87-1689 WHITE - CITY CLERK
PINK - FINANCE G I TY O F SA I T PA U L Council �•1_�! �9
CANARV - DEPARTMEN7 F�Ie NO.
BLUE -MAVOR
�
oun ' R lution
Presented By ��
Referred To Committee: Date
Out of Committee By Date
RESOLVED: That Application (I.D.#74941) f r a Gambling Manager License
by Cliff Whitson DBA Westside B oster Club at 883 Payne Avenue
be and the same is hereby appro ed.
COUNCILMEN Requested by Department of:
Yeas � Nays �
Nicosia [n Favor
Rettm�n ,�
Scheibel Against BY
Sonnen
Weida
W1130t1 NOV i g 1987 Form Approve C' tto
Adopted by Council: Date
Certified Pass b ounc�l S et BY
By
A►pprov by Ylavor: ' ' � Approved by Mayor for Submission to Council
By
j
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. �' • � .dl° �11333 ,
�-jt�A�nC2 � � . .�d.c,��. DEPARTMENT , - - - - - -
-4�r �—S �_� _i c2�if:r CONTACT NAME
�G 5�-.5 OS Co PHONE
;
� 1 c�l zS�I Y'� DATE �
ASSIGN NUMBER Ft�R OU�, TING„�,�; (See reverse ide.)
_ Department Director _ Mayo� (or Assistant)
_ Finance and lianagement Bervices Director � City Clerk
� Budget Difector � �w-�.cl�� �. Ac�
� City Attorney _
TOTAL NUMBER OF SIGNATUR� PAGES: (Clip al locations for signature.)
W N ? (PurposejRationale)
�. �-�-C�,o�G�l-�-� ' ' �v..o--��.o �- �- u�Y�i�+��
�'�-_ �- �c���re.. bn� C� � c...Q> C..��...�?� �a��ve- o Y-P,�G�
� �c��Q �-(,� c�,,_�-. o ��d� . -
�. 0 a'L--�--`
U ND P RSO EL MP C C D:
',r� 1A
F N C 0 T AC IV T NUMB 0
(liayor's sigxtsture not required if under $10�00 .)
Total �lmount of Trsns�ction: n� Activity Number: '� �/`}'
Funding Source: 1n,�
ATTACHHIYIIENTS: (List and number all attachments.
`��'`��
�,P.Q,�.�'�.='
�e, .c.� �
ADISINISTRATIVE PRO�EDURES �1Pt
_Yes ' _No Rules, Regulations, ProceBure , or Budget Amendment required?
_Yes _No If yes, are they or timetable attached?
DEPARTMENT REVIEW CITY ATTORNEY REVIEW
✓Yes _No Co�utcil resolution required? Resolutiot► required? �!Yes _No
_Yes �No Insurance required? Insurance sufficientZ _Yes _No -
_Yes �No Insurance attached?
. � ��7 i��
� �
DIVISION OF LICENSE AND PERMIT ADMINISTRATION DATE p / IC� 1( 7
INTERDF.PARTMFNTAL REVIEW CHECKLIST Appn Processed/Received by
Lic Enf Aud
A�plicant � � H me Address � '1 Gj � ���p,�,A,� .
Rus ine s s Name w,Ap7l,.s���x,����p H me Phone �� - �j a �I
Business Address �X?���J � _ T pe of License(s) ���-�—'. «�► '
u
Business Phone `1'1(0 _ (3�c�
Public Hearing Date I � License I.D. 4{ ''� �� C� �
at 9:00 a.m. in the Council Chambers,
3rd floor City Hall and Courthouse State Tax I.D. ��
llate Notice Sent; Dealer �� � I�
to Applicant � �3 ,z �� �d�$ ���
�ederal Firearms 4� j'�
Public He�iring
DATE IIv'SPECTION
REVIEW VERFIED (COMPUTER) CUMMENTS
A proved Not A r ed
Bldg I & D �
� I�
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Health Divn. '
�'� i
� �
i
Fire Dept. i �
� n�� �
I
Police Dept. I
License Divn. �
1 Q� 2�l I C� �
City Attorney � OI Z� �
I
Date Received:
Site Plan 1(j 1 � � ��
To Council Research JO�Z� � �'��_
Lease or Letter Date
from Landlord � �� � �7�
T
���--� U 1!3 33
� • 1 � .
CURRENT INFORMATION NEW INFORMATION
Current Corporation Name: New Corporation Name:
Current DBA: New DBA:
Current Officers: Insurance:
Bond:
Workers Compensation:
New Officers:
Stockholders:
�.
--. � ��7 -/��`�
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��'�, • :, •
City of Saint P ul
. ' � Department oi Finance and Ma agement Services
Division of License and Pe i[ Registr,�,tio�
� __ ... „
INFORMATION RE UIREA WITH APPLICATION FOR PERMIT TO CONDUCT':�C�ARITABI:E��GAMBLING GAME IN
SAiNT PAUL `=
..,,�..�� � � ' ��' "�
�,:'J__ „ ' '=
1 . Full and complete name of organization which i applying for license
�s� S�d e u3o��.¢ers C
��
2. Address where games will be held ��3 S � Jr���
Number Street City Zip
3. Name of manager signing this application who w 11 conduct, operate and manage
Gamb?ing Games �, �u , ��(-� �' �y Date of Birth �-/� ' �{�
�/
(a) Lengc`� o� tiae manager has been member of pnlicant organization 0 i� �
1 �
4. �.ddress of Manager � g� �; V' ` � C, jl . �J'�-c,�.�.. `J�/
Yumoer SE eet City Zip
5. Day, dates, and hou.s th;s aoolication is for � + � - ,�, �- , ��'
c
6. Is t:�e appi=cant or o:rgar.�zation organized und r the laws or the State of MN? ( ��J
—T---
7. Date oi incor�orat'_on y s ' �
8. Lidt_ +1[72.^. �e?�_SC2::S 'JZL1 C:C�.' Ji:B'i�e cJi .ii131t25v a �C����{ �� 1q � (p
9. HOW ZOII� 12S O�QaIIlZ�C_Or �i7EEi1 lIl 2.{iSCet10E� �j
� �.
I0. How 'ong nas c;an:_ac_en oeen in eYistence in St. Pau1? ( C'i (�
11. �NC1d±' is c:�z ?c;_�ose o= �ae or;anization? ,�r \ '� � � t� �
� �
12. Of�icers o� a���'_caa� or;-��zatjon '
Yau:e �1'� �.�1.! N i�'! � ame r
:�ddress ��1 � ��r ��ic� r1 ddress �� I � . U"lC)(�'�-�`��,�
Tic1e ' DOB (� '�O '1�9 itleTr��C.lSi.t 1'� � DOB ([i �/ � �:C�
Vame � � �U� I��O N : ame r-�
.
Address �� . ddress `J �-� � �(a fti� �F(;�
Title � � DOB - �C ' � icle�" � i '. DOB 7 -��C
13. Give names oL o=='_c�:s , or ar..� at�er persons w o paid Eor services to the organization.
vame � ame
Address ddress
Title itle
(.=�c.�::1 S2'JdL3C2 snee� _`o add_t_c�u? aaTes . )
• • ' , . (��7-/��`q
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.
14. Attached hereto is a list of names and addres es of all members of the organization.
15. In whose cuscody will organizacion's records e kept?
Name Address �C,�( f= , �Q�r ��
16. Persons who will be conducting, assisting in onducting, or operating che games:
�ame , ? �<;Sc. �.�- ' C " � Date of Birth � ' �� '� ��
J i
Address l L. . �1; � �� �'
� ,
�ame oL Soouse �j C Date of Birth
Bates wher. sucR person will conduct, assist, r operate �ub�,v�, aS V�C.�6I)
Vame �� �� � '� Date of Birth (L ' ,�� � �-�
�ddress ;�� � C.1' �.(� r�
Vame o� Soouse ` � ` Date of Birth
Jat=_s .:;,e:: suc`-1 person wi11 conduct, assist, o operate �U��n1�fAS �)��
L7. �ave ;ou read and do you thoroughly understand the provisions of all laws, ordinances,
and ra�*1_3L:OP_S �ove-aing the operation of Cha itable Gambling games? C�
I8. a��ac:^.e_ ae�e_o on c�e form furnished by the C ty of St. Paul is a Financial Report
�R=ca :��m'_zes a?? receipts, expenses, and dis ursements of che applicant organization
�s %%e_'_ as �?_ oroan_zac:ons wE�o have received funds for the preceding calendar year
�a?ca :zas �e=_� s'_5�ed, prepared, and verified y
Name
Address
::�.o '_s cze of the applicant Organization.
vame oi Office
'°. Oper���= o= pr=�+=s�� �he-e games wiil be held:
`1a�e P •C C tt
3us'_:�ss �dd�ess ,� /�� � �i � sT � �
�c�e _�::c�ess
20. L:.oc^c o� �er,c �a_d 'o;� applicant �rstan:�acion or rent of the hall; specify amount
�a=_ �e� 1—:ZC�: se�s=on
� ' L,y , ' ` �
. -, .. � •
�-�7����'�'j
�1. The proceeds of the games vill be disbursed iter deducting prize layout costs and
operating expenses for the following purpose and uses:
!� ���7<< e . G� :f 3" �
22. Has the premises where the games are to be h ld been certified for occupancy by [he
City of Sainc Paul? ,4
23. Has your organlzation filed Eederal form 990 T? IF answer is yes, please actacn
a copy with this application. If answer is o, explain why:
?.ny changes desired by the applicant Association ay be made only wich the consen� oi cr�e
Cic� Councf?.
1��.sT s e �a-.� T��r' 4
Org niz ion
Date `� -�j'�t'�'� /
�• anager in c arge oL game
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