87-1469 WHITE - CiTV GIERK� COUI1C11
PINK - FINANCE � G I TY OF SA I NT PA U L f �'�—/��a
CANARY - DEPARTME T �
BLUE - MAVOR � FIl@ NO.
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� Co cil R olution ,-
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Presented By .
Referred �To Committee: Date
Out of CQmmittee By Date �
RESOLV�D: That Application (I.D.#26821) for a One Day City of St. Paul
Gambling Permit (Raffle) by St. Paul Ramsey Medical Center
Volunteer Service at 640 Jackson Street on October 15, 1987,
between the hours of 3:30 P.M. and 4:00 P.M. be and the same is
hereby approved.
i
COUNCILMEN Requested by Department of:
Yeas Dr��„� Nays �
� In Favor
i2ettman
Scheibel, � Against BY
S�n
W�ida ,
wilson �CT — j` �87 Form A proved y ity tt ey
Adopted by Coun�il: Date
Certified Pa: nc'1 S r ta BY
By
A rov Mav4r: Date
"`�' ° - �"u� Approved by Mayor for Submission to Council
PP Y �
By BY
P��SpEp 0 C T 1 ? 198�
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� @�-�7-��r�9
DIVISION 0� LICENSE AND PERMIT ADMINISTRATION DATE
INTERDEPAR�MENTAL REVIEW CHECRLIST
I
Applicant . C�.� Home Addre s � IC.d.prvt,,,� •
� �a� �
Business l�ame � Home Phone
Business A�ddress L Qn -� , Type of License(s) ff`(C�� .�.���.
Business �hone '�`�� -?�� � 5
Public He�ring Date I(7 � —� ��l'"1 License I.D. # le� 01 (
at 10:00 �.m. in the Council Chambers,
3rd FloorjCity Hall and Courthouse State Tax I.D. # n I�
� � << �,�ti �
REVI ATE DATE INSPECTION
APPN REC'D VERFIED COMPUTER COMMENTS
�' ed Not roved
Housing &I Bldg �
Code Enf o�cement �I l� -_ _1 � • �
� JV�-�6'�
Public Heialth �
j C� �
G� cr I
t
�
Fire Prev�ention 4
� ' i/ � �i
� 5
I
Police I �
n � '
�
City Att�rney �
i I
ENS � I
' I
� � i
300 FootlNotice �
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Licensellnspector's Comments:
I HAVE EEN GIVEN A COPY OF THIS NOTIFICATION AND UNDERSTAND THAT MY ATTENDANCE AT
THE PUB IC HEARING IS REQUIRID.
I
._. . - , . . — .-. . . . . .t " ' � . �•S:,ye.�'� ",-� ... . . , . . �" .��''1 . . r ..
CURRENT INFORMATION NEW INFORMATION
Current Corporation Name: New Corporation Nsme:
Current DBA: New DBA:
Current Officers: Insurance:
Bond:
New Officers:
Stockholders:
�l 1 i ur �1 . rauL �'X'P f'�?�r�
' � ` DEP.�RTZ��iT OF rT13tL�C: A?ID tlAi;.'�C-:.1��?T �E'_�VICc S
DIVISIOiI OF LICr�•1SE :�ND PEF?��ffT ADMIr?IST�ATIOl+T o�d� �
, � , ���r��
., i��+=01?Y4ATICN ? 'C,UI� � r;1ITH 2.PDLIC�ITIOPd r OR �i?�Si TO CC�•IDUCT Gti�3IS:iG Sr,SSIOP�; I:d ST. PAUL
l. i�ame� of ;Organization �'. ,PAvL A�Y�S�iY/!l�/CAL L►.�A1'T� I/Oj-(/��T�-/� ��V��
2. Address 'where Organization's regular meetings are held��(0 �flC�'SdN �T� ST��f�4'L- 55'/O1
3. Day and time of :neetin�s 15� TK1�5�1� /�Q�TJ�-�L� �i�� /� �C�
!�. Addre ss 'whe re Gambli.n� Se s sion ,,ri.11 he held��l� ;7��So,�J 5T, $'7Z ,��q-c.Z S'S/� /
5. Is aap7.�.cant owner of property T�rhere Gamblin€ Session taill be held'_�Yes�_No
6. If leas�d, who is owner of pronerty wr,ere Gamblin€ Session �aill be held?
7. If leas�d, attach letter of permission to conduct Ga.�blin� Session, signed by lessor.
fi. Name of', officer maFang application � 'S'T, �i�- ��S�Y /j'1�� ����� V OC.•
s _
9. Address, of officer maIQ.ng application 6�/a �. �'��Date of birth
�
10. Ptame of', manager wY;o will conduct Gambling Session .�� �C/-�(�'LUC./�
11. Addressi of mana.ger�SJ` f��A1/Tal� �,a5_F.tlI1.L,� j�5//3 Date of birth
I.2. In coru�}ection �rith what enent is this Gambling Session being held?
�� A-N�vA� 8t}zA�4��
--r
13• 6�1Yiat tgpe of ga�blir� device(s) wil.l be used? Paddlewr�el 'I�pboard F.af`'le�
Ilt. Day, d�tes and hours this application is for a.nd number of sessions.
' - .� ;vv p�� l
Day(s ) �f�v�� Dates QCT• /5, ��jB�Hours — y P.o. of Sessions
15. f1i11 p�i.zes �e paid in money or merchandise? �O�
lb. Is the applicant association organized under the laws of the State of P��innesota? I�
�
17. How lomg has Crganization been in existence? 'o�O� y��5
1S. T+r*hat i� the pux�t�ose of the Organization? �jeOd�D� I�OL(JI'fT��',�.s iQ'I� �k�.
�n�c�l'� ���1r�-� -,p,���� FvN1�s � 7',�-T'i �T P�� , _
19. Office�s of the Organization
' �1ame-Title Address �ate of birth
� �.�¢��.�-� �`�5� ��ze.�� a�,�Q��*��c
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o�-� _�.� � � �1�.,�x��. .�, O�.P ss�i �
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ss��
' �-— Sf �.e
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- ' ��,��-1����y
20. Give na�es qf officers or any other persons paid for services to the Or�anization.
, id�me-Title Address �ate of birtr
�Nlc� K�ss s�✓U�,� Yqas i� ���9 /a/y/s3 -
�
�`y � � /
tf�DY�'L �i�l�/��. S�C�t�i9��/ ��.G'��`�►�r S.S�/3 D�f /D /�Gl
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21..- In whose cu$tody will records o� Qrganization's Gambling Sessions be kept?
�Vame �/OL� ��o2v1 C� ���' Address � y� cJ1��%�S°�N s� J� U�j9'�.L �5/�/
22. Attach a copy of your Organization's membersr.ip roster and date each member joined.
23. Attach the Gambling Session i4a.nager's bond. _
2l.�. �ttach a co�y of the Department of the ?'reasux�y, Internal �evenue Service "Retvrn of
Organizatiop� :xempt from Income '"ax", Form 990.. (Chapter Li1.9.OL (1).)
25. Atta.ch a cdpy of Bepartment oi the Treasury, Internal Pevenue Service, "Fxemnt Or�an-
ization Busliness Income Tax", Form 990T. (Chapter l�19.01� (2).)
26. Attach the annual report required of charitable organizations by i�.innesota Statutes,
Section 30r�.53. (Chapter Lt19.0l� (3). )
27. f:ave you r�ad and do you thor.ou�hly un�erstand the provisions of all la�rs, ordinances
and regula�ions �overnin� the operation o� Gambling Sessions? __ � ,o_
�—
28. Ar�y chanF-e3 desired by the appL.cant association may be ma�e only- with the consent of
the Licens$ Committee.
29. Has any pe�son(s ) participating i.n the operation of any of the gambling sessions cov-
ered by t�s license ever been convicted of a felon in the State of i°Iinnesota or in
a.� other tate or rederal Court? Yes . No�. If answer is "yes", provi.de
names, addresses and birth-dates.
� Q � (/
• Organization �
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, — B� � V �i����J
� (0 f er-Title
and
' . (I�anager in c'�.arge of Gambling Session
State of Minnesota)
)SS
County of Ransey )
I and
being duly sworn sa� that they are the petitioners in the above a�plication; that �hey have
r�zd the foregqing petition and Trnow the contents thereof; that the same is `.r�ae of treir
own kno�aled�e.
Subscribed and sworn to before me t:�.i� � w,�,�,,,,,,,,,��,
1�lday o��?�� 19�_ d ,
� _�,�,��„` KFi1STINA L SCHWEIN!Fa
� � ±�s NOTARY�U�Li�—;.i!M�aFS',�A
���' \ _ \ (; � ` DAK.'JT;1^^ti",.:
� ;-� �5:�-�,�� , �o- ,
Notary Public,' �,�;t-«- , * wv co�a.���g���:,r.. � �^�t
Countv ��iinnesota z...,,�,�
;�iy commi.ssion xpires ',1 .-, „�. ��-��+; �
Building Depar�:�ent Approved Disapprovecl� b�
Fire Departrien�i :�pproved �isanproved by _ _
PoLice Department :�pproved--Disapproved--by
_ �nnesota Charitable Gambling Control Board LAWFUL GAMBLING EXEMPTION
�, , �oom N475 Griggs-Midway Building FOR BOARD USE ONLY
11821 University Avenue
E�q,,,;�� $t. Paul,MN 55104-3383 ��/-���0
, `-�►�- �+....%�' (�121642-0555
� ��
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INSTRUCTIONS:. 1. Submit request for exemption at least 30 days prior to the occasion..:
'� 2. When completing form, do not complete shaded areas.
', 3. Give the gold copy to the City or County. Send the remaining copies to the Board. The copies will be
' returned with an exemption number added to the form.When your activity is concluded;complete the
PLEASE TYPE financial information, sign and date the form,and return to the Board within 30 days.
. Organization Name ��' . License N�mber�M a.renny w previaah/Mcer�aedl
St. Pa i-Ramse M �tot Iicensed
Address � City,County,State,Zip Code
o�+t� Ja�icson Straet St. Paul , Ramsey, �l�nnesota, 55101
Chief Executive Officer'$Name Phone Number Manager's Name Phone Number
Mary ,1aps, Pres(dent (612)429-43SCJ �• ��id Schmuck (612) �3&-3�i5
Type of Organization I If Other Nonprofit Organization(Check Onel
� Fraternal ❑ Veterans C�IRS Designation
❑ Religion •(�(Other Nonprofit Organization (�Incorporated with Secretary of State
- - - --- -- - -�--_ -- .� :._ _ - --�--. = _.: —--. .- ...: -- .
" � - � - ��Affifiate of-Parent Nonp�ofit Organization
Name of Premises Wher Activity Will Occur Datels)of Activity
St. r�:u 1-�amsey Med t ca t Cer�te r Gymnas 1 ura Bctaber 15, 1987
Premises Address
640 Jaeksqn St i B8t (�antsey Caunty) e St, �dtl� i �H �5 i Q�
Games ' Yes No Gross Receipts Value of Prizes Expenses Profit
Bingo
-r,_..�> .
� � Raffles. X
��..J..�:..N�.
S" _
'�'°� ' Paddlewheels
Tipboards �
Pull-Tabs
Use of Profit I
- Distributor From Whom IGambling Equipment Acquired Distributor's License No.
, I affirm all infor ation submitted to the Board is true, accu- I affirm all financial information submitted to the Board is
rate, and complefte. � ' � true, accurate;.and complete. ; -
`�' .a �, %� L:.a� ,�'c .i " � ,�i,' .
�
Chief Executive Officer ignature ` Date Chief Executiva Officer Signatura Date
ACKNOWLEDGMENT OF NOTICE BY LOCAL GOVERNING BODY
I hereby acknow,edge receipt of a copy of this application. By acknowledging receipt, I admit having been served with notice
that this applica�ion will be reviewed 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 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 COUNTY TOWNSHIP
Name of Local Govemi Bady ICity or Countyl Township Name(Must be notified when County is the approving body)
_ � �
� Signature of Person Re eiving Application , � Sig�ature of Person Receiving Application '
-=�,:.. i� ' -f t"=.-'�`
Title ,�,, �" �j Oate Received Title Date
�� A r + , 9/15/$7
CG-00020-01 14/861 ; White—Board Canary—Board retums to Organization to keep
' Pink—Organization Gold—City or County
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