';' Title Title
E. ' President Traasurer
�_'
t; Business Phone Number Business Phone Number
�'
�;: f 612 1 �+55�8663 1 f,12 1 452,-�'i��
�;
<: 19. Name of establishment where gambling will be 20. Street address(not P.O.Box Number)
�-: conducted
�=
Zde�l :iall 1494 '�i� � A
� 21. City,State,Zip 22. County(where gambling premises is located)
�� St . :�ul, :'In. 351�7 �amye�
�..
CG-0001-02(8J86) White Copy-Board Canary-Applicant Pink-Local Goveming Body
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'Gambling License Application P89e 2
Type of Application: ❑Class A ❑Class B ❑Class C �Class D
QQYes❑No 23. Is gambling premises located within city limits?
CFYes�No 24. Are all gambling activities conducted at the premises listed in 1�19 of this application7 If not, complete a separate
-- application for each premises(except raffles)as a separate license is�equired for each premises.
OYes�No 25. Does organization own the gambling premises?If no,attach copy of the lease with terms of at least one year.
' mYes�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 Sj,75.00+ $1�l.00 e�--
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: "''". ` `" ��I
°ers �1edr.•e�daYs. 1 :�)`��5:'•)(?PT.""°s :
(�Yes❑No 29. Has the S 10,000 fidelity bond required by Minnesota Statutes 349.20 been obtainedT Attach copy of bond.
30. Insurance Company Name 31. Bond Number
�ou �:,onnor T�sur�ncA �P�29729v
32. Lessor Name 33. Address 34. City,State,Zip
"sat ' s S'i�ItF�r 1?t70�'> »a��ciale :1ve. �d.�t . i'�u1 .'1:^.. 55??^
35. Gambling Manager Name 36. Address 37. City,State,Zip
�1nn �r�i�h 12�� ;; :�l.dri��e �t Y�.�zl ;�n :-�S I3
38. Gambling Manager Business Phone 39. Date gambling manager became
� f 13 � �i��4-�733 memberoforganization: re}� Z g�
GAMBLING SITE AUTHORIZATION
By my signature below,local law enforcement officers or agents of the Board are hereby authorized to enter upon the site,
'`r: � 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 cur�ent gambling rules and law. ��3 '
};;. - OATH _
1 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
S
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�hereto. •
40. Official,Legal Name of Orga�ization_ _ 41. Sign�ture(muspbe signed by C 'ief Executive Officer)
MBry,:l��:t��r u:. .I��ey;ivood tiop� :i^�1±'^ � r ' '
` ' IIX'' 6�.�iWwl L1� t/ryr� f
Title of Si ner Date �� '
�r�sid^n� (1
������ ,�., �
,
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 belowl,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 Controf
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
� . � �� addition to the county signature:
� `Z- � - '�+„ .���._,�
Signatur�of pe�son receiving application 43. Name of Township
} �r ' � ` i ,, ,�`' ' �/�:
X• ; �
1 itle� ' Date received(30 day period Signature of person receiving application
begins fro this date)
h_:tc . ' + i� 1 `!�� X
44. Na,me of Person deliveri applicafion to Local Goveming Body Title
/tis��t ;�. �..�..
CG-0001-02 (8/86) White Copy-Board Canary-Applicant Pink-Local Governing Body
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