87-972 WHITE - CITV CLERK
PINK - FINANCE G I TY OF SA I NT PA U L Council
CANARV - DEPARTMENT 1 -
BLUE - MAVOR Flle NO• � �
1
Co nc 'l e lution
Presented By � �
Referred To Committee: Date
Out of Committee By Date
RESOLVED: That Application (I.D.#15923) for the renewal of a State Gambling
License (Class A - Bingo, Raffles, Paddlewheels, Tipboards, and
Pulltabs) by 4th District VFW at 1060 University Avenue be and the
same is hereby approved.
COUNCILMEN Requested by Department of:
Yeas prPw Nays
�*'*���^� � In Favor
Nicos�a
SChe�bel p Against BY �
Sonnen
�T.YA9eeA�
W�Iso� .��� � �� 1987 Form Approv d by City Attorney
Adopted by Council: Date
Certified Pas � uncil Sec ar BY
gy,
A►ppro y Mavor: Date �L � � ��1 Approve Mayor for Submission to Council
B BY
Pu�ltst�A .��� 1 1. 1987 �
- . . � �� 9 y�-
nuni� . .
;••�o��?� Charitable Gambling Control Board FOR BOARD USE ONLY
" '�•9�, Room N-475 Griggs-Midway Building �� u���N��. --�
- �'� 1821 University Avenue
St. Paul, Minnesota 55104-3383 PAID
(612) 642-0555 AMT
a'`��' CHECK#
DATE
GAMBLING LICENSE APPLICATION
INSTRUCTIONS:
A. Type or print in ink.
r " 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:
�Class A — Fee S 100.00(Bingo,Raffles,Paddlewheels,Tipboards,Pull-tabs)
❑Class B — Fee 5 50.00(Raffles,Paddlewheels,Tipboards,Pull-tabs) ���kspayablsto:
❑Class C — Fee S 50.00(Bingo only) Minnssota Charitabk GambRng Control Board
DClass D — Fee S 25.00(Raffles only)
�,Yes❑No 1. Is this application for a renewal? If yes,give complete license number � - v`� %�� � - 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
- license number(middle five digits)
` Yes�No 3. Have Internal Controls been submitted previously?If no,please attach copy.
�<
��. 4.�/Ap�plicaqt(Official,legal name of organization) 5. Business Address of Organi2ation
�� 7 ���T v��- r��r' Ur ��.� /� �Ls �n/;i��=.117/ r'7 ✓!
€:' 6. City,Sta�,Zip 7. Cou�ty 8.�usiness Phone Number
�;� $- j.4�� /`1.,� ,f.T� ;:�" �f..�.YS_� 1 /� ► G yL-S.�r3
F��` 9. Type of organization: ❑Fraternal eterans ❑Religious ❑Other nonprofit`
�:'• . 'If organization is an'bther nonprofit"organization,answer questions 10 through 13.If not,go to question 14."Other nonprofit"organizations�
�''Y= must document its tax-exempt status.
��:
�''" Yes�No 10. Is or anization inc r orated as a non rofit or anization?If es, ive number assi ned to Articles or a e and
i^,1-; 9 P 9 Y 9� 9 P 9
�::: book number. 1r � �'��i' 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�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.
;,,;>,
-� OYes�INo 14. Has license ever been denied,suspended or revoked7 If yes,check all that a ly:
I';`.;
� ❑Denied ❑Suspended ❑Revoked Give date: - -
� 15. Number of active members 16. Number of years in existence Note: If less than four years,attach
�s � � � `J evidence of three years
;, � �� � � � �,��r existence.
r:
R 17. Name of Chief Executive Officer 18. Name of treasurer or person who accounts for other revenues
(' • qf the organization.
/1�r?n/K J C,' r/i'�I /,t,� i J,c'1 S � iY��',,�J�/� t!E L
�" Title Title
��- /��
�=" l. l1t/.�lAN�fiP - 4�� /�� t — �up�iE/2KASTC�
�� � Business Phone Number Business Phone Number
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�; c L/� ► .z� `,�" �� y� -' � � � Z ► �.z ?—J�// °
E, 19. Name of establishment where gambling will be 20. Street address(not P.O.Box Number)
F4:• conducted • - • ,/ E
��;: ; /l�G� U,���,:.�r,T, v�- /�Gv G',✓��i.�s ,rY t�✓
� y ty g g premises is located)
�„- :. 21. Cit ,State,Zip 22. Coun (where amblin
�':' � � �
�. $,;. /A v L , .�-� v.�'/J S� /' �:;+,r1 s,E
CG-0001-02(8/86) White Copy-Board ' Canary-Applicant Pink-Local Governing Body
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Gart�bling License Application Page 2
' Type of Application: ,�IClass A ❑Class B ❑Class C ❑Class D
JX�Yes�No 23. Is gambling premises located within city limits?
�Yes�No 24. Are all gambling activities conducted at the premises listed in It 19 of this application? If not, complete a separate
application for each premises(except raffles)as a separate license is required for each premises.
�Yes�'No 25. Does organization own the gambling premises?If no,attach copy of the lease with terms of at least one year.
�Yes�Bf 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 $ � � u�
is not required for Class D applications. �`''�07 =',t' :�lE�,�
�3Yes�No 28. Do you plan on conducting bingo with this license?If yes,give days and times of bingo occasions:
Day4- . Times
t',r't �.:7�/ ��7f :NUU�t/ ��'�- � �,?
�PJYes❑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;.,B�nd Number � �
i `_- ..,�
F1:� .�'.�t �c:, a.I.: �.�` i l '� i��% v r Y
32. Lessor Name � 33. Address 34. City,State,Zip
. ��/�.r�' • '" i�.,+.-I;'':.=;Z �,`s� �::� � G �1�,�1�✓.f: : � ; j,✓s F -�%�c.. �iJ Si/G�
35. G mbling Man�1ager Name 36. Address ,� � 37�City,,,S.�ate,Zip
%(�t L �il� v L��f i`i'L+�;�•�'r .ft i/E 7 /-/UC. �'�.: .Srr�,:i��
38. Gambling Manager Business Phone 39. Date gambling manager became
�L,�� � �� �_���� member of organization: �,�f- _ /:�y4
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
practice.
BANK RECORDS AUTHORIZATION
By my signature below,the Board is he�eby authorized to inspect the bank records of the General Gambling Bank Accounr
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 atl activities to be conducted; � �=-,
6. I will familiarize myself with the laws of the State of Minnesota respecting gambling and rules of the B�ard add agree,
if licensed,to abide b those laws and rules, includin amendments thereto. � "=
_ 40t1 �fic�I,Legal Name of O�gani1zation . 41. Sig�ature(must be signeti by�Chief Executive Offic�rr�;
T , i% � � (J!'.a " V t R�' � �'-_•���f � ��� �'f N •"7�'""
Titl�.pf Signer � ate ✓ � � ?c
Cr� D f-f/y,�.v,�E f u � � � J � --t
� c
ACKNOWLEDGEMENT OF NOTICE BY LOCAL GOVERNING BODY " {
I hereby acknowledge receipt of a copy of this application. By acknowledging receipt, I admit having bee�erved with
notice that this application will be reviewed by the Charitable Gambling Control Board and if approved by t e 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.
�
Signature of person receiving application 43. Name of Township
x ��'����-� '
Tit e Date received(30 day period � Signature of person receiving application
'���r'r�SE� ���5�"<]`or begins from this date! �/ $ X
44. Name of Person delivering application to Local Goveming Bod Title
CG-0001-02 (8/86) White Copy-Board Canary-Applicant Pink-Local Governing Body
, , , ��7�7�
. � - „ � City of Saint Paul
.` � Deparcment of Finance and Management Services
Division of License and Permit Registration
INFORMATION REQUIRED WITH APPLICATION FOR PERMIT TO CONDUCT CHAR.ITABLE GAMBLING GAME IN
SAINT PAUL
1. Full and complete name of organization which is applying for license
y � �,s�; v��J
2. Address where games will be held ��(o D 1�j�1��E,Qri%l�yf• S;��v� S�/oy
Number Streec City Zip
3. Name of manager signing this application who will conduct, operate and manage
Gambling Games PC J �i�,y,,�,��.2 Date of Birth /.�2�/7����
(a) Length of time manager has been member of applicant orgar.ization /Qv� - /9 y9
4. Address of Manager Z D/J� � c.AeE �vE. S;. /AV� -s-f���
Number Screet City Zip
S. Day, dates, and hours this application is ior
/I���As� /�"f1F.PNoo.�s- - /.'.�a --�:,3a
6. Is the applicant or organization organized under the laws o: t�e State of �I? E.f
7. Date of incorporation ;� � �p,Qi� � y- /� FG - �l 9�� 5�N
8. Date when registered with the State oi Mircnesota De-r �2 7"/9�� '
9. How long has organization beea in existence? ��p�� �� y�
10. How Iong has organization been in existence in St. Pau1� � 9 y�—
11. What is the purpose of the organization? ��';E�,�,� o F �d.��e-,L ,�, �,cJ,4ic.
/-�C,4��,r.�a� P,Q,-R,oc;e
I2. Officers of applicant organization
Name C.0 �1i4J�NAE.e f'�PArv�c 5��•+►iv._ vame J,Etf /F �o� �?/GOE'Z-
Address � 9� � �sffE��c.t /�u�✓ Address 9f�o� �GATf
Title (,"oHH,a d��.� DOB Tit1e �,(�l.«/AlTEiC DOB
,.Name �?. ��E �9N.�1- �LiiYE1 C o.u,vac.�v Name �LJvn�r�+..� �I.cD B.�/a
' Address ��O y1r yE.v�v�1v I'v - �-�/// 3ddress i 9.�� E y�.;� 9`
T'itle SR �/CE G vili'f DOB Tit1e �,P �i�6 Coil�y• DOB
13. Give names of officers, or any ot::er persons •�no paid �or ser�ices to tne organizat;en.
Name � Vama
, �
Address :�ddre�s �' ^
Title --��z
(Attacr separate sze�r� .'• _ �c::_:or.s_ ���as• �
. � � , ���7-9��
'ZI. The proceeds of the �ar�es wili be disbursed after deducting prize layout costs and
operating expenses for the iollowing purposes and uses:
10GAv �S'�[!TH �EAG✓tt � � ,(��STR/C : /�lA�'!7'�rlrf /al� LlAGu£ ^- /Z i E,4�yc
., � ` „ 1 a
�DG�E ✓ �,EAGvE ' �S �lAiY! •
/7Gj�iTr4l. LrldRK� //•y �Oj/• " /(J/CE of �E/y �d�..P.O�f�^ �OC�A�//iGNlC�/YJO•r � 0%�j(�t
SER�•�'E'•y�•� G'�.�+sE.�- .S9re�.a.. ��y.�r���s - Pop/Y QuFt..�No✓rer :- �GAKE Ow.aSto:/o.,r�-
2Z. Has the premises where the gzmes are co be held been certified for occupanc}• by the
City oE Sainc Paul? ��S
�
23. Ras your orgar.ization �iled =ederal torm 990-T'. �� I� answer is yes, please attach
a copy wit;� tnis applicac:on. Ic answar is no, e:cplain why:
�it��e� c..- QDtI- SA�S cJ� Di�� �T Na�E /N�v�s� Evu..c.sTo �AvE
?o �iaC.
Any changes desired bv tae apo�?ce.1c �ssociacion ma� be �ade onl;r wich t;;e consent oi the
City Council.
y � " �
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Orgaa'_zac:on
Date �.'�`� By:
Maaa�e: in charge o* game
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