87-1502 WHI7E - CITY CLERK . 1 � .
PINK - FINANCE COl1jIC11
CANARV - OEPARTMffNT GITY OF SAINT PALTL � o'C,.
BLUE - MAVOR File � NO. �� ��
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Council esolution ;s-
Presented By
:_Referred To Committee: Date
Out of Gommittee By Date
RESOLVED: That Application (I.D.#18737) for a Class B State Gambling License
(Pulltabs and Tipboards) by Hayden Heights Booster Club at
429 South Robert Street (West Side Bar) be and the same is hereby
approved.
COUNC[Ll1�EN Requested by Department of:
Yeas Dr2W Nays
�� � In Favor
Rettman ' �
Scheibel
Sonn�n Against BY
Weida
W11�OI1 �Cj ; ' '��7 Form prov d by 'ty Attorney
Adopted by Council: Date
Certified ed by Council Secr tary BY
By. � ��c-�o-y��
Appr by iVlavor: Da ` �CT � � 19�7 Approved by Mayor for Submission to Council
— BY
P(1�_���� - ;:�� ;;'
�, . �,c�7_ /57��
.N° 011413 �
ti DEPARTMENT , - - - - - -
� � CONTACT NAME
- PHONE
q� 0 DATE .
SS �� � B p ROUTING ORDER: (See reverse side.:�
_ Departm nt Director _ Maqor (or Assistant)
_ Finance and Management Services Dfrector � City Clerk „
_ Budget irector _
� City At orney _
0 G AG (Clip all locations for signature.)
W I T ? (Purpose/Rationale)
-"(�,e. l.e c.:E;w4•- ' ��...,,.� w i.4.Q l�- -��i V cQ c..�a...-� �'Iti�.
��, „Q�, b o� � G*� �i w--�..5�-� w��" .�ctiwAa.. .J�-A�.c-�aas4 i�� � .
e��.� � �.,.--� o�-��°' .
0 BNE U A CS N .
Y��A
I C S WE A BRC DO TD:
(Mayor's si ature not required if under $10,000.)
Totai Am t of Trans�ction: !� � Activity Number: � ��' '
Funding rce: 1(`� �
�TACHMENTS: (List and number all attachments.).
�°�
p� � �
cJl��. .
DM N T 0 EDURES - � Ip�
_Yes Nv J Rules, Regulations, Procedures, o�r Bndget Amendment required?
_Yes Po if yes, are they or timetable at��t+e�hed? '
D T V EW CITY ATTORNEY REVIEFi
�Yes o Council resolution required? Resolution required? y`/Yes _No
_Yes � o Insurance requirad'F Insuranc� sufficient? iYes _No
_Yes o Insurance attached?
- �' � C',�=j�7--i,s��
DIVISION OF LICENSE AND PERMIT ADMINISTRATION DATE �ll gZ / q ( c�/�
INTERDFP�IRTMENTAL REVIEW CHECKLIST Appn Processed/Received by
Lic Enf Aud
Applicant -��,���_ � Home Address ��1� }�,��-�- �� ,
Rusiness Name ��¢„„-����d��ta Home Phone �Z�� — (���,�
Business Address �,�q �.;���� Type of License(s) CQr,�.a, �,"r,.� "_ �
. V
Business 'Phone �G�-(�(��?� ��,_`_�-
Public Hearing Date (��,�, , 1 � < < Ci�-] License I.D. 4i l �S'� 3�--�
at 9:00 a.m. in the Council Chambers,
3rd floor City Hall and Courthouse State Tax I.D. ��� � _ �S o2�1 l >1
llate Notice Sent; Dealer 4� In��
to Applicant
Federal Firearms 46 1� ,�
Public Hearing
DATE INSP�:CTION
REVIEW VERFIED (COMPUTER) COMMENTS
A roved Not A roved
�
Bldg I & D �
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Health Divn. '
�
� �� �
Fire De�t. i � `� �
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Police bept. I
G� v� I�
License' Divn. �
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City AtKorney �
1 C.�/� i l�- L
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Date Received:
Site Plan ��,t�� � n
To Council Research � lA C'�D•,�� �(L,
Lease or Letter Date
from Land�.ord � � 1���—� �
.���..� �
' c� �t�13
, ��is��
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,:••;;uo�;��. Charitable Gambli�g Control Board FOR BOARD USE ONLY
��'• Room N-475 Griggs-Midway Building -
':� 1821 University Avenue u`."�°N°„'e°`
_ St. Paul, Minnesota 55104-3383 AMD
" " 1612) 642-0555
�'l�' CHECK#
DATE
GAMBLING LICENSE APPLICATION
INSTRUCTIONS. •
A. Type or print in ink.
B. Take completed application to local governing body,obtain signatu�e and dfite 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 S 100.00(Bingo,Raffles,Paddlewheels,Tipboa�ds,Pull-tabs)
Class B — Fe�e S 50.00(Raffles,Paddlewheels,Tipboards,Pull-tabs) Makecheckspayablsto:
❑Class C — Fee S 50.00(Bingo only) Mlnneaota Cfiaritable GambRng Control Bosrd
❑Class D — Fee S 25.00 IRaffles only)
❑Yes,P�INo 1. Is this application for a renewal? If yes,give complete license number � - 0 - 0
❑Yes�No 2. If this is not an application for a renewal,has or9anization been licensed by the Boa�d before? �f yes,give base
license number(middle five digits) �
❑Yes�No 3. Have Internal Controls been submitted previously?If no,please attach copy.
4. Applicant(Official, egal name of organization) 5. Business Add'r�jss of O�g�aQnization
i-��Y[�L�/`!` i�l•- ��' `rl Ty ,L�C'..?Ti.+�. ��t�:�J �r7�S e� /`��3' !gw
r
6. City,State,2ip � 7. County 8. Business Phone Number
�r ,�-���+ � /�,�� �ti fi , ,,�,-�.�.��� � �(o/� b?9d'-�Ya3
9. Type of organization: ❑Fraternal ❑Veterans ❑Religious �Other nonprofit"
•If organizatian is an"other nonprofiY'orgarn a iq4,answer questions 10 through 13.If not,go to question 14."Other nonprofit"organizations
must document its tax-exempt status. /��ft
DYes�No 10, Is organization incor orated as a nonprofit organization?If yes,give numb r a�ssigned to Articles or page and
book number: Attach copy of.certificate. y`�l�
❑Yes�No 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 taxl If yes,please attach letter from IRS or Department of
Revenue declaring exemption or copy of 990 or 990T.
DYes.�No 14. Has license ever been denied,suspended or revoked?If yes,check all that a ly:
❑De�ied OSuspended ❑Revoked Givedate: - -
15. Number of active members 16. Number of years in existence Note: If less than four years,attach
-^� evidence of three years
.nS �,�,t .�f-' ��;"f'�e-= existence.
17. Name of Chief Executive Officer 18. Name of treasurer or person who accounts for other revenues
of the organization.
/�a� � �i c:fl�"r ; h T L A�Ne ����p✓�
Title ' Title
�
� ��4`L� rsi � � ` ^� �` � � ` ��t/l� Y.r
Business Phone Number Business Phone Number
� rcla � � 77�-5��? � r��� , 77��- 7�oa
19. Name of est2�blishment where gambling will be 20. Street address(not P.O. Box Number)
conducted � , !� -�
� �," /�, i;
i.� i =S T � �� � ;o:/'�r,�. %-f:� � o�e ;'C!_•-f C-�� /
21. City,Stste,�Zip 22. County(where gambling premises is Iocatedl
�r �',4.0� ���/�� SS/D ? .�.��r��c=y
CG-0001-02(8/86) White Copy-Board Canary-Applicant Pink-Lxal Goveming Body
^ - . , ��7/5��
Gambling L;�ense Applicatio� Page 2
Type of Apptic�tion: OClass A �Class B ❑Class C ❑Class D
�1(es�No 23. Is gambling premises located within city limits?
- '` �Yes�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(except raffles)as a separate license is required for each premises.
❑Yes o 25. Does o�ganization own the gambling premises�If no,attach copy of the tease with terms of at least one year.
i ❑YesJ�(No 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
is not required for Class D applications. 4���
❑Yes�No 28. Do you plan on conducting bingo with this license?If yes,give days and times of bingo occasions:
Days Times
es ONo 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
U � < < � �
32. ssor Name 33. Address 34. City,State,Zip
� ` � C L,. C�" (,�.
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35. Gambling Maria er Name 36. ddress 37. City,State, ip
1�� �r� { �
38. Gamblirig M ager Business Phone 39. Date gambling man�ger became
( f � ..,,,� _ t� member of organization:
��I�1- `1�3 cl�y�t,�:
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 forany unauthorized game or
practice.
BANK RECORDS AUTHORIZATION
By my signature below,the Board is hereby authorized to inspect the bank records of the General Gambling Bank Account
, wheaever 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 chi�ef 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 agree,
if licensed,to abide b those laws and rules, includin amendments thereto.
40. 4fficial,Legal Name of Organization 41. Signature(must be.,signed b�(Chief Executive Officerl
� , .
� ' 4 F e� ./�✓ ( X ' f (. —� � .i,,.�ew�/�
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Title-�of igner Date '� � �
,- . � . P .e��j� �
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ACKNOWLEDGEMENT OF NOTICE BY LOCAL GOVERNING BODY
I hereby acknowledge receipt of a copy of this application. By acknowiedging receipt, I admit having been served with
notice that this application wiil be reviewed by the Charitable Gambling Control Board and if approved by the board, will
become effecti�e 30 days from the date of receipt(noted belowl,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 30i 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
n --�� addition to the county signature.
� �• �; t '
,� '��.�` :, y.�, �` . �t
Signature of.person receiving application 43. Name of Township
X ' � � �� �-�
Title � ' Date received(30 day period Signature of person receiving application
- begins fram this date)
`` �'� i ! '1 1 <-� X
>, 1, l. -
•`' � 44. Name of Perso�delii�eri�g application to Local Goveming Body Title
Ji
�':. : r ra /S �it � rt .��""
CG0001-02 �8/8 � White Copy-Board Canary-Applicant Pink-Local Governing Body
-------------------------------- AGENDA ITEMS =________==______-------------- �r ���a�
- ---- ---- -------- ------ -------------- �.
ID#: [305 ] DATE REC: [10/06/87] AGENDA DATE: [00/00/00] ITEM #: f_ 7
SUBJECT: [CLASS B GAMBLING LICENSE - HAYDEN HEIGHTS BOOSTER CLUB ]
STAFF ASSIGNED: [NONE ] SIG:[SCHEIBEL ] OUT-[ ] TO CLERK [10/06/87]
ORIGINATORe[LICENSE DIV. ] CONTACT:[ ]
ACTION:[ ]
C 7
C.F.# [ ] ORD.# [ � FILE COMPLETE="X" [ ]
+� : � +� �r +� � � � � � r�
FILE INFO: [RESOLUTION/CHECKLIST/GAMBLING APPLICATION ]
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