87-1468 N�HITE - CITV CL�RK
PINK - FINANCE G I TY O F SA I NT PA iT L Council �,�_f��
CANARV - DEPARTMENT L+
BLUE � - MAVOR . . clle NO.
�
uncil esolution �
� w � � �
Presented By
Referred To Committee: Date
Out of Committee By Date
RESOLVED: That Application (I.D.#76110) for a One Day City of St. Paul Gambling
Permit (Raffles, Paddlewheels, Tipboards, and Pulltabs) applied for
by the St. Paul Rehabilitation Center Inc. at 2550 University Avenue
(Court International) on October 24, 1987, between the hours of
7:30 P.M, and 11:30 P.M, be and the same is hereby approved.
COUNCILMEN
Yeas Nays Requested by Department of:
Drew �
�ia [n Favor
Rettman �
Scheibel __ Against BY
�
Weida
Wi.lsOn �CT — �i �987 Form Ap roved y y ney
Adopted by Council: Date
Certified Pas e ouncil Sec ta BY
By
Approved 'Vlavor: Date �" Approved by Mayor for Submission to Council
By By
E ,
���.5 �� ` -. , . .�_�'!���� -
������
�t°_ �1i38�, �
� � � . DEPARZ`MENT . - - - - -- -
�� CONTACT NA1�JE
- -Co PHONE
� � • Q� DATE .
SS R NG 0 D (See reverse side.)
_ Depart nt Director Mayor (or Assistant)
_ Finance and l�iianagament Services Director �, City Clerk pc� • `� �a-
Budget irector _ �
� C ity At orney _
(Clip all locations for signatura.)
FTT V BY 0 N I Y (Purpose/Rationale)
� IM1-c.- • ' �
V-t� W tX�
��- �- `� `,'�' M°° C� �""�-�-�- � ,��i-Gwe�
�� o��%�'� � a..��A obL�.� �x° •
��
C S U D AC S D:
1��(�-
FTN C N A V BER D 0 C D D:
(Mayor•s si tutre not required if under $10,000.) • '
Total Amo t of TransBction: 1��(�t Activity Number: n I�4
Funding S rce:�I�
ATTACHMENTS (List and number all attachments.)
�� _. .
" 1_ `��
D S T R CEDURES � �A-
l
_Yes No Rules, Regulations, Procedures, or Budget Amendment required?
_Yes No If yes, are they or timetable attached?
DEPARTM NT I W CITY ATTORNEY REVIEW
�Yes i�o Council resolution� required? Resolution required? �+�!Yes _No
_Yes o Insurance required? . Insuranae sufficient? _Yes _No
Yes No Insurance attached?
i
; ��y-���d�
DIVISION! OF LICENSE AND PERMIT ADMINISTRATION DATE �,12� � c��'�,
INTERDEP�IRTMENTAL REVIEW CHECKLIST
Applican� � .�{�,�.�Ip_ CQ�,.�.�.�� Home Address � �b�
Business II Name 5��1 �. Home Phone aa 1-��`'�l,�
Business�Address �Sp ` �-U � Ty e of License(s) :�n,,,,�,�p.��_a,,,"�
y � � w
Business II Phone �',�"�- � 1 � ��afQ�Q�����.c�i *"��n�cAre� I �1'r..�1-�u�Q�
, �
Public H�aring Date �'��,-Q _'�� �,� License I.D. # '�� p l l C�
at 10:00,a.m. in the Council Chambers,
3rd Floo� City Hall and Courthouse State Tax I.D. # ��
�
.,� :� J �� ~ S_ �J_ O �3�
REVI j D TE D TE NSPECTION
APPN REC'D VERFIID COMPUTER) C01�4IENTS
�oved Not raved
Housing S� Bldg f
Code Enf dreement �� � �o �� -
�(l..c�'rF �t�-
Public Helalth I
� �� � `�
, �
I
Fire Prev�ention �
, il � i
I
Police I
� tl
'� i
City Atto�rney �
l
I
ENS , �l � t/
�
300 Foot #�otice �� I (
1
I
License I�spector's Comments:
I HAVE BE�N GIVEN A COPY OF THIS NOTIFICATION AND UNDERSTAND THAT MY ATTENDANCE AT
THE PUBLI� HEARING IS REQUIRID.
�
I
� . � � . � , .. , . . . .� . . . . . . . _ . . . . , .., , .1 .. .
CURRENT INFORMATION NEW INFORMATION
Current Corporation Name: New Corporation Name:
Current DBA: New DBA:
Current Officers: Insurance:
Bond:
New Officers:
Stockholders:
_ . . . ,������
I; Minnesota�Charitable Gambling Control Board LAWFUL GAMBLING EXEMPTiON
j Room N475 Griggs-Midway Building FOR BOARD USE ONLY
' 1821 University Ave�ue
- - j St. Paul,MN 55104-3383
�•:�•��'� ' 1612)642-0555
INSTRUCTIONS: 1. Submit request for exemption at least 30 days prior to the occasio�.
: I 2. When compieting 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 I financial information, sign and date the form; and retum to the Board within 30 days.
� OrganizationName j . . � . �icenseMn+berlMc�rrm�WaprsNOUdv�icansedl
SPkC, ind. ' �
ii�l�w�l:J�i�IC� �•.
Address ', City,County,State,Zip Code
. 3i� �ayl�' �treet �t. Paul , ��r�sa,�, ;�;��, �:;li:� � c
Chief Executive OfficBr's Name Phone Number Manager's Name Phone Number
JOIli1 :�+UYtI'� ��i-���:7 i :;�r�n •:oi�r _�1-��+;i
Type of Organization'I If Other Nonprofit Organization(Check Onel
0 Fraternal � ❑ Veterans �I IRS Designation
❑ Religion L� Other Nonprofit Organization ❑ Incorporated with Secretary of State
❑ Affiliate of Parent Nonprofit Organization
Name of Premises Wh�are Activity W' Occur`L Datelsl of Activity
_ i _n.-t_,,.'r��-4'�'.�`..t' ��(.1/T ��f�/ ild�U/�ul •JC:i)ti'L'C ��'r� i°.;�:/
PremisesAddress I_ oZ,��`a �]II�erJ/�Z/ US• T` QU � �5�� /� �
'.*�'-'�v�'c�"J!��l Tz-1" `� ��.1ai-�:-?r--.�rE��— ��
�,--��, Games I Yes No �: .G�ross Receipts ' Valeie�o�E�rize�: Expenses. Profrt
�: Bingo � ,, � ��,
, ,
, ..
.
, . �
: , ,
-
� �.;� . ; •
� Raffles , � ��'� i �'
.��� ;� -`<
Paddlewheels r�"� N
ti ��=
` ��=
.
Ti boards
,
.�
P
� � ..5:_
' , .
Pull-Tabs ' � e �;
'�'�
�� ���� �� � " �� ,; � �" �
a, ���� , � �,��,� -a� �" � ;,�., �:t�'�k�"�i,'
� �rnar� �,6� ��� , Distributor`sErcensa�Na;.
.. �i °`" �� ��"t'�� ��`""°�,-
I aff�rm all inforrr�ation;submixted-to•the�B�ard is�true, accur ,tA.af�im��ai�finacrciaL:infocrnation:submitted-to:the Baard is
�
rate;�and compl�te.�, `ti r � �ue�;.accucate�an�eo�rtpl�te:
�. � � ) �
��-��� � � � �j� �`. �.1.. - .�. �� ; ,/ r�'1 '� .
,
� �.,` � � /
Chief Executive Office Sigoature ` Date Chief Exactttive;UtfieerSignamre: '`Oate "
�-' ACKNOWLEDGMENT OF NOTICE BY LOCAL GOVERNING BODY
I hereby acknovv�ledge receipt of a copy of this application. By acknowledging receipt, I admit having been served with notice
that this.applicakion will be�eviewed by the Charitable Gambling Control Bo�ard and will become effective 30 days from the
date of receipt( oted below) by the City or County, unless a resolution of the local governing body is passed which specifi-
cally disallows �uch activity and a copy of that resolution is �eceived by the Charitable Gambling Control Board within 30
days of the beloWv noted date.
• � ClTY OR COUNTY TOWNSHIP
Name of�ocal Governi g Body ICtity or Co�nty) ' Township Name(Must be notified when County is the approving bodyl
T )
�.�
� 1��� 1✓.'► j�
Signat of rson Re eiv-'� p i ion t�.,,//��) � ! Signature of Person Receiving Application
� �r'�q , �9 y.���/ .� tA'?� s'�' , I/.��,Y
rcie �� _� oe e e���ed reie oate
�"` �'w,�✓ `�=�=_
, �/'•%.r r(? ��?/ .'��� j �
� CG-00020-01 14/86) White—Board Canary—Board returns to Organization to keep
Pi�k—Organization Gold—City,or County
:
cz� oF s�. P�U� (.f��'/
. .� ' ' DEP.�,�?.T!•�'idT OF rT?v'r1�;CE :'�ID riAitaGEl`SE2TT SE?�VICES ���
DIVISIOPt Or ISCEIJS:: �ND_ P�R��ffT ADMIT:IST�ATIOP�
Il3r OFt�iATICN I �C,UI� ?•iITH AP°LIC�TIOP1 FOR t'''T_''�:�T TO CCP�;DUCT GAi•�3LIiIG S�SSIOt' �:•? ST. PAUL
1. Pdame o$ Organization SPRC, Inc.
2. Addres5 where Organization's regular meetings are held 319 EaQle Street _
3. Day an� time of :neetin�s Board meets uarterl Exe utive Corr�ni t mee s m n ;�
• � U�u� N�4rtc'NRt Zcbt� UAitvF.Y.SrT�` �4�''c;
l�. AddresS where Gamblint? Session wi.11 he held--L�tYdmartc-C-�rrte�75--We-s'C-5ttr
5. Is aopl!icant owner oi property where Gamblin€ Session will be held' Yes XX �To
6. If lea�ed, who is owner of pro�ertp �«here Gamblin� Session �rill be held?
' Ramsey County
7. If leasled, attach letter of permission to conduct Gambling Session, signed by lessor.
8. Name of officer maIQng application John Mohr, President of SPRC
9. Addressi of officer maIQ.ng application 5838 Thomas Ave, Mpls. Date of birth 12-13-40
10. Pdame of; mana.ger who will conduct Gambling Session John Mohr'
11. Address�� of manager 5838 Thomas Ave, Mpls. Date of birth 12-13-40
12. In conn!Pction with what event is this Gambling Session being held? Halloween dance
and fundraiser for SPRC. �
13• 6�Rzat type of gambli.ng device(s) yaill be used? PaddlewY:ee1 XX "�pboard XX P..a.ffle XX
1l�.. �ay, dajtes and hours this application is for and number of sessions.
Il�30
Day(s)�aturdav Dates 10-24-87 Hours 7;3Q- T:o. of Sessions 1
15. 'r1ill pr,fzes be paid in money'or merchandise? Both
16. Is the anplicant association or.ganize��under the laws of the State of ?�iinnesota? e�_
�
17. Hor�r lon� Y:as Organization been in existence? 39 vedrs
18. ��v'hat is the purnose of the Or�anization? Outaatient rehabilitation for disabled/dis-
advant�qed children and adults.
,
, , .
19. Officer� of the Organization E,
P1ame-Title Address Date �af birth
Board Cha�i r . �
Rachelll Dockman Chase 808 Nicollet Mall 2-26-47
Presiden� �
John F. Mohr 5838 Thomas Ave S, Mpls 12-13-40 -
Executiv Vice resi ent ' � �
David . Fro d 9727 16th Bloomington 12-5-42
� �
,
20. Give nar.ies of of�icers or ar�y other persons paid for services to the Or�anization.
' ' ;dame-Title �ddress �ate of birth
��-�-����
No one w�111 be paid for work at the event.
21. In whose '�ustody will records oi Organization's Gambling Sess�ons be kept?
Name Ginr�y Wojt Adc�sess 319 Eaqle Street
22. Attach a icopy of your Organization's membersr.ip roster and date each member joined.
23. Attach thie Gambling Session i4anager's bond.
2lt. �ttacr a copy of the Department of the Treasuj-y, Internal ?evenue Service "Return of
Organizat�ion �empt from Income Tax", Form 990.. (Chapter l.119.OLt (1).)
25. Attach a cony of Department oi the Treasury, Internal Pevenue Service, "�.xemnt Organ-
ization Husiness Income T3X��� r^orm 990T. (Chapter �.19.01� (2). )
26. Attach th�e annual report required of charitable organizations by i�.innesota Statutes,
Section 3�'09.53. (Chapter 419.OL� (3). )
27. F:ave youlread and do you thoroughly understand the provisions of a11 lar�rs, ordinances
and re�uljations governin€ the operation of Gambling Sessions? yes
28. Ar�y chan.�es desired by the applicant association may be made only with the consent of
the Licer�se Committee.
I
29. �ias any rjerson(s ) participating i.n the operation of any of the gambling sessions cov-
ered by i#his license ever been convicted of a felony in the State of j�jinnesota or in
a�y other State or Federal Court? Yes No XX If answer is "yes", provide
nataes, addresses and birth-dates.
SPRC Inc.
aniz on
B , President
Off er _ tle
' an President
�i r in c'r�arge of Cambli . Session)
State of iti.nn�sota)
', )SS
County of Rar�ey )
John Mohr and ---
being duly sw xn sa� that they a^e the petitioners in the above a�plication; that they have
read the fore�oing petition and Trnow the contents thereof; that the same is true of tY:eir
oc�n ?rnowTed�e; �
Subscribed an�,sworr� to before me t"15
/.f day �i_c'��i� �9�
�-
��� �I
Notary Public amsey Countv, :•ii.nnesota
tiy co�mission e:cpires 10/12/90
BLtilding Depa�:�ent Approved Disapproved by
Fire Depart,�ent :�pproved �i.sa�proved bp
Police Department Approved�isapproved-by