97-1249Council Fi1e � q7 — t ��{,9
Ordinance #
Green Sheet # 50227
39
r-. m � �-, .
F
�% € �, i �. . � .
Presented By�
Referred To
RESOLUTION
CITY OF SAINT PAUL, MINNESOTA
Committee: Date
1
2
3
4
5
6
7
8
9
10
11
12
13
14
1S
16
1?
18
14
20
21
>Z
?3
RESOLVED: That application, ZD #B-01991, for a State Class B Gambling Premise Permit by
East Twins Babe Ruth League, Inc. at Paul's Lounge, 1045 Hudson Road, be and
the same is hereby agproved. '
Requested by Department of:
Off'ce of License Insgections and
Envizonmental Protection
By: ��.a �. �
Adoption Certified by Council Secretary
BY � � .�,� . � �,�
Approved by Mayor: Date � e�,l� 15}-
By: �
Form Approv by City A ney
By: _�/ _�,'J
Approved by ayor for Submission to
Council
By:
Adopted by Council: Date (`� �, � �`��
Na 50227
** NEED COPY I1 **
�NiMENT/DFFICE/COUNCIL
LIEP/License
TACT PEfl50N & PHONE
William F. Gunther - 26b-9132
T BE ON CAUNCIL AGENDA BY (DASE)
Hearing: /� j,Q`gij
TOTAL # OF SIGNATURE PAGES
FOR
GREEN SHEET ���
INIilAVOATE INRfAUDATE —
DEPARTMENT DIRE � pTY COUNCIL
piYATiORNEY � QTY CLERK
BU�GET DIRECTOR Q FlN. & MGT SERVICES DIR.
MA'/OR (Ofl AS$ISSAtJn �
(CLiP ALl IOCATIONS FOR SIGNATURE)
"'""""""`° Michael H. Snaza on hehaZf of East Twins Babe Ruth League, Inc. requests Council
approval of their application for a State Class B Gambling Premise Permit, ID 96B-01991,
at Paul`s Lounge, 1045 Hudson Road.
FiECOMMENOAT10N5. AFP�ove (A) or Re)ect (R)
_ PIANNING CAMMISSION _ qVIL SERVICE COMMISSION
_ Cf8 COMMITTEE _
_ STAFG _
_D15TRICTCWR7 _
SUPPORTS WHICH GOUNCll06JECTIVE?
PERSQN0.� SERYICE CONTRACTS MUST ANSWER THE FOIIOWING QUESTtONS:
7. Has Ynis persoNfirm ever worke� under a coniract tor ffiis tlepartmentt
YES NO
Z. Has this personlfirm ever been a ciry employee?
YES NO
3. Does this personNirm pos5es5 a skill rrot normally possessed by any current ciry employee?
YES NO
EsD�aln ati yea answers on separate sheet anE attach to green aheet
When. Where. WhYI
�OVANTAGES
a�s��??-i:?� ���Y� �7f�!'
��;'' � 4 ;�37
OUNT OF TRANSACTION S
FORffiASiON (EX7lAiN)
COSLREVENUE BUDGE7ED(CBCLE ONE)
ACTIVITY NUMBER
YES NO
'I ! "' 1 ,.�
FOR BOARD USE ONLY
L�2;�
� xs+;
%{nnesota Lawfilt GambIing
Premises Permit Application - Part 1 of 2
�
ti2r,[-w'2
Or base license nomber
?;zmazs permit number
N ew
BASE k
PP #
CHECK
INIT4ALS
DATE
Class ol premises permit
(C�1CCS( O(1B}
� A(St00) Puil•tabs, tipboards, paddlewhee!s, rar.'�es. 0��90
[� B{5250) Pull•tabs, Uphoards, paddla,vheeis, ranles
� C ($200} &ngo onty
❑ ota7so� aae�5«,y
F l.<' . ( .
Oryarxization frFf'dr7nafiimz:�'�-.
,za�e ct Or.;an's2aaon
,.. . ...J � n � ./� _i l. i _ .
__ _.nazs :.xress of Organizauon - Strset w P. O 8ox (Do not u3r the address ol your qarnbhn9 manag
L2.��C' fa'f�{—cz.�P.
' . State Zip Gode Counry
,a-.a ;: �„e: esac�„e�ve omcer (cannot be your
r .
n
�.�.Q� �
.,,.�r..�zr
��r��E� �5r��.� � t'�esrd.er27' ' ��,a»�i����rt�s�
B:ngo Occasions
:_,p;;�� g for a ciass A or C permit, fill in days and 5egicuung & endLng hours of bingo occzsiors:
�., -:cre Lhan seven bingo occassons may be conducted by your or�aniaUon per week.
__ �ey::s�u�g/Ending Houts Day BegirviingJEnd(ng Hours Day Be�kv:Lng 1=�Zd:^3 ^:ccrs
to
to
co
ing Preizzises� In:
a��snmen: where gamb6n5
ro
Tlbiztgo will not b� conductcd, check here �
veet�Address (do�not use a aosi oflice bm
:o
t'�z1..�1'S Lnr�;�cc�, /0�1� N�rcfsnn �ct. .Sf,P�itl��l n �rc�t
,:ce ,iem:sas iocatco wani ary iimits? ,�}Yes Q No 1� no, is iownship � organized 0 u�organ¢ed (_ cn:r.cr,na.ao
�.. ,r•. Cc,.ry «nere 9arnbiing prem�ses �s Iocaied OR Townsbip and Gounry where gambling premises is located if oua�ce or ar� hmns
•s. a.'LC a�cress ol :eqal owner
t
�
__=s to_� o�;::�.za�.ar. cwn ihe buAding where the qambfing w��l be conducfed? Q Y"c5 � RO �
!; nc. anach tne falfowinq;
• a copy of the tsase (tprm LG202� with terms iot at feast one year.
• a mpy et a sketch of rhe fleoc plan wih dimensions. sho�nng wha! poroon is being IeaseC
A lease and sketcA are rrot requi�ed Iw C�ass D appiicapons.
��ddress of storage space of �amblin� equipment
. ..cc�ess Gry Staca dp code
Minnesota Lcuvful Gambling
Premise Permit Application - Part 2 of 2
r�
Gambling Site Autaortzauon
I nereby consent that bcal law anforcemsnt ofticars, the
:rvc o� agents ot ihe board, or the commissioner of
�e�r>n,;a or pu'�fic salery, o� ageMS of iha cbmmissionen,
-zy a^.ar the pramises to eniorce the law.
Bank Records Information
�na txa�c �s authorized to inspect the bank records of the
^,�,^oLr.g account whanever necessary to tuNill
raGuir2mems ot current gambling ru4es and law.
Oath
'. cac�ase ;har.
: nzva raad ;n�s application a�d all informat�ron Submitted
:o tnz ward �s true, accurate and complete;
�au ciner req::�red iniormation has been fu11y disdosed;
S:cnature af cni
L,ocat Gauernmeret
Bank Account Number
q'3 -1�,� °i
d am the ohie( oxecutive ofticet of tho organization;
•I assume SuA responsi6ifity for Ihe fair and Iavrfui opera•
tion ot all adivhies to be wnducted;
•I will iamiliarize myseil with the taws ol Minnesota
goveming IavAul gambling and roles ol ihe boar0 ana
agree, if licensad, to a'oide by those taws and rules,
incfuding amendmants to them;
�any changes+n applicatwn intormauon wi0 oe suom.^:ec
lo the board and local uni[ oi govemmeN whhin 10 days
olthe change;and
•I understand ihzt tailure to provide required inlormat;on
or providin9 false or misleading in}ormation may resuf, in
the deniai or revocation o( the {icense,
Date
,.� �- �- � 7
nemerit :'::.`".:
.?r.2 cny 'rnust s�gn this application if the gambling prem•
�ses �s iocaled wilhin city limits.
2 7ne covncy "AND township" must sign this application it
•ra szmoli�y premises is bcated within a township.
,,. T,e �o:ai vnn govammenf (cT� cr coun�/) must pass a
ieso,_:�cn spec�l�caily approwng or denying this appiication.
C�' or County��
L„y cr Counry Name
� �� �cz.�� �
S c � ol „e'rson re iving aPFlica
� .� �, � ��-�L�;�l: t
_,,,� r,tiNc�- �a�-�
Date Received
;aie� ;o tne mswa�ons ia requi�ed artachmenu
!l.a,io GemCllnqConlrol6oard
Aowwood Plazs South, 1rd Ftoor
t71t W. Co�nry Ao+d B
Ro�evllle, I.IN 55113
4. A coo� o( th e local vnr� o� qQyemmenl's resoiu'�c� ao�
prov�no this aoohcation must be attached to �hi� aonhca+lo�_
5. It this appllcation is denied by ihe {oca! unn of gove;nmer,�„
it shouid not be submittad to the Gambling Control Board.
iownship: By sign2Nre beio�N, lhe towr,sh�p acRrc«'edoas
ihat ihe organizalion is applyin4 for a prem�ses perm:; wnn;n
township limits.
Township Narne
SiqnaNre of person receiving applicauon
r�ae
I Da:e Aeceiwc
LG214(Part 2)
(A.v)/19N ry
Council Fi1e � q7 — t ��{,9
Ordinance #
Green Sheet # 50227
39
r-. m � �-, .
F
�% € �, i �. . � .
Presented By�
Referred To
RESOLUTION
CITY OF SAINT PAUL, MINNESOTA
Committee: Date
1
2
3
4
5
6
7
8
9
10
11
12
13
14
1S
16
1?
18
14
20
21
>Z
?3
RESOLVED: That application, ZD #B-01991, for a State Class B Gambling Premise Permit by
East Twins Babe Ruth League, Inc. at Paul's Lounge, 1045 Hudson Road, be and
the same is hereby agproved. '
Requested by Department of:
Off'ce of License Insgections and
Envizonmental Protection
By: ��.a �. �
Adoption Certified by Council Secretary
BY � � .�,� . � �,�
Approved by Mayor: Date � e�,l� 15}-
By: �
Form Approv by City A ney
By: _�/ _�,'J
Approved by ayor for Submission to
Council
By:
Adopted by Council: Date (`� �, � �`��
Na 50227
** NEED COPY I1 **
�NiMENT/DFFICE/COUNCIL
LIEP/License
TACT PEfl50N & PHONE
William F. Gunther - 26b-9132
T BE ON CAUNCIL AGENDA BY (DASE)
Hearing: /� j,Q`gij
TOTAL # OF SIGNATURE PAGES
FOR
GREEN SHEET ���
INIilAVOATE INRfAUDATE —
DEPARTMENT DIRE � pTY COUNCIL
piYATiORNEY � QTY CLERK
BU�GET DIRECTOR Q FlN. & MGT SERVICES DIR.
MA'/OR (Ofl AS$ISSAtJn �
(CLiP ALl IOCATIONS FOR SIGNATURE)
"'""""""`° Michael H. Snaza on hehaZf of East Twins Babe Ruth League, Inc. requests Council
approval of their application for a State Class B Gambling Premise Permit, ID 96B-01991,
at Paul`s Lounge, 1045 Hudson Road.
FiECOMMENOAT10N5. AFP�ove (A) or Re)ect (R)
_ PIANNING CAMMISSION _ qVIL SERVICE COMMISSION
_ Cf8 COMMITTEE _
_ STAFG _
_D15TRICTCWR7 _
SUPPORTS WHICH GOUNCll06JECTIVE?
PERSQN0.� SERYICE CONTRACTS MUST ANSWER THE FOIIOWING QUESTtONS:
7. Has Ynis persoNfirm ever worke� under a coniract tor ffiis tlepartmentt
YES NO
Z. Has this personlfirm ever been a ciry employee?
YES NO
3. Does this personNirm pos5es5 a skill rrot normally possessed by any current ciry employee?
YES NO
EsD�aln ati yea answers on separate sheet anE attach to green aheet
When. Where. WhYI
�OVANTAGES
a�s��??-i:?� ���Y� �7f�!'
��;'' � 4 ;�37
OUNT OF TRANSACTION S
FORffiASiON (EX7lAiN)
COSLREVENUE BUDGE7ED(CBCLE ONE)
ACTIVITY NUMBER
YES NO
'I ! "' 1 ,.�
FOR BOARD USE ONLY
L�2;�
� xs+;
%{nnesota Lawfilt GambIing
Premises Permit Application - Part 1 of 2
�
ti2r,[-w'2
Or base license nomber
?;zmazs permit number
N ew
BASE k
PP #
CHECK
INIT4ALS
DATE
Class ol premises permit
(C�1CCS( O(1B}
� A(St00) Puil•tabs, tipboards, paddlewhee!s, rar.'�es. 0��90
[� B{5250) Pull•tabs, Uphoards, paddla,vheeis, ranles
� C ($200} &ngo onty
❑ ota7so� aae�5«,y
F l.<' . ( .
Oryarxization frFf'dr7nafiimz:�'�-.
,za�e ct Or.;an's2aaon
,.. . ...J � n � ./� _i l. i _ .
__ _.nazs :.xress of Organizauon - Strset w P. O 8ox (Do not u3r the address ol your qarnbhn9 manag
L2.��C' fa'f�{—cz.�P.
' . State Zip Gode Counry
,a-.a ;: �„e: esac�„e�ve omcer (cannot be your
r .
n
�.�.Q� �
.,,.�r..�zr
��r��E� �5r��.� � t'�esrd.er27' ' ��,a»�i����rt�s�
B:ngo Occasions
:_,p;;�� g for a ciass A or C permit, fill in days and 5egicuung & endLng hours of bingo occzsiors:
�., -:cre Lhan seven bingo occassons may be conducted by your or�aniaUon per week.
__ �ey::s�u�g/Ending Houts Day BegirviingJEnd(ng Hours Day Be�kv:Lng 1=�Zd:^3 ^:ccrs
to
to
co
ing Preizzises� In:
a��snmen: where gamb6n5
ro
Tlbiztgo will not b� conductcd, check here �
veet�Address (do�not use a aosi oflice bm
:o
t'�z1..�1'S Lnr�;�cc�, /0�1� N�rcfsnn �ct. .Sf,P�itl��l n �rc�t
,:ce ,iem:sas iocatco wani ary iimits? ,�}Yes Q No 1� no, is iownship � organized 0 u�organ¢ed (_ cn:r.cr,na.ao
�.. ,r•. Cc,.ry «nere 9arnbiing prem�ses �s Iocaied OR Townsbip and Gounry where gambling premises is located if oua�ce or ar� hmns
•s. a.'LC a�cress ol :eqal owner
t
�
__=s to_� o�;::�.za�.ar. cwn ihe buAding where the qambfing w��l be conducfed? Q Y"c5 � RO �
!; nc. anach tne falfowinq;
• a copy of the tsase (tprm LG202� with terms iot at feast one year.
• a mpy et a sketch of rhe fleoc plan wih dimensions. sho�nng wha! poroon is being IeaseC
A lease and sketcA are rrot requi�ed Iw C�ass D appiicapons.
��ddress of storage space of �amblin� equipment
. ..cc�ess Gry Staca dp code
Minnesota Lcuvful Gambling
Premise Permit Application - Part 2 of 2
r�
Gambling Site Autaortzauon
I nereby consent that bcal law anforcemsnt ofticars, the
:rvc o� agents ot ihe board, or the commissioner of
�e�r>n,;a or pu'�fic salery, o� ageMS of iha cbmmissionen,
-zy a^.ar the pramises to eniorce the law.
Bank Records Information
�na txa�c �s authorized to inspect the bank records of the
^,�,^oLr.g account whanever necessary to tuNill
raGuir2mems ot current gambling ru4es and law.
Oath
'. cac�ase ;har.
: nzva raad ;n�s application a�d all informat�ron Submitted
:o tnz ward �s true, accurate and complete;
�au ciner req::�red iniormation has been fu11y disdosed;
S:cnature af cni
L,ocat Gauernmeret
Bank Account Number
q'3 -1�,� °i
d am the ohie( oxecutive ofticet of tho organization;
•I assume SuA responsi6ifity for Ihe fair and Iavrfui opera•
tion ot all adivhies to be wnducted;
•I will iamiliarize myseil with the taws ol Minnesota
goveming IavAul gambling and roles ol ihe boar0 ana
agree, if licensad, to a'oide by those taws and rules,
incfuding amendmants to them;
�any changes+n applicatwn intormauon wi0 oe suom.^:ec
lo the board and local uni[ oi govemmeN whhin 10 days
olthe change;and
•I understand ihzt tailure to provide required inlormat;on
or providin9 false or misleading in}ormation may resuf, in
the deniai or revocation o( the {icense,
Date
,.� �- �- � 7
nemerit :'::.`".:
.?r.2 cny 'rnust s�gn this application if the gambling prem•
�ses �s iocaled wilhin city limits.
2 7ne covncy "AND township" must sign this application it
•ra szmoli�y premises is bcated within a township.
,,. T,e �o:ai vnn govammenf (cT� cr coun�/) must pass a
ieso,_:�cn spec�l�caily approwng or denying this appiication.
C�' or County��
L„y cr Counry Name
� �� �cz.�� �
S c � ol „e'rson re iving aPFlica
� .� �, � ��-�L�;�l: t
_,,,� r,tiNc�- �a�-�
Date Received
;aie� ;o tne mswa�ons ia requi�ed artachmenu
!l.a,io GemCllnqConlrol6oard
Aowwood Plazs South, 1rd Ftoor
t71t W. Co�nry Ao+d B
Ro�evllle, I.IN 55113
4. A coo� o( th e local vnr� o� qQyemmenl's resoiu'�c� ao�
prov�no this aoohcation must be attached to �hi� aonhca+lo�_
5. It this appllcation is denied by ihe {oca! unn of gove;nmer,�„
it shouid not be submittad to the Gambling Control Board.
iownship: By sign2Nre beio�N, lhe towr,sh�p acRrc«'edoas
ihat ihe organizalion is applyin4 for a prem�ses perm:; wnn;n
township limits.
Township Narne
SiqnaNre of person receiving applicauon
r�ae
I Da:e Aeceiwc
LG214(Part 2)
(A.v)/19N ry
Council Fi1e � q7 — t ��{,9
Ordinance #
Green Sheet # 50227
39
r-. m � �-, .
F
�% € �, i �. . � .
Presented By�
Referred To
RESOLUTION
CITY OF SAINT PAUL, MINNESOTA
Committee: Date
1
2
3
4
5
6
7
8
9
10
11
12
13
14
1S
16
1?
18
14
20
21
>Z
?3
RESOLVED: That application, ZD #B-01991, for a State Class B Gambling Premise Permit by
East Twins Babe Ruth League, Inc. at Paul's Lounge, 1045 Hudson Road, be and
the same is hereby agproved. '
Requested by Department of:
Off'ce of License Insgections and
Envizonmental Protection
By: ��.a �. �
Adoption Certified by Council Secretary
BY � � .�,� . � �,�
Approved by Mayor: Date � e�,l� 15}-
By: �
Form Approv by City A ney
By: _�/ _�,'J
Approved by ayor for Submission to
Council
By:
Adopted by Council: Date (`� �, � �`��
Na 50227
** NEED COPY I1 **
�NiMENT/DFFICE/COUNCIL
LIEP/License
TACT PEfl50N & PHONE
William F. Gunther - 26b-9132
T BE ON CAUNCIL AGENDA BY (DASE)
Hearing: /� j,Q`gij
TOTAL # OF SIGNATURE PAGES
FOR
GREEN SHEET ���
INIilAVOATE INRfAUDATE —
DEPARTMENT DIRE � pTY COUNCIL
piYATiORNEY � QTY CLERK
BU�GET DIRECTOR Q FlN. & MGT SERVICES DIR.
MA'/OR (Ofl AS$ISSAtJn �
(CLiP ALl IOCATIONS FOR SIGNATURE)
"'""""""`° Michael H. Snaza on hehaZf of East Twins Babe Ruth League, Inc. requests Council
approval of their application for a State Class B Gambling Premise Permit, ID 96B-01991,
at Paul`s Lounge, 1045 Hudson Road.
FiECOMMENOAT10N5. AFP�ove (A) or Re)ect (R)
_ PIANNING CAMMISSION _ qVIL SERVICE COMMISSION
_ Cf8 COMMITTEE _
_ STAFG _
_D15TRICTCWR7 _
SUPPORTS WHICH GOUNCll06JECTIVE?
PERSQN0.� SERYICE CONTRACTS MUST ANSWER THE FOIIOWING QUESTtONS:
7. Has Ynis persoNfirm ever worke� under a coniract tor ffiis tlepartmentt
YES NO
Z. Has this personlfirm ever been a ciry employee?
YES NO
3. Does this personNirm pos5es5 a skill rrot normally possessed by any current ciry employee?
YES NO
EsD�aln ati yea answers on separate sheet anE attach to green aheet
When. Where. WhYI
�OVANTAGES
a�s��??-i:?� ���Y� �7f�!'
��;'' � 4 ;�37
OUNT OF TRANSACTION S
FORffiASiON (EX7lAiN)
COSLREVENUE BUDGE7ED(CBCLE ONE)
ACTIVITY NUMBER
YES NO
'I ! "' 1 ,.�
FOR BOARD USE ONLY
L�2;�
� xs+;
%{nnesota Lawfilt GambIing
Premises Permit Application - Part 1 of 2
�
ti2r,[-w'2
Or base license nomber
?;zmazs permit number
N ew
BASE k
PP #
CHECK
INIT4ALS
DATE
Class ol premises permit
(C�1CCS( O(1B}
� A(St00) Puil•tabs, tipboards, paddlewhee!s, rar.'�es. 0��90
[� B{5250) Pull•tabs, Uphoards, paddla,vheeis, ranles
� C ($200} &ngo onty
❑ ota7so� aae�5«,y
F l.<' . ( .
Oryarxization frFf'dr7nafiimz:�'�-.
,za�e ct Or.;an's2aaon
,.. . ...J � n � ./� _i l. i _ .
__ _.nazs :.xress of Organizauon - Strset w P. O 8ox (Do not u3r the address ol your qarnbhn9 manag
L2.��C' fa'f�{—cz.�P.
' . State Zip Gode Counry
,a-.a ;: �„e: esac�„e�ve omcer (cannot be your
r .
n
�.�.Q� �
.,,.�r..�zr
��r��E� �5r��.� � t'�esrd.er27' ' ��,a»�i����rt�s�
B:ngo Occasions
:_,p;;�� g for a ciass A or C permit, fill in days and 5egicuung & endLng hours of bingo occzsiors:
�., -:cre Lhan seven bingo occassons may be conducted by your or�aniaUon per week.
__ �ey::s�u�g/Ending Houts Day BegirviingJEnd(ng Hours Day Be�kv:Lng 1=�Zd:^3 ^:ccrs
to
to
co
ing Preizzises� In:
a��snmen: where gamb6n5
ro
Tlbiztgo will not b� conductcd, check here �
veet�Address (do�not use a aosi oflice bm
:o
t'�z1..�1'S Lnr�;�cc�, /0�1� N�rcfsnn �ct. .Sf,P�itl��l n �rc�t
,:ce ,iem:sas iocatco wani ary iimits? ,�}Yes Q No 1� no, is iownship � organized 0 u�organ¢ed (_ cn:r.cr,na.ao
�.. ,r•. Cc,.ry «nere 9arnbiing prem�ses �s Iocaied OR Townsbip and Gounry where gambling premises is located if oua�ce or ar� hmns
•s. a.'LC a�cress ol :eqal owner
t
�
__=s to_� o�;::�.za�.ar. cwn ihe buAding where the qambfing w��l be conducfed? Q Y"c5 � RO �
!; nc. anach tne falfowinq;
• a copy of the tsase (tprm LG202� with terms iot at feast one year.
• a mpy et a sketch of rhe fleoc plan wih dimensions. sho�nng wha! poroon is being IeaseC
A lease and sketcA are rrot requi�ed Iw C�ass D appiicapons.
��ddress of storage space of �amblin� equipment
. ..cc�ess Gry Staca dp code
Minnesota Lcuvful Gambling
Premise Permit Application - Part 2 of 2
r�
Gambling Site Autaortzauon
I nereby consent that bcal law anforcemsnt ofticars, the
:rvc o� agents ot ihe board, or the commissioner of
�e�r>n,;a or pu'�fic salery, o� ageMS of iha cbmmissionen,
-zy a^.ar the pramises to eniorce the law.
Bank Records Information
�na txa�c �s authorized to inspect the bank records of the
^,�,^oLr.g account whanever necessary to tuNill
raGuir2mems ot current gambling ru4es and law.
Oath
'. cac�ase ;har.
: nzva raad ;n�s application a�d all informat�ron Submitted
:o tnz ward �s true, accurate and complete;
�au ciner req::�red iniormation has been fu11y disdosed;
S:cnature af cni
L,ocat Gauernmeret
Bank Account Number
q'3 -1�,� °i
d am the ohie( oxecutive ofticet of tho organization;
•I assume SuA responsi6ifity for Ihe fair and Iavrfui opera•
tion ot all adivhies to be wnducted;
•I will iamiliarize myseil with the taws ol Minnesota
goveming IavAul gambling and roles ol ihe boar0 ana
agree, if licensad, to a'oide by those taws and rules,
incfuding amendmants to them;
�any changes+n applicatwn intormauon wi0 oe suom.^:ec
lo the board and local uni[ oi govemmeN whhin 10 days
olthe change;and
•I understand ihzt tailure to provide required inlormat;on
or providin9 false or misleading in}ormation may resuf, in
the deniai or revocation o( the {icense,
Date
,.� �- �- � 7
nemerit :'::.`".:
.?r.2 cny 'rnust s�gn this application if the gambling prem•
�ses �s iocaled wilhin city limits.
2 7ne covncy "AND township" must sign this application it
•ra szmoli�y premises is bcated within a township.
,,. T,e �o:ai vnn govammenf (cT� cr coun�/) must pass a
ieso,_:�cn spec�l�caily approwng or denying this appiication.
C�' or County��
L„y cr Counry Name
� �� �cz.�� �
S c � ol „e'rson re iving aPFlica
� .� �, � ��-�L�;�l: t
_,,,� r,tiNc�- �a�-�
Date Received
;aie� ;o tne mswa�ons ia requi�ed artachmenu
!l.a,io GemCllnqConlrol6oard
Aowwood Plazs South, 1rd Ftoor
t71t W. Co�nry Ao+d B
Ro�evllle, I.IN 55113
4. A coo� o( th e local vnr� o� qQyemmenl's resoiu'�c� ao�
prov�no this aoohcation must be attached to �hi� aonhca+lo�_
5. It this appllcation is denied by ihe {oca! unn of gove;nmer,�„
it shouid not be submittad to the Gambling Control Board.
iownship: By sign2Nre beio�N, lhe towr,sh�p acRrc«'edoas
ihat ihe organizalion is applyin4 for a prem�ses perm:; wnn;n
township limits.
Township Narne
SiqnaNre of person receiving applicauon
r�ae
I Da:e Aeceiwc
LG214(Part 2)
(A.v)/19N ry