97-1115Council File $ �S
ordinance #
Green Sheet # 37915
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Presented
Referred To
RESOLVED: That application, ID �B-0�639, £or a State C1ass B Gambling Premise Permit by
church of the Incarnation at Pickles Lounge, 1082 Arcade Street, be and the
same is hereby approved.
Committee: Date
Requested by Department of:
• - -- - - -
a� • u�-� _ ��� -
� �� . �''
Adoption Certified by Council Secretary
By:
Approved by Mayor:
By:
Date �
Form Appro by City �ney
By: L/,�GQ � ��,-,.c,t.
Approved by Mayor for Submiasion to
Council
By:
RESOLUTION
CITY OF SAINT PAUL, MINNESOTA ,33
Adopted by Council: Date �
** NEED COPY IMMEDIATELY ** � � � ` S
DEWWTAENTIOFFlCHCOUNCIL DATE INITIATED J � � � �
LIEP GREEN SHEE
CONTACT PERSON & PHONE INITIAVDATE INRIALIDATE
O DEPAPTMENT DIRECTOA O CRY COUNCIL
William F. Gunther - 266-9132 ASSIGN O CITYATfORNEY � C17YCLEFK
MUSTBEONCAUNCIIAGENDABY DATE NUYBE0.FOR
( � ROUi1NG O BUDGEf DIRECTOR O FIN. & MGT. SERVICES Dlfl.
Hearing: CJ �Q g� OfiOEN � y�qYOR (ORASSISTANn �
TOTAI # OF SIGNA7URE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE)
ncnoNaEOUesreo F=. Robert Monaghan on behalf of Church of the Incarnation, ID l�B-00639,
requests Gouncil approval of their application for a State Class B Gambling Premise Permit
at Pickles Lounge, 1082 Arcade St.
RECOMMENOqTIONS: Appmve (A) or qeiect (R) PERSONAL SERVICE CONTRACTS MUST ANSWER TME FOLLOWfNG UUESTIONS:
_ PLqNNING COMMISSION _ CIVII SEflVICE CAMMISSION 1. Has [his person/Firm ever worked under a contrect for this department?
_ CIB COMMITTEE _ YES NO
2. Has this person�rm ever been a city employee?
_ STAFF
— YES NO
_ DISTR�CTCOURT _ 3. DOeSthis
personttirm possess a skill not normatfy possessetl by any Currefrt ciry employee?
SUPPoRTSWNICNCOUNCIL46JECTIVE? YES NO
Expfain ail yes answers on separate sheet ana attaeh to green sheet
INITIATING PROBLEM. ISSUE, OPPORTUNITY (Who. Wha[, When, Whera, Why):
ADVANTAGESIPAPPROVED: �
DISADVANTAGES IF APPROVED.
�
+�,s�e:�� ��Y�6 ��i
� "� 2 � i��J7
;`;:�
DISADVANTAGES IF NOTAPPROVED: �� � �
TO7AL AMOUNi OF TRANSACTION $ COS7/REVENUE BUDGETED (CIRCLE ONE) YES NO
FUNDI{3G SOIfBGE ACTIVfTV NUMBEH
FINANCIAL INFORFiATIpN: (EXPLAIN)
LG2t 4
n.zss,>
.. �
�� .
3iinnesata Lu3U�ut GambIing ._
�` � Prernises Pei=iiut Application�= Part T 2� ::
Aenewal . - . - � _ - _ . . � .. _ . .
Orgalization base 4'�cense number
Premises permi[ num'xr �
New
° l'1. �\�g
FOR BOARD ll5E ONLY
9ASE �
PP x
FEE= - '
CHECK -
INITiALS ' '
DATE �
Class of premises peanit . .
� - - . (check one)` . �- -- � . ,
� A(5400J Put!-tabs, Gpboards, paddlewheeis, ra!5es. bingo
�,( H(5250) PuO=abs, Gpbcards, pad�ewheets, raf�es
❑ C (5200) 8ingo only � �
u � (Siso) Ratnes mH .
If appiying for a cIass A or C permit, fill in days and 5eginn{n� & ending hours of btngo occasions:
\o more than seven bingo occasions may he conducted by your organtzation per week, ,: �.: :. ..
- Day � Begtzurtng/Ending Hours ` _.� �_ �� .� .__ Be,gnninglEndtng Hours "' _" Day -' Beginniti8 /EadSng Hours �`.� `_
.. _ � . , i. _ to ' = ' ` ' to ' .
a R ��„ } ti
- - - :r ;, ^. . _ .
� " tn �'to � � - � �' - to
�.. .__ -...�._-' r, . - ' ,...
,� -_.,. - . , _ . . _ ,„ .,, �,,, ..:, - _ ....-. _ . ... . _ .-
"- _ to Ifbingo m1I not be conducted cbeck hese �
� , , n _ a ._.� ..
�b.' 3F4� i�
.� . -��»�. �.� . . .
L
$ Gambi�ng P_`rem3ses Information� � " z � � ��` z �" <`� � -� �
-- ' o �-" �..:. . xo,. .,,nzaT � ,... - "�`' , �.. . . Y,, r - m� . .
'� ' Name ot establ�shment wliere gamblurg will be conducted - ^- � SVegt Address {do nof use a po5t oflice bos number) �. L �
1�/�,(�l�S' .L011Ndex - /D8a- A/2Hi3,oL> - x,�. _ =r '
�.-`<<_ Is the p�emises located vnthm Gm2s� �jYes C No } If no �s townsh�p �� wgan¢ed Q unorganized , � wu�corpora ed Y �. �,� ,_-
_ Minnesota Lawful Gambling
� ��- Premise Permit Application - Part 2 of 2
- . �
. _ ' j - .. ,.. _ _ _
/��. �:.D: t ..xi � 9� ., � ) � [. ♦.�� i �j'.:]i�..t y x,".,x�.i.. K � � F,� �
j � b G �^`
ISiLlJLLf2Z�Q�f-TG[![]L - �la`' £ �c: ,- tiv r '- "�- .w a.-.x.y .
. ..: . . � ., . .« � . -�. ..: -
- 3ank Name . -.. -• - . - flank Account Numbet -
, �.Cs; ��An>K� , . -173i��aa�7�/�:_..
aa�.o�s , < = -_ a � y , c��e n -; .
�3n �S�„r-.� .S'-�- i�� Ir ' iy,.,. ` 35��� i//o
-- � .
� �.:�.-�<�_, __._ _ ..._ :.= ,.,_ . ,__
L . —�,�._-.__ � . ..,.
� �PRr�T% /r�o.v��it.�.� ��i�z�._s.��r, /�r/s. ��a ,
f In.l.ile !� ��l�l��/'Y/i �K�� /_FAJ1%[L N/JG � �/�S. Y9S�/•(/�i�/) !•/CT
<
Gamh2iag Site AuthorIzstioat •t am the chiaf executive officarot ttie organ¢atiort;
t heraby mnserri that bcal taw enforcemenl of;'ican, fhe •1 assume tuR respons+b+7rty fw the fair and lawful opera-
, board or agecits of 2he board, or the cammissionet of tion of af1 adivrties to be conduded•
revenue w pubC�c satety, or agants oi the c�mmissionars, .� wiU famitiarize myseH with the laws ot Minnesota
may enter the premises to eniorce the taw. governing tawFul gambfing and rules of the bcard and
Baai: Records Ixtformatioa zgree, d licensed, to a6ide by those ;aws and rutes,
The board is authorized to insped the bank reprds of the 9nctuding amendments to them;
; ganbling aGrount whertever necessary to fu�U •any cfianges in appi'�cation information wii� be submitted
requirements of cuneni gambiing rutes and Iaw. - — - to the board and bcal unit of govemment within 10 days
Oath of the change; and
1 dectare that: ,. ::..- : �. -•t understand thzt faifure to provide required intarrrsatton
d kave read this application and all informafien submitted or pmvidirtg £alse or misteading informatan r.�ay resuli in
2o She board is irue, accurate and complete; � tt�e denial or revocation af the license_
, •att otber rsqu'ved infamaiior has been tutty dsd ed. �. ,_� � -_ -�.,,.,=:� �.�� ._ �,
S�gnacure
`_�
-a Loca1"'
3ctrt' e oH r . ' :-. . - ate - � - � - �
S
� �4`{ ? _... _.. .'
1. Tlie city'must sign this apptication if the gamb6ng prem<�,
; ises is bcated witbm. aty limits _-" ��-%.� 1
2. The county.•�'AND tavnship must sgn ihu appTicaLOr� d'.
� ihe gamWing pram+ses s localed within a Sownsh�p: ;`°° "°`
� v, z : -
a -� :. .h
:�..:: n '' -� y; ,>„�.: �
4. A Eopy of the � i unit ot aovernment's reso(ution ao- .-� _
� �.,,uc�r, rhie wiu�C�ion must be attached to this aooGeation. �- � �
5. lf this app�ication is denied by the bcal un3 of government, _ "�
R should not be wbmiited to the GambGng Conirol Board.:. _.,�'. , ..
. r �, -� _ ` ;
, Townshtp: 8y sgn`afure below the fownship adcr�owledges ,, :''
Council File $ �S
ordinance #
Green Sheet # 37915
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13
14
15
16
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18
19
20
21
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23
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28
29
30
Presented
Referred To
RESOLVED: That application, ID �B-0�639, £or a State C1ass B Gambling Premise Permit by
church of the Incarnation at Pickles Lounge, 1082 Arcade Street, be and the
same is hereby approved.
Committee: Date
Requested by Department of:
• - -- - - -
a� • u�-� _ ��� -
� �� . �''
Adoption Certified by Council Secretary
By:
Approved by Mayor:
By:
Date �
Form Appro by City �ney
By: L/,�GQ � ��,-,.c,t.
Approved by Mayor for Submiasion to
Council
By:
RESOLUTION
CITY OF SAINT PAUL, MINNESOTA ,33
Adopted by Council: Date �
** NEED COPY IMMEDIATELY ** � � � ` S
DEWWTAENTIOFFlCHCOUNCIL DATE INITIATED J � � � �
LIEP GREEN SHEE
CONTACT PERSON & PHONE INITIAVDATE INRIALIDATE
O DEPAPTMENT DIRECTOA O CRY COUNCIL
William F. Gunther - 266-9132 ASSIGN O CITYATfORNEY � C17YCLEFK
MUSTBEONCAUNCIIAGENDABY DATE NUYBE0.FOR
( � ROUi1NG O BUDGEf DIRECTOR O FIN. & MGT. SERVICES Dlfl.
Hearing: CJ �Q g� OfiOEN � y�qYOR (ORASSISTANn �
TOTAI # OF SIGNA7URE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE)
ncnoNaEOUesreo F=. Robert Monaghan on behalf of Church of the Incarnation, ID l�B-00639,
requests Gouncil approval of their application for a State Class B Gambling Premise Permit
at Pickles Lounge, 1082 Arcade St.
RECOMMENOqTIONS: Appmve (A) or qeiect (R) PERSONAL SERVICE CONTRACTS MUST ANSWER TME FOLLOWfNG UUESTIONS:
_ PLqNNING COMMISSION _ CIVII SEflVICE CAMMISSION 1. Has [his person/Firm ever worked under a contrect for this department?
_ CIB COMMITTEE _ YES NO
2. Has this person�rm ever been a city employee?
_ STAFF
— YES NO
_ DISTR�CTCOURT _ 3. DOeSthis
personttirm possess a skill not normatfy possessetl by any Currefrt ciry employee?
SUPPoRTSWNICNCOUNCIL46JECTIVE? YES NO
Expfain ail yes answers on separate sheet ana attaeh to green sheet
INITIATING PROBLEM. ISSUE, OPPORTUNITY (Who. Wha[, When, Whera, Why):
ADVANTAGESIPAPPROVED: �
DISADVANTAGES IF APPROVED.
�
+�,s�e:�� ��Y�6 ��i
� "� 2 � i��J7
;`;:�
DISADVANTAGES IF NOTAPPROVED: �� � �
TO7AL AMOUNi OF TRANSACTION $ COS7/REVENUE BUDGETED (CIRCLE ONE) YES NO
FUNDI{3G SOIfBGE ACTIVfTV NUMBEH
FINANCIAL INFORFiATIpN: (EXPLAIN)
LG2t 4
n.zss,>
.. �
�� .
3iinnesata Lu3U�ut GambIing ._
�` � Prernises Pei=iiut Application�= Part T 2� ::
Aenewal . - . - � _ - _ . . � .. _ . .
Orgalization base 4'�cense number
Premises permi[ num'xr �
New
° l'1. �\�g
FOR BOARD ll5E ONLY
9ASE �
PP x
FEE= - '
CHECK -
INITiALS ' '
DATE �
Class of premises peanit . .
� - - . (check one)` . �- -- � . ,
� A(5400J Put!-tabs, Gpboards, paddlewheeis, ra!5es. bingo
�,( H(5250) PuO=abs, Gpbcards, pad�ewheets, raf�es
❑ C (5200) 8ingo only � �
u � (Siso) Ratnes mH .
If appiying for a cIass A or C permit, fill in days and 5eginn{n� & ending hours of btngo occasions:
\o more than seven bingo occasions may he conducted by your organtzation per week, ,: �.: :. ..
- Day � Begtzurtng/Ending Hours ` _.� �_ �� .� .__ Be,gnninglEndtng Hours "' _" Day -' Beginniti8 /EadSng Hours �`.� `_
.. _ � . , i. _ to ' = ' ` ' to ' .
a R ��„ } ti
- - - :r ;, ^. . _ .
� " tn �'to � � - � �' - to
�.. .__ -...�._-' r, . - ' ,...
,� -_.,. - . , _ . . _ ,„ .,, �,,, ..:, - _ ....-. _ . ... . _ .-
"- _ to Ifbingo m1I not be conducted cbeck hese �
� , , n _ a ._.� ..
�b.' 3F4� i�
.� . -��»�. �.� . . .
L
$ Gambi�ng P_`rem3ses Information� � " z � � ��` z �" <`� � -� �
-- ' o �-" �..:. . xo,. .,,nzaT � ,... - "�`' , �.. . . Y,, r - m� . .
'� ' Name ot establ�shment wliere gamblurg will be conducted - ^- � SVegt Address {do nof use a po5t oflice bos number) �. L �
1�/�,(�l�S' .L011Ndex - /D8a- A/2Hi3,oL> - x,�. _ =r '
�.-`<<_ Is the p�emises located vnthm Gm2s� �jYes C No } If no �s townsh�p �� wgan¢ed Q unorganized , � wu�corpora ed Y �. �,� ,_-
_ Minnesota Lawful Gambling
� ��- Premise Permit Application - Part 2 of 2
- . �
. _ ' j - .. ,.. _ _ _
/��. �:.D: t ..xi � 9� ., � ) � [. ♦.�� i �j'.:]i�..t y x,".,x�.i.. K � � F,� �
j � b G �^`
ISiLlJLLf2Z�Q�f-TG[![]L - �la`' £ �c: ,- tiv r '- "�- .w a.-.x.y .
. ..: . . � ., . .« � . -�. ..: -
- 3ank Name . -.. -• - . - flank Account Numbet -
, �.Cs; ��An>K� , . -173i��aa�7�/�:_..
aa�.o�s , < = -_ a � y , c��e n -; .
�3n �S�„r-.� .S'-�- i�� Ir ' iy,.,. ` 35��� i//o
-- � .
� �.:�.-�<�_, __._ _ ..._ :.= ,.,_ . ,__
L . —�,�._-.__ � . ..,.
� �PRr�T% /r�o.v��it.�.� ��i�z�._s.��r, /�r/s. ��a ,
f In.l.ile !� ��l�l��/'Y/i �K�� /_FAJ1%[L N/JG � �/�S. Y9S�/•(/�i�/) !•/CT
<
Gamh2iag Site AuthorIzstioat •t am the chiaf executive officarot ttie organ¢atiort;
t heraby mnserri that bcal taw enforcemenl of;'ican, fhe •1 assume tuR respons+b+7rty fw the fair and lawful opera-
, board or agecits of 2he board, or the cammissionet of tion of af1 adivrties to be conduded•
revenue w pubC�c satety, or agants oi the c�mmissionars, .� wiU famitiarize myseH with the laws ot Minnesota
may enter the premises to eniorce the taw. governing tawFul gambfing and rules of the bcard and
Baai: Records Ixtformatioa zgree, d licensed, to a6ide by those ;aws and rutes,
The board is authorized to insped the bank reprds of the 9nctuding amendments to them;
; ganbling aGrount whertever necessary to fu�U •any cfianges in appi'�cation information wii� be submitted
requirements of cuneni gambiing rutes and Iaw. - — - to the board and bcal unit of govemment within 10 days
Oath of the change; and
1 dectare that: ,. ::..- : �. -•t understand thzt faifure to provide required intarrrsatton
d kave read this application and all informafien submitted or pmvidirtg £alse or misteading informatan r.�ay resuli in
2o She board is irue, accurate and complete; � tt�e denial or revocation af the license_
, •att otber rsqu'ved infamaiior has been tutty dsd ed. �. ,_� � -_ -�.,,.,=:� �.�� ._ �,
S�gnacure
`_�
-a Loca1"'
3ctrt' e oH r . ' :-. . - ate - � - � - �
S
� �4`{ ? _... _.. .'
1. Tlie city'must sign this apptication if the gamb6ng prem<�,
; ises is bcated witbm. aty limits _-" ��-%.� 1
2. The county.•�'AND tavnship must sgn ihu appTicaLOr� d'.
� ihe gamWing pram+ses s localed within a Sownsh�p: ;`°° "°`
� v, z : -
a -� :. .h
:�..:: n '' -� y; ,>„�.: �
4. A Eopy of the � i unit ot aovernment's reso(ution ao- .-� _
� �.,,uc�r, rhie wiu�C�ion must be attached to this aooGeation. �- � �
5. lf this app�ication is denied by the bcal un3 of government, _ "�
R should not be wbmiited to the GambGng Conirol Board.:. _.,�'. , ..
. r �, -� _ ` ;
, Townshtp: 8y sgn`afure below the fownship adcr�owledges ,, :''
Council File $ �S
ordinance #
Green Sheet # 37915
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
Presented
Referred To
RESOLVED: That application, ID �B-0�639, £or a State C1ass B Gambling Premise Permit by
church of the Incarnation at Pickles Lounge, 1082 Arcade Street, be and the
same is hereby approved.
Committee: Date
Requested by Department of:
• - -- - - -
a� • u�-� _ ��� -
� �� . �''
Adoption Certified by Council Secretary
By:
Approved by Mayor:
By:
Date �
Form Appro by City �ney
By: L/,�GQ � ��,-,.c,t.
Approved by Mayor for Submiasion to
Council
By:
RESOLUTION
CITY OF SAINT PAUL, MINNESOTA ,33
Adopted by Council: Date �
** NEED COPY IMMEDIATELY ** � � � ` S
DEWWTAENTIOFFlCHCOUNCIL DATE INITIATED J � � � �
LIEP GREEN SHEE
CONTACT PERSON & PHONE INITIAVDATE INRIALIDATE
O DEPAPTMENT DIRECTOA O CRY COUNCIL
William F. Gunther - 266-9132 ASSIGN O CITYATfORNEY � C17YCLEFK
MUSTBEONCAUNCIIAGENDABY DATE NUYBE0.FOR
( � ROUi1NG O BUDGEf DIRECTOR O FIN. & MGT. SERVICES Dlfl.
Hearing: CJ �Q g� OfiOEN � y�qYOR (ORASSISTANn �
TOTAI # OF SIGNA7URE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE)
ncnoNaEOUesreo F=. Robert Monaghan on behalf of Church of the Incarnation, ID l�B-00639,
requests Gouncil approval of their application for a State Class B Gambling Premise Permit
at Pickles Lounge, 1082 Arcade St.
RECOMMENOqTIONS: Appmve (A) or qeiect (R) PERSONAL SERVICE CONTRACTS MUST ANSWER TME FOLLOWfNG UUESTIONS:
_ PLqNNING COMMISSION _ CIVII SEflVICE CAMMISSION 1. Has [his person/Firm ever worked under a contrect for this department?
_ CIB COMMITTEE _ YES NO
2. Has this person�rm ever been a city employee?
_ STAFF
— YES NO
_ DISTR�CTCOURT _ 3. DOeSthis
personttirm possess a skill not normatfy possessetl by any Currefrt ciry employee?
SUPPoRTSWNICNCOUNCIL46JECTIVE? YES NO
Expfain ail yes answers on separate sheet ana attaeh to green sheet
INITIATING PROBLEM. ISSUE, OPPORTUNITY (Who. Wha[, When, Whera, Why):
ADVANTAGESIPAPPROVED: �
DISADVANTAGES IF APPROVED.
�
+�,s�e:�� ��Y�6 ��i
� "� 2 � i��J7
;`;:�
DISADVANTAGES IF NOTAPPROVED: �� � �
TO7AL AMOUNi OF TRANSACTION $ COS7/REVENUE BUDGETED (CIRCLE ONE) YES NO
FUNDI{3G SOIfBGE ACTIVfTV NUMBEH
FINANCIAL INFORFiATIpN: (EXPLAIN)
LG2t 4
n.zss,>
.. �
�� .
3iinnesata Lu3U�ut GambIing ._
�` � Prernises Pei=iiut Application�= Part T 2� ::
Aenewal . - . - � _ - _ . . � .. _ . .
Orgalization base 4'�cense number
Premises permi[ num'xr �
New
° l'1. �\�g
FOR BOARD ll5E ONLY
9ASE �
PP x
FEE= - '
CHECK -
INITiALS ' '
DATE �
Class of premises peanit . .
� - - . (check one)` . �- -- � . ,
� A(5400J Put!-tabs, Gpboards, paddlewheeis, ra!5es. bingo
�,( H(5250) PuO=abs, Gpbcards, pad�ewheets, raf�es
❑ C (5200) 8ingo only � �
u � (Siso) Ratnes mH .
If appiying for a cIass A or C permit, fill in days and 5eginn{n� & ending hours of btngo occasions:
\o more than seven bingo occasions may he conducted by your organtzation per week, ,: �.: :. ..
- Day � Begtzurtng/Ending Hours ` _.� �_ �� .� .__ Be,gnninglEndtng Hours "' _" Day -' Beginniti8 /EadSng Hours �`.� `_
.. _ � . , i. _ to ' = ' ` ' to ' .
a R ��„ } ti
- - - :r ;, ^. . _ .
� " tn �'to � � - � �' - to
�.. .__ -...�._-' r, . - ' ,...
,� -_.,. - . , _ . . _ ,„ .,, �,,, ..:, - _ ....-. _ . ... . _ .-
"- _ to Ifbingo m1I not be conducted cbeck hese �
� , , n _ a ._.� ..
�b.' 3F4� i�
.� . -��»�. �.� . . .
L
$ Gambi�ng P_`rem3ses Information� � " z � � ��` z �" <`� � -� �
-- ' o �-" �..:. . xo,. .,,nzaT � ,... - "�`' , �.. . . Y,, r - m� . .
'� ' Name ot establ�shment wliere gamblurg will be conducted - ^- � SVegt Address {do nof use a po5t oflice bos number) �. L �
1�/�,(�l�S' .L011Ndex - /D8a- A/2Hi3,oL> - x,�. _ =r '
�.-`<<_ Is the p�emises located vnthm Gm2s� �jYes C No } If no �s townsh�p �� wgan¢ed Q unorganized , � wu�corpora ed Y �. �,� ,_-
_ Minnesota Lawful Gambling
� ��- Premise Permit Application - Part 2 of 2
- . �
. _ ' j - .. ,.. _ _ _
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Gamh2iag Site AuthorIzstioat •t am the chiaf executive officarot ttie organ¢atiort;
t heraby mnserri that bcal taw enforcemenl of;'ican, fhe •1 assume tuR respons+b+7rty fw the fair and lawful opera-
, board or agecits of 2he board, or the cammissionet of tion of af1 adivrties to be conduded•
revenue w pubC�c satety, or agants oi the c�mmissionars, .� wiU famitiarize myseH with the laws ot Minnesota
may enter the premises to eniorce the taw. governing tawFul gambfing and rules of the bcard and
Baai: Records Ixtformatioa zgree, d licensed, to a6ide by those ;aws and rutes,
The board is authorized to insped the bank reprds of the 9nctuding amendments to them;
; ganbling aGrount whertever necessary to fu�U •any cfianges in appi'�cation information wii� be submitted
requirements of cuneni gambiing rutes and Iaw. - — - to the board and bcal unit of govemment within 10 days
Oath of the change; and
1 dectare that: ,. ::..- : �. -•t understand thzt faifure to provide required intarrrsatton
d kave read this application and all informafien submitted or pmvidirtg £alse or misteading informatan r.�ay resuli in
2o She board is irue, accurate and complete; � tt�e denial or revocation af the license_
, •att otber rsqu'ved infamaiior has been tutty dsd ed. �. ,_� � -_ -�.,,.,=:� �.�� ._ �,
S�gnacure
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-a Loca1"'
3ctrt' e oH r . ' :-. . - ate - � - � - �
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1. Tlie city'must sign this apptication if the gamb6ng prem<�,
; ises is bcated witbm. aty limits _-" ��-%.� 1
2. The county.•�'AND tavnship must sgn ihu appTicaLOr� d'.
� ihe gamWing pram+ses s localed within a Sownsh�p: ;`°° "°`
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a -� :. .h
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4. A Eopy of the � i unit ot aovernment's reso(ution ao- .-� _
� �.,,uc�r, rhie wiu�C�ion must be attached to this aooGeation. �- � �
5. lf this app�ication is denied by the bcal un3 of government, _ "�
R should not be wbmiited to the GambGng Conirol Board.:. _.,�'. , ..
. r �, -� _ ` ;
, Townshtp: 8y sgn`afure below the fownship adcr�owledges ,, :''