97-1556Council File # 9�
Ordinance #
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7
8
9
10
ll
12
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2�
28
�' t �", , �
`� r . .F i
OF
Presented By
Referred To
Green Sheet # 50271
MINNESOTA
39
Committee: Date
RESOLVED: That application, ID #B-04988, for a State Class B Gambling Premise Permit by
Aliveness Project, Inc. at Trik]ac, 490 N. Robert Street, be and the same is
hereby approved.
Requested by Department of:
OfEice of License. Inspections and
Environmental Protection
By � f✓.�. ��
Form Approved by City Attorney
Adopted by Council : Date L.� a-c. . a���� gy; -- tt V�� ��,��/,
Adoption Certified by Council Secretary Approved by Mayor for Submission to
� Council
By \"�
By:
Approved by Mayor: Date t1�LE , S L
sy: ��
N� 50271
DEP11R7MENTIOFFICECOUNQL DATE INITIATED l � _' ��
LIEp � GREEN SHEE
CONTACT PERSON 8 oHONE INITIAVDATE INITIAVDATE
�DEPARTMENTOIflECTOR �qTVCOUNGIL
j1T111187R Gunther - 266-9132 ASSIGN aCITYATTORNEV �CRYCLERK
MUST BE ON COUNC�L AGENDA BY (OATE) NUMBEfl FOF O BUDGET DIRECTOR � FIN. 8 MGT SEAVICES DIR.
flOUTING
OROER � MAVOR (OR ASSISTANT) �
Hearing:
TOTAL # OF SIGNATURE PAGES (CIIP AlL LOCA710NS FQR SIGNA7UREj
pCTION flEOVE5fE0:
ScoYt Schlaffman on behalf of Aliveness Project, Inc. requests Council approval
of their application for a State Class B Gambling Premise Permit (ID /6B-04988) at
TriklcY� 490 N. Robert Street.
RECOMMENOATIONS. AOP� lA) a REject �R) PERSONAL SERVICE CONTRACTS MUS7 ANSWER THE FOLLOWING OUESTIONS:
_ PLANNING COMMISSION _ GVIL SERVICE COMMISSION 1- Has this persoNfirm ever worketl untler a contract for tnis department?
_ CB COMMITfEE _ YES NO
_ STpFF 2. Nas <his personRirm ever been a ciry employee?
— VES NO
� DtSTR�GTCOVai _ 3. Does thi5 pe�son/firm possess a skill not nortnally possessetl by any currant city empl0yee?
SUPPORTS WHICH COUNCIL 061ECTIVE? YES NO
Explsln all yes answers on seperate ahee[ and ettaeh to green shaet
INITIATING PflOBLEM, ISSUE. OPPORTUNIiV (Who, Whet. When. Where. Why).
A�VAMAC+ES IF APPROVED
�ISAOVANTAGES IF APPftOVED
OISADVANTA6E5IF NOT APPROVED:
6f6�lAs� �'
DEC 0 9 1997
TOTAL AldOUNT OF TRANSACTION S COST/REVENUE BUOGETEO (CIRCLE ONE) YES NO
FUNDIWG SOUpCE ACTIVITY NUM9ER
FINANCIAL INFOBMATIpN (EXPLAIN)
�1-155G
12IB5I1997 10:32 6126363878 ESSENT?AL BUSINESS D
� ." LG2Td
• �.�,�
3iinnesata Lau:�iZ Gaanhling
Premises Permit Application - Par� 1 of 2
PRGE 01
D USE ONLY
BASc" # _
PP #
=EE
cr;ccx
[tdf, 44LS
oarE
m.v� � ' � � . ! " �Yt4�Y . .S11
�«
: .� .' e # �F.A '}�� .. 4Nsv'�. . 9, s4y � ���
_ .� : o . � . � �
. . .P-. .� ��.4'i�(�.i�l C� /°'..�'. ...Ci :�'R Iv� .. m.4 :;k -� �u a'4na � ° i
Ks
C}ass at gremises pamiC
a Ranewal , (checic one)
Orpanlzatlan 9ase P,carse nwnbes {� A($4C0} P�4-taba, :ipboatds, pad7�ewheots, ef9es, Girrjo
Premisea perme �un'�er �$�5250} Pull-�bs, ��oarC5, paddiewheelE, 2Me5
� �'� ' Q C {$2�07 8i�go cnlY .
❑ nts�soa �f�sesmy
n
m
to cc
LEhiztgo xul not be coaductcd, chwY hasa �
Is me premises located wiEun ciry 6mis� �Yas O Yo it na, iz townsh;p Q c�ganizetl � unorganized .p unincxpora�d
C%ry and Cou�ry rvi�ere gambfng peemises is b�ated OH Tn»nship end Gounty whera yambFnq prtmises is iarate4 it aut5�e ct_ciry fimits
� D� �� a,� � _ � I
addrasa of legd owner
yaur
�'1 �
�t ff0� 9t18G11 WB fb1�OWIMj: � ' ' — ,"� _
' a Lopy.ol tlie lease (tam LG202) wlth tarms for at leazt me yeat.
• a myy ef a sket� ot 1he 11ooi pEn widi d�++ensipns. shwrinq what portion is bei� teased
A teass ar}d skacrh ara rat rsquired !a C�aw D appBcaCOns. .
�� o t f(, ��h�- ��#rozz r'i�is rnr� �s"�lo�
Ii apptying for a r.lass A or C�e:mit, flll in days and beginring & endtng hovrs of bingo occzsinru:
Nn mc.c trsan scven bingo occasio:ls may be conducted by your org� »= n per wtek. .
llay Se�nn]ng/Endtr.gHours �� Day Be�:ntLLng/EndC�gHouxs Day HeginnLz%/F_++dSngHaurs
a� -�s s �
12I05/1997 10;20 6126363070
ESSENTiAL BUSINESS D
3Sinne.sota I.awJul Gunilsiing
Prern3se Perrnit Apgl3cation - Part 2 of 2
PAGc 03
�° ---" -""""•"°"""` •I am Sha ohtot axecutive oN3cer of the organizatSon•
1 hereby careertt that bca! faw anforcement ofllcsn, tha .t assumc 4ui1 responsibTiiyla ifia {air and Sawlul epara-
board or agents of .he baard, or the cammiuioner oi tion ot ai+ attivhiea to be mnduGed;
revanua ar pubi'�c safety, a agonts of tha mmmisabnara,
may gnter the promisas to antorce the Ww. •I wili fami7iarize myseH with the laws ci idinnesm.a
Bank Recorcfs Information govarning lawful gambling and rutes ofi the board and
The board is authorizod ta ins�ect tha bank racords cl ;he agroa, rf ticensed, Eo abida by tMse laws and rvlas,
gam67ing acwunt whonover neceasary 1a fu�@ mduding amendmants ;o ihem;
•any Changes m appl"roaticn inicrmalion wiil be submdlM
requirements of curfent gart:biing mles and law, to 1he boa�C at�d bc3�t Ur7R Of govemmetlt wRhin 50 day8
08th of the change; and
f daclare that: •I undorstand t};at iailure to provide reqoirad intormation
•I have read this aflplication antl ali in}crmation submttted or providing taise or misieading inform�yion may result in
to .he board is true, aceutate and c�mplate; the denial or revpcation of Lhe licansa.
•al! othsr r informatiort has been fu[ry disdc�.ad;
St�natore oF chie} esecutive aHfCer p yfa
��{.JTGl9./� �� r-n-�
��QCGIZ 1
7. The cAy'musl sign ihis applicatan iF the gamb{ing prem•
isas ;s bcatad vrithin aty limits.
2. 7Y,e c�unty �-AND townsnip^ must sig� this application il
the gambling premises is bcated within a township.
3. 'tha bcal un@ govemment [trty or coun,y) must pass a
resciuticn specifically approving or d¢nyir,g ihis app!ication.
a. A r_q9y �f the bcal unit af aovashm6M's �e�ct�tipn ao-
ar_ovina It+is anolicatiea must be attact�ad to Shis �tpii tron.
5. it;his app{icatian is denied by iha Soca{ une af gavemmenl,
d should rwt ba s�bm�tlad to Sha Gambling Cont:ol 6ezrQ.
7cwnshtp: By si�nature b¢SOw, tha 4ownship �cknowledr,es
that ihe organixalion is applying fpr a premises petmit within
township Iimits.
Nartla
$b
Ae�ar m th9 inswaions for r�µured a_achma�ts.
Mait W: Gsmb�inp C-a�kvi Borrd
Ro�swaod plszs $outh, Ad Fioo�
t1lt W_ Cou�ty Roatl 8
RotOrl(t�, i.tAt SSti1
Township Namg
SiBnatucs o( petSOrt �B�Eivin9 �PPricatian
rne
� Dato qawiwd
�czta{A.rt z�
�a..rimsp
�� �- S��L�� (olS�-7 6� Str�Z�Z, mats ssyo5 �-�-�z��� 1�r�./1
� �c�r Zc,��- - v'�s s ssuo� msm��
_VI?� ui_ 1,c9� c. taJ 2�2� �.r��., ✓I...�a/6oZ .apis Sc ��r�nFL£2
Council File # 9�
Ordinance #
1
2
3
4
5
6
7
8
9
10
ll
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
2�
28
�' t �", , �
`� r . .F i
OF
Presented By
Referred To
Green Sheet # 50271
MINNESOTA
39
Committee: Date
RESOLVED: That application, ID #B-04988, for a State Class B Gambling Premise Permit by
Aliveness Project, Inc. at Trik]ac, 490 N. Robert Street, be and the same is
hereby approved.
Requested by Department of:
OfEice of License. Inspections and
Environmental Protection
By � f✓.�. ��
Form Approved by City Attorney
Adopted by Council : Date L.� a-c. . a���� gy; -- tt V�� ��,��/,
Adoption Certified by Council Secretary Approved by Mayor for Submission to
� Council
By \"�
By:
Approved by Mayor: Date t1�LE , S L
sy: ��
N� 50271
DEP11R7MENTIOFFICECOUNQL DATE INITIATED l � _' ��
LIEp � GREEN SHEE
CONTACT PERSON 8 oHONE INITIAVDATE INITIAVDATE
�DEPARTMENTOIflECTOR �qTVCOUNGIL
j1T111187R Gunther - 266-9132 ASSIGN aCITYATTORNEV �CRYCLERK
MUST BE ON COUNC�L AGENDA BY (OATE) NUMBEfl FOF O BUDGET DIRECTOR � FIN. 8 MGT SEAVICES DIR.
flOUTING
OROER � MAVOR (OR ASSISTANT) �
Hearing:
TOTAL # OF SIGNATURE PAGES (CIIP AlL LOCA710NS FQR SIGNA7UREj
pCTION flEOVE5fE0:
ScoYt Schlaffman on behalf of Aliveness Project, Inc. requests Council approval
of their application for a State Class B Gambling Premise Permit (ID /6B-04988) at
TriklcY� 490 N. Robert Street.
RECOMMENOATIONS. AOP� lA) a REject �R) PERSONAL SERVICE CONTRACTS MUS7 ANSWER THE FOLLOWING OUESTIONS:
_ PLANNING COMMISSION _ GVIL SERVICE COMMISSION 1- Has this persoNfirm ever worketl untler a contract for tnis department?
_ CB COMMITfEE _ YES NO
_ STpFF 2. Nas <his personRirm ever been a ciry employee?
— VES NO
� DtSTR�GTCOVai _ 3. Does thi5 pe�son/firm possess a skill not nortnally possessetl by any currant city empl0yee?
SUPPORTS WHICH COUNCIL 061ECTIVE? YES NO
Explsln all yes answers on seperate ahee[ and ettaeh to green shaet
INITIATING PflOBLEM, ISSUE. OPPORTUNIiV (Who, Whet. When. Where. Why).
A�VAMAC+ES IF APPROVED
�ISAOVANTAGES IF APPftOVED
OISADVANTA6E5IF NOT APPROVED:
6f6�lAs� �'
DEC 0 9 1997
TOTAL AldOUNT OF TRANSACTION S COST/REVENUE BUOGETEO (CIRCLE ONE) YES NO
FUNDIWG SOUpCE ACTIVITY NUM9ER
FINANCIAL INFOBMATIpN (EXPLAIN)
�1-155G
12IB5I1997 10:32 6126363878 ESSENT?AL BUSINESS D
� ." LG2Td
• �.�,�
3iinnesata Lau:�iZ Gaanhling
Premises Permit Application - Par� 1 of 2
PRGE 01
D USE ONLY
BASc" # _
PP #
=EE
cr;ccx
[tdf, 44LS
oarE
m.v� � ' � � . ! " �Yt4�Y . .S11
�«
: .� .' e # �F.A '}�� .. 4Nsv'�. . 9, s4y � ���
_ .� : o . � . � �
. . .P-. .� ��.4'i�(�.i�l C� /°'..�'. ...Ci :�'R Iv� .. m.4 :;k -� �u a'4na � ° i
Ks
C}ass at gremises pamiC
a Ranewal , (checic one)
Orpanlzatlan 9ase P,carse nwnbes {� A($4C0} P�4-taba, :ipboatds, pad7�ewheots, ef9es, Girrjo
Premisea perme �un'�er �$�5250} Pull-�bs, ��oarC5, paddiewheelE, 2Me5
� �'� ' Q C {$2�07 8i�go cnlY .
❑ nts�soa �f�sesmy
n
m
to cc
LEhiztgo xul not be coaductcd, chwY hasa �
Is me premises located wiEun ciry 6mis� �Yas O Yo it na, iz townsh;p Q c�ganizetl � unorganized .p unincxpora�d
C%ry and Cou�ry rvi�ere gambfng peemises is b�ated OH Tn»nship end Gounty whera yambFnq prtmises is iarate4 it aut5�e ct_ciry fimits
� D� �� a,� � _ � I
addrasa of legd owner
yaur
�'1 �
�t ff0� 9t18G11 WB fb1�OWIMj: � ' ' — ,"� _
' a Lopy.ol tlie lease (tam LG202) wlth tarms for at leazt me yeat.
• a myy ef a sket� ot 1he 11ooi pEn widi d�++ensipns. shwrinq what portion is bei� teased
A teass ar}d skacrh ara rat rsquired !a C�aw D appBcaCOns. .
�� o t f(, ��h�- ��#rozz r'i�is rnr� �s"�lo�
Ii apptying for a r.lass A or C�e:mit, flll in days and beginring & endtng hovrs of bingo occzsinru:
Nn mc.c trsan scven bingo occasio:ls may be conducted by your org� »= n per wtek. .
llay Se�nn]ng/Endtr.gHours �� Day Be�:ntLLng/EndC�gHouxs Day HeginnLz%/F_++dSngHaurs
a� -�s s �
12I05/1997 10;20 6126363070
ESSENTiAL BUSINESS D
3Sinne.sota I.awJul Gunilsiing
Prern3se Perrnit Apgl3cation - Part 2 of 2
PAGc 03
�° ---" -""""•"°"""` •I am Sha ohtot axecutive oN3cer of the organizatSon•
1 hereby careertt that bca! faw anforcement ofllcsn, tha .t assumc 4ui1 responsibTiiyla ifia {air and Sawlul epara-
board or agents of .he baard, or the cammiuioner oi tion ot ai+ attivhiea to be mnduGed;
revanua ar pubi'�c safety, a agonts of tha mmmisabnara,
may gnter the promisas to antorce the Ww. •I wili fami7iarize myseH with the laws ci idinnesm.a
Bank Recorcfs Information govarning lawful gambling and rutes ofi the board and
The board is authorizod ta ins�ect tha bank racords cl ;he agroa, rf ticensed, Eo abida by tMse laws and rvlas,
gam67ing acwunt whonover neceasary 1a fu�@ mduding amendmants ;o ihem;
•any Changes m appl"roaticn inicrmalion wiil be submdlM
requirements of curfent gart:biing mles and law, to 1he boa�C at�d bc3�t Ur7R Of govemmetlt wRhin 50 day8
08th of the change; and
f daclare that: •I undorstand t};at iailure to provide reqoirad intormation
•I have read this aflplication antl ali in}crmation submttted or providing taise or misieading inform�yion may result in
to .he board is true, aceutate and c�mplate; the denial or revpcation of Lhe licansa.
•al! othsr r informatiort has been fu[ry disdc�.ad;
St�natore oF chie} esecutive aHfCer p yfa
��{.JTGl9./� �� r-n-�
��QCGIZ 1
7. The cAy'musl sign ihis applicatan iF the gamb{ing prem•
isas ;s bcatad vrithin aty limits.
2. 7Y,e c�unty �-AND townsnip^ must sig� this application il
the gambling premises is bcated within a township.
3. 'tha bcal un@ govemment [trty or coun,y) must pass a
resciuticn specifically approving or d¢nyir,g ihis app!ication.
a. A r_q9y �f the bcal unit af aovashm6M's �e�ct�tipn ao-
ar_ovina It+is anolicatiea must be attact�ad to Shis �tpii tron.
5. it;his app{icatian is denied by iha Soca{ une af gavemmenl,
d should rwt ba s�bm�tlad to Sha Gambling Cont:ol 6ezrQ.
7cwnshtp: By si�nature b¢SOw, tha 4ownship �cknowledr,es
that ihe organixalion is applying fpr a premises petmit within
township Iimits.
Nartla
$b
Ae�ar m th9 inswaions for r�µured a_achma�ts.
Mait W: Gsmb�inp C-a�kvi Borrd
Ro�swaod plszs $outh, Ad Fioo�
t1lt W_ Cou�ty Roatl 8
RotOrl(t�, i.tAt SSti1
Township Namg
SiBnatucs o( petSOrt �B�Eivin9 �PPricatian
rne
� Dato qawiwd
�czta{A.rt z�
�a..rimsp
�� �- S��L�� (olS�-7 6� Str�Z�Z, mats ssyo5 �-�-�z��� 1�r�./1
� �c�r Zc,��- - v'�s s ssuo� msm��
_VI?� ui_ 1,c9� c. taJ 2�2� �.r��., ✓I...�a/6oZ .apis Sc ��r�nFL£2
Council File # 9�
Ordinance #
1
2
3
4
5
6
7
8
9
10
ll
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
2�
28
�' t �", , �
`� r . .F i
OF
Presented By
Referred To
Green Sheet # 50271
MINNESOTA
39
Committee: Date
RESOLVED: That application, ID #B-04988, for a State Class B Gambling Premise Permit by
Aliveness Project, Inc. at Trik]ac, 490 N. Robert Street, be and the same is
hereby approved.
Requested by Department of:
OfEice of License. Inspections and
Environmental Protection
By � f✓.�. ��
Form Approved by City Attorney
Adopted by Council : Date L.� a-c. . a���� gy; -- tt V�� ��,��/,
Adoption Certified by Council Secretary Approved by Mayor for Submission to
� Council
By \"�
By:
Approved by Mayor: Date t1�LE , S L
sy: ��
N� 50271
DEP11R7MENTIOFFICECOUNQL DATE INITIATED l � _' ��
LIEp � GREEN SHEE
CONTACT PERSON 8 oHONE INITIAVDATE INITIAVDATE
�DEPARTMENTOIflECTOR �qTVCOUNGIL
j1T111187R Gunther - 266-9132 ASSIGN aCITYATTORNEV �CRYCLERK
MUST BE ON COUNC�L AGENDA BY (OATE) NUMBEfl FOF O BUDGET DIRECTOR � FIN. 8 MGT SEAVICES DIR.
flOUTING
OROER � MAVOR (OR ASSISTANT) �
Hearing:
TOTAL # OF SIGNATURE PAGES (CIIP AlL LOCA710NS FQR SIGNA7UREj
pCTION flEOVE5fE0:
ScoYt Schlaffman on behalf of Aliveness Project, Inc. requests Council approval
of their application for a State Class B Gambling Premise Permit (ID /6B-04988) at
TriklcY� 490 N. Robert Street.
RECOMMENOATIONS. AOP� lA) a REject �R) PERSONAL SERVICE CONTRACTS MUS7 ANSWER THE FOLLOWING OUESTIONS:
_ PLANNING COMMISSION _ GVIL SERVICE COMMISSION 1- Has this persoNfirm ever worketl untler a contract for tnis department?
_ CB COMMITfEE _ YES NO
_ STpFF 2. Nas <his personRirm ever been a ciry employee?
— VES NO
� DtSTR�GTCOVai _ 3. Does thi5 pe�son/firm possess a skill not nortnally possessetl by any currant city empl0yee?
SUPPORTS WHICH COUNCIL 061ECTIVE? YES NO
Explsln all yes answers on seperate ahee[ and ettaeh to green shaet
INITIATING PflOBLEM, ISSUE. OPPORTUNIiV (Who, Whet. When. Where. Why).
A�VAMAC+ES IF APPROVED
�ISAOVANTAGES IF APPftOVED
OISADVANTA6E5IF NOT APPROVED:
6f6�lAs� �'
DEC 0 9 1997
TOTAL AldOUNT OF TRANSACTION S COST/REVENUE BUOGETEO (CIRCLE ONE) YES NO
FUNDIWG SOUpCE ACTIVITY NUM9ER
FINANCIAL INFOBMATIpN (EXPLAIN)
�1-155G
12IB5I1997 10:32 6126363878 ESSENT?AL BUSINESS D
� ." LG2Td
• �.�,�
3iinnesata Lau:�iZ Gaanhling
Premises Permit Application - Par� 1 of 2
PRGE 01
D USE ONLY
BASc" # _
PP #
=EE
cr;ccx
[tdf, 44LS
oarE
m.v� � ' � � . ! " �Yt4�Y . .S11
�«
: .� .' e # �F.A '}�� .. 4Nsv'�. . 9, s4y � ���
_ .� : o . � . � �
. . .P-. .� ��.4'i�(�.i�l C� /°'..�'. ...Ci :�'R Iv� .. m.4 :;k -� �u a'4na � ° i
Ks
C}ass at gremises pamiC
a Ranewal , (checic one)
Orpanlzatlan 9ase P,carse nwnbes {� A($4C0} P�4-taba, :ipboatds, pad7�ewheots, ef9es, Girrjo
Premisea perme �un'�er �$�5250} Pull-�bs, ��oarC5, paddiewheelE, 2Me5
� �'� ' Q C {$2�07 8i�go cnlY .
❑ nts�soa �f�sesmy
n
m
to cc
LEhiztgo xul not be coaductcd, chwY hasa �
Is me premises located wiEun ciry 6mis� �Yas O Yo it na, iz townsh;p Q c�ganizetl � unorganized .p unincxpora�d
C%ry and Cou�ry rvi�ere gambfng peemises is b�ated OH Tn»nship end Gounty whera yambFnq prtmises is iarate4 it aut5�e ct_ciry fimits
� D� �� a,� � _ � I
addrasa of legd owner
yaur
�'1 �
�t ff0� 9t18G11 WB fb1�OWIMj: � ' ' — ,"� _
' a Lopy.ol tlie lease (tam LG202) wlth tarms for at leazt me yeat.
• a myy ef a sket� ot 1he 11ooi pEn widi d�++ensipns. shwrinq what portion is bei� teased
A teass ar}d skacrh ara rat rsquired !a C�aw D appBcaCOns. .
�� o t f(, ��h�- ��#rozz r'i�is rnr� �s"�lo�
Ii apptying for a r.lass A or C�e:mit, flll in days and beginring & endtng hovrs of bingo occzsinru:
Nn mc.c trsan scven bingo occasio:ls may be conducted by your org� »= n per wtek. .
llay Se�nn]ng/Endtr.gHours �� Day Be�:ntLLng/EndC�gHouxs Day HeginnLz%/F_++dSngHaurs
a� -�s s �
12I05/1997 10;20 6126363070
ESSENTiAL BUSINESS D
3Sinne.sota I.awJul Gunilsiing
Prern3se Perrnit Apgl3cation - Part 2 of 2
PAGc 03
�° ---" -""""•"°"""` •I am Sha ohtot axecutive oN3cer of the organizatSon•
1 hereby careertt that bca! faw anforcement ofllcsn, tha .t assumc 4ui1 responsibTiiyla ifia {air and Sawlul epara-
board or agents of .he baard, or the cammiuioner oi tion ot ai+ attivhiea to be mnduGed;
revanua ar pubi'�c safety, a agonts of tha mmmisabnara,
may gnter the promisas to antorce the Ww. •I wili fami7iarize myseH with the laws ci idinnesm.a
Bank Recorcfs Information govarning lawful gambling and rutes ofi the board and
The board is authorizod ta ins�ect tha bank racords cl ;he agroa, rf ticensed, Eo abida by tMse laws and rvlas,
gam67ing acwunt whonover neceasary 1a fu�@ mduding amendmants ;o ihem;
•any Changes m appl"roaticn inicrmalion wiil be submdlM
requirements of curfent gart:biing mles and law, to 1he boa�C at�d bc3�t Ur7R Of govemmetlt wRhin 50 day8
08th of the change; and
f daclare that: •I undorstand t};at iailure to provide reqoirad intormation
•I have read this aflplication antl ali in}crmation submttted or providing taise or misieading inform�yion may result in
to .he board is true, aceutate and c�mplate; the denial or revpcation of Lhe licansa.
•al! othsr r informatiort has been fu[ry disdc�.ad;
St�natore oF chie} esecutive aHfCer p yfa
��{.JTGl9./� �� r-n-�
��QCGIZ 1
7. The cAy'musl sign ihis applicatan iF the gamb{ing prem•
isas ;s bcatad vrithin aty limits.
2. 7Y,e c�unty �-AND townsnip^ must sig� this application il
the gambling premises is bcated within a township.
3. 'tha bcal un@ govemment [trty or coun,y) must pass a
resciuticn specifically approving or d¢nyir,g ihis app!ication.
a. A r_q9y �f the bcal unit af aovashm6M's �e�ct�tipn ao-
ar_ovina It+is anolicatiea must be attact�ad to Shis �tpii tron.
5. it;his app{icatian is denied by iha Soca{ une af gavemmenl,
d should rwt ba s�bm�tlad to Sha Gambling Cont:ol 6ezrQ.
7cwnshtp: By si�nature b¢SOw, tha 4ownship �cknowledr,es
that ihe organixalion is applying fpr a premises petmit within
township Iimits.
Nartla
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