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87-1305 N�HITE - C�TV CLERK PINK - FINANCE GITY OF SAINT PAUL Council �?_ � � CANARV - DEPARTMENT File NO• ��� BLUE -MAVOR � Co cil R olution ` � �5Presented By � Referred_To Committee: , _ Date Out of Committee By Date RESOLVED: That Application (I.D.#42907) for a Class B State Gambling License applied for by Neighborhood House at 199 E. Plato (Awada's) be and the same is hereby approved. COUNCILMEN Yeas ��P"' Nays Requested by Department of: ��`7h,.�., 'Mn�m� N�cos,e In Favor scneibel _ a�- � Against BY �/I e i �E� �_,. �.� Adopted by Council: Date SEP - g 1987 Form Approved by City Attorney Certified Pa s ouncil e BY By �+ A►ppro y 17avor: Date JG �'9 ��7 Approved by Mayor for Submission to Council BY BY P�{��p S�P 1 9 1987 � ��j- / � p� DIVISION OF LICENSE AND PERMIT ADMINISTRATION DATE INTERDEPARTMENTAL REVIEW CHECRLIST Applicant o , Home Address 1� �1 � ��b�,,, 5-� Business Name �jc-.c�D , Home Phone adl-�1��t � Business Address � Ctr'L �C .��G�n 1�pe of License(s) �C� �j �9- � p� � Bus ine s s Phone ,l(yti,.a,.� •�,Q;,►�,�,:tn.�-i c.C�'-t a,-� Public Hearing Date License I.D. # 'T�a.�C�1 at 10:00 a.m. in the o ncil Chambers, 3rd Floor City Hall and Courthouse State Tax I.D. # n(/�- REVIEW DATE DATE INSPECTION APPN REC'D VERFIED COMPUTER) COMMENTS iroved Not raved Housing & Bldg �I � . Code Enforcement � � I Public Health I I� I I I Fire Prevention � 1`��a i i Police c�l 1C/ � b � City Attorney � t I ENS � � �� � 300 Foot Notice I � �� � � License Inspector's Comments: I HAVE BEEN GIVEN A COPY OF THIS NOTIFICATION AND UNDERSTAND THAT MY ATTENDANCE AT THE PUBLIC HEARING IS REQUIRID. . _ . , , . . .. .. � . . . _ " . . . ,.__#'.,r,4 . , . � . , � ..r.-.. �..�Yd . . .. , .�i' . . CIIRRENT INFORMATION NEW INFORMATION Current Corporation Name: New Corporation Name: Current DBA: New DBA: Current Officers: Insurance: Bond: New Officers: Stockholders: �`7 _/,J�..� • ` „ ' s _ -"�� � ° Charitable Gamblin Contro�Board d,.�r--�?`"', . pLLLDU �2,,, g � FOR BOARD USE ONLY'� �- . :.<_ -��,�, , �� �� Room N-475 Griggs-Midway Building u�e�SeN��,ne� 1821 University Avenue µ`�� St. Paul, Minnesota 55104-3383 �- � - (612) 642-0555 qNjD �`l�' '. CHECK# ��u.m DATE GAMBLING LICENSE APPLICATION INSTRUCTIONS: ; A. Type or print in ink. P 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 retumed. Type of Application: �Class A - Fee S 100.00(Bingo, Raffles, Paddlewheels,Tipboards,Pull-tabs) � ,��C'fass B - Fee S 50.00 lRaffles,Paddlewheels,Tipboards, Pull-tabs) Makecheckspayableto: ❑Class C - Fee 5 50.00(Bingo only) Minnesota Charitable Gambling Control Board ,. OClass D - Fee S 25.00(Raffles only) � 0 - � - 0 �Yes�l�lo 1. Is this application for a renewal? If yes,give complete license number ❑Yes C�11to 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 •IVo 3. Have fnternal Controls been submitted previously?If no,please attach copy. _ 4. Applicant(Official,legal name of or anization) 5. Business Address of Organization Nei�'�borhood t{o,:se Assoc�t��a��n, Inc. I7� ': ^o'�;V "�. ' �<� 6. City,State,Zip 7. County 8. Business Phone Number ��''"" St. Paul, '•^1 �51Q7 Rs:^sey ( 612 ) 227_�;��t Y,�- . ,ies:°. :'� 9. Type of organization: ❑Fratemal ❑Veterans ❑Religious 1�Other 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. � ' [�Yes�No 10. Is organization incor orated as a nonprofit organization? If yes,give number assigned to Articles or page and book number. F'� 'vs.517 Attach copy of certificate. • Yes❑No 1 1. Are articles filed with the Secretary of State? �oCi3I �:I° "�i 1�� ❑Yes❑No 12. Are articles filed with the County? f�Yes ONo 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 L7No 14. Has license ever been denied,suspended or revoked?If yes,cFieck 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 ., � ` � evidence of three years `��' - �f'` existence. 17. Name of Chief Executive Officer 18. Name of treasurer or person who accounts for other revenues of the organization. '`arily?: r. �'i �i1 .'�ss . . .�sa:ez Title Title E1Qcutive '?�-ect�r ?t�s�zess `'ana?ez - Business Phone Number Business Phone Number ' ` � 512 � 227-'�291 � 41' � 227-y2.�1 19. Name of establishment where gambling will be 20. Street address(�ot P.O. Box Number) conducted `� .���a�}_> i�s ... ri,�to �sv�. , 21. City, State,Zip �' 22. County(where gambling premises is located) , t .�.'�t. n3L1 `.�:i :�J��.�7 ^�*1Sn.r a CG-0001-02(8/86) White Copy-Board Canary-Applicant � Pink-Local Governing Body t , ` f . �,� ; .. � , . . � ��- ���.�" Gam4lii�g License Application Page 2 � �.yRe of Application: ❑Class A QClass�B`^ `' ❑Class C ❑Class D QYes�No 23. Is gambling premises located within city limits? L�Yes�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 raffles)as a separate license is required for each premises. ❑Yes QNo 25. Does organization own the gambting premises?If no,attach copy of the lease with terms of at least one year. �Yes DIVo 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 4��•�� is not required for Class D appiications. DYesG�No 28. Do you plan on conducting bingo with this license?If yes,give days and times of bingo occasions: Days Times ❑Yes ONo 29. Has the 510,000 fidelity bond required by Minnesota Statutes 349.20 been obtained?Attach copy of bond. 30. Insurance Company Name 31. Bond Number - 1 State ruTetv Comnan # ,;2561� 32. Lessor Name 33. Address 34. City,State,Zip :'tyra3a's 35. Gambling Manager Name 36. Address 37. City, State,Zip . 2'� r. Ro?�?e Str�et St. Pau1, '.�: 5�107 38. Gambling Manager Business Phone 39. Date gambling manager became � �1� � � � member of organization: �-_�? 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. � k �, . ' 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 a�d 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 Executive Officer) *:eif;h�orhoa� House lssoci,�rion X , f; : .. Title of Signer Date " . ��_ �X8CU�2V(' v12'°CtOT •" /��` � . � 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 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. � ` . . � '� v� �.-.! i��'� ��.. t..J�'-. Signature.of person receiving application 43. Name of Township . X '�' Y , . Title; ' ; ` Date received 130�ay period Signature of person receiving application ' begins from this date) /-�� 1 :' F '�� '' X 44. Narrie of Person delivepng ppli on>f ocal Governing Body Title i �-�,:�� :r � �''��' � " CG-0001-02~(8/86) � v tNhite Co�iy-Board Canary-Applicant Pink-Local Governing Body ,. i �' .