97-1006Council File # ��"����n
Ordinance #
Green Sheet # 37902
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
F"i ;"y � � � 4 f �= 7
�.� �
�°"\ i i I : r° � �
Presented By
Re£erred To
OF
�1
Committee: Date
Y7
RESOLVED: That application, -02925, for a new State Class B Gambling Premise
Permit by Epilepsy Foundation of Minnesota at Skarda's Liquors, 728 Armstrong
Avenue, be and the same is hereby approved.
Requested by Department of:
Off;ce of License Tnspections and
Environmental Protection
By: LfA,1NAa+i �`�tc�
Adppted by Council: Date � �4Ut�1
,-'-"-�.'-��
Adoption Certified by Council Secretary
BY' � �'-�-_{� �'� _ _ �.�
t�� �
Approved by Mayor: Date �(LUi�',�
$ � ��-
Form Approved by City Atto
By:
Approved by ayor for Submission to
Council
By:
9�-toaG
����,�
UEfM1flTM�ENTNFFICFJCOUNCIL OATEINITIATED GREEN SHEE J I J V L
CONTACf PEFSON & PHONE INITIAVDATE INITIAVDATE
O �EPARTMENT DIflECTOR � CffY COUNCIL
William F. Gunther - 266-9132 A���N O pT1'ATTORNEY O CITYCLERK
MUST BE ON COUNCIL AGENDA BY (DATE) NIIYBEF FOR O BUD(iET DIREGTOR O FM. & MGT. SERVICES Dlfi.
AOUTING
Hearing: g f� G� ONOEH OMAYOR(ORASSISTANT) O
TOTAL # OF SIGNATURE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE)
ncrioNaEQUesreo- Sean Gorell on behalf of Epilepsy Foundatin of Minnesota requests Council
approval of their application for a State Class B Gambling Premise Permit at Skarda's
Liquors, 728 Armstrong Avenue.
RECOMMENDATIONS: Approve (n) or Reject (R) PEFiSONAL SERVICE CONTRACTS MUST ANSWEfl THE FOILOWING QUESTIONS:
_ PL4NNING COMMISSION _ CIVIL SERVICE COMMISSION �� Has this person/firm ever worked untler a contract for ihis department?
_ CIB COMMITfEE YES NO
2. Has this person/firm ever been a ciry employee?
_ STAFf — YES NO
_ DIS7RICT COUf�T _ 3. Does this person/firm possess a skill not normally possessed by any current city employee?
SUPPOFiTS WHICH COUNCIL OBJECTIVE? YES NO
Explain all yes answers on separate sheet antl etteeh to green sheet
INITIATING PROBLEM, ISSUE. OPPORTUNIN (Who, What, When, Wh¢re, Why):
��������
JUL � 1 ]997
��°��� �� � Y
ADVANTAGESIFAPPROVEO:
DISADVANTAGES IF APPROVED:
�biiw�i '"l:'�ti.'.,T,4''.='�i„a e�'.....q(�'
o'� n G{;
J(!L � a �;�r1
DISADVANTAGESIFNOTAPPROVED: � � � ��
TOTAL AMOUNT OF TRANSAC710N $ COST/REVENUE BUDGE7ED (CIRCLE ONE) YES NO
FUNDIfBG SOURCE AC71VI7Y NUMBEP
FINANCIAL INFORN"�ATION: (EXPLAIN)
Greensneet # ; 3� - 790�2 — L.I.E.P. REVIE\!J CHECKLIST Date: /�� �
In Tracket?_�_�,��(T� MP'n Received / AaP'n Processed
License 1D # B-02928 LiCense Type: State Class B Gambling Premise Pecmit
COmp3ny Name: Enilepsv Foundation of Minnesota DBA: EniZe� Foundation of Minnesota
Business Addresss: Jean Gore11 — CEO Business Phone: 646-8675
Contact Name/Address?� ��ond Ave. 55114 Home Phone: 646-8675
Date to Council Research: ��/9"�
Public Hearing Date: f Labets Ordered: N/A
Notice Sent to Applicant: ��/ ��9� District Council #: 09
Notice Sent to Public: N/A Ward
Department/ Date Inspections Commenis
CityAttorney �f°�'2',��! � C�� "' �� �/°�1/��
f
Environmental
Health
'"��
Fire
' " ��
LlCense Site Plan Received:_
Lease peceived:
�/�
Police 1t�C�'4YC� �-�e�° ��'1 � i'��/"�SS .
�f���
��
Zoning
�1�
lJ�
LG214
��v
. �.. .. ...\'�.. • � ..�.i. ....:Fi:...1f:�. .., '
FOR BOARD USE ONL`
BASE �
PP #
FEE
CHECK_�_
INITIAL$ `
DA7E
MirtneSOtCt LCUOfui Gatmbliag . • _: . .
Premises Permit Applicatioa - Part 1 of 2���
� Renewal
• � _,'; _O�anization base 1'Kense number
. � , , . . . , . . �. .
� Premises pertnit number � '
�� .. � l�. ,' \ . .t�Yµ � . � � . . . .
Clus of ptemis.es pe�mit
(eheck one)
❑_J! (F�'00) PulHahs. apbcn�cs. Wddiewhsels, taffies, bingo
,� B(S250) PuU-rabs. 5pboards. Paddlewheel$, raffles .
❑ C (82001 Bingo oniy. . � . . , ,
❑ � (StSO) Ratfles onry
G
/.J�
7J
w
_ _ �. .
« �
�� �
If bingo wffl aot be condncted, chcck he
.,�� � . . . _ .. ..
� � .;
O l O � - .
la ihe Premises Sxated witlnn dty Gmits4 Yes C1 Na {t no. {s �ip p aganaed p unaganaed p unincorparated
Ciry and Counry where garQhli[iq premises ia located Oq Township ar�d County where gambtirg pramises is bcated if outsida cf dty limits
S
wn own me cuuang wnere me gamau�y wui oe wraucrea� U TCJ � nv
ff no, ariach the foVbwing:
• a copy ot the leasa (fortn LG202) with mrtns tor at least one year.
° a copy ot a skeuh of the floor plan with dimensions, stwwing wfiat poNOn is dai�g 4eased.
A lease and ske0� ars not required for Class 0 applicaCOns.
��c
If applying for a class A or C permit. flll in days and beginning & ending hours ot bingo occaslons:
No more than seven bingo occasions may be conducCed by your�r��nfzaHon per week.
Day Beg8uiing/Ending tioun Day Begfcuung/Endfng Hoius Day Beg3nning /Endtng Hours
Minnesota Lau�ful Gambling '
Premise Permit Application - Part 2 of 2
_.��-- Bank Account
..�� . � A
1 hereby mnsent that bcal iaw enforcement officers, the
board or agents of the board, or the commissioner of
revenue or public satery, or agents of the commissioners,
may enter the premises to enforce the law.
Bank Records Informatioa
The baard is authorized to insped t6e bank records of the
gambling axount whenever necessary to fuftill
requirements ot current gambling rufes and la�v,
Oath
{ declare that:
•I have read this application and al{ information submitted
to the board is true, accurate aM complete;
•aIl other reauired information has been fully disGased;
1. The city •mvst sign this appl'ication if the gambling prem-
ises is bcated within city limits.
2. The courrty ••AND township•• must sign this appf'ication if
the gambting premises is bcated within a township.
3. The local unit government (c'rty or counry) must pass a
resolution specif'roally approving or denying this appiication.
City or County Name � �, �
n., t ,.
irp ot
// 0
�G
� Date
i
the instructions iw
Mail to: Gambling Control Board
Rocewood Ptav South, Srd Ftoor
17tt W, Counry Noad B
Rosevllle, MN 55113
/
r
•1 am the chief executive officer of the organization;
•1 assume full rasponsibility tor the fair antl lawfut opera-
tion of all aclivities to be conduded;
•I will familiarize myseif with lhe laws of Minnesota
governing lawful gambling and rules of ihe board and
agree, it licansed, io abide by those laws and rules,
inciuding amendments to them; • � •
•any changes in application infortitation wiil be submicced
to the board a�d bcai unrt o{ government within t0 days
of the change; and
•I understand that tailure to provide required information .
or providing talse or misleading iniormation may resuft in
the denial or revocafwn of the license.
4. A coov ot the (ocal unit of aovernmenYs resoiution ao-
provina this aoolication must be atta�hed to this aooliqtion.
5. lf this application is denied by the bcal unh of govemment,
k should rwt be submitied to the Gambling Control Soard.
Township: By signature be(ow, the township acknowledges
that the organizalron is applying tor a premises permh within
township limits.
Tawnship Name
Signature of person rewiving appfication
Title
� Data Receivad
LG21d(Pert 2)
�r�«�.eas+r
Council File # ��"����n
Ordinance #
Green Sheet # 37902
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
F"i ;"y � � � 4 f �= 7
�.� �
�°"\ i i I : r° � �
Presented By
Re£erred To
OF
�1
Committee: Date
Y7
RESOLVED: That application, -02925, for a new State Class B Gambling Premise
Permit by Epilepsy Foundation of Minnesota at Skarda's Liquors, 728 Armstrong
Avenue, be and the same is hereby approved.
Requested by Department of:
Off;ce of License Tnspections and
Environmental Protection
By: LfA,1NAa+i �`�tc�
Adppted by Council: Date � �4Ut�1
,-'-"-�.'-��
Adoption Certified by Council Secretary
BY' � �'-�-_{� �'� _ _ �.�
t�� �
Approved by Mayor: Date �(LUi�',�
$ � ��-
Form Approved by City Atto
By:
Approved by ayor for Submission to
Council
By:
9�-toaG
����,�
UEfM1flTM�ENTNFFICFJCOUNCIL OATEINITIATED GREEN SHEE J I J V L
CONTACf PEFSON & PHONE INITIAVDATE INITIAVDATE
O �EPARTMENT DIflECTOR � CffY COUNCIL
William F. Gunther - 266-9132 A���N O pT1'ATTORNEY O CITYCLERK
MUST BE ON COUNCIL AGENDA BY (DATE) NIIYBEF FOR O BUD(iET DIREGTOR O FM. & MGT. SERVICES Dlfi.
AOUTING
Hearing: g f� G� ONOEH OMAYOR(ORASSISTANT) O
TOTAL # OF SIGNATURE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE)
ncrioNaEQUesreo- Sean Gorell on behalf of Epilepsy Foundatin of Minnesota requests Council
approval of their application for a State Class B Gambling Premise Permit at Skarda's
Liquors, 728 Armstrong Avenue.
RECOMMENDATIONS: Approve (n) or Reject (R) PEFiSONAL SERVICE CONTRACTS MUST ANSWEfl THE FOILOWING QUESTIONS:
_ PL4NNING COMMISSION _ CIVIL SERVICE COMMISSION �� Has this person/firm ever worked untler a contract for ihis department?
_ CIB COMMITfEE YES NO
2. Has this person/firm ever been a ciry employee?
_ STAFf — YES NO
_ DIS7RICT COUf�T _ 3. Does this person/firm possess a skill not normally possessed by any current city employee?
SUPPOFiTS WHICH COUNCIL OBJECTIVE? YES NO
Explain all yes answers on separate sheet antl etteeh to green sheet
INITIATING PROBLEM, ISSUE. OPPORTUNIN (Who, What, When, Wh¢re, Why):
��������
JUL � 1 ]997
��°��� �� � Y
ADVANTAGESIFAPPROVEO:
DISADVANTAGES IF APPROVED:
�biiw�i '"l:'�ti.'.,T,4''.='�i„a e�'.....q(�'
o'� n G{;
J(!L � a �;�r1
DISADVANTAGESIFNOTAPPROVED: � � � ��
TOTAL AMOUNT OF TRANSAC710N $ COST/REVENUE BUDGE7ED (CIRCLE ONE) YES NO
FUNDIfBG SOURCE AC71VI7Y NUMBEP
FINANCIAL INFORN"�ATION: (EXPLAIN)
Greensneet # ; 3� - 790�2 — L.I.E.P. REVIE\!J CHECKLIST Date: /�� �
In Tracket?_�_�,��(T� MP'n Received / AaP'n Processed
License 1D # B-02928 LiCense Type: State Class B Gambling Premise Pecmit
COmp3ny Name: Enilepsv Foundation of Minnesota DBA: EniZe� Foundation of Minnesota
Business Addresss: Jean Gore11 — CEO Business Phone: 646-8675
Contact Name/Address?� ��ond Ave. 55114 Home Phone: 646-8675
Date to Council Research: ��/9"�
Public Hearing Date: f Labets Ordered: N/A
Notice Sent to Applicant: ��/ ��9� District Council #: 09
Notice Sent to Public: N/A Ward
Department/ Date Inspections Commenis
CityAttorney �f°�'2',��! � C�� "' �� �/°�1/��
f
Environmental
Health
'"��
Fire
' " ��
LlCense Site Plan Received:_
Lease peceived:
�/�
Police 1t�C�'4YC� �-�e�° ��'1 � i'��/"�SS .
�f���
��
Zoning
�1�
lJ�
LG214
��v
. �.. .. ...\'�.. • � ..�.i. ....:Fi:...1f:�. .., '
FOR BOARD USE ONL`
BASE �
PP #
FEE
CHECK_�_
INITIAL$ `
DA7E
MirtneSOtCt LCUOfui Gatmbliag . • _: . .
Premises Permit Applicatioa - Part 1 of 2���
� Renewal
• � _,'; _O�anization base 1'Kense number
. � , , . . . , . . �. .
� Premises pertnit number � '
�� .. � l�. ,' \ . .t�Yµ � . � � . . . .
Clus of ptemis.es pe�mit
(eheck one)
❑_J! (F�'00) PulHahs. apbcn�cs. Wddiewhsels, taffies, bingo
,� B(S250) PuU-rabs. 5pboards. Paddlewheel$, raffles .
❑ C (82001 Bingo oniy. . � . . , ,
❑ � (StSO) Ratfles onry
G
/.J�
7J
w
_ _ �. .
« �
�� �
If bingo wffl aot be condncted, chcck he
.,�� � . . . _ .. ..
� � .;
O l O � - .
la ihe Premises Sxated witlnn dty Gmits4 Yes C1 Na {t no. {s �ip p aganaed p unaganaed p unincorparated
Ciry and Counry where garQhli[iq premises ia located Oq Township ar�d County where gambtirg pramises is bcated if outsida cf dty limits
S
wn own me cuuang wnere me gamau�y wui oe wraucrea� U TCJ � nv
ff no, ariach the foVbwing:
• a copy ot the leasa (fortn LG202) with mrtns tor at least one year.
° a copy ot a skeuh of the floor plan with dimensions, stwwing wfiat poNOn is dai�g 4eased.
A lease and ske0� ars not required for Class 0 applicaCOns.
��c
If applying for a class A or C permit. flll in days and beginning & ending hours ot bingo occaslons:
No more than seven bingo occasions may be conducCed by your�r��nfzaHon per week.
Day Beg8uiing/Ending tioun Day Begfcuung/Endfng Hoius Day Beg3nning /Endtng Hours
Minnesota Lau�ful Gambling '
Premise Permit Application - Part 2 of 2
_.��-- Bank Account
..�� . � A
1 hereby mnsent that bcal iaw enforcement officers, the
board or agents of the board, or the commissioner of
revenue or public satery, or agents of the commissioners,
may enter the premises to enforce the law.
Bank Records Informatioa
The baard is authorized to insped t6e bank records of the
gambling axount whenever necessary to fuftill
requirements ot current gambling rufes and la�v,
Oath
{ declare that:
•I have read this application and al{ information submitted
to the board is true, accurate aM complete;
•aIl other reauired information has been fully disGased;
1. The city •mvst sign this appl'ication if the gambling prem-
ises is bcated within city limits.
2. The courrty ••AND township•• must sign this appf'ication if
the gambting premises is bcated within a township.
3. The local unit government (c'rty or counry) must pass a
resolution specif'roally approving or denying this appiication.
City or County Name � �, �
n., t ,.
irp ot
// 0
�G
� Date
i
the instructions iw
Mail to: Gambling Control Board
Rocewood Ptav South, Srd Ftoor
17tt W, Counry Noad B
Rosevllle, MN 55113
/
r
•1 am the chief executive officer of the organization;
•1 assume full rasponsibility tor the fair antl lawfut opera-
tion of all aclivities to be conduded;
•I will familiarize myseif with lhe laws of Minnesota
governing lawful gambling and rules of ihe board and
agree, it licansed, io abide by those laws and rules,
inciuding amendments to them; • � •
•any changes in application infortitation wiil be submicced
to the board a�d bcai unrt o{ government within t0 days
of the change; and
•I understand that tailure to provide required information .
or providing talse or misleading iniormation may resuft in
the denial or revocafwn of the license.
4. A coov ot the (ocal unit of aovernmenYs resoiution ao-
provina this aoolication must be atta�hed to this aooliqtion.
5. lf this application is denied by the bcal unh of govemment,
k should rwt be submitied to the Gambling Control Soard.
Township: By signature be(ow, the township acknowledges
that the organizalron is applying tor a premises permh within
township limits.
Tawnship Name
Signature of person rewiving appfication
Title
� Data Receivad
LG21d(Pert 2)
�r�«�.eas+r
Council File # ��"����n
Ordinance #
Green Sheet # 37902
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
F"i ;"y � � � 4 f �= 7
�.� �
�°"\ i i I : r° � �
Presented By
Re£erred To
OF
�1
Committee: Date
Y7
RESOLVED: That application, -02925, for a new State Class B Gambling Premise
Permit by Epilepsy Foundation of Minnesota at Skarda's Liquors, 728 Armstrong
Avenue, be and the same is hereby approved.
Requested by Department of:
Off;ce of License Tnspections and
Environmental Protection
By: LfA,1NAa+i �`�tc�
Adppted by Council: Date � �4Ut�1
,-'-"-�.'-��
Adoption Certified by Council Secretary
BY' � �'-�-_{� �'� _ _ �.�
t�� �
Approved by Mayor: Date �(LUi�',�
$ � ��-
Form Approved by City Atto
By:
Approved by ayor for Submission to
Council
By:
9�-toaG
����,�
UEfM1flTM�ENTNFFICFJCOUNCIL OATEINITIATED GREEN SHEE J I J V L
CONTACf PEFSON & PHONE INITIAVDATE INITIAVDATE
O �EPARTMENT DIflECTOR � CffY COUNCIL
William F. Gunther - 266-9132 A���N O pT1'ATTORNEY O CITYCLERK
MUST BE ON COUNCIL AGENDA BY (DATE) NIIYBEF FOR O BUD(iET DIREGTOR O FM. & MGT. SERVICES Dlfi.
AOUTING
Hearing: g f� G� ONOEH OMAYOR(ORASSISTANT) O
TOTAL # OF SIGNATURE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE)
ncrioNaEQUesreo- Sean Gorell on behalf of Epilepsy Foundatin of Minnesota requests Council
approval of their application for a State Class B Gambling Premise Permit at Skarda's
Liquors, 728 Armstrong Avenue.
RECOMMENDATIONS: Approve (n) or Reject (R) PEFiSONAL SERVICE CONTRACTS MUST ANSWEfl THE FOILOWING QUESTIONS:
_ PL4NNING COMMISSION _ CIVIL SERVICE COMMISSION �� Has this person/firm ever worked untler a contract for ihis department?
_ CIB COMMITfEE YES NO
2. Has this person/firm ever been a ciry employee?
_ STAFf — YES NO
_ DIS7RICT COUf�T _ 3. Does this person/firm possess a skill not normally possessed by any current city employee?
SUPPOFiTS WHICH COUNCIL OBJECTIVE? YES NO
Explain all yes answers on separate sheet antl etteeh to green sheet
INITIATING PROBLEM, ISSUE. OPPORTUNIN (Who, What, When, Wh¢re, Why):
��������
JUL � 1 ]997
��°��� �� � Y
ADVANTAGESIFAPPROVEO:
DISADVANTAGES IF APPROVED:
�biiw�i '"l:'�ti.'.,T,4''.='�i„a e�'.....q(�'
o'� n G{;
J(!L � a �;�r1
DISADVANTAGESIFNOTAPPROVED: � � � ��
TOTAL AMOUNT OF TRANSAC710N $ COST/REVENUE BUDGE7ED (CIRCLE ONE) YES NO
FUNDIfBG SOURCE AC71VI7Y NUMBEP
FINANCIAL INFORN"�ATION: (EXPLAIN)
Greensneet # ; 3� - 790�2 — L.I.E.P. REVIE\!J CHECKLIST Date: /�� �
In Tracket?_�_�,��(T� MP'n Received / AaP'n Processed
License 1D # B-02928 LiCense Type: State Class B Gambling Premise Pecmit
COmp3ny Name: Enilepsv Foundation of Minnesota DBA: EniZe� Foundation of Minnesota
Business Addresss: Jean Gore11 — CEO Business Phone: 646-8675
Contact Name/Address?� ��ond Ave. 55114 Home Phone: 646-8675
Date to Council Research: ��/9"�
Public Hearing Date: f Labets Ordered: N/A
Notice Sent to Applicant: ��/ ��9� District Council #: 09
Notice Sent to Public: N/A Ward
Department/ Date Inspections Commenis
CityAttorney �f°�'2',��! � C�� "' �� �/°�1/��
f
Environmental
Health
'"��
Fire
' " ��
LlCense Site Plan Received:_
Lease peceived:
�/�
Police 1t�C�'4YC� �-�e�° ��'1 � i'��/"�SS .
�f���
��
Zoning
�1�
lJ�
LG214
��v
. �.. .. ...\'�.. • � ..�.i. ....:Fi:...1f:�. .., '
FOR BOARD USE ONL`
BASE �
PP #
FEE
CHECK_�_
INITIAL$ `
DA7E
MirtneSOtCt LCUOfui Gatmbliag . • _: . .
Premises Permit Applicatioa - Part 1 of 2���
� Renewal
• � _,'; _O�anization base 1'Kense number
. � , , . . . , . . �. .
� Premises pertnit number � '
�� .. � l�. ,' \ . .t�Yµ � . � � . . . .
Clus of ptemis.es pe�mit
(eheck one)
❑_J! (F�'00) PulHahs. apbcn�cs. Wddiewhsels, taffies, bingo
,� B(S250) PuU-rabs. 5pboards. Paddlewheel$, raffles .
❑ C (82001 Bingo oniy. . � . . , ,
❑ � (StSO) Ratfles onry
G
/.J�
7J
w
_ _ �. .
« �
�� �
If bingo wffl aot be condncted, chcck he
.,�� � . . . _ .. ..
� � .;
O l O � - .
la ihe Premises Sxated witlnn dty Gmits4 Yes C1 Na {t no. {s �ip p aganaed p unaganaed p unincorparated
Ciry and Counry where garQhli[iq premises ia located Oq Township ar�d County where gambtirg pramises is bcated if outsida cf dty limits
S
wn own me cuuang wnere me gamau�y wui oe wraucrea� U TCJ � nv
ff no, ariach the foVbwing:
• a copy ot the leasa (fortn LG202) with mrtns tor at least one year.
° a copy ot a skeuh of the floor plan with dimensions, stwwing wfiat poNOn is dai�g 4eased.
A lease and ske0� ars not required for Class 0 applicaCOns.
��c
If applying for a class A or C permit. flll in days and beginning & ending hours ot bingo occaslons:
No more than seven bingo occasions may be conducCed by your�r��nfzaHon per week.
Day Beg8uiing/Ending tioun Day Begfcuung/Endfng Hoius Day Beg3nning /Endtng Hours
Minnesota Lau�ful Gambling '
Premise Permit Application - Part 2 of 2
_.��-- Bank Account
..�� . � A
1 hereby mnsent that bcal iaw enforcement officers, the
board or agents of the board, or the commissioner of
revenue or public satery, or agents of the commissioners,
may enter the premises to enforce the law.
Bank Records Informatioa
The baard is authorized to insped t6e bank records of the
gambling axount whenever necessary to fuftill
requirements ot current gambling rufes and la�v,
Oath
{ declare that:
•I have read this application and al{ information submitted
to the board is true, accurate aM complete;
•aIl other reauired information has been fully disGased;
1. The city •mvst sign this appl'ication if the gambling prem-
ises is bcated within city limits.
2. The courrty ••AND township•• must sign this appf'ication if
the gambting premises is bcated within a township.
3. The local unit government (c'rty or counry) must pass a
resolution specif'roally approving or denying this appiication.
City or County Name � �, �
n., t ,.
irp ot
// 0
�G
� Date
i
the instructions iw
Mail to: Gambling Control Board
Rocewood Ptav South, Srd Ftoor
17tt W, Counry Noad B
Rosevllle, MN 55113
/
r
•1 am the chief executive officer of the organization;
•1 assume full rasponsibility tor the fair antl lawfut opera-
tion of all aclivities to be conduded;
•I will familiarize myseif with lhe laws of Minnesota
governing lawful gambling and rules of ihe board and
agree, it licansed, io abide by those laws and rules,
inciuding amendments to them; • � •
•any changes in application infortitation wiil be submicced
to the board a�d bcai unrt o{ government within t0 days
of the change; and
•I understand that tailure to provide required information .
or providing talse or misleading iniormation may resuft in
the denial or revocafwn of the license.
4. A coov ot the (ocal unit of aovernmenYs resoiution ao-
provina this aoolication must be atta�hed to this aooliqtion.
5. lf this application is denied by the bcal unh of govemment,
k should rwt be submitied to the Gambling Control Soard.
Township: By signature be(ow, the township acknowledges
that the organizalron is applying tor a premises permh within
township limits.
Tawnship Name
Signature of person rewiving appfication
Title
� Data Receivad
LG21d(Pert 2)
�r�«�.eas+r