87-1343 WHITE -GITV CIERK
PINK - FINANC�E GITY OF SAINT PAUL Council //
CANARV - DEPARTMENT ����// r•{ �
BLUE -MAVOR . FIlE NO.
' !i=-
Cou cil Re lution
, � ��-
Presented By �
. Referred To Committee: Date
Out of Committee By Date
RESOLVED: That Application (I.D.#50707) for the renewal of a Class B State
Gambling License (Tipboards, Pulltabs) by Johnson Area Hockey
at 955 Seminary (Minnehaha Lanes) be and the same is hereby
approved.
COUNCILMEN Requested by Department of:
Yeas Drew Nays
� � [n Favor
Rettman
Scheibel {J _ Against BY
Sonnen
Weida
WilsOri SEP � 5 �� Form Appr ed by City Attorney
Adopted by Council: Date
Certified Pass d by Council Secretary BY
<
gy,
A►ppro by Mlavor: Date S� � � Approved Mayor or Submission to Council
By
�1iBUSl1ED ��P 2 G 198
�4-�, C�►� P��-i-��3
' 'DIVISION OF LICENSE AND PERMIT ADMINISTRATION DATE • � �l ! �
INTERDEPARTMENTAL REVIEW CHECRLIST
Applicant Home Address � �
Business Name �p�.�,,,�¢, Home Phone ��?�- a-g5�(
Business Address �s5 Se�h�LV��Y� Type of License(s�V1�,Q,�.) CQ�,�,n ,t'�
Business Phone �
Public Hearing Date � License I.D. �j U '�(S �7
at 10:00 a.m. in the Co ncil am ers, (�,m�p, �;�•
3rd Floor City Hall and Courthouse State-�ex—�.D. # � - p0'1S( �- d�a __
REVIEW DATE DATE INSPECTION
APPN REC'D VERFIID COMPUTER COZ�II�iENTS
ed Not roved
Housing & Bldg �
Code Enforcement f1,�r �
I
Public Health I
h �r� �
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f
Fire Prevention n '� 4
f
I
Police �
O �� ,
City Attorney �
I
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ENS � �� �
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300 Foot Notice � I� j
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.
. _ - . . : .
- .. ,
CURRENT INFORMATION NEW INFORMATION
Current Corporation Name: New Corporation Name:
Current DBA: New DBA:
Current Officers: Insurance:
Bond:
New Officers:
Stockholders:
. - (1��7-�3y-3
`�� '��.s`fa``�
:• ,��o� �Ti,� Charitable Gambling Control Board FOR BOARD USE ONLY
:.6�0_ __hp .
°�'���0.� Room N-475 Griggs-Midway Building
_ � License Number
1821 University Avenue
_ _ St. Paul, Minnesota 55104-3383 PAID
.. (612) 642-0555 AMT
�';l�g+��•�.
CHECK#
DATE
GAMBLING LICENSE APPLICATION
INSTRUCTIONS:
A. Type or print in ink.
� B. Take compfeted 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. I�complete applications will be returned.
Type of Application:
OClass A - Fee S 100.00(Bingo,Raffles,Paddlewheels,Tipboards, Pull-tabs)
,�Class B - Fee S 50.00(Raffles,Paddlewheels,Tipboards,Pull-tabsl Makecheckspayableto:
�Class C - Fee S 50.00(Bingo only) Minnesota Charitable Gambing Control Board `
❑Class D - Fee $ 25.00(Raffles onlyl
� - I - -i ;..� - ' ���
- L�Yes❑No 1. Is this application for a renewal?. ff yes,give complete license number --: '��:� !>��
❑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)
J�Yes�No 3. Have Internal Controls been submitted previously?If no,please attach copy.
4. Applicant(Official,legal name of organization) , 5. Business Address of Organization
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6. City, State,Zip 7. Count 8. Business Phone Number
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9. Type of organization: ❑Fraternal ❑Veterans ❑Religious �QDther nonprofit*
•If organization is an"other nonprofit"organization,answer questions 10 through 13.If not,go to question 14."Other nonprofiY'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: � � Attach copy of certificate.
Yes�No 11. Are articles filed with the Secretary of State?
❑Yes�1No 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.
❑Yes, 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
� >, /
evidence of three years
� -.f� ' �' existence.
17. Name of Chief Executive Officer � 18. Name of treasurer or person who accounts for other revenues
,
� ; r ,'� �'ll� ��'� i� �./ of the orgarnzation ��.
" 7"'� . �'". .,;�' , '; � . ,
Title �--T_, Title
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Business Phone Number Business Phone Number
1 l 7�� � � ( )
19. Name of establishment where gambling will be 20. Street address(not P.O.Box Number►
conducted � � , _ � •��-,°- �- ;r , f 'r _
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21. City,State,Zip 22. County(where gambling premises is located)
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CG-0001-02 IS/86) White Copy-Board Canary-Applicant Pink-Local Governing Body
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` tiambling License Application Page 2
;,- Type of Application: �Ciass A �],Class B ❑Class C ❑Class D
r
�yes❑No 23. Is gambling premises located within city limits?
Yes❑No 24. Are all gambting 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�7,No 25. Does organization own the gambling premises?If no,attach copy of the lease with terms of at least one year.
❑Yes�1No 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:
`` ' oa�s Times
Yes❑No 29. Has the S 10,000 fidelity bond required by Minnesota Statutes 349.20 been obtained?Attach copy of bond.
30. Insurance Company Name _, / i� 31. Bond Number
�S""'� ��- --`��u, k F � "I f�'`�r�/7r,�i.1 S� � t='j -�`�u `'� '/" --.c�
32. LessorName � J( J r,_ � 334,AddressL '' ��, `, 34. C�, Stat�p� / �l,J�r��� .�r
%f /�L f[����� T!-f �f.1L: � ,,�� _�:..�ir_l ;'c'":. ,�J � .,� / � .�-L L� •.i.,.� ' i
35. Gambling Manager Name 36 Address �-- 37 City, State Zip
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38. Gambling Manager-Business Phone 39. Date gambling manager became
( �.,_ - =, � � 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.
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.TOfficjal,Legal Name of Organizatio� � . 41. Signature(must be signed by Chief Executive Officer)
" �:` %`•�;���. ����.i ���r� ' � ����c�f� � �, —�--,y l. x ;i" -�,� --
Title of Signer ;�� r. ` �., ��' Date ,�
. �''�. = i I �:�it-J - ,
ACKNOWLEDGEMENT OF NOTICE BY LOCAL GOVERNING BODY
- -- - I hereby acknowledge receipt of°a copyofthis-application. By acknowledging-receip� I adrrsit'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
�1 ty 0'`� J�. �dUl � addition to the county signature.
Signature of person receiving application 43. Name of Township
X �.�. � . .L. �C� ����
Title Date received(30 day period Signature of person receiving application
Li�c'.f1S�', i t�5>_'C LOt' begins from this date)
_ :�9�/^7 X
44. Name of Person delivering application to Local Governing Body Title
CG-0001-02 (8/86) White Copy-Board Canary-Applicant Pink-Local Governing Body