87-1164 WHITE - CITV CLERK COlII1C11
PINK - FINANCE - G I TY OF SA I NT PA LT L
CANARV - DEPARTMENT ��/// .
BLUE - MAVOR File NO. �''
�
Council Resolution �
�
Presented By
Referre o Committee: Date
Out of Co ittee By Date
RESOLVED: That Application (I.D.#59536) for renewal of a State Gambling License
Class B (Tipboards and Pulltabs) by Westside Youth Hockey at
567 Stryker Avenue (Brown Derby) be and the same is,hereby approved.
COUNCILMEN Requested by Department of:
Yeas D�eW Nays
Nicosia � �n Favor
Rettman �
Scheibel Against BY
Sonnen
Weida
Wi180A AUG 1 � 1987 Form Approv by City Attor ey
Adopted by Council: Date
Certified Pa_ %�I��"' '1 Se tar BY
g�,
Approve y Mavor: Date A� � � :� Approved b Mayor or Submission to Council
By
����D A U G 2 2 1987
, , ..( �31� �� �,�-=��-//�
� DIVISION OF LICENSE AND PERMIT ADMINISTRATION DATE
INTERDEPARTMENTAL REVIEW CHECKLIST
Applicant ����{_Si c.�v l-�U�.�.�1 �dC�l� Home Address �,�� �..��-��„�
Business Name �^�cL Home Phone ,�a 1 - 5�I 3�
Business Address �(�'� �-yc� Lcsr Typu�f License(s) �.,,�� rnc,•���pa
Buainess Phone �a�t - 5�3CP '� G,,,,,,h . �,�,�n�'c, c.,�i c�-, J�1:5�3 2�
Public Hearing Date � �� '"1 License I.D. # �?� �(p(j � �'� �153 C.P
at 10:00 a.m. in the Cou il Chambers,
3rd Floor City Hall and Courthouse State Tsx I.D. # ►'1 � �
REVIEW DATE DATE INSPECTION
APPN REC'D VERFIED COMPUTER COI�iENTS
baved Not
Housing & Bldg �
Code Enforcement �
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Public Health I
�n ��- '
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Fire Prevention �
n 1� �
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Police �
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City Attorney � �/ �
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I
ENS �
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300 Foot Notice I
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License Inspector's Comments:
I HAVE BEEN GIVEN A COPY OF THIS NOTIFICATION AND UNDERSTAND THAT MY ATTENDANCE AT
THE PUBLIC HEARING IS REQUIRID.
� • - .. .-!'1.� . � .. . � .-..t �" . .. . - .. • �- � �-�'1 . ,v. . �..� ��" .n . �. i�"t� • 'S. � .� . . .
CURRENT INFORMATION NEW INFORMATION
Current Corporation Name: New Corporation Name:
Current DBA: New DBA:
Current Officers: Insurance:
Bond:
New Officers:
Stockholders:
_; � � � n.F �y-i/��
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• ���?4�;a� Charitable Gambling Control Board � FOR BOARD USE ONLY
:.6S��L6 DU MpR.
��'��r, Room N-475 Griggs-Midway Building _
' ��� �H2� UI11V8fSIL�/AV2f1U@ licenseNumber
� ` � K St. Paul, Minnesota 55104-3383 PAID
��: � - (612) 642-0555 AMT
`�iti':.....+��
��� _ -• _ CHECK#
' DATE
GAMBLING LICENSE APPLICATION
INSTRUCTIONS:
A. Type or print in ink.
B. Take completed application to local 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:
OClass A - Fee S 100.00(Bingo,Raffles,Paddlewheels,Tipboards,Pull-tabsl
IgGlass B - Fee S 50.00(Raffles, Paddlewheels,Tipboards,Pull-tabs) Makecheckspayableto:
❑Class C - Fee$ 50.00(Bingo only) Minnesota Charitable GambGng Conpol Board
❑Class D - Fee S 25.00(Raffles only)
'�fes�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) � ����� �' �
Yes ONo 3. Have Internal Controls been submitted previously?If no,please attach copy.
4. Applicant(Officia►,legal name of organization) � 5. Business Address of Organization .
i �: , '__ .., ' � ' ti``,, . _. l'. � . __
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6. City,State,Z�ip .� �� ' - - -� 7. County 8. Business Phone Number
- �. _ . � , _ �..., � �� ;`.,�;� , - � � � ._-Y �� . � .��
9. Type of organization: ❑Fraternal ❑Veterans ❑Religious C�Other nonprofit*
•If organization is an"other nonprofit"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 number assigned to Articles or page and
book number: � � -�7 Attach copy of certificate.
Yes❑No 1 1. Are articles filed with the Secreta�y of State?
F�3'Yes�No 12. Are articles filed with the County?
L�Yes O 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�INo 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
��-�' / `i �°:' ''-S existence.
17. Name of Chief Executive Officer 18. Name of treasurer or person who accounts for other revenues
� .� / of the organization. ; ____r_
, �,�, . „ %� L:1s. � � !
. \ .y,7 -T f /:_j ��r'��{� ��r7 . /t j��j/1<i
Title � Title ' �
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f_"��°�!/r,���y+ ?'G �/ s�� �:�{��' /'
Business Phone Number Business Phone Number
t/i2 � Z �� - 75� � � �'r '? � �����? - 'iHb �
19. Name of establishment where gambling will be 20. Street address(not P.O. Box Number)
conducted.� � / ; �
!�;✓<�:.!iY1 �(7,%7�/ 11il.J�%j'C'�. ✓(�. � �,i:rr/��fe;_"rr�
21. City, Stste,Zip 22. County(where gambling premises is focated)
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CG-0001-02(8/86) White Copy-Board Canary-Applicant � Pink-Local Governing Body
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. Gambling License Application Page 2
Type of Application: OClass A �llClass B ❑Class C `� ❑Class D
.�lYes�No 23. Is gambling premises located within city limits?
,�lYes�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�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 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 $
is not required for Class D applications. r�t -'
❑Yes G7No 28. Do you plan on conducting bingo with this license? If yes,give days and times of bingo occasions�
Days Times
.�.-
Yes ONo 29. Has the S 10,000 fidelity bond required by Minnesota Statutes 349.20 been abtained?Attach copy of bond.
�30. Insurance Company Name/ 31. Bond Number �-+
a�N, � -^ �.-, ,, ��`� T �f v .� f' � � ` ^ --7`-'i — �
32. Lessor Name J 33. Address 34.� City,State,Zip
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35. Gambling Manager Name 36. Address � 37. City,�Statte,Zip
�/',�. �; , i i�� :'1- � .. • "'� � � � %r�f'f i d �� 't�'r Yi.s� / r'�� ,e�' ���`���
38. Gambling Manager Busiri'ess Phone 39. Date gambling manager became � �
i � member of organization: , , ,,: P.,�
1: -/ 1 � ; �v2�
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 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
1 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 familiariie 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. Official, Legal Name of Organization 41. Signature(must be signed b�c Chief Executive Officer)
� i ' i . • _ ' X —' . .,.-•-'_'___-,
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� Title of Signer r . Date ' ..--�— :,
- ;-;� .;.� . -"'� -vL/' A ' I � '
ACKNOWLEDGEMENT OF NOTICE BY LOCAL GOVERNING BODY
I hereby acknowledge receipt of a copy of this application. By acknowledging recei�t, I admit having been served with
notice that this application will be reviewed by the Charitable Gambling Control Boa�l 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 ILocal Governing Body) If site is located within a township,item 43 must be completed,in
addition to the county signature.
Signature of person receiving application 43. Name of Township
� 1 , � ,`y �-°`' �
X ~�ri-'.;(�� !�'� �✓,GU../�-.�'---~--ir`�� ,
Title Date received(30 day period Signatu�e of person receiving application
" begins from this date)
_ _ '1 ! . �_" � X
44., Name of Person detiveciAg application to Local Governing Body Title
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CG-0001-02 (8/86) White Copy-Board Canary-Applicant Pink-l.ocal Governing Body