87-1448 I
NIHITE — C�TV GLgRK
PINK — FINANCE G I TY OF SA I NT PAiT L Council �s � '/ .
CANARV — DEPARTMENT � t J/�� f�f���//
BLUE — MAVOR . Flle NO. `� � /�` v
�
Cou il Re lution
t . , i ,�
Presented By
Referred To Cnmmittee: Date
Out of Committee By Date
RESOLVED: That Application (I.D.#92049) for a One Day Gambling Permit (Bingo,
Raffles, Paddlewheels and PulltabsJ by the Church of St. Agnes
at 530 Lafond on October 18, 1987 between the hours of 1:00 P.M.
and 5:00 P.M, be and the same is hereby approved.
COUNCILMEN Requested by Department of:
Yeas DreW Nays `
�a T� In Favor
Rettman �
Scheibel __ Against BY
�
�Q
Wilsori ��T — �' 1987 Form A proved y ttorney
Adopted by Council: Date
Certified Pa by Council Sec ary BY
By
A►ppr by Mavoir. Da e �s�. ` ° Approved by Mayor for Submission to Council
By BY
P�3BI.ISi� u G l �'I 'i 5 i�7
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DEPARTI�lIENT . ,�,
�.0 r CONTACT NAl#E
- S PHONE
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ASS � r ,B FOR ROUTI�TG Q1tDER; (See revar�e side.)
_ Depart nt Directar Mayor (or Ass3staat)
_ Financ ar�d Nanagement Services Director � City Clerlr� ��/Q—6- �`7..
Budget irector _ � h
1� Citq A orney _
(Clip all locations for signature.) ,
? (Yurpose/xstionale)
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OS UD ET ND S L C D:
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N UD A C ' E T
(l�iayor's si ture not required if under $10,000.)
Total t of Trans�ction: Yi�ff Activitq Number: �'Pt
Funding S rce: �,p�-
ATTACHMEN'rS: (List and number ail attachments.)
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ADMINISTRATI OC II S � ',p� _ •
_Yes 1Qo Rules, Regulations, Procadures, or Budget Amendment required?
_Yes No If yes, are they or timetable attached?
EP NT V W CITY ATTORNEY REVIEi1
✓Yes o Council resolution required? &esolutinn required4 •✓Yes ,�No
_Yes � o Insurance required? Insurance sufficient? _Xes _No
Yes o Insurance attached?
. � ��r l�s��
. ` ' I�Ainnesota Charitable Gambling Control Board LAWFUL GAMBLING EXEMPTION
���..
�ioom N475 Griggs-Midway Building FOR BOARD USE ONLY
1821 University Avenue
- $t. Paul,MN 55104-3383
:°°'%�� �612)642-0555
INSTRUCTIONS; 1. Submit request for exemption at least 30 days p�ior to the occasion.
2. When completing form, do not complete shaded areas.
�I 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.
Organization Name � ucenae Mumner In cunenUy«pevia,sly li�naed)
��ry� �
�hurcr. n�' :a�.nt -ne� `:�,:.r:� ��ul 'ir.::e�--,r� -. . -_=
Address City,County.State,Zip Code
5:a.5 i4�YUI:'J �.~fE' . T,. ,�Ul ^tcn-r ; r..n�.^f.� -tT r�^
Chief F�cecutive�tficer'is-Narpe� Phone Number Manager's Name Phone Number
.. -..w . ii l:.it�
:l::�ic�i� u ,l:�u�Gr ����1 ��L' .j ,.� �`,-'�.. .",�
:,. ^r:,-'
Type of Organization If Other Nonprofit Organizatio�(Check Onel
. Q Fraternal ❑ Veterans ❑ IRS Designation
O�Religion � Other Nonprofit Organization ❑ Incorporated with Secretary of State
❑ Affiliate of Parent Nonprofit Organization
Name of Premises Wheee Activity WiII Occur Datelsl of Activity "
�.i�'iLY'Cil `T� :?.',. :t ^ac H;. _}1 c'::7^Z �„± � _ + ' _ _
Premises Address
53U L��ion'; �{v� . ���._::t :'�u' '�.•n. �,.�:;�
� ,
Games Yes No °,G�ReceipR� ;-. Va[�e�c��Prize� �cpens�s' , Profi�; '
Bingo ;; ����=a
Raffles _, { ?
�,.�;�'
� �,: �
Paddlewheels 4 " ��` ` �
Jt ��',�°� � $F k�' � � � �":„
.
� e w �
trk '
,- . ..;.,,- .,,_ ._m.^ ,x „ , .,.t ,-:
, .,
., M. »
.,,.�:.. _.,. .._. 7,��_ . - , , .
. .. .,..�. , ,: . ,_.;
A
Tipboards � �€� � Y g*,� ��; , � " ''
����;� ��- �
,�
Pull-Tabs t '� '��'
use�o€�Pra€i�, � ���� � ,����`� �: ''
's4�� �
r� �;��a.�`- °�'' �, ` <„'� 3�R�`' �`
D�tcib�torFra� 6 �t�ea� ±� Disiri6utar'sLicenseNor..
3 � �. ,�+f«' t
"*w+'* ��,�� j,�a �Aiti:k'r'ASR„�����
I affirm all infoc ation submitted to the Board is true, accu- :�`°;a�f�Eictrrsa[�fti��tr�:ia�i�����atia�=submitted�t� th�Baard°is
rate, and complete. <tru�,;,��rat�an�cu�eplet� .
�I�i c n:�r,� �'.t '�- ,i : .,_ _�.._.____„ ., �
Chief Executive Officer ignature Date Chte�E9aecutiue°OfftcecSignatnt�. aate
ACKNOWLEDGMENT OF NOTICE BY LOCAL GOVERNING BODY
I hereby acknowl�dge receipt of a copy of this application. By acknowledging receipt, I admit having been served with notice
that this applicat�On will be reviewed by the Charitable Gambling Control Board and will become effective 30 days from the
date of receipt (n�Oted be�ow)by the City or County, unless a resolution of the local governing body is passed which specifi-
cally disallows such activity and a copy of that resolution is received by the Charitable Gambling Control Board within 30
days of the belovW noted date.
CITY OR COUNTY TOWNSHIP
Name of Local Governin Body(City or Couniy) � Township Name(Must be notified when County is the approving body)
��� � � � �� ^i/�! /
Signatu erson Rec ivi g tion Q / _ Signature of Person Receivirtg Application
i
. `1i8 ;.
Title �t - ate Received Title Date
J; . !j!� � ;, `l .� � y:
CC�-0902(�'-01 14/861 WHite—Board , Canary—Board retums to Organization to keep
Pink—Organizadort� Gold—City or County
, . �
. �
. � CIT� OF ST. PAUL ��7 �y��
. , .. � D:P.4RT?•::�:�IT OF r ITv'Al;CE �ID tf.Ai3,'�G�;IIEI'T SE�.VICES
. DIVI�IOit Or ISCEIdS� �ND PEF�•ffT ADMIr1IST3ATTOP�t
IPdF'OR1�.ATION FyCUIr� :•iIT'r! n.�°LIC�iIOP�I FOR PT_?i�MSi TC CCl'•{DLTCT GAi��3LIi�G SESSIOP' I:•I ST. PAUL
1. r�ame df �rgani.zation /�•
2. Addre�s where Organization's regulax meetings are held v�"yS /.y6- ���
3. Day ar�d time of ineetings
!�. Address where Gamblin� Session c�rill he helc�'-f/���� �� �
5. Is aop�licant owner of property where Gamblin� Session will be held' �s `?o
6. If lea�sed, who is owner of property where Gamblin€ Session wi11. be held?
l
7. If leahsed, attach letter of permission to conduct Gar�bling Session, signed by lessor.
8. Name af officer maI�ng application � �� -y�• ` �
9. Addresls of officer ma�ng aAplication��e-�eo SS`,f— �Date of birth�°� -'zy'��
._' C7'�
10. Pdame of manager who will conduct Gambling Session
11. Addres�s of ma�ager ! �. � � � G�.o � � ���\Date of birth�� '3'��
12. In con�ection with what event is this Gambling Session being held?
��.�2 � -e�
13• tiv'hat type of gambling device(s) will be used?p Padd wr.�el��"�pboard F.af f'le�_
��c-c!�`�a.(,�� �a�
ut. Day, d�tes and hours this application is for and number of sessions.
Day(s)� � � � 7ates �—��-��'-� Hours l' (�� ��%° ° Pdo. of Sessions l
I.S• t�Ji]1 p�izes be pai.d in money or mercrandise? �,�'��
�
16. Is the applicant association orga..nized under the laws of the State of t�Iinnesota?_�
17. How lo�tig has Crganization been in existence? l �8 �
18. 4Jhat i� the purpose of the Organization? �
I
19. Office�s of the Orgaaization ' ^�
! �1ame-Title Address ''y�� - �ate of birth
Di,-�d- r,• ,.
' � �J .
.
G� ��
r-P�c,�- - �' �-�'-.-�'••"-' ��J' .
��.� � s�.� � /� - �-rd�
�
�
� ������
20.. �ive na.�e5 of off�.cers or any other oersons paid for services to the Or�anization.
� - ' , Name-Title �ddress � �ate of birtr
,�o���
�
21. In whose c�ustod �aill records oi Or anization's Gamblin Sessions be t?
Y � g kep
:iame , ��'�-dL��c� Address !-L `� � 'o ��--� /ri�`�� .�',('/C,/'
22. Attach �opy of your Organization's membersr.ip roster and date each member joined.
23. Attach th� Gambling Session �ianager`s bond.
1
2I�. �ttach a �opy of the Depa.rtment of the Treasur�, Internal ?evenue Service "RetUrn of
Organizati;on `acemnt from Income '"ax", For�n 99e.. (Chapter L�19.0lt (1;.)
j -
25. Attach a copy of Department of the Treasusy, Internal Pevenue Service, "�.�cemnt Qr�a.n-
ization B�siness Income Tax", Form 990T. (Chapter �.19.01� (2). }
26. Attach th� annual report required of charitable org,anizations by ,�.innesota Statutes,
Section 3a9.53. (Chapter 1�19.0l� (3). )
27. `:ave ,you read and do yeu thoroughly understand the provisions oi all laFrs, ordinances
and re�ul�,tions governin� the operation of Gamblin� Sessions? �7�/�r/'
28. �y char�-eIs desired by the applicant association may be made only with the consent of
the Licens�e Committee.
29. Has any person(s) participat�ng in the operation of any of tY�,e gambling sessions cov-
ered by thp.s license ever been convicted of a felony in the State of I°jinnesota or in
ar�y other State or Federal Court? Yes - P1o_�'�. If answer is "�es", provide
names, add�resses and birth-dates.
� Organization
By
, (Officer-Title
and � -
� (i�ianage n c",arge of Gambling Session)
State of l�innes�ta)
)SS
C ounty of Rans e� )
and
being duly swo sa� that '- s-e the petit�oners in the above a�plication; that they have
read the forego}ng petit' �� . rrnow the contents thereof; that the same is �r•se of treir
own ?mowled�e. � ;;,
Subsc 'bed and,�wo J�}� e ' �� trs$
day os � . 1_°�
J��7q r��
i10 b� "�',�. .d�� County, �znnesotz
��p cosuniss ofr��
� •
Building Depa.�, nt �lpproved Disaoproved by
Fire �epart.;ient Approved ?isapproved bg
Police Departmen!t Approved--�isapproved--oy
I