87-1390 WHITE — CITY CLERK
PINK — FINANCE COU�lC1I ��J j�p]
CANARV — OEPARTMENT CITY OF SAINT PAUL File NO. / 7�
BLUE —MAVOR
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Co cil R olution
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Presented By
Referred To Committee: Date
Out of Committee By Date
RESOLVED: That Application (I.D.#70900) for a Class B State Gambling License
applied for by St. Andrew's Youth Athletics at 1013 Front Avenue
(Half Time Rec) be and the same is hereby approved.
COUNCILMEN
Yeas Drew Nays Requested by Department of:
Nicosia
Rettman In Favor
Scheibel
Sonnen a _ Against BY
Weida
Wi1SOri SEP 2 ?_ 1�8T Form Approv y ' y Att ey
Adopted by Council: Date
Certified Pas e oun�ec y BY
By
A►pprove b � avor: Date 'g'� C `-�t 1� Approved r for Submission to Council
y BY
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DIVISION OF LICENSE AND PERMIT ADMINISTRATION DATE C�,,
INTERDEPARTMENTAL REVIEW CHECRLIST
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Applicant � _�y�('��(ew�l�_p�h H'1'�1 Ut�`�oSme Address �SGj� 1�' ,Ca St.
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Business Name CjC�.�¢� Home Phone �C�.. ,Sp ZZ
Business Address ��j ►?, �yp-Y� �� _ Type of License(s) C-,a.�vr�5p(�,n G�y�UCs-�,�
Business Phone ���_ x,(�a� �j�.PS�c�.�
Public Hearing Date License I.D. # � �G(Q(�
at 10:00 a.m. in the oun il Chambers, (.,;c.n.ws�e
3rd Floor City Hall and Courthouse State �--I..12. �� -(�p2-�333- (�O�
REVIEW DATE DATE INSPECTION
APPN REC'D VERFIED COMPUTER COMMENTS
NOt
Housing & Bldg �
Code Enforcement � �(�- �
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Public Health n I� I
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Fire Prevention � I �
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Police �
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City Attorney �
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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.
y.
CtTRRENT INFORMATION NEW INFORMATION
Current Corporation Name: New Corporation Name:
Current DBA: New DBA:
Current Officers: Insurance:
Bond:
New Officera:
Stockholders:
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cuu�in
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, °�o�no�.�2, Charitable Gambling Control Board , � FOR BOARD USE ONLY
��'�gn Room..N�475 Griggs-Midway Building
, - :� 1821 University Avenue u`°"'°"�mbe`
_ St. Paul, Minnesota 55104-3383 A�ID
(612) 642-0555
�*1�' .. 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$100.00(Bingo,Raffles,Paddlewheels.Tipboards,Pull-tabsl
�Class B - Fee 5 50.00(Raffles,Paddlewheels,Tipboards, Pull-tabs) Makecheckspayableto:
❑ClassC — Fee S 50.00IBingoonly) MinnesotaCharitableGambRngControlBoard
❑Class D - Fee S 25.00(Raffles only)
�Yes�No 1. Is this application for a renewal? If yes,give complete license number � - b12 =�3 _ <�«/
❑Yesf�No 2. If this is not an application for a renewal,has or anization been ticensed by the Board before? If yes,give base
license number(middle five digits)
❑Yes❑No 3. Have Internal Controls been submitted previously?If no,please attach copy.
4. Ap�licant(Official,legal name of organization) 5. Business Address of Organization
�:.,i`N,v I/ll.�r+� . �`./_")w7.ti ff rr1G�/c 1 -
, -' 6. City,State,Zip 7. Count 8. Business Phone Number
ST f�.�<i� -,�%.. �.%P"�rG��` ( 1
9. Type of organization: f�i�l �I�rrs Religious �
"' a' "If organization is an"other nonprofit"organizatio�,answer questions 10 through 13.If not,go to question 14."Other nonprofit"organizations
must document its tax-exempt siatus.
❑Yes[�No 10. Is orga�i2ation incor orated as a nonprofit organization?If yes,give number assigned to Articles or page and
, book number: Attach copy of certificate.
❑Yesl�jNo 1 1. Are articles filed with the Secretary of State?
❑Yes�No 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 Give date: - -
15. Number of active members 16. Number of years in existence Note: If less than four years,attach
evidence of thres years
^ 3 S� �E.F-���� existence.
; 17. JVame of Chief Exec ive fficer� i r^���'S 18. Name of treasurer or person who accounts for other revenues
��%�' %}-� ' f � �OQ�'c %� of the organization. , �
;;l,j; �� ;� /_ l/��:�,�,, L r ,.�'�/f1 ✓EiC/ 2
;fitl� r'i2<<S'« Title
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Business Phone Number Business Phone Number
��� r / /� /7
( ,_/�'� Z� �.;�- i.r .a 5�j ( �'�'{- 1 / ��'.� -� y `-''�S`
19. Name of establishment where gambling will be 20. Street address(not P.O. Box Number)
conducted - � -' �
: --'.=r',=�� /r%i�/� :`�.=` .i� ."� � � .� .�i.���� � � •
21. City,Stste,Zip 22. County Iwhere gambling premises is located)
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CG-0001-02(8/861 White Copy-Board Canary-Appt�ant Pink-Local Governing Body
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Gamblir�g License Application % Page 2
Type of Application: ❑ClassA �C1ass B ❑Class C � �Class D
�lYes ONo 23. Is gambling premises located within city limits?
QYes❑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 iexcept raffles)as a separate license is required for each premises.
DYes No 25. Ooes organization own the gambling premises?If no,attach copy of the lease with terms of at least one year. . .
❑Yes tlxNo 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 �5� .:� �
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
�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 31. Bond Number
, .:G -- ,,, _. �� :�: T . - �..'.t'. , . a, � -�� - : _:i
� 32. Lessor Name , 33. Address 34. City,State,Zip
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,::,i,-, � ' . -✓ /_ . .-,�-�,� _�,� �.J,✓�G ,� '`- .��+i �%'� _,�""/,?
35,Gambling,Manager Name 36. Address -; 37. City State,Zip
'f -'''•��'t c: t i�,`i,:;` �'�• ,.: ' .,j'�.s� - i=�.i - .+='�7
38. Gambling Manager Business Phone 39. Date gambling manager became
( ; r � � � ,� �U L Z member of organization: �- •'� — 6�
--.._..-
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 GamblingBank Account `
����wvhenever 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 agres,
if licensed,to abide b those laws and rules, includin amendmentgtFa�eto:. r �
40.^ Official„Legal Name of Organization 41. Signat�e lmust be•signedrtiy Chief Executive Officer)
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Title of Signer J Date ,';`
�G��rt,?c�� i . � �.
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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(noted 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
�� addition to the county signature.
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Signature of person receiving application 43. Name of Township
X �, � �i_� -1
Title Date received(30 day period Signature of person receiving application
°, begins from this date)
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-.�,t . f � 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