97-512Council File # l� S �
Ordinance #
Green Sheet # 35334
1
2
3
4
5
6
7
S
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
�s��t� -
i�� ; . : _
Presented By
Re£erred To
RESOLUTIOIV
CITY OF SAINT PAUL, MINNESOTA
34
RESOLVED: That application, ID #B-02925, £or a new State Class B Gambling Premise
Permit by Spilepsy Foundation of Mi.nnesota at Herges Bar, 981 University
Ave. w., be and the same is hereby approved.
Yea�a�s� A r" h � Requested by Department of:
O£f�ce of License rn�pections and
Environmental Protection
Adopted by Council: Date
Adoption Certified by Council
By
Approved
By:
. Date �
/ �������'" ii
-1
._i �i
Form Approved by City Attorney
U
Approved by Mayor for Submission to
Council
By:
�A �� w
** NEED COPY IMMEDIATELY ** � •�`i�r'
DEPARTh7ENT/OFFICEICOUNCIL DA7EINITIA7ED r REEN SHEE �° �35334
LIEP �� - -
CONTACT PEFSON & PHONE O DEPARiMEM DIfiE CfOR Nrtip � A � O CfTV COUNCIL �NRIAVDAiE
ASSIGN CT'ATfORNEY CRVCLERK '
W'1 ia F. Gunther - 26 - 13 N�ygERFOR � �
MUST 8E ON COUNCIL AGENOA BY (DAT� q ��� � BUDC+ET DIRECTOR O FlN. & MGT. SERVICES DIR.
r QRDER O MAYOR (OP ASSISfANn ❑
r"n : �
TOTAL # OF SIG ATU E PAGES (CUP ALL LOCATONS FOR SIGNATUR�
ACIION REQUESTED:
Joanne Susens on behalf of Epilepsy Foundation of Minnesota requests Council
approval of their application £or a new State Class B Gambling Premise Permit, ID �1B-02928,
at Herges Bar, 981 University Avenue W.
RECOMMENDA710N5: npprove (A) a Rejea (p) PEFiSONAL SEAYICE CONTRACTS MUS7 ANSWEN TXE FOLLOWSNG �UESSfONS:
_ PIANNING COMAll$SION _ CML SERVICE COMMISSION �� Ha5 this pef50NfirR1 eVCr wOrkBd under a ODMrdCt ftlr Mis tlePefhnent? -
_ CIB COMMR7EE YES NO
_ S7aFF 2. Has Uiis person/firm ever been a city employee?
— YES NO
_ DISTRICT COUtiT _ 3. Does ihis perwnttirm possess a sltill no[ normally possessed by any curteM city employee?
SUPPOfiTS WHICH COUNdL OBJECi1VE4 YES NO
Explain ali yes answers on separate sheet and attach to grcen sheet
INRIATINCa PflOBLEM, ISSUE, OPPC7RTUNITY (WM, What, NTBn, Where. Why).
R�CE����
APR 14 i997
���� ��� � ��
AOVANTAGESIFAPPNOVED:
DISADVANTAGES IFAPPROVED:
G VSt181tt� j"`?A3ti?�rtR2s �.'��fYj
� 6t�
�$�ti �, � f�s��
-- _..
— — _<; ��
DISADVANTAGES iF NOTAPPROVED:
TOTAL AMOUNT OF TRANSACTION S COS7/REVENUE BUDGETEp (CIHCLE ONE) YES NO
FUNDIHG SOURCE ACTIVITY NUMBER
flNANCIAL MFORMATION: (DtPLA1M
Greensneet# 3 L.I.E.P. REVIEW CHECKLIST �ate: /��5��
In Trackel? �l-ic ApP'n aecaivea 1 ApP'n arocessed
B-02928 State Class B Gambling Premise Permit
License ID # License Type:
COmpany Ndme: Epilepsy Foundation of Minnesota pBA_ Epilepsy Foundation of Minnesota
Susiness Addresss: 981 University Ave. W. (Herges) Business Phone: 646-8675
oanne usens
Contact Name/Address: ��7 RavmnnA a.,o 551y.� Home Phone: 646-8675
Date to Council
Labels Ordered: N/A
Disirict Councii #: ��
Pubiic Hearing Date: � � / i�t
Notice Sent to Appiicant: ht �1�/�`1 ____
Notice Sent to Public: Ward #: Ol
Department/ Date Inspections Comments
CiryAttorneY ,/��/�� (� C��� � /%°� '�j��(4�
7" /
Environmental
Heaith
/v/!�/
Fire
!� f �3
License si�e Pian Rece��ed:_
Lease Received:
�� �
Police ��C�� ��2�!' e
�� ��� �
��
Zoning
,v��
_ ._ ,.:
_ - .^<:'
, _ - , _ .;x;"
= -.:.
- �.'LG2�4 -�� .,.
- :.4rlvuyi. � -
�- - , �-� _� - `]FS�liTiQSOtA
�'ie��ises Peimit :
:1 �
:,�rn _ „_� . .,_ _, ..... _- _......._
-- , .: .-- - Ctassofp�emisesPecr^rt - ,` .^.r_.:- . -
-- - . ._ .. .. .........._�.._.;:. ..�. ..-.-`:--:-_. . - - _'.,; .
� Renewal ; - " _ � - -' (ehedc one) . - -,.`" > ---. '-.- -
', s, boards. Paddlewheels. raffles. bingo `
` ''.. � A tS400l. PWi-uut sp
, _. .. Organ'¢ationbase.l'kense m�mhei � -, . _ ,� , - . ., . _,;.., ... :_ i. : �-'�. ;. � 4 -
Premises permit number .. � :."� 8(5250)��PuA-tabs. SPboards• Pad�eafieels,�fatfles� .
� r � = � .
� � ._ ._.. , , . �:.,'� ... - - - � - ,. ' -
New �,.,,.�;, _ ..
❑ � (S1S0) Raffies only
tn — — —
�. .. . �. . .. . . . _ _ � . . _ _ . " . �.,..._ _._...
. . ' '�. - ... . :.�.- , . . . -:.,:.:.-..,
� : ... ... _: .
_. ._..._� . . .. IfbiagowIIlaotbecoadncYcd.checkhere �
_. _. - . --:_ ,_. _,
� ____......,.�..w,..,..�.�„�<
{s ifie premises located wiihin city 6adts? �
Citv and Counri where 9ambGng premises is
O � r
�
� otganaed p uiorganized C� unincorpara�d
ere gamb6ng premises is bcated if outside of dry 6mils
. . Tjp coae - - " . _ " " _ ", -
vi . � C �'J/Cl- - -
Lf aPPlying for a class A or C permit, Hll m aays ana oe.�'n� oc �i:�_!o .u+�..� �� �+•••6� ��^^�^^"".•
No more than.seven bingo occasions may be conducted by youi'�r ax�atton per week.
Day geginn{ngyEnding Hovzs Day Begitu�ing/EadinS Hoius - DaY . Beg�tng i�nding Hotus
` a copy of the fease (tam LG202) with oirms mr ac �easc one year. rtaa is bein leased.
• a copy of a sketch of ihs floor Plan with dmiensions. showinB what po ' 9
A �ease and skekh are rat required for CJass D appGcaSons - _ . -. .
- �. - x - :
. ��..� �
_ �bTs� � �-��,��;�� a
c�ur�ft.�ccourct�n
�� sarilc Mame : _ _ -i..-� _. ----. - -- ,� `
,. - .-. . ' :- - . .- . - 7
� - . F,
tQ �+f�f7�j i,-y
Apphcatio
'^"a ----- --"^--"'_"-- .
f hereby consent ifiat bcaf law errforcement oTticers, the
board or agents of the board, or the commissioner of
revenue or pubfic safety, or agents of the commissioners,
may enter the premises to enfoma the law.
Bank Records Information
The board is authorized to insped the bank records of the
gambling acxourrt whanevec necessary to tulfi(1
requirements of current gambling tules and law.
Oath
I dedare that: -
-1 have read this application and all information submitted
to the board is true, accurate and complete;
-all other requirad'+nfo has b een f ully di
S�qn�tlire of chief executive officer
1. The ciry •must sign this appt�ca#ion 'rf the gambling prem-
ises is bcafed within aty limits.
2. The �ur�ty "AND towaship" must sign this apptication i(
the gambling premises is bcaied within a township.
3. The bcai unit govemment (city or county) must pass a
resotution specificatly approving os denying this appf�ation.
City
/�(/ / /
Signature of
�� y �
Refer tn the insfructions fw required attachmenrs.
Mail ta: Gamb(Sng Control8oard
Rosewood Plaza South, 3rd Floor
1711 W. Counry Road 8
Rosevllle, MN 557'13
c : r My:;a'SS�.�;'^`�i r':= 'r�'c:.' � . . .
carabti.rcg - :
n = Part;2 of 2��, �7"-S �'-
Bank/
^N . _- _ . _ . , _ _ �.. . _ � - � .. ' -
•I am the chief executive officer of the organization;
•f assume fuli responsibiliry forthe fair and iav,�uf opera-
tion oi all adivities to be conduded;
•1 will familiarize myself with ihe laws of Minnesota
governing iawFul gambfing and rutes of the board and
agree, 'rf ficensed, to abide by those laws and rules, ..
induding amendmenu to them;
•any changes in appl'ication information wi11 be submitted
to the board and bcal unit of govemment wBhin 10 days
of She change; and
•I understand that faifure to provide required iniormation
or providing false or misleading informafio� may result in
the denial or revocation of the license.
Date
3 as
4. �, copv of the bcal unit of aovernmerrt's resolution ao-
orovina this aoolication must be attached to this �Qolication.
5. N this application is denied by the bcal un+t of govemment,
it should not be submitied to ihe GambGng Control Board.
Townshlp: By sgnature below, the township adcnowiedges
that the organ'izatron is appiy'ing tor a premises permit within
township limits.
7ownship Narne
Signaiu�e of person recei�ing appl'ication
TiBe
1 Date Received
LG2�4(Part 2)
(Rev7f2991)
�ocLn.�.� S�s�� ��53 -�i�-(2r� ��e. �f.ltiu-C �ire�iit/��'
Council File # l� S �
Ordinance #
Green Sheet # 35334
1
2
3
4
5
6
7
S
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
�s��t� -
i�� ; . : _
Presented By
Re£erred To
RESOLUTIOIV
CITY OF SAINT PAUL, MINNESOTA
34
RESOLVED: That application, ID #B-02925, £or a new State Class B Gambling Premise
Permit by Spilepsy Foundation of Mi.nnesota at Herges Bar, 981 University
Ave. w., be and the same is hereby approved.
Yea�a�s� A r" h � Requested by Department of:
O£f�ce of License rn�pections and
Environmental Protection
Adopted by Council: Date
Adoption Certified by Council
By
Approved
By:
. Date �
/ �������'" ii
-1
._i �i
Form Approved by City Attorney
U
Approved by Mayor for Submission to
Council
By:
�A �� w
** NEED COPY IMMEDIATELY ** � •�`i�r'
DEPARTh7ENT/OFFICEICOUNCIL DA7EINITIA7ED r REEN SHEE �° �35334
LIEP �� - -
CONTACT PEFSON & PHONE O DEPARiMEM DIfiE CfOR Nrtip � A � O CfTV COUNCIL �NRIAVDAiE
ASSIGN CT'ATfORNEY CRVCLERK '
W'1 ia F. Gunther - 26 - 13 N�ygERFOR � �
MUST 8E ON COUNCIL AGENOA BY (DAT� q ��� � BUDC+ET DIRECTOR O FlN. & MGT. SERVICES DIR.
r QRDER O MAYOR (OP ASSISfANn ❑
r"n : �
TOTAL # OF SIG ATU E PAGES (CUP ALL LOCATONS FOR SIGNATUR�
ACIION REQUESTED:
Joanne Susens on behalf of Epilepsy Foundation of Minnesota requests Council
approval of their application £or a new State Class B Gambling Premise Permit, ID �1B-02928,
at Herges Bar, 981 University Avenue W.
RECOMMENDA710N5: npprove (A) a Rejea (p) PEFiSONAL SEAYICE CONTRACTS MUS7 ANSWEN TXE FOLLOWSNG �UESSfONS:
_ PIANNING COMAll$SION _ CML SERVICE COMMISSION �� Ha5 this pef50NfirR1 eVCr wOrkBd under a ODMrdCt ftlr Mis tlePefhnent? -
_ CIB COMMR7EE YES NO
_ S7aFF 2. Has Uiis person/firm ever been a city employee?
— YES NO
_ DISTRICT COUtiT _ 3. Does ihis perwnttirm possess a sltill no[ normally possessed by any curteM city employee?
SUPPOfiTS WHICH COUNdL OBJECi1VE4 YES NO
Explain ali yes answers on separate sheet and attach to grcen sheet
INRIATINCa PflOBLEM, ISSUE, OPPC7RTUNITY (WM, What, NTBn, Where. Why).
R�CE����
APR 14 i997
���� ��� � ��
AOVANTAGESIFAPPNOVED:
DISADVANTAGES IFAPPROVED:
G VSt181tt� j"`?A3ti?�rtR2s �.'��fYj
� 6t�
�$�ti �, � f�s��
-- _..
— — _<; ��
DISADVANTAGES iF NOTAPPROVED:
TOTAL AMOUNT OF TRANSACTION S COS7/REVENUE BUDGETEp (CIHCLE ONE) YES NO
FUNDIHG SOURCE ACTIVITY NUMBER
flNANCIAL MFORMATION: (DtPLA1M
Greensneet# 3 L.I.E.P. REVIEW CHECKLIST �ate: /��5��
In Trackel? �l-ic ApP'n aecaivea 1 ApP'n arocessed
B-02928 State Class B Gambling Premise Permit
License ID # License Type:
COmpany Ndme: Epilepsy Foundation of Minnesota pBA_ Epilepsy Foundation of Minnesota
Susiness Addresss: 981 University Ave. W. (Herges) Business Phone: 646-8675
oanne usens
Contact Name/Address: ��7 RavmnnA a.,o 551y.� Home Phone: 646-8675
Date to Council
Labels Ordered: N/A
Disirict Councii #: ��
Pubiic Hearing Date: � � / i�t
Notice Sent to Appiicant: ht �1�/�`1 ____
Notice Sent to Public: Ward #: Ol
Department/ Date Inspections Comments
CiryAttorneY ,/��/�� (� C��� � /%°� '�j��(4�
7" /
Environmental
Heaith
/v/!�/
Fire
!� f �3
License si�e Pian Rece��ed:_
Lease Received:
�� �
Police ��C�� ��2�!' e
�� ��� �
��
Zoning
,v��
_ ._ ,.:
_ - .^<:'
, _ - , _ .;x;"
= -.:.
- �.'LG2�4 -�� .,.
- :.4rlvuyi. � -
�- - , �-� _� - `]FS�liTiQSOtA
�'ie��ises Peimit :
:1 �
:,�rn _ „_� . .,_ _, ..... _- _......._
-- , .: .-- - Ctassofp�emisesPecr^rt - ,` .^.r_.:- . -
-- - . ._ .. .. .........._�.._.;:. ..�. ..-.-`:--:-_. . - - _'.,; .
� Renewal ; - " _ � - -' (ehedc one) . - -,.`" > ---. '-.- -
', s, boards. Paddlewheels. raffles. bingo `
` ''.. � A tS400l. PWi-uut sp
, _. .. Organ'¢ationbase.l'kense m�mhei � -, . _ ,� , - . ., . _,;.., ... :_ i. : �-'�. ;. � 4 -
Premises permit number .. � :."� 8(5250)��PuA-tabs. SPboards• Pad�eafieels,�fatfles� .
� r � = � .
� � ._ ._.. , , . �:.,'� ... - - - � - ,. ' -
New �,.,,.�;, _ ..
❑ � (S1S0) Raffies only
tn — — —
�. .. . �. . .. . . . _ _ � . . _ _ . " . �.,..._ _._...
. . ' '�. - ... . :.�.- , . . . -:.,:.:.-..,
� : ... ... _: .
_. ._..._� . . .. IfbiagowIIlaotbecoadncYcd.checkhere �
_. _. - . --:_ ,_. _,
� ____......,.�..w,..,..�.�„�<
{s ifie premises located wiihin city 6adts? �
Citv and Counri where 9ambGng premises is
O � r
�
� otganaed p uiorganized C� unincorpara�d
ere gamb6ng premises is bcated if outside of dry 6mils
. . Tjp coae - - " . _ " " _ ", -
vi . � C �'J/Cl- - -
Lf aPPlying for a class A or C permit, Hll m aays ana oe.�'n� oc �i:�_!o .u+�..� �� �+•••6� ��^^�^^"".•
No more than.seven bingo occasions may be conducted by youi'�r ax�atton per week.
Day geginn{ngyEnding Hovzs Day Begitu�ing/EadinS Hoius - DaY . Beg�tng i�nding Hotus
` a copy of the fease (tam LG202) with oirms mr ac �easc one year. rtaa is bein leased.
• a copy of a sketch of ihs floor Plan with dmiensions. showinB what po ' 9
A �ease and skekh are rat required for CJass D appGcaSons - _ . -. .
- �. - x - :
. ��..� �
_ �bTs� � �-��,��;�� a
c�ur�ft.�ccourct�n
�� sarilc Mame : _ _ -i..-� _. ----. - -- ,� `
,. - .-. . ' :- - . .- . - 7
� - . F,
tQ �+f�f7�j i,-y
Apphcatio
'^"a ----- --"^--"'_"-- .
f hereby consent ifiat bcaf law errforcement oTticers, the
board or agents of the board, or the commissioner of
revenue or pubfic safety, or agents of the commissioners,
may enter the premises to enfoma the law.
Bank Records Information
The board is authorized to insped the bank records of the
gambling acxourrt whanevec necessary to tulfi(1
requirements of current gambling tules and law.
Oath
I dedare that: -
-1 have read this application and all information submitted
to the board is true, accurate and complete;
-all other requirad'+nfo has b een f ully di
S�qn�tlire of chief executive officer
1. The ciry •must sign this appt�ca#ion 'rf the gambling prem-
ises is bcafed within aty limits.
2. The �ur�ty "AND towaship" must sign this apptication i(
the gambling premises is bcaied within a township.
3. The bcai unit govemment (city or county) must pass a
resotution specificatly approving os denying this appf�ation.
City
/�(/ / /
Signature of
�� y �
Refer tn the insfructions fw required attachmenrs.
Mail ta: Gamb(Sng Control8oard
Rosewood Plaza South, 3rd Floor
1711 W. Counry Road 8
Rosevllle, MN 557'13
c : r My:;a'SS�.�;'^`�i r':= 'r�'c:.' � . . .
carabti.rcg - :
n = Part;2 of 2��, �7"-S �'-
Bank/
^N . _- _ . _ . , _ _ �.. . _ � - � .. ' -
•I am the chief executive officer of the organization;
•f assume fuli responsibiliry forthe fair and iav,�uf opera-
tion oi all adivities to be conduded;
•1 will familiarize myself with ihe laws of Minnesota
governing iawFul gambfing and rutes of the board and
agree, 'rf ficensed, to abide by those laws and rules, ..
induding amendmenu to them;
•any changes in appl'ication information wi11 be submitted
to the board and bcal unit of govemment wBhin 10 days
of She change; and
•I understand that faifure to provide required iniormation
or providing false or misleading informafio� may result in
the denial or revocation of the license.
Date
3 as
4. �, copv of the bcal unit of aovernmerrt's resolution ao-
orovina this aoolication must be attached to this �Qolication.
5. N this application is denied by the bcal un+t of govemment,
it should not be submitied to ihe GambGng Control Board.
Townshlp: By sgnature below, the township adcnowiedges
that the organ'izatron is appiy'ing tor a premises permit within
township limits.
7ownship Narne
Signaiu�e of person recei�ing appl'ication
TiBe
1 Date Received
LG2�4(Part 2)
(Rev7f2991)
�ocLn.�.� S�s�� ��53 -�i�-(2r� ��e. �f.ltiu-C �ire�iit/��'
Council File # l� S �
Ordinance #
Green Sheet # 35334
1
2
3
4
5
6
7
S
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
�s��t� -
i�� ; . : _
Presented By
Re£erred To
RESOLUTIOIV
CITY OF SAINT PAUL, MINNESOTA
34
RESOLVED: That application, ID #B-02925, £or a new State Class B Gambling Premise
Permit by Spilepsy Foundation of Mi.nnesota at Herges Bar, 981 University
Ave. w., be and the same is hereby approved.
Yea�a�s� A r" h � Requested by Department of:
O£f�ce of License rn�pections and
Environmental Protection
Adopted by Council: Date
Adoption Certified by Council
By
Approved
By:
. Date �
/ �������'" ii
-1
._i �i
Form Approved by City Attorney
U
Approved by Mayor for Submission to
Council
By:
�A �� w
** NEED COPY IMMEDIATELY ** � •�`i�r'
DEPARTh7ENT/OFFICEICOUNCIL DA7EINITIA7ED r REEN SHEE �° �35334
LIEP �� - -
CONTACT PEFSON & PHONE O DEPARiMEM DIfiE CfOR Nrtip � A � O CfTV COUNCIL �NRIAVDAiE
ASSIGN CT'ATfORNEY CRVCLERK '
W'1 ia F. Gunther - 26 - 13 N�ygERFOR � �
MUST 8E ON COUNCIL AGENOA BY (DAT� q ��� � BUDC+ET DIRECTOR O FlN. & MGT. SERVICES DIR.
r QRDER O MAYOR (OP ASSISfANn ❑
r"n : �
TOTAL # OF SIG ATU E PAGES (CUP ALL LOCATONS FOR SIGNATUR�
ACIION REQUESTED:
Joanne Susens on behalf of Epilepsy Foundation of Minnesota requests Council
approval of their application £or a new State Class B Gambling Premise Permit, ID �1B-02928,
at Herges Bar, 981 University Avenue W.
RECOMMENDA710N5: npprove (A) a Rejea (p) PEFiSONAL SEAYICE CONTRACTS MUS7 ANSWEN TXE FOLLOWSNG �UESSfONS:
_ PIANNING COMAll$SION _ CML SERVICE COMMISSION �� Ha5 this pef50NfirR1 eVCr wOrkBd under a ODMrdCt ftlr Mis tlePefhnent? -
_ CIB COMMR7EE YES NO
_ S7aFF 2. Has Uiis person/firm ever been a city employee?
— YES NO
_ DISTRICT COUtiT _ 3. Does ihis perwnttirm possess a sltill no[ normally possessed by any curteM city employee?
SUPPOfiTS WHICH COUNdL OBJECi1VE4 YES NO
Explain ali yes answers on separate sheet and attach to grcen sheet
INRIATINCa PflOBLEM, ISSUE, OPPC7RTUNITY (WM, What, NTBn, Where. Why).
R�CE����
APR 14 i997
���� ��� � ��
AOVANTAGESIFAPPNOVED:
DISADVANTAGES IFAPPROVED:
G VSt181tt� j"`?A3ti?�rtR2s �.'��fYj
� 6t�
�$�ti �, � f�s��
-- _..
— — _<; ��
DISADVANTAGES iF NOTAPPROVED:
TOTAL AMOUNT OF TRANSACTION S COS7/REVENUE BUDGETEp (CIHCLE ONE) YES NO
FUNDIHG SOURCE ACTIVITY NUMBER
flNANCIAL MFORMATION: (DtPLA1M
Greensneet# 3 L.I.E.P. REVIEW CHECKLIST �ate: /��5��
In Trackel? �l-ic ApP'n aecaivea 1 ApP'n arocessed
B-02928 State Class B Gambling Premise Permit
License ID # License Type:
COmpany Ndme: Epilepsy Foundation of Minnesota pBA_ Epilepsy Foundation of Minnesota
Susiness Addresss: 981 University Ave. W. (Herges) Business Phone: 646-8675
oanne usens
Contact Name/Address: ��7 RavmnnA a.,o 551y.� Home Phone: 646-8675
Date to Council
Labels Ordered: N/A
Disirict Councii #: ��
Pubiic Hearing Date: � � / i�t
Notice Sent to Appiicant: ht �1�/�`1 ____
Notice Sent to Public: Ward #: Ol
Department/ Date Inspections Comments
CiryAttorneY ,/��/�� (� C��� � /%°� '�j��(4�
7" /
Environmental
Heaith
/v/!�/
Fire
!� f �3
License si�e Pian Rece��ed:_
Lease Received:
�� �
Police ��C�� ��2�!' e
�� ��� �
��
Zoning
,v��
_ ._ ,.:
_ - .^<:'
, _ - , _ .;x;"
= -.:.
- �.'LG2�4 -�� .,.
- :.4rlvuyi. � -
�- - , �-� _� - `]FS�liTiQSOtA
�'ie��ises Peimit :
:1 �
:,�rn _ „_� . .,_ _, ..... _- _......._
-- , .: .-- - Ctassofp�emisesPecr^rt - ,` .^.r_.:- . -
-- - . ._ .. .. .........._�.._.;:. ..�. ..-.-`:--:-_. . - - _'.,; .
� Renewal ; - " _ � - -' (ehedc one) . - -,.`" > ---. '-.- -
', s, boards. Paddlewheels. raffles. bingo `
` ''.. � A tS400l. PWi-uut sp
, _. .. Organ'¢ationbase.l'kense m�mhei � -, . _ ,� , - . ., . _,;.., ... :_ i. : �-'�. ;. � 4 -
Premises permit number .. � :."� 8(5250)��PuA-tabs. SPboards• Pad�eafieels,�fatfles� .
� r � = � .
� � ._ ._.. , , . �:.,'� ... - - - � - ,. ' -
New �,.,,.�;, _ ..
❑ � (S1S0) Raffies only
tn — — —
�. .. . �. . .. . . . _ _ � . . _ _ . " . �.,..._ _._...
. . ' '�. - ... . :.�.- , . . . -:.,:.:.-..,
� : ... ... _: .
_. ._..._� . . .. IfbiagowIIlaotbecoadncYcd.checkhere �
_. _. - . --:_ ,_. _,
� ____......,.�..w,..,..�.�„�<
{s ifie premises located wiihin city 6adts? �
Citv and Counri where 9ambGng premises is
O � r
�
� otganaed p uiorganized C� unincorpara�d
ere gamb6ng premises is bcated if outside of dry 6mils
. . Tjp coae - - " . _ " " _ ", -
vi . � C �'J/Cl- - -
Lf aPPlying for a class A or C permit, Hll m aays ana oe.�'n� oc �i:�_!o .u+�..� �� �+•••6� ��^^�^^"".•
No more than.seven bingo occasions may be conducted by youi'�r ax�atton per week.
Day geginn{ngyEnding Hovzs Day Begitu�ing/EadinS Hoius - DaY . Beg�tng i�nding Hotus
` a copy of the fease (tam LG202) with oirms mr ac �easc one year. rtaa is bein leased.
• a copy of a sketch of ihs floor Plan with dmiensions. showinB what po ' 9
A �ease and skekh are rat required for CJass D appGcaSons - _ . -. .
- �. - x - :
. ��..� �
_ �bTs� � �-��,��;�� a
c�ur�ft.�ccourct�n
�� sarilc Mame : _ _ -i..-� _. ----. - -- ,� `
,. - .-. . ' :- - . .- . - 7
� - . F,
tQ �+f�f7�j i,-y
Apphcatio
'^"a ----- --"^--"'_"-- .
f hereby consent ifiat bcaf law errforcement oTticers, the
board or agents of the board, or the commissioner of
revenue or pubfic safety, or agents of the commissioners,
may enter the premises to enfoma the law.
Bank Records Information
The board is authorized to insped the bank records of the
gambling acxourrt whanevec necessary to tulfi(1
requirements of current gambling tules and law.
Oath
I dedare that: -
-1 have read this application and all information submitted
to the board is true, accurate and complete;
-all other requirad'+nfo has b een f ully di
S�qn�tlire of chief executive officer
1. The ciry •must sign this appt�ca#ion 'rf the gambling prem-
ises is bcafed within aty limits.
2. The �ur�ty "AND towaship" must sign this apptication i(
the gambling premises is bcaied within a township.
3. The bcai unit govemment (city or county) must pass a
resotution specificatly approving os denying this appf�ation.
City
/�(/ / /
Signature of
�� y �
Refer tn the insfructions fw required attachmenrs.
Mail ta: Gamb(Sng Control8oard
Rosewood Plaza South, 3rd Floor
1711 W. Counry Road 8
Rosevllle, MN 557'13
c : r My:;a'SS�.�;'^`�i r':= 'r�'c:.' � . . .
carabti.rcg - :
n = Part;2 of 2��, �7"-S �'-
Bank/
^N . _- _ . _ . , _ _ �.. . _ � - � .. ' -
•I am the chief executive officer of the organization;
•f assume fuli responsibiliry forthe fair and iav,�uf opera-
tion oi all adivities to be conduded;
•1 will familiarize myself with ihe laws of Minnesota
governing iawFul gambfing and rutes of the board and
agree, 'rf ficensed, to abide by those laws and rules, ..
induding amendmenu to them;
•any changes in appl'ication information wi11 be submitted
to the board and bcal unit of govemment wBhin 10 days
of She change; and
•I understand that faifure to provide required iniormation
or providing false or misleading informafio� may result in
the denial or revocation of the license.
Date
3 as
4. �, copv of the bcal unit of aovernmerrt's resolution ao-
orovina this aoolication must be attached to this �Qolication.
5. N this application is denied by the bcal un+t of govemment,
it should not be submitied to ihe GambGng Control Board.
Townshlp: By sgnature below, the township adcnowiedges
that the organ'izatron is appiy'ing tor a premises permit within
township limits.
7ownship Narne
Signaiu�e of person recei�ing appl'ication
TiBe
1 Date Received
LG2�4(Part 2)
(Rev7f2991)
�ocLn.�.� S�s�� ��53 -�i�-(2r� ��e. �f.ltiu-C �ire�iit/��'