87-1235 �NHITE - CITV CLERK
PINK - FINANCE GITY OF SAINT PAUL Council
CANARV - DERARTMENT / Flle NO. ��s���� --
BLUE - MAVOR
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Council Resolution -�,
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Presented By �--
Referred Committee: Date
Out of mmittee By Date
RESOLVED: That Application (I.D.#58941) for a State Gambling License Class A
(Bingo, Raffles, Paddlewheels, Tipboards, and Pulltabs) by
Mahtomedi Youth Hock y Assoc ation at 1324 E. Rose be and the same
is hereby wppre�re�-.�„�;.e� .
�
COUNCILMEN Requested by Department of:
Yeas Drew Nays �
Nicosia � In Favor
Rettman
Scheibel �__ Against BY
Sonrien
Weida
wilson AUG � � �J$j Form Approve b City Attorney
Adopted by Council: Date
Certified Pas e ' u cil ,ecr r BY
B�I � A
A►pprove Mavor: Da '- ' ►9�i Approved by ayor for Submission to Council
By
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C- _�- `61 ti '�-I � �� /..�a �..--
• DIVISION OF LICENSE AND PERMIT ADMINISTRATION DATE �/' �1- �'2`�
INTERDEPARTMENTAL REVIEW CHECKLIST
Applicant Y �Y ��m�Q;�_��►�`�#Iome Address��,("�,�x ��
W� ��e.✓nu� s�o`��
Business Name �(�r�.� Home Phone �a� - �l 3�
Business Address �?��- �. 12,c�¢- 1�pe of License(s) �� � 5-��-
Business Phone ' �r1`7 'p�S d� ��� . h�C��-
Public Hearing Date , �� License I.D. # ��� `-t' ,
at 10:00 a.m. in the Cou il Chambers,
3rd Floor Citq Hall and Courthouse State Tax I.D. # Il�
REVIEW DATE DATE INSPECTION
APPN REC'D VERFIID COMPUTER CO1rII�IENTS
�oved NOt
Housing & Bldg �
Code Enforcement � IA �
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Public Health � �� j
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Fire Prevention p I � 4
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Police I
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City Attorney �
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ENS � I� I
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300 Foot Notice I
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License Inspector's Comments:
I HAVE BEEN GIVEN A COPY OF THI5 NOTIFICATION AND UNDERSTAND THAT MY ATTENDANCE AT
THE PUBLIC HEARING IS REQUIRED.
, - , _ �- , • y u � . ?
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CURRENT INFORMATION NEW INFORMATION
Current Corporation Name: New Corporation Name:
Current DBA: New DBA:
Current Officers: Insurance:
Bond:
New Officers:
Stockholders:
. . . 0 �, � , _
v��„ „ C� c�'� /�7.�5
' -���� Charitable Gambling Control Board FOR BOARD USE ONLY
.�o„�o�„��
:.{�-' U.��•
, ��':&� Room N-475 Griggs-Midway.�uildin� UcenseNumber
- �'� 1821 University Avenue,,. �. ,_ ':�:,
_ _ _ St. Paul, Minnesota 551.04-�3'$3��t,:�� �;.r A�p
(612) 642-0555
�;��s; . ��8� ,J�L �� F'� Z; 29 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:
�ClassA - Fee S 100.00(Bingo,Raffles,Paddlewheels.Tipboards,Pull-tabs)
❑Class B - Fee S 50.00(Raffles, Paddlewheels,Tipboards,Pull-tabs) Makecheckspayableto:
__ ❑ClassC - Fee S 50.00IBingoonly) MinnesotaCharkableGambBngControlBoard
❑Class D - Fee 8 25.00(Raffles only)
OYes ONo 1. Is this application for a renewal? If yes,give complete license number � - 0 - 0
_ ❑Yes C1No 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�1No 3. Have Internal Controls been submitted previously?If no,please attach copy.
4� Man omeG�f�'outhgai�a{n�e�for�ganiz�tion) 5. Business Address of Organization
.,ociat_on p,�,��x_ 6��!+, 4iillerni�. ?�ri 55�9n
6. City, State,Zip 7. County 8. Business Phone Number
Wi?ierniF�, ?�!ti 55G�10 Waa:;in :.ton ( 612 � 777-i?�?,'
9. Type of organization: ❑Fraternal ❑Veterans ❑Religious �Other nonprofit"
*If organization is an"other nonprofiY'organization,answer questions 10 through 13.If not,go to question 14."Other nonprofit"organizations
must document its tax-exempt status.
Yes�No 10. Is organization incor orated as a nonprotit organization?If yes,give number assigned to Articles or page and
book number: ��yy � �� Attach copy of certificate.
QYes ONo 11. Are articles filed with the Secretary of State?
�Yes�No 12. Are articles filed with the County?
�(es�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�1No 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
1 EQ evidence of three years
l 8 existence.
17. Name of Chief Executive Officer 18. �lame of treasurer or person who accounts for other revenues
of the organization.
Mike .farsha2l '_�aynard Soderber�
Title Title
President �r2asurer
sirt s Phone Number Business Phone Number
or�e
1oI2 � 426-515; � 612 � i33-1249
19. Name of establishment where gambting will be 20. Street address(not P.O.Box Number►
conducted ,� �
r'n A r.;G� rV i ;il C� � 3 z-`I L,�+s C !"<0 5 e 5 L
21. City,State,Zip 22. County(where gambling premises is Iocated)
St �a.:l, :•'in;:esota R2r�£ey
, CG-0001-02 18/86► White Copy-Board Canary-Applicant Pink-Local Goveming Body
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� Gambiing License Application Page 2
� Type of Application: �Class A ❑Class B ❑Class C �Class D
Q.Yes�No 23. Is gambling premises located within city limits?
f�Yes ONo 24. Are all gambling activities conducted at the premises listed in #19 of this application? If not, comptete 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 m 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 $ � ��
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
'iHL;:�SDLi1S 7 :i70 � �G li :�JC:} � .:1.
�]Yes❑No 29. Has the 510,000 fidelity bond required by Minnesota Statutes 349.20 been obtained?Attach copy of bond.
30. Insurance Com�any Name 31. Bond Number
.s i ! � � �� a.��;,. 5�rF�c S� c,'' �o ) �S ?Z SO(�
32. Lessor Name 33. Address 34. City,State,Zip
/�fA.t/G/N /NC // 7 Lr?,E:B,v�C 5�' SL`. Friu.�
35. Gambling Manager Name 36. Address 37. City, State,Zip
Roger J. Baron ;i;l 70t� Street � � t ���� '�i s
38. Gambling Manager Business Phone 39. Date gambling manager became
� ��2 � ���_��9_ memberoforganization: �/�.j�o�
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 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 othe�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. t 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 Executiv� fficer)
?�iattto*�edi Xouth �iocka�r Association X -�s��,,r"�.� �! '�i�.�`�'st/��`-�-<'� '
Title of Signer Date
Presi:.tei:t 6/2.�%37
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 resotution 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
addition to the county signature.
Signat�re of person receiving application 43. Name of Township
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x �.-,�,�:��, }' ',�i .,,;,:.`�r_ �„s�
Titl�i �� � Date received 130 day period Signature of person receiving application
��,��!� v, _ ,r:f begins from this date) �`f' , — _,
' f I . �'J : ,X
44. Name of Persmn delivering application to Local Governing Body Title
Y
CG-0001-02 18/861 White Copy-Board Canary-Applicant Pink-Local Goveming eody
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. ���-�-���s
- City of Saint Paul
'. � ' Department oF cinance and Management Services
� Division of License and Yermit Registration
INFORMATION REQUIRED WITH APPLICATION FOR PERMIT TQ CONDUCT CHARITABLE GAMBLING GAME IN
SAINT PAUL
1. Full and complete name of orRanization which is applying for license
Mahtomedi Youth Hockey Association
2. Address where games will be held 1324 East Rose St, St paul
vumber Screec Cicy Zip
3. Name of manager signing this application who will conduct, operate and manage
Gambling Games Joan Forliti Date of Birth 2-15-38
(a) Length of time manager has been member or applicant orgar.ization 11 yrs
4. Address of Manager 530 Robert Court Mahtomedi 55115
Number Street Cicy Zip
5. Day, dates, and hours this application is ror THURSDAYS 7 •00 P.M. TO 11 •00 P.M.
6. Is the applicant or crganization orgar_fzed ur.der the Iaws o= t�e State of �IN? Yes
7. Date of incorporation 10/24/69
8. Date when registered �aith the State of �I�nnesoca 11/5/'69
9. How long has organiZation been in e:tiscence? 18 years
10. How long has organization been in eYistence in St. Paul^:
11. What is the purpose of the organization? promote and manage a youth Y:ockey
pr��r.a�r� ir. the ?'�ah,tomedi area.
I2. Officez+s of applicant organizacioa
0
1
Naaia� �=Mike Marshall ;��e :'udge Soderberg
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A��ess^ 67 Grove St. , Mahtomedi 55115 Address 308 Charing Ln. , Willernie, MN 55090
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T�'1� ¢r�esident DOB �, !�,����;� Title Treasurer DOB � -:��= ' `�::
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Vame�� ,127.ck Spannbauer Name Jim LeMere
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Address :�ddress 36 Grove St, Mahtomedi 55115
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TYtle Vice Pres DOB ��� �? '� `-+'� �'_ci� Secretary 'pB Cj - a Co-� �
13. Give names of officers, or any ot:�er persor.s ane ?a:d ::or se:r:ces to �ae organi�at�on.
�'ame Vame
Address address
Title _y�?2
(Attach separata �ne��� -. - ac:i=�_c--- .._=_s. '
C�-�'7-i.� 3S
� 2I. The proceeds o: che ga�aes will be disbursed after deducting pri2e layout costs and
operating expenses for the following purposes and uses:
To promote Youth Hockey in Mahtomedi
22'. Has the premises where the games are co b� held been certified for occupanc}� by the
City of Sainc Paul? Yes
23. Eias your orga.�zation riled cedera' �orm 990-T' yeS IL answer is yes, please attacn
a copy WiC�I t�,is applicac�on. Ic answar is no , explain why:
P.ny changes desirec �•, tae a��?�caz� 1ssociac'_on ma� be �ade only wich t;;e conser.t or the
City Counc�l.
Mahtomedi Youtfi Hockey Association
Or�az_zaclon
�ate � - �-��7 By:
Lia ger in charge or ga�
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____________���________________ AGENUA ITEMS -_--________���_-�_����______-__-
___ ___ _ _ __ _ _ __ _ _
ID# C152 7 DATE kEC.: CU1/28/07] AGENUA AATE: C00/00l00] ITEM #: C ]
SUBJECT: CGAMBLING LICEMSE ARRROVAL - PIAHTO�IEDI YOUTH NOCkEY ASSM ]
5TAFF ASSIGMED: C ] SIG:C ]OUT-C ] TO CLERK:C04/00/00]
ORI6IMATOR:CLICENSE DIV. ] COMTACT:C ]
ACTIOM:C ]
C J
ORD/RES #:C ] FTLED:C00/00/00 ] I.00.:C ]
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FILE INFO: CRESOLUTIOM/CHECKLIST/APPLICATIQN ]
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C 7
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