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87-1163 �NHITE - CITV CIERK PINK - FINANCE G I TY OF SA I NT PAU L Council CANARV - DEPARTMENT BI.UE - MAVOR File NO• � �� Council Resolution �� Presented By Referr d To -Commi ttee: Date Out of C mittee By Date RESOLVED: That Application (I.D.#10976) for a State Gambling License (Class B- Raffles, Paddlewheels; Tipboards, and Pulltabs) by Anderson/Nelson VFW Post 1635 be and the same is hereby approved. COUNCILMEN Requested by Department of: Yeas Drew Nays Nicosia Rettman [n Favor Scheibel � Against BY Sonnen Weida wilson AUG 1 1 1987 Adopted by Council: Date Form Appr d by City Attorne Certified Passed o '1 Secre BY g�, A�pproved avor: Date v� ' � Approved by Mayor for Submission to Council By BY Pll�tr�NED r`.'._.' a `� ' 1987 . , � (,�,�-��r�3 DIVISION OF LICENSE AND PERMIT ADMINISTRATION DATE ✓I �3� �� INTERDEPARTMENTAL REVIEW CHECKLIST Applicant ��(��r� 11lUSoY� ��W�oz{• Home Address `�i��g�.,,,,_,_ ,� S{ L(D3S Business Name �s� Home Phone l.e �� `�. �..�i,�a�n �►p c c�.� Business Address e of License s) � � Business Phone �1(..Q - �.�3S C.�-4-G`�C1Z ..�'`40�C�-�. ��-�-V Public Hearing Date . l�1� License I.D. # 1C7q�.CD at 10:00 a.m. in the Coun 1 Chambers, �-i C�-.-.� 3rd Floor City Hall and Courthouse 3tate �$7�'T.'I5. i� � - �� 3 a -Gpa REVIEW DATE DATE INSPECTION APPN REC'D VERFIED COMPUTER COI�IlKENTS ed Not ed Housing & Bldg � Code Enforcement ( I Public Health I I I I Fire Prevention 4 f I Police � i City Attorney � ! I ENS � I i 300 Foot Notice I 1 I License Inspector's Comments: I HAVE BEEN GIVEN A COPY OF THIS NOTIFICATION AND UNDERSTAND THAT MY ATTENDANCE AT THE PUBLIC HEARING IS REQUIRID. . .. . , -..4�, .. . .� . ,. , . • -'. , . - ... :.,� . --..Y_� . d� . .. . , � . . . , ,e_: , ' " ., -. . f � CURRENT INFORMATION NEW INFORMATION Current Corporation Name: New Corporation Name: Current DBA: New DBA: Current Officers: Insurance: Bond: New Officers: Stockholders: , _ , ��7- ///3 � y^�tIII_1ll?y�1/Il///`r!1 �T�Ya�.�.S�T� ` ..6ZO��E�U,y�4'�.�j� Charitable Gambling Control Board FOR BOARD USE ONLY ��'�O�'� Room N-475 Griggs-Midway Building . • • ' :� 1821 University Avenue ' �. LicenseNumber I '^`'.• _ _ . � St. Paul, Minnesota 55104-3383 • � - (612► 642-0555 1 PAID i� ; AMT ��"� ' CHECK# DATE GAMBLING LICENSE APPLICATION 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 S100.00(Bingo,Raffles,Paddlewheels,Tipboards,Pull-tabs) $1Class B — Fee S 50.00(Raffles, Paddlewheefs,Tipboards,Pull-tabs) Makecheckspayableto: O Class C — Fee S 50.00(Bingo only) Minnesota Charitable Gambfing Control Board ❑Class D — Fee 5 25.00(Raffles only) �7Yes❑No 1. Is this application for a renewal? If yes,give complete license number � - +` i Q?� - �'1? �Yes ONo 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) flYes�No 3. Have Internal Controls been submitted previously?If no, please attach copy. 4. Applicant(Official,legal name of organization► 5. Business Address of Organization r�r�- `� 1 ¢ �T�t: f' �� ,.�r /� p, 6. City,State,Zip 7. County 8. Business Phone Number � �-� �E �6� ► 7 5- '� 9. Type of organization: ❑Fraternal ;QVeterans �Religious ❑Other nonprofit" 'If organization is an"other no�profit"organization,answer questions 10 through 13.If not,go to question 14."Other nonprofit"organizations must document its tax-exempt status. �Yes�No 10. Is organization incor orated as a nonprofit organization?If yes,give numbe�assigned to Articles or page and book number: Attach copy of certificate. DYes�No 1 1. Are articles tiled with the Secretary of State? ❑Yes ONo 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�:�Vo 14. Has license ever been denied,suspended or revoked?If yes,check all that a ly: ❑Denied ❑Suspended ❑Revoked Givedate: - 15. Number of active members 16. Number of years in existence Note: If less than four years,attach evidence of three years e�3 j� existence. 17. Name of Chief Executive Officer 18. Name of treasurer or person who accounts for other revenues of the organization. i�orr�ar. Lir,�ce ��larnnc� L. �ic!�: Title Title Cou�mander GJuarLe��r:as�er Business Phone Number Business Phone Number Ib12 ► 771-oq�� ( :�1?_ ) 4=�a-21Q�. 19. Name of establishment where gambling will be 20. Street address(not P.O. Box Number) conducted ander�o.n �Jelson ��rt�l Fos� 16�5 0�13 L. La�,J�on :�n�. 21. City,Stste,Zip 22. County(where gambling premises is located) 5t . ��ul . :T`I. ti�; ��fi R:-��tse CG-0001-02(8/86) White Copy-Board Canary-Applicant Pink-Local Governing Body - . � � �',,_-��-i�� .. Gambling License Application Page 2 Type of Application: ❑Class A -�7Class B ❑Class C..•� ❑Class D C�Yes�No 23. Is gambling premises located within city limits? . C„�Yes�No 24. Are all gambling activities conducted at the prem�ises listed in t�19 of this application? If not, complete a separate - application for each premises(except raffles)as a separate license is required for each premises. ' es�No 25. Does organization own the gambling premises? If no,attach copy of the lease with terms of at least one year. ❑Yes�No 26. Does the orga�ization lease the entire premises?If no,attach a sketch of 27. Amount of Monthly Rent the premises indicating what portion is being leased.A lease and sketch � � is not required for Class D applications. ❑Yes�No 28. Do you plan on conducting bingo with this license?If yes,give days and times of bingo occasions: Days Times C;�Yes❑No 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 i'I'3215 :�iil�i:.ca Cc. 5304�743 32. Lessor Name 33. Address 34. City, State,Zip 35. Gambling Manager Name 36. Address 37. City, State,Zip G�ral,? r. Verd��_�! 10:�u J�.�sv<;!�r;e Ci. S� Pa�zi , �,11. ;5�" '' 38. Gambling Manager Business Phone 39. Date gambling manager became 1��12 ► ti::�-7oj'2 memberoforganization: ;-13—�3 GAMBLING SITE AUTHORIZATION Sy 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 for any 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 whenever 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 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 mysetf 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. Official,Legal Name of Organization 41. Signature(must be signed,by Ghief Exec�rtive Officer) Ande2'SCI'? :`'i�1SOri �IF';J POS� 16�5 X �� Y �_ � � Title of Signer Date- ', -' ` " - CGL'7I72;;'.3:'_^ � .. ;'/� ,--,%i. ' '� ACKNOWLEDGEMENT OF NOTICE BY LOCAL GOVERNING BODY I hereby acknowledge receipt of a copy of this application. By acknowledging receipt, I admit having been served with notice that this application will be reviewed by the Charitable Gambling Control Board and if approved by the board, will become effective 30 days from the date of receipt Inoted below), 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 30 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 addition to the county signature. City af St. Pau� Signature of person receiving application 43. Name of Township x , ►, a -�� ` �� '� '�'- � ^ Title Date received(30'day period Signature of person receiving application Li c�nse i f15�LC�0T" begins frp �`�te) � X 44. Name of Person delivering application to Local Goveming Body Title CG-0001-02 (8/86) White Copy-Board Canary-Applicant Pink-Local Governing Body :� � .1 , , ' ��--��-//� 3 . ✓�� City of Saint Paul . Deparcme�it oE Finance and Management Services Division of License and Yermit Registration INFORMATION REQUIRED WITH APPLICATION FOR PERMIT TO CONDUCT CHAR.ITABLE GAMBLING GAME IN SAINT PAUL 1. Full and complete name of orRanization which is applying for license .' � �,;''�.'��",j' ��-�� l rV.r� �Ir j-, r ,y' �i�.. .:+-�- :1 ',S � . � 2. Address where games will be held ',, �+� y � ��+'?.J S�� .�.f S %r• !".�� = ,�`5� J,� �� Number Streec City Zip 3.. Name.of manager__signing this application who will conduct, operace and manage �: `,.._� +' `�r�•- Gambliag �ames r.�"-��e3 •� •-�� +� ,s" j�' ��.t N.% Date o f B irth -- {� (a) Length of time manager has been member oi applicant organization ��;y; /U rr� �� °. 4. Address of Manager /.JQ�'-f �F SS��^�,�1,� t" `�� `^'��_ "��`� `� `�� Number StFeet City Zip S: Day, dates, and hours this application is for - 6. Is the applicant or organization organized under the laws o= the State ot .�? �'�^ �' 7. Date of incorporation _ 8. Date when registered with the State of Kinnesota 9. How long has organization been in existence? �� .,' ��, � _ . � 10. How long has organization been in eYiscence in St. Pau1? �� '� •. ; r� A I 1. What is the purpose of •the organization? ^'"�r.' - :.' • -i--- � - -� �� ,�--' T*'".t�-'!=-� °-. � 12. Officers of applicant organization Name J � �� "" vame � �;.-. (�°n •,-` ;�,� ; .. ��. Address 7,-� � � ��•� , •' _ �;�-T Address �C "' �� irll/) !� x-�.1'-` Title rY`��, ;�.- DOB � Tit1e "r�, :J,�#=~ �''t�.'w,f�OB Name ;�° -� , .-`r ,e.:`,� 1,�;. v ame � / ✓� .� �.;'� �_- --• �, ` � :' Address S� �;��!.//G-! ;?I+!'�'� �ddress ?,� � G«� � /� f� , ';..�r ° Title �/�. V l!r= �'r�NittDOB Title�,,:.'',r:� r,�r,=:.,, �.,��,r,� � 13. Give names of officers, or ac�y otaer oersons ahe ?aid �or SE'r'+�C°S to �ne o;r�anization. Name � �ame Address � ' Address _ Title -"�e (Attach separate �aa��- - - .3ci�.±-:,,^'-' - _.�_'-;. . � � Gfi��-�� . • . , 14. Attached hereto is a list of names and addresses of all members of the organization:� 15. In whose custody will organization's records be kept? Name ��j,J J�oST /�r 3 � Address ��i�S,s �', L/��S�J� .�SIQ 16. •Persons who will be conducting, assisting in conductfng, or operating the games: Name �j-J=f�,�t� }/ �''Q L-�D d✓ Date of Birth �- �1- �� Address �U � � .�j F C �,r2,��.,,i*-= z" S T f� � � .S'�J >1 7 Name of Spouse Date of Birth Dates when such person will conduct, assist, or operate Name � f f 2/�) U/j J f_ �) G, L L Date of Birth �''- � �'- �� Address 1� f' � F l'�1' T�f7 I� S�T /�� `-J(,9 � Name of Spouse Date oF Birth Dates u%nen such person �ai?1 concect, ass:st, or ope-ate 17. Have you read and do ;rou thoroughiy unde-stand the orov�sions of all laws, ordinances, and regulatibns �overning tne operat:on of Charitable Gamblin� games? j�;.3 18. Attached hereto on t:�e form furzished b�r the City of St.. Paul is a Financial Report which itemizes al? receipcs, e::pezses, and disbursemencs of che aoplicant organization as we�l as ali orgar,±zations crho nave :��e:�red `unds �or the precediag calendar year which ;�as bee� s:gaed� pre,rJ�red, and ve_i�ied b�r :iame Addr�ss � who is che oL the aoplicant Organization. `lame oL Of�ice 19. Operator of premises �.rhe�e zames aill be he1d: Name � f � Business Address Home Address 20. Amount of rent paid by aop�:canc Or2uni�acio� Eor re�t oi che ha1Z; specify amounc paid per 4-hour se��;on � � r . .�� ,�y�-,�� , /. The proceeds ot the games will be disbursed after deducting prize layout costs and operacing expenses for the following purposes and uses: �. V .��-�,,,�� }�P� �a �� -� � % �'r=�� —� ��: y ,�.s� � ,:. ��) �.�z� I t.J --- �G�.c, K� t .r/s�' �r�' /t'I�/Y ►�l n_ry ,�•'�= � , �� , ! �+1 l _ s - I�d s��Q i� 2Z_ Has �the pr.emises w!Zere the games are to be held been certified for occupanc}• by the City oE Saint Paul? ��',� 23. Has your orgar.iaatfon ciled tederal form 990—T.' 1�r.� I[ answer is yes, please atcacn a cop� with thls -.zpplica�i.o�. Ic dL1SG%21' is no , e:cplain why: _ Any changes desired bJ �ie a�ol�canc �ssoc�acion ma� be �ade only wich the consent oi the City Counc�l. Organ:za�:.on Date Bv: � Manag2r in charge of game v v � � � z� _ ,. �- :� � � �o '-e � � :n r _ ,: '� C'� cn rt T � -r f 1 = — -� � '� I O r. 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