87-1236 WNITE — C�TV CLERK
PINK — FINANCE COUIICII -��sJ �J (//�
CANARV — DEPARTMEN G I�TY OF SA I NT PALT L �! �/K�l� �
� BLUE — MAVOR File NO•
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Council Resolution , ;�
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Presented By
Referre T Committee: Date
Out of mittee By Date
RESOLVED: That Application (I.D.#59630) for a State Gambling License (Class
B - Pulltabs, Tipboards) by Como Area Hockey Association at
1084 W. Larpenteur (Ted's Rec) be and the same is hereby
approved.
COUNCILMEN Requested by Department of:
Yeas Drew Nays �
Nicosia
Rettman [n Favor
Scheibel d Against BY
Sonnen
W�ida
WilsOri AUG � � 1�a� Form Approve y City Attorn
Adopted by Council: Date
Certified Pass d y C ncil S cret By
gy.
A►pproved iVlavor: Date
� — � ��T Approved by ayor for Submission to Council
By BY
pUB�ISNED S L P 1 2 19�8T �
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� G.�-- � �3l ��"1 � � ��"� � 51
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� DIVISION OF LICENSE AND PERMIT ADMINISTRATION DATE � '02 �(I ��I
INTERDEPARTMENTAL REVIEW CHECRLIST
Applicant � rY�p IfiYeS�.�,v� �����e Address �� '1 (..� �e�S�eC,� �� •
Business Name �-��A. Home Phone `�t'�l - ( o� �i S�
Business Address l c� t{� (.,J.���.:�� TYPe of License(s) l��.[,��5� �
Business Phone "Ng�� �`Z�'1,Y C,���1�.r.� �CstM.�-
Public Hearing Date (� $ License I.D. � '� 4 (.P�j �
at 10:00 a.m. in the Cou il C ambers,
3rd Floor City Hall and Courthouse State Tax I.D. #
REVIEW DATE DATE INSPECTION
APPN REC'D VERFIED COMPUTER) COI�IENTS
baved Not ra�ved
Housing � Bldg ��� (
Code Enforcement �
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Public Health �
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Fire Prevention � \ 4
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Police �
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City Attorney �� � � �
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300 Foot Notice n '� ;
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License Inspector's Comments:
I HAVE BEEN GIVEN A COPY OF THIS NOTIFICATION AND UNDERSTAND THAT MY ATTENDANCE AT
THE PUBLIC HEARING IS REQUIRID.
.. s
CURRENT INFORMATION NEW INFORMATION
Current Corporation Name: New ,Corporation Name:
Current DBA: New DBA:
Current Officers: Insurance:
Bond:
New Officers:
Stockholders:
! ,' 1
� ���,,,,,�, � � � ��� �G'
;'ZO����Ih� Charitable Gambling Control Board FOR BOARD USE ONLY
��'�� Room N-475 Griggs-Midway Building
- :� 1821 University Avenue ���B��N�►
_ St. Paul, Minnesota 55104-3383 PAID
(612) 642-0555 AMT
�,*i�} .. 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:
�Class A — Fee S 100.00 IBingo,Raffles,Paddlewheels,Tipboards, Pull-tabs)
�Glass 6 — Fee S 50.00(Raffles,Paddlewheels,Tipboards,Pull-tabs► Makecheckspayableto:
❑Class C — Fee S 50.00 IBingo onlyl Minnesota Charitable GambRng Control Board
❑Class D — Fee S 25.00(Raffles o�ly)
❑Yes�1Vo 1. Is this application for a renewal? If yes,give complete license number � - � - 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 Internat Controls been submitted previously?If no,please attach copy.
4 Applican (0fficial,legal name of organization� 5. Business Add,r.�ess of Or ization
`� ~' �D.�'7;? L .
i1'J D �'�' G JT.� a t�)' 'f S< . c/ vt �.'
6. �ity,St ,Zip 7. C9(lity 8. usiness Phone Number
J i� J! .SSI D�3 ��5�" 1�1.� ► '�1�$ '!� i�
9. Type of organization: ❑Fraternal aVeterans ❑Religious �Other nonprofit*
'If organization is a�"other nonprofiY'organization,answer questions 10 through 13.If not,go to question 14."Other nonprofiY'organizations
must document its tax-exempt status.
�,,Yes O No 10. Is organization incor orated as a nonprofit organization? If yes,give number assigned to Articles or page and
book number. � �� -3� Attach copy of certificate.
,�(Yes❑No 1 1. Are articles filed with the Secretary of State?
�es ONo 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.
DYes�lo 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
�O� � �e�s evidence of three years
existence.
17. Name of Chief Executive Officer 18. Name of treasurer or person who accounts for other revenues
of the organizatian.
�� �� � C /"a J7 J+� ��J J�l�r
Ti e Title
' E s : D F ,�; ��,�s v,e,�,z
Business Phone Number Business Phone Number
� � .�► �g � - G � 98 � Gf �► �� 8� - o� s �
19. Name of establishment wheie�gambling will be 20. Street address(not P.O.Box Number)
condy�s� � � �t L / � `� � v�/ �A(����l T,tC/9 v
/
21. City,State,Zip 22. Co�y(where gambling premises is Iocatedl
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S s , tJ L ��hl . � .`� �Q G: l�i� t`/� s .0
CG-0001-02(8/86) � White Copy-Board Canary-Applicant Pink-Local Governing Body
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Gambting License Application Page 2
• Typa of Application: ❑Class A �lass B ❑Class C �Class D
�Ces�No 23. Is gambling premises located within city limits?
DYesl�elo 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 raffles)as a separate license is required for each premises.
❑Yes�o 25. Does organization own the gambling premises?If no,aitach copy of the lease with terms of at least one year.
DYes�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�jllo 28. Do you plan on conducting bingo with this license?If yes,give days and times of bingo occasions:
Days Times
Yes�No 29. Has the 510,000 fidelity bond required by Minnesota Statutes 349.20 been obtained?Attach copy of bond.
30. surance Compan Name 31. Bon Number
�%'t3�'�= � �,E -r �� 9 y/
32. Less r Name 33. Addre� 34. City,S�^dte,Zip �
r�.�.tii 0� .L� ��'/I7' "! 5 3� � �t,JE.�L/��/� ..S i•�/¢'JL , . SJ/� 7
35. G bling Manager Name 36. Address f 37. City,St�a ,Zip
!C t? r� /_� 1��?�o C_��.-n 0 �,: S?'. T 1��L. ff�i?� •S_S �.�
38. Gambling Manager Business Phone 39. Date gambling manager became �
( � � � � �j 1 _ G! member of organization: � _ �, b -��
I ��-� -J / � 7S
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 AUTHORI2ATION
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 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, Le I Name ofprganization 41. Signat��se lmust be sigr7red b hj�f Ex utive Officer)
� ;?�;� � � r� >C c�f_ :/ 5 S�, x -:�'�! <..��� �l ��. �
Title of Signer� � j ,'- Date ✓, �.;y, i���.-,(�
"f^.. t"'f_'r^''�iJ/ Lr�L! '?'� ' � �!J �
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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 Inoted 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
-I _ addition to the county signature.
� � �
Signatur�of person receiving application 43. Name of Township
X', , ' • - �
Title Date received(30 day period Signature of person receiving application
begins from this date)
!.� . --T ; -,-� 4 <;``�1 x
44. Name of,Person delivering application to Local Governing Body Title
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CG-0001-02 (8/86) White Copy-Board Canary-Applicant Pink-Local Governing Body
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______________________________ AGENUA t�'�.Mti --_—_—_—___�-��__����—_—_____—__—
ID �G�151 ] DATE kEC.: C01/28l07] AGENDA UATE: C00/00/007 ITEM #: C ]
SUBJECT: CGAM$LING LICENSE APF'kOVAL — COMO AREA HOCKEY ASSN AT TED'S R£C ]
STAFF ASSIGNED: C 7 SIG:C ]OUT—C ] TO CLERK:C00/00/00]
OkIGIMATOR:CLICENS� UIV 7 CONTAC7:C ]
ACTIOMeC ]
C ]
OFD/RES #:C ] FILED:C00/00/00 ] LOC.:C ]
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FILE INFO: CRESOLUTION/CHECKLIST/APRLICA7ION ]
C ]
C ]
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