87-1554 WHITE - GITV CLERK �
PINK - FINANCE GITY OF SAINT PALTL Council {/�+
CANARV - DEPAqTMENT File .. N0. " � ��+�
BLUE - MAVOR �
�
Co ncil esol tion
Presented By � '
Referred To Committee: Date
Out of Committee By Date
RESOLVED: That Application (I.D.#43032) for a Class B State Gambling License
(Pulltabs F� Tipboards Only) by Highland Area Hockey Association
at 825 Jefferson be and the same is hereby approved.
COUNCILMEN Requested by Department of:
Yeas � Nays �
Nicosia tn Favor
Rettman �
Scheib�l Against BY
Svnnen
�
WilsOri OC'� 2 7 �8� Form Appro b City ttorne
Adopted by Council: Date
Certified a s d b Counci , c y BY
By
t�pprov �avor: Date � r Approved by M or for Submission to Council
y BY
PUBLtSl�Ep ;b�V 7 — 1987
� - .���-�s3��
� N.° Q11396 �
- EPARTMENT . - - - - —
CONTACT NA1�IE
� PHONE �
/t) DATE ,
S GN F (See raverse side.)
_ Depa ment Director Mayor (or Assistant)
_ Fina e and Management Services Director ,� Cit Clerk
Y
Budge Director ,� n,w�_ �c _ l �--�- � �.
_,j_ City ttorney _ —"+�
0 U (Glip all locations for signature.)
W V Y T ON ? (Purpose/Rationale)
Th.�. � �cv4�+�., P�- �.�.-� w•.�Q, !a�"' �
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OS B BU G T AND NNE AN C D:
� '�
N C GTA V E D:
(Maqor's s gnature not required if under $10,000.) :
Total Am t of Trans$ction: n �/� Activity Number: � t A
Funding ource: � I�
ATTACHMENT : (List and number all attachments.)
���� � ;
��"""'� � '
. �(. �
ADMINIS P OCE U� � '�
_Yes No , Rules, Regulations, Procedures, or Budget Amendment required?
_Yes No If yes� are they or timetable attached?
�,EPARTMENT EV EW CITY ATTORNEY� REVIEW
✓Yes No Council resolution required? Resolution required? ✓Yes _No '
_Yss o Insurance required? Insurance sufficient? _Yes _No
Yes o Insurance attached7
(',����s��/
UIVISION OF LICENSE AND PERMIT ADMINISTRATION DATE � ( ' / [ g
INTERDF.PARTMENTAL REVIEW CHECKLIST Appn Processed/Receive by
Lic Enf Aud
Applicant Home Address ,"Z �� ` ,1'�� ,,, ��� j� ,
Business I3ame ��� Home Phone (� �l(� - s� $'b
Business Address � Type of License(s) ��� �.c�����,,�;�
� _CQ � C��� �
Busine�s Phone ��[�- � �-� �,�Qp �
Public Hearing Date � License I.D. 4� '�3 Q 7ja
at 9:00 a.m. in the C unci Cham ers,
3rd floor City Hall and Courtho�u,s�e$ State Tax I.D. ��
llate N�tice Sent; � Dealer �� �
to Applicant �f � 8 7
Federal Firearms �� ���
Public Hearing
DATE INSPECTION
R�VIEW VERFIED (COMPUTER) COMMENTS
A roved Not A roved
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Bldg 'I & D I I
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Health Divn. '
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Fire Dept. i � �� �
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Polic'e Dept. � � �� I
License Divn. ' � �
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City Attorney ���� �
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Date Received:
Site Plan ��/�
To Council Research 1(� zb �1
Lease or Letter ate
from La�dlord 1 rj �1.C� �`�
�n�..�.-� ��-��' 0113�1 �P
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' ` =��' ,•` �`�'�� Charitable Gambling Controi Board
`.f' •J`t��yLDUh��. FOR BOARD USE ONLY�
°����� Room N-475 Griggs-Midway Building
-..,.:r„�:
- :� 1821 University Avenue u�N°"'�`
� '� ' St. Paul, Minnesota 55104-3383
(612► 642-0555 ,PqNjD
, �.+i�' . CHECK#
� - ' DATE
GAMBLING LICENSE APPLlCATION
E
�
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� INSTRUCTIONS: �
A. Type or print in ink.
� B. Take completed application to locat 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 S 100.00(Bingo,Raffles, Paddlewheels,Tipboards,Pull-tabs)
� (�Class 8 — Fee 5 50.00(Raffles,Paddlewheels,Tipboards, Pull-tabsl �e�nedcapayee�co:
; . C(Class C — Fee S 50.00(Bingo onlyl Minneaota Charitable GambGng Control Board
= ❑Class D — Fee S 25.00(Raffles only)
; �IYes 0 No 1. Is this application for a renewal? If yes,give complete license number � - 0 - �
❑Yes�No 2_ If this is not an application for a renewal,has or anization been licensed by the Board before? If yes,give base
license number(middle five digits)
es ONo 3. Have Intemal Controls been submitted previousty?If no,please attach copy.
4. Applicant(Official,legal name of organization) 5. Business Address of Organization
! 'j .. . ; �.�i: _... . �j i . - f'`
6_ City,State,Zip 'V ' 7. County " 8. Business Phone Number
y.Y;,� ti � 1 °"+ �:.� +'" ( : ) '/ ' J % �.,
9.. Type of organization: ❑Fraternal ❑Veterans ❑Religious ther nonprofit"
� _ " ''�"'.''Iforganization is.acr."other nonprofit"organization,answer questions 10 through 13.If not,.go to question 14."Other nonprofit"organizations
,. __ _
�,._
t, must document its tax-exempt status. "- - � °- � • -.. - -
� ❑Yes�No 10. Is organization incor orated as a nonprof�it organization?If yes,give number assigned to Articles or page and � �
book number: �` ' `' ' �✓ Attach copy of certificate.
�(es❑No 1 1. Are articles filed with the Secretary of StateZ.
f ❑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,chec��y:
❑Denied ❑Suspended ❑Revoked Givedate:
15. Number'of active members 16. Number ot years in existence Note: If less than four years,attach
evidence of three years '�=
�
�Y �':�' existence.
17. Name of Chief Executive Officer f 18. Name of treasurer or person who accounts for other revenues
> � of the organization. .
. '�-'":-=�•�../� f� .�,;`._..'.r�- �. . . , , �_ , r.
Title r . Title
. j,J ,�,�,�� �_ :
. Business Phone Number Business Phone Number
�
� �' r�`� , Y �-�C.I ._ l_ .�_ .!.'. /� ..� i� ��' _� _ ' -�.
� -'' 1 °/ -�1 :.r
19. Name of establishment where gambling will be 20. Street address(not P.O.Box Number)
conducted
21. City,Stste,Zip 22. County(where gambling premises is located)
, �,
` _ !� � ' - i" _ -'---,..
; • CG-0001-02(8✓86) White Copy-Board Canary-Applicant Pink-Local Governi�g Body
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i :' Gambling License Application
� Type of Application: �Class A ❑Class B ❑C1ass C �Class D
� DYes�No 23. Is gambling premisesJocated within city timits? �
't E�es ONo 24. Are all gambling activities conducted at the premises listed in �119 of this application? If not
r - application for each premises(except raffles)as a separate license is required for each premi:
` ❑Yes l3No 25. Does organization own the gambling premises?If no,attach copy of the lease with terms of<
i
:; �Yes,E�INo 26. Does the organization lease the entire premises?If no,attach a sketch of 27. Amount c
; the premises indicating what portion is being leased.A lease and sketch S -_
' � is nox required for Class D applications.
�
F= DYes L�lo 28. Do you plan on conducting bingo with this license?If yes,give days and times o bingo occa
s . Days Times
�
} � "�
y� No 29. Has the S 10,000 fidelity bond required by Minnesota Statutes 349.20 31e�Bond Numbetta�
• � urance Company Name
- � ,, ./ � — -;�
. 'li�sor Name '�/ 33. Address �• , 34. City,S
'' a / F . ,, �• a .:L�-�''t ''
__ i � ._ �..,, , 37. City,S
_:�mbling Manage�Name - 36. Address _
� � 8. Gamblin Manager Business Phone 39. Date gambling manager became I
` 3 9 ,
. member of orgarnzation:
� :�:� . 1 ..
, GAMBLING S1TE AUTHORIZATION
� By my signature below,local law enforcement officers or agents of the Board are hereby authorized
i at any time, gambling is being conducted,to observe the gambling and to enforce the law for any
practice. BANK RECORDS AUTHORIZAT.ION
9 � "r=By m�signature:.below,the Board ishereby authorized to inspect the bank records of��the General G�
, � �� whenever necessa'ry 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;
F 3. All other required information has been futly 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�
if licensed,to abide b those laws and rules, includin amendments thereto.
_ � 41. Signature(must be signed by Chief
� 40. Official,Legal Name of Qrganization : ,,�� �
` X ,'�'�. �.�:�• .�� s-
_ E . �� � � `���� I Date '� ��_
�•, Title of Signer '� , ;;
_j -
,_.--
� ACKNOWLEDGEMENT OF NOTICE BY LOCAL GOVERNING BODY
� I hereby acknowledge receipt of a copy of this application. By acknowiedging receipt, I admit h�
; notice that this application will be reviewed by the Charitable Gambling Co�trol Board and if app�
become effective 30 days from the date of receipt Inoted below),unless a resolution of the local gc
f which specifically disallows such activity and a copy of that resolution is received by the Chari
`• Board within 30 da s of the below noted date.
l If site is located within a township,item
42. Name of City or County(Local Governing Body) addition to the county signature.
; City o� St. �aul
43. Name of Township
4 Signature of person receiving application ��
', �� ' , � .:•
f X +��S�pI� L�r�.~.�Ld� `j .^.� i.`��,n,� ��. � .
Date received(30 da�r penod v Signature of person receiving applicatic
� Title _
�..ie�nse ,I;�spector beginsfromyt�is.d�� X
( - -
: 44. Name of Person deiivering application to Local Goveming Body Title
CG-0001-02 18/861
White Copy-Board Canary-Applicant
I
________________________________ AGENDA ITEMS =_______________________________
�,:-�7�ssy
ID#: [367 ] DATE REC: [10/20/87] AGENDA DATE: [00/00/00� ITEM #: [ �
SUBJECT: [CLASS B STATE GAMBLING LICENSE - HIGHLAND AREA HOCKEY ASSN ]
STAFF ASSIGNED: [NONE ] SIG:[RETTMAN ) OUT-[X] TO CLERK�OrT6�%OOj ��%Z �
ORIGINATOR:[LICENSE DIV. ] CONTACT:[SCHWEINLER - 5056 ]
ACTION:[ ]
[ ]
C.F.# [ ] ORD.# [ ] FILE COMPLETE="X" [ ]
� � � � � � � � � � � �
FILE INFO: [RESOLUTION/CHECKLIST/APPLICATION )
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