87-1388 WHITE - CITV CLERK
PINK - FINANCE G I TY OF SA I NT PAU L.. Council . �'}� ��fy
CANARV - OEPARTMENT
BLUE - MAVOR . . Flle NO�• '
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Coun 'l Res ution
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Presented By
Referred To Committee: Date
Out of Committee By Date
RESOLVED: That Application (I.D.#95540) for a One Day City of St. Paul
Gambling Permit (Bingo, Raffles, Pulltabs, and Tipboards) applied
for by Hayden Heights Booster Club at 1975 Hoyt on September 27,
1987, between the hours of 12:00 P.M, and 4:00 P.M. be and the same is
hereby approved.
COUNCILMEN Requested by Department of:
Yeas Dr2W Nays �
Nicosia [n Favor
Rettman
Scheibel � _ Against BY
So�er�-
Weida
WilsOn Form Appr e b y Att ney
Adopted by Council: Date SEP 2 � �8�
Certified Yass d y cil Sec ry � BY
By
Approve Mavor. Date � ��� �.�P �87 Approved by Mayor for Submission to Council
By
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DIVISION OF LICENSE AND PERMIT ADMINISTRATION DATE
INTERDEPARTMENTAL REVIEW CHECRLIST
Applicant " �-�ome Address ��'�'��_T� ,.�.
Business Name �'Y, ,�„ �, Hame Phone ��qg- �5[l��
�
Business Address ' Z�pe of License(s)
Business Phone � �� �?_� � � S� ,�,��t�p
Public Hearing Date License I.D. # �-" D
at 10:00 a.m. in the Co ncil Chamber ,
3rd Floor City Hall and Courthouse State Tax I.D. # ��
REVIEW DATE DATE INSPECTION
APPN REC'D VERFIED COMPUTER COI�IENTS
�oved NOt
Housing & Bldg �
Code Enforcement � �a n ' ( �
I `
Public Health � � �
a� �
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Fire Prevention �I a � -
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I
Police �
n ��, �
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City Attorney �
I
ENS �
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/ 300 Foot Notice I
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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.
_ , . �,'tl�_ . � :4 . .. , . - .. . . _ ' . , �(. . i . � .
CURRENT INFORMATION NEW INFORMATION
Current Corporation Name: New Corporation Name:
Current DBA: New DBA:
Current Officers: Insurance:
Bond:
New Officers:
Stockholders:
. . �1'//U.W
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�I'ViSIO;� 0� ut.'..r,:i�: :i.'�7 ?:�cii�S i t�t::Lli 1J_.11__C t
I-':='QP?ATICN �CU'I� :�'IT� �.r°�C�iIC"I cOR '='�r:°II': T� CC":^CCT G1,:`�JI:'G S��SIOi' I:I ST. F�?TL
� � � 1�� l-�e�yhfs /��vs�� �fu..S �
?. ::a.-:� oi �roar::,ai=on
Z. ;d�ss c�he� �ar.izatior.'s re��.il� neetings ars r.e�a/97s E ��ir A-�e- Si/��euC.T/
3. La� ar.a ti:.e of �eetir.FS �TCC.LO .L�A, i'�t�1�,�-X.Q,�� d'L� !S 9'/- � G/ �DO /��? • --
��. :d;��ss ;yre� Camb?�nP Session *.a-�i� r� hgla i -`/'��'�-ll1�a`T C4,e.�Q,*s� 0/fu-�, �'ylf7
�. �s �r.�ca,� o*.a:.er of prope`-t�� ;,*�ers Ga::.b�:� Se�sicn T•ri„_ re _".e;�^. �es !/ 'To
rJ. I� 1.°35@C� :•ir0 �.S o��mer Oi pr0�@��� t•it':°r° lr8I�.��1P.�' C6SS1C^ :�t"S=1 c72 r?�a:'
� �P��
7. If leased, at�ac`: letter of per.-ti.ssion to conduct Gar.tbl�r_� Session, s=gr.ed by lessor.
�. �+2.��ne of oi=icer :��a� applica�icn •��.i. (511.�{.l.Ulft,t,i,'�'
w
9. AdcL:ess of oiiicer ma:�.ng a�plication a() 7 LU`' '� � T ate of birt� ��-a�-
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10. ::ane of ranaFer w'r_o c,rill conduct Carcblir,g Se�sion Q. . LLU�
?1. �d�ss of r:���ger a��7S �Jy ��C. G � Y l�-� {�2 �ate of birth�/-�r-
12. In cor=ection wi.th =�rhat event is th`s GambLr.g Session beir:g held? ��/Vt.v�-l.� �iJl1{h'L.
I3. ti�'hat �ype oi �a�blinF device(s) will be used? Paddle��reel "�pboard �P..aff'l.e �
IL. �ay, da�es anc hours this aaplication is =or and nur.tber of sess�ons.
Da�(s) � Dates 9-�7'�7 uou.rs .�" YY1 i'o. of Sessicns l
.._. 1�. '�1'z.�? prizes be paid i.n none� or ^�erc�:andise? �U.c1/�-�A �� -
_ i0. IS �i 2 3DD'�C2S_u n.iSCC��:iO.i OI'_'?*':::°'� 11-'1G�°=' ii.il° �'�WS O_° L�':2 St2.t@ OT' :'�l^P.°SOt3�
17. row lo*� ra� Cr�anizatior. been in existe^.ce? �S.
lE. T;'hat is t.e �urpose of the Or�ar�,.zation? Li,i� JN t- 'ud'�v GLG�1U� �d-
._. `_ �/h7 11_n1Al J AI.T _
Z9.. of�icers os the Organization
i�a�ce-Title Address �ate of birth
� ' n'U7�1" - �d 77 �.' C�rruc..�e Cttr� S%fJi9c.cl ��' a�'S�
4'Ol�tw: CQh�f P 1'P� _l�7.1`Lf � l�e(1�� �l pi8w� g- a s-��
C Cvn�rereS � 7S'� �' �t1��Q Si/�/�itu� 3-a�'S�
�1Z�.�. in�.�cw al�� I�����sr�
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G��"/-�,��
2'��. �ive ^z::�s o; ci_`;cers or ar:,; o�:�er pe�so^s ��� 'ar sz�=ces �o �'r.e �:"-_'2*'=1.SLi0I�.
?iar.�.e-:�t�e �c�i?SS �ate o? ^i�±r
Zi. l� TRr08° ClLS�CG��' :�P� �'OCO�CS OL QI'�3Z11Z3��.Cri�S :3I.^i0�_�:� Sess:ons }'° �2TJ��
`.��ne A.et.u.t �lddress ;,�075 -1�3�-I �r1'C. ��..S%�/�c-�. �jn S-Sl[�
2�. �ttach a copy of ;�ou: Crga..�ization's members'r.ip roster and da�e each �e�her joined.
� ,2�. Attac: the Ganh;,i� Sessior. '•anaFer's bond.
/
�. ityi,B.C!^_ 3 COD3 Oi �i,::2^�@r.2...'"L:�:er_� OI ��',@T`T'�°SSLI.�� I:lvE?I'^?�. �2V2rL'2 ::2?"�C° °TD��U:'_^_ Or
C'i�3a'I.I.Z2.t�CP. �7C2[�_.r,,t', i�0?i. '�:aCOI."i@ T3X��� i 0�'"1 qC(1. �".�;2��°Z' �.�d..ri��' �11.1
�. �t.t.3C:: 8 CODf 02' ='@�2Z't�'9P.t'. .7I �i1@ ;'r°r.?5�-� T1�.°r^Ql �a%'entl@ �@.^V;.C°� __rn^D� �P�c:l_
� izaticn 3usiness �ncome '^ax", Forn 9°0�. (CY�apter !:1?.0►� (2).i
2�. �ttach the arLr.ual reDOrt recuired of cr.aritable organ�zations by i�1i::nesoia Statutes,
� Sec�ion 309.53. (CrSDt2?' L�19.0�� (3). )
27. I:a�e fou read an� do veu thorou�r1� unaerstar_d the *�roz=sior.s o'_' all I�.*frs, ordizar.ces
anc reculations �cver^in� t!:e operation oi Ca::riin�- �es�ions? �
ZC. a.^.3' ci�a.*L��es des�=ed b;� �i=8 2.�p1�C2.:.L ZSSCC�2�_OP_ �2jr i?? iRcC@ OIll� :+Pt:l �ii8 COrSPII+., Oi
t:�e License Cocruaittee.
29: iias ar� person(s ) �a:t�cipzt;.ng in the operztion of any o° t"e ga^:b1in� sessior�s cov-
ered by this L.cense eve: been concicted of a felon in t:-e State of .•ir�esoLa or i.z
- ` �� � any ot:zer State or �?ederai Court? Yes :lo �. I� as:swer is "�es", provi�'e
r.�res, zddresses and birtr.-dates.
. . �7L�,t� �I)f��d'�V l l.�-ul
Gr�ar.ization
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(Gffic�r-?'�t1�
- ard_� ��
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(.�n�;zr in c:.ar�.e of Canb7�.nr Sessionl
Staia of .�ii.^�esota)
)SS
�ou:.t� of ?�.se,, )
�an��!/ S��im��f a,nd l�af� �vndurawf
being �uly sworn sa� that t"ey 3��= t.'�e pet�t=eners in �he above a�pLcat:on; ihat �:e� have
rsz� the *oregoing oet�tion � '�.cw �he contents. t�ersof; Lllat �he sa.me :s -:se o_° �`z�r
o:•rri knoc�rledF=.
Subscr_bed and sworn to bef�re �e t!�.is �
o�7y"�1 ,G3� Oi ?�87 `� �:'':��'�, NP.tvCY A. BLAIR �
. � �' NOTARY PUBUC - MINNESOTA �
a ��`� RAMSEY COUNTY Y
�C�/�� ��Z.i�,. My commission expires 5/4/92 i
:;ota.�� ? �c, Covn�v :L'uiesot `
'•�: cc�riission e:cpi�es ,�=����.-
� Lu:ldir� ^ena,x V:aer.t :�p�roved Lisapproved by �
:i:e �@*J3Z'L.:,ent ��aroved �isa�p:oved ��
� Poiice �ega.rt;�er_i ipproved—�;saroroved—�;v
. ��_�.��
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' " Minnesota Charitable Gambling Control Boa�d LAWFUL GAMBLING EXEMPTION
. .��<.
"��•.. Room N475 Griggs-Midway Building FOR BOARO USE ONLY
1821 University Avenue
= St. Paul,MN 55104-3383
'":;������ (612)642-0555
INSTRUCTIONS: 1. Submit request for exemption at least 30 days prior to the occasion.
2. When completing form, do not complete shaded areas.
3. Give the gold copy to the City or County. Send the remaining copies to the Board. The copies will be
returned with an exemption number added to the form.When your activity is concluded;complete the
PLEASE TYPE financial information, sign and date the form, and return to the Board within 30 days.
Organizatio�Name � l ucense Wmber Of currenW or vre�ouslv�icensed�
..,, �,i��, E(�: i � =,�L��r �' ���s
Address �,� �1 City,County,State,2i Code
{ ' C.
�'� � j ;� T T�)C. ` ::`�"��t� . _(,l 1 r ;�'1_. j�(1 j � �
Chiei�Executive Officec"s Name Phone Number Manager's Name Phone Number
,�"�r r���I �_� �c; >i�-�- � -��m ;�"� '� t ,��;,,-i � ��:�u.r � %--��t �..�.?
Type of Organiz ion If Other Nonprofit Organization ICheck One)
❑ Fraternal �,Veterans ❑ IRS Designation
❑ Religion �Other Nonprofit Organization ❑ Incorporated with Secretary of State
E� Affiliate of Parent Nonprofit Organization
Name of Premises Where Activity Will Occu� ;�. Datels)of Activity
;--��:1�; �ti�� r�n,; �{; ��'�.�. �� ��;��
Premises Address ( l �1' C�� ��'�'�
� �f /5 r= � �`i�l'J }'���-+ r > � JJ '1'-,� � r f-1 ,�1
Games Yes No Gross Receipts Value of Prizes Expenses.' Profit
Bingo ,
Raffles �,�
Paddlewheels
Tipboards �
Pull-Tabs �
lisaof Prottv
Di i utor From Whom Gambting Equipment Acquired, Distributor's License.No.
�t.t� �u�� l�i+�s � �" — � ��.� � ��`�t�"' � �.�t�`%�'
I affirm all infoFination submitted to the Board is true, accu'- t affirm al1 finaneial information submitted to the Board is
rate, and complete. true,accurate,and complete.
�' ; •
,—
,.._., j. �, �
Chief Executive Officer Signature Date Chiaf Executive OfficecSignaYUre Date
ACKNOWLEDGMENT 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 Baard and will become effective 30 days from the
date of receipt(noted below) by the City or County, unless a resolution of the local governing body is passed which specifi-
ca�ly disallows such activity and a copy of that resolution is received by the Charitable Gambling Control Board within 30
days of the below noted date.
� CITY OR CO TY TOWNSHIP
Name of ocal Governing B y(City or unt Township Name(Must be notified when County is the approving body)
a -
Signat of so�Receiv' p i tio� Q Signature of Person Receiving Application
• °a�/g
Title ate Receiv d Title Date
. �
CG-00020-01 14/861 Wh'e—Board Canary—Board returns to Organization to keep
Pink—Organization Gold—City or County