Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
91-1805
����o�a� L.�-� Council File ,� �"` Green Sheet #` 16311 RESOLUTION OF SAINT PAUL, MINNESOTA � Presented s J Referred To Committee: Date RESOLVED: That application (ID #B-03047-001) for a State Class B Gambling Premise Permit by Phoenix Learning Services, Inc. at Joseph's Bar, 537 State Street, be and the same is hereby approved. Yea Nays Absent Requested by Department of: imon �� osws z on �— License & Permit Division acca ee =__� e tman ane i son i BY= Adopted by Council: Date �, Form Approved by City Attorney Adoption Certified by Counc�,t cretary ' �/� / �� / By: By: �.�-- Approved b yor: Date SEP 2 7 1991 Approved by Mayor for Submission to Council gy; �����/2a�� B . Y' "������'c� C�T ��`91 . ._ - j �/-/�A� � DEPARTMENT/OFFICE/COUNCIL DATE INITIATED N� 16 311 Finance/License GREEN SHEET CONTACT PERSON&PHONE INITIAL/DATE INITIAUDATE �DEPARTMENT DIRECTOR �CITY COUNCIL Christine Rozek-298-5056 ASS�aN �CITYATfORNEY �CITYCLERK NUMBER FOR MUST BE ON COUNCIL A(iENDA BY(DATE) City Clerk ROUTING �BUDGET DIRECTOR �FIN.&MQT.SERVICES DIR. Hearin � 9—�y91 e V B � 9-10-91 ORDER �MAYOR(OR ASSISTAN� � rn,�ni� R TOTAL#OF SIGNATURE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE) ACTION REQUESTED: Approval of an application for renewal of a State C1ass B Gambling Premise Permit. Notification/ 9-3-91 Hearin / 9-17-91 RECOMMENDATIONS:Approve(A)or Reject(R) PERSONAL SERVICE CONTRACTS MUST ANSWER THE FOLLOWING�UESTIONS: _PLANNINCi COMMISSION _ CIVIL SERVICE COMMISSION �• Has this person/firm ever worked under a cOntrect for this department? _CIB COMMITfEE _ YES NO 2. Has this personlfirm ever been a city employee? _STAFF — YES NO _DISTRIC7 COURT — 3. Does this personlfirm possess a skill not normally possessed by any current city employee? SUPPORTS WHICH COUNCIL OBJECTIVE? YES NO Explain all yss answera on seperate shest�nd ettach to green sheet INITIATINQ PROBLEM,ISSUE,OPPORTUNITY(Who,What,When,Where,Why): Sandy Bjornstad on behalf of Phoenix Learning Services, Inc. requests Council approval of their application for renewal of a State Class B Gambling Premise Permit at Joseph's Bar, 537 State Street. Proceeds from the pulltab sales are used to create opportunities and offer special financial assistance to developmentally disabled persons. ' ADVANTAGES IF APPROVED: If Council approval is given, Phoenix Learning Services, Inc. will continue to operate a pulltab booth at Joseph's Bar, 537 State Street. DISADVANTAQES IF APPROVED: COUt1Cl! RBS����� a"`�—�.�� SFP 0 9 1991 DISADVANTAGES IF NOT APPROVED: RECEIVED SEP 16 1991 CITY CLERK TOTAL AMOUNT OF TRANSACTION S COST/REVENUE BUD(iETED(CiRCLE ONE) YES NO FUNDING SOURCE ACTIVITY NUMBER FINANCIAL INFORMATION:(EXPLAIN) �� . � , NOTE: COMPLETE DIRECTIONS ARE INCLUDED IN THE GREEN SHEET INSTRUCTIONAL MANUAL AVAILABLE IN THE PURCHASING OFFICE(PHONE NO.298-4225). ROUTING ORDER: Below are correct routings for the five most frequent rypes of documents: CONTRACTS(assumes authorized budget exists) COUNCIL RESOLUTION (Amend Budgets/Accept. Grants) 1. Outside Agency 1. Department Director 2. Department Director 2. City Attorney 3. City Attorney 3. Budget Director 4. Mayor(for contracts over$15,000) 4. Mayor/Assistant 5. Human Rights(for contracts over$50,000) 5. City Council 6. Finance and Management Services Director 6. Chief Accountant, Finance and Management Services 7. Finance Accounting ADMINISTRATIVE ORDERS(Budget Revision) COUNCIL RESOLUTION(all others,and Ordinances) 1. Activity Manager 1. Department Director 2. Department Accountant 2. City Attorney 3. Department Director 3. Mayor Assistant 4. Budget Director 4. City Council 5. Ciry Clerk 6. Chief Accountant, Finance and Management Services ADMINISTRATIVE ORDERS(all others) 1. Department Director 2. City Attorney 3. Finance and Management Services Director 4. City Clerk TOTAL NUMBER OF SIGNATURE PAGES Indicate the#of pages on which signatures are required and paperclip or fFag sach of these pages. ACTION REQUESTED Describe what the projecUrequest seeks to accomplish in either chronologi- cal order or order of importance,whichever is most appropriate for the issue. Do not write complete sentences. Begin each item in your list with a verb. RECOMMENDATIONS Complete if the issue in question has been presented before any body, public or prfvate. SUPPORTS WHICH COUNCIL OBJECTIVE? Indicate which Council objective(s)your projecUrequest supports by listing the key word(s)(HOUSING, RECREATION, NEIGHBORHOODS, ECONOMIC DEVELOPMENT, BUDGET,SEWER SEPARATION). (SEE COMPLETE LIST IN INSTRUCTIONAL MANUAL.) PERSONAL SERVICE CONTRACTS: This information will be used to determine the citys liabiliry for workers compensation claims,taxes and proper civil service hiring rules. INITIATING PROBLEM, ISSUE, OPPORTUNITY Explain the situation or conditions that created a need for your project or request. ADVANTAGES IF APPROVED Indicate whether this is simply an annual budget procedure required by law/ charter or whether there are specific ways in which the Ciry of Saint Paul and its citizens will benefit from this projecVaction. DISADVANTAGES IF APPROVED What negative effects or major changes to existing or past processes might this projecUrequest produce if it is passed (e.g.,traffic delays, noise, tax increases or assessments)?To Whom?When? For how long? DISADVANTAGES IF NOT APPROVED What will be the negative consequences if the promised action is not approved7 Inability to deliver service?Continued high traffic, noise, accident rate?Loss of revenue? FINANCIAL IMPACT Although you must tailor the information you provide here to the issue you are addressing, in general you must answer two questions: How much is it going to cost?Who is going to pay? �.�,�o� DIVISION OF LICENSE AND PERMIT ADMINISTRATION DATE �l `j / INTERDEPARTMENTAL REVIEW CHECKLIST Appn Processed/Received by . �"Sa.ad y �,ion�s�11��-a� Applican�ho�n�x ��n�n�5�«sT.n�• Home Address f�gt� �'T�,Spn $� �,,5'/�� Business Name SQWI � Home Phone ,►���- Do2'j� C.7�os s � ���� � Business Address _��rJ � e, $�' Type of License(s) _�� �4SS /�1 Business Phone ���-Qo2�15` �/�j��S'E'� 7��1^�I/� "ji°�?��Q/ Public Hearing Date � 1� License I.D. 4� ,8 �' Q',�d��a�'f at 9:00 a.m. in the Counci C ambers, 3rd floor City Hall and Courthouse State Tax I.D. 4� �9��3(2�� Date Notice Sent; Dealer � �//9' to Applicant �3��� Federal Firearms 4� Public Hearing �I �(� (:�d' "_/_ . � DATE INSPECTION REVIEW VERFIED (COMPUTER) COrIl�IENTS A roved Not A roved Bldg I & D ! ��� Health Divn. � � � Fire Dept. I ���-i Police Dept. �l ailq!( �'�� License Divn. ��� I �'1/ � City Attorney � ga� 9, i Date Received: Site Plan ���/�/ To Council Research � S � Lease or Letter �j ate f rom Landlord 4 � ' �9� � � ' 4 � ,. /�/V__ FOR BOARD USE ONLY LG214 FEE y �i vurso► ' C}iECK INITIALS � DATE Minnesota La.wful Gambling � Premise Permit Application - Part l _ - _ _. ' :�:<:;..:::::�;::::.:::>::.:>::::::::• ::<.�:.>:.;�;.:>:<.>::.>:.:.;.�.>::.:�:.::.«.::,::..:>:.::.:.::.::<..::.;:..<.;..::_:«n:<;..:;<:.::«.>:;::;::::<;::,:<.:.<;.>:: � ,:.��:::::.:�.:::.�.::.::�<.:�.:�::::.:;.;::. :A::.::.:;r:.> . .r . .. . .3 ,... ................. ........ .......... :,, ..........._. .................. . :�:>,�<�..<:� :{:.. . ,.j�.. _ . . ... ........ _.. _.... ....................A.:..:.,-,.....r....:.:::.::.:°�`.• :�:.�::. ..::::::..n��.o.:;...:.;..; ....:. , .►.........;, ,..,..... .........v.'iTi:n:r.sw.v.�rS�'.r:rx•v,n.g}.v..:n4{M..A;{Tr .fl1+...- ...;..� ... ... ..�.'�t:.a�.::::... •:>+.t<`.x.y...:•::•`.a:•:::h......:•<•:>:e�.�1'>S:i:�3i;y;;;.;y:.:;;;q;i::.,•!;:7• ..,._._ ,._. ..2.. :.5.;..,-.;:.,.. ..�,a�:>:e;:::..a..:+:.•:r.,..�:.�:+::::::?:.:::::.:.. . . :. �., ............................. ..•::::::;..:.:..,...:::`.`:..�: .,;.,v,. .. >'�:t•:>:.?�:a::4:::::>::�:>.......+i:':+�': .ni.::x,`.r.:a'�:ii::a. :::::�:..o::�.:..:::w::..w:•:..•:::::::::::::::.. ;.; . :::::.:.:...... ::'ir::•'r.'•`•:�:±,.,•:::::::::::::::... ...5;'�"i:::.'•'- •:»w7 v::....w:..:+ � flr: a�zc�ot�.:�'n :o :: . afion:<:«<:>:.... ...� �'m . . :,::..,:..,:.::. .... :::«.:�:w«;.<..<.....�....«.<>:».. ::<..:::::>::..,:.......:.:::::.�:.............::.r.: . .. ...:>..,.:..:.,.:...:::::::::.. .>.»::..- :r.>:.;:::.;.::.: �� . .. .... :_ _.. ._:.. . .......... .. ........ . . . .......... .....�.................,:>:::.:.�:.:...:::.:r..::,:.::::.:::..�..�>.:«:.:�:;;......>.s.: � >:........::....................... ........�............ .........................,.f�........._ ............ �:,:..:...... . ..:::.:.<.::::.;::«::;: : :. : ........ .... .......... ... .. ... . ........::: ...........:.................................................................................�.:::<.. . ..................... ...=- _..._.. .C�,x........ .. .... ................ - . .. . .... ...... ... .. . ... ...... .... - Legal Name of Organizadon � / .- � � . /���i21ti i n ;��1�.��.�E..Ej. . .__ _. ._ _. _ . ' . .. , . . .. ... _ . Business Address of Organizaton-Street ot P.O B x(Do not us address of gambiing manager) -- . . jC .. . _.. . _. . .. , _:,. . - - - - - - . - . - . _ ... . City „ ' � State Zip C ry Business phone number _.�� ,�-�� - _ ��� ..__ _ s�-�f. ----- -. ����y _ _ ����� ����oa�.� ; -: . - Name af ief execupve o cer(cannot gambling manager) , . .,.,Tide _ - Business phone number . 'a�r�.5�t� �g. �,5 • , ... ��r�� �,�,��oZ7s . Address of chief eativ fficer-Street or P.O. Box � . , � � �,�.E:,� iry � tate p ode oun — _ . �fl/, �5��: � ` _. - . ..1%r�S B _ . . . :.:,•:..•...,,M...,:..:�:::.:::::.,w.H.,w:.:.w,,:..;;:.;:..;:..:.v.,:.;:.:,:::.,::;,..,..;.;.:;:.,..r.,,:,....,...v,�,.;;,,,�..,.ri.;.,•.......::......,...::...,.,n•.,,.:...:.,.,k:.,,,....�M„M..,:,•.,,,;,:,..:.,x �:::.::.:�:.,:•<:.;: :.:.:,:•... .:..:..: ........ . .. . ....... .......... � -�::•::•>:>::..... :.,•n,•.........:.::..,�:.,,:•::.,:..:,,,.:.......;.. ..<r.. ::•> .. ::::::••.... . .......:. ............::::>::::;::: � - :•::::::::..:.:... ...: :::�:�:,. �.�.,.,..;.,;......:,:::.�;;>:�;:;�r<�:::�::.�::�.�:.�:::�a;>:�>;:<�s>:;•s�;x:;;;s:s>:=>s>:a:s;>::.:;•:<:�:•>:;;:�;:�;::ti»»:�:;•>•.:-.a�s<»:•;;>��:::::•:: �>:<'�»S<:�»»»>>::;>�:�rs;:z;::>:':'::::;>::>:<2'�:�s>;s>;>�»r�`� ..:::• � ....t..........................a.r....:..;.......:::..+.•::::..;..:,::::.;�..::�::.:. •:.�h�rr:..�:;.,.;•;•:�::::i.:.:::::::::.ii::.i:i•i:•ii:�ii:"�i:.iiiiii:�ii:y.j�i::G:::; . . . .. .ti� ...........n...:......:........:• . . -:.+:<-::'ti�::2•:•`::�{'v:`i... .. .... . . .. ,.. . . :.:: . . ;;.,.::::::.�.:�:::�::::._.�::::::.r:.:::._:::::ti.:�:..,::::.:�::.>�:.:;•.:':.::•..�:•::•:r�::::........... �: . � � � ::::::•::::::.::::.x::::::::.�:::.:.>�:::::::::...:.:.:..r:•::.:.:::.:.:.:.....r.. ; . . . :: :: �E.'LI�L . ..:_.::.::�::•.�.:::,:::::::.�:.�:. . . .:.:......::::::::: ..........,..-,:::::.:::....<..:::::;.,:<.;:;.:.;::.;>,:.;:;<•:;;:.;;:;:.;:•;:.;:.;;:<::::::>:;:»:; e..f� ... � DTf...................................::.;:::.;:.;:.;:.;:.;;:•;;:.:::;:.:-:;;:.;:.;;>;;;;:.::.::�::.:;:::.;;:.;;::.:.;:.;�.,_:::,,:.....>...........,..........�:..::,:.::.:.....:.....,........... ..................... �P..:.::::::.�.�PP...::. >:.... ........:::::::::....... <.;,.>:.::.::.::.::::.::::::::::::::: .:::::.: Class of Premise Permit - _ Fee . - _ _ _ • .: _. _< ,,: : . ❑ Class A— Bingo, Raffles, Paddlewheeis,Tipboards, Pull-tabs . 5200 � - �ss B— Raffles, Paddlewheels,Tipboards, Pull•tabs � � : ��gt 25 � - The class of premise permif ❑ Ctass C— Bingo only � - � - � St oo must be reflecfed by c/ass of Q Ctass D— Raffles oniy _ ; �75 the organizatton llcense. , _ _ . _ .. ._ _.. _ . _ _ ._ :_ _.,._ _... _ _ .. .. .. , .__ _ Bin.go Occasions � __. . _.. . . .... . __ . .. If class A or C, flll in days and beginniag and ending hours of bingo occasioas: � - - � No more than seven bingo occasions may be condncted by an organization per week. � . Day Beg.nning/Ending Hours Day Bcgiruiing/Eading Hours '. Day Beginnfag/Ending Hours : to to to tn to to to • . • .. ., t . . - :.TT:J?Y!:rM:M}..>YM. . Y::+:^F.•%A::P^��l@nt^wp,y.}}X vav,.gnY.!'{'.H .?.:MMVM'. +y0[OOOM• 51 s.;,2L':'^Y•y:'{•:;c..wau�,m:p`x:^X:,,r...y}y...,;.....v�v � .....:...... .....,y . '.,._'k'•,.,-.;:,.'.•.' ' "':"..�:: .,-....?�••::::..`.2? , :.•::•rr::::::.;,`.`.). .::.•:..•..�:.:•.�...,;.;.....:.•..: `•2??.'•�,. ..�i?nr» .:k.-..•.:r�:�: _ ............. r...........:..,...v,s... ,::::::.. •c::::.:.. n.:... ......... -,..............: .:�:�;•: •...�::.:::....i...-: :.>r:::9`:��..:>:::•::c:::•.:.�°. �c..t`�?"•'�' ..��,+.�,�� . .: ....r... r:v:y�:•:::4i:�:!i':...................... \r........... .::n.�........... ... - .........n.........::{:.ii::............i�.....::.� � v.v.........v.�..n..v �..........}..uv. v v�� ..... � '. i. ...................................................w:.n................... ...�.......... 2. ••vv;:vM'.t'�v..�v }4{.}i::tiJi:v:::.:...... { ......�...r ' ........... ............................................................. ............ ......... • .:r:�.��....... .......}iii}?v:�•::'tiG;.}}xi:•.�'•:i::ii::.s..... }}...�.}•q. . . . . . .;.}x:::�:}v.�:.:::.:v::n. x:\w::::.w v:\vvvS�4::::•.4?.vv.v: : x::J.-n-0::n •:A. .ti,}.., x.;�sm .....,..,•. ........ •:::.:_:,..:.:...�..:,•: ::..,...,.....:::. �a..�.•>;o ::........ .. :•.. ..*�... :.�>�..;�..,-�,::.......•::...,....:.:::::.::,....�••:.�:•:::•:::................:...�::::.>•.,..:>..:>.>•••. , :aX-�.�:.•.G;::s.:�w:.>,:::::::::2:;�:!•'.%`. . ;..., v; .;;::�:.;:•::::•:::•::....:..... ....,....,...... �:::....... ....•.:.,:t•: ,t-:>:::�:::b:::..,., .>:..:f•.N;.::�?::::•:.:.w::.a.,,....•..:%..:.,,• ....''':;:::�:;;i:�:':;:;:;;;:::;::::;;�:::;>i . . .. .........,.... ,......... .. .. ,�::.���.:�•� r••�•�y y-. �.:<•:::� .;•;. _ . .:. :. w�.,��{, y.,;{� .: .j 1,::.. .... ... .... ...: .......c:•..•:.�.�..r.>°..'s,'•�'�:::.�,:;,.,�:::.:r.v-r�-::»:::.+;.�ii<;:;;:. :�:a�s:�xas;:_,,•-;n::2h:;":•:-`.x.:.... .r. . _.. I� �w � k ...2....k..;S...h...:... ..�4•:?-:�.::.:...2 t ..o:s:•:.,�::t...;.:..;,-.?a,:•>:.^•.:;:�..�.::::.:•.>o-�SS: > .. :;� V Wl�.C•'��L�7Q'�Y��4u�..tC.� 6:11G1.s�,�r=,�•,i :i:•h{:.?:r:•.;�rpy6;.}}}};{;•:y.;..,-:v. n}yny:Y::: - rirR.v:v\i.i:.v.��. ........�..,�.::� ...... $ .........:...:. ................................................................... . �x::�.�:.v....v: .x: ' ......�..................................................................:.�::.�:::..v:.�._:.. .:?>:L:t:Lr:t.iii:v•n•:i.:v x::..S\:.::::::..;r•;.•.?1:•':>:r.+6.•v'.•.�. " w:.....�M.:.-:•._>.,;s,n,{:•+`?a'v:':YGwv::::::::ji:<`:;Y:?�>Ti::i.::::: . ...�-.�•�:::.............................r.........�:•:v:::::�::::.�:n:�...,-,............,-.,.,....::v::.���/%�.:.;n;.....,C^z,.. .............;.'a.:..{..v�}., .}..:� {.:}.vY:::.:::::::::.:::::.n.. ...r.... ...�:..s.:.,•:::.•::...:,.:::.,::.:..r..�;u:..�;:..a;::;:::..:.}o•:?•r%•:i . . ..:...:r•:.:+a.�',^:a:<.:�:<•::�::�:;•:::v:•�r:_:•::.;:.:....+��::::,::o::::.:::::...v.,:.�..:::;•::r.;;•+:.+r:;•::.�:::::::.........rFv-::s.;t•. ..�•: ...........,...............,:.. .x. ...... . ... .....::::::.:�::::::.�:•.�:..�:Y%:'• - s:.i.. ,�:.<�.�:::..:•..�:.�::s:�2�-..,�.:::.�:..�:::.::.. . ?;1+.'..hY.. .,�:.�.. :::i..a::. .� � �q:;..*.�.,-;..,;:: �:::::.. .:...... ........ ..::.;:a::.a. � ............ ...y::........ ........... ..�.: ... .:.......:•:::�:::::::::::�::::::::::::�,�.�:::•::.>.r... .....,:...•::::::•..;,,,•...a ... . .. v ...............:...>....,. ................:.... .:t.,.`.;c••.:;:•:�>:.::c.:....s+::;•:: :•..•:c9Qvw::�:t�.. ...:: �•::�::: :•.. •^t'?Y5:•:::�::�;:�;:;.::>v..::':::%' . :•.�.a::::•:r:Xk:::>:..�.:.�::::.r...:s.�:.:+:. .a,v. {-:. s•:::•:.�:::•:.: 2�i -- ::..,:....,. �...;., ,...... .�::•::..;.:.;....... ......� ............... ....... ......,:.::-y:,.:;:a. ..:.::...t� ..;;r:;:j;•::�::'•::�:�:•>;:i'... :•+•:�••:`•:�';��:::�:.;�:.t�:So:::::�:.:,.. �. .,...•.t�::•::y�>::....... ... r........ .. .....>.. :':�::: ,at�£•.?.......:.•:.......::�::�:::::at:::s..... .. .. ..::.�.. '. . .L«.v....tZ+.........,....�..:..,....,.....:.C..wx�a....,..ti...,..<..v3.w„+c....a...{,�.�,�.,...w..,.wcv.w..wu.....u....,:.•....fA,fi.r...v�.»:..•::cax:::•::.:.•�.+fu�.�:,a:d�aai::'i;?poR:�::;.ah«..SZ2 . _ _. .-. .. _. .. .. - .. . , .. . . . . .,_ .. . . .. .. ....__ . - . _ ;. Statns of Premise Permit - check one: - - -.- ,: . • . _ .:_ .. ..: .. _ . . .. . �� ., � . ..... ..:. _. , : .. . _ _: .:.� . _ _. , . . ❑ w premise—FII in�g organization premise petmit number - -. . . _. . . � -�'�newal of exisiing premise permit-FII in comolete premise permit number �"�3�� '!j o.�� ��_- ' ' � . _ -. , : ❑ Previous(y expired premise permit—FII in comDlete�premise pertnit number ` ' " � - ' ` � : _ . . J.� . . . . . . . . . �-� :�.� .-_ : .-.:�� , .. �-. .�. .... _ .._. - - ' . --. . - . _ .., . _ � -. -.:. . . , , _. �_._ _�. . _� . . . _ . .. .. . -.� _ _:. _�_ ._.. - .._.. .. . . _. ._ `., _�. '�-' ' ....,_. . . . . . . . , .. .. _ . _ . n: .. . . � . .. _ . . . . . _ � - . - . ,-, .- : � .. _... _ . .... _� _.-_.'. , . ..... .- _. . ... _ .. � . .. .. . . ... - y.i t -: .:. r.. ,y .. � • - . : . _ �9�_i�e.�' _ �- _ . _ -. �. LG214 ::.: : ..; '=: _:: , _ . : ... . . _ _._ . _ - ._. _. , . .. ;. . _ . .. - _.. - _ . .... - - � _ . . -_ :_.. �. . ,::r :_: . ...:__ �;_. __ . ... _. . .. _. _ . , _ .. Miruiesora I.muful Gambling , � _ �Premise Permit Application Part 2 y �. �. �.,.�,�- b.M.:.<. � � . .. ,r� .. � hi�.i�. �- �J. �.�- .�.e: �A:� � . ' _ .- � m. � >�y� - t, � j .� � �+ -� n+iir' ��Y � �,. ._ wL .�� rt� 2�1' .'�['ww_,.. '..'. '�. . . . i �. ��.._ �.t'. . �.:.- �..� �...._.. e �.-yY _.� -.. . .__ . -. _ . ._ �.. . �i�.... .. . . _ `st•'-_..�...'.��..' ....,- . ....:�,._. . {�•.1-. .f.? ' n;n .. ' ♦ ' . .. .. - •. . n...•: '�a..v.. • . •. ' .. 'sMG, 4 ,H'+w -Y- . . .. . .. . . . ;.. . . ... . . . . , v ... . •.....:.....:. .� v . .... ' :., � ,. . . ' i � �Name of establishmeM where yamb6ng wil oonduceed�. SU^eet Address(do not use a post o(fiae box rwmbe -��Q ., ___ : _ _ . ,._ �� � . _,.. _ .,..�-y _ _; .. ,.,,... - -.. • _- ... . 1� ' � %r� . .. ._ .�.._.._.,.._�;..� _ �t:.�s.. � , . Is the premises IacaLed witfun a Gmits? -:: yes :_�no �._ . H . � -_ 2 _= .. . - � . _ r = , 4�.' ;_Ciry and Coiinry where gaml�I'mg premises is located OR Townahip�d CouMy where 9amb6r►9 Premises is located'd aitside of .;aty irtMts , ::.< . " + ' �/r� -���l�� fi t�.� " � _ -- . ` ' � {,"' �..-� Y�'r '.. .-.. .. . _ �� J - J _.i W' ��� ;.. �.. . �.. . _ .. _� . . , . _... n��+�. -' _: `Name aixi Addreas of Legal Owner of Premicea :;, ;.; Ciry -.:_- ._ .. ,. S'tate __ Zip Code -,: _ - _ s :� �-_. .:_ -. ::.,.. .. .. .: .. . . : .. ... . n` - -- . �,� --_ _ . -: ._- --- _ , �C � -�,ASS��� �3:�?:^�h��� � �u`�..J���y%l`,✓. --��/d � - _ Does the aganization own the buidng wt�ere the gambGng wi9 be oonducced?�YES .. NO . _ _ _ : . �� NOTE:Organizations may not pay themsefves rent'rf they own the building or have a holding comparry. A letter must be sub- -- .- � '` ` �� mitted showing rent payments as zero from gambling funds i(the organ¢ation s holding company owns the premises The � � - . :_ .. : - - letter must be signed by the chief executive officer.) �-� `��` '" � G . .-... .�.. . .. .� . .. - . . . .. �. . . . . _. .. :.�.� :•.. . . '� -� '. .-. If NO;attach the foilowing: �� - � ` " _ .: _ :_. : ., . - . , ., : _ . ...... :. . __,. , .: . . _, , _ _ .. - = a copy of the lease with terms for one year.- -, - . _, --. -.; . � _. _.. __ _ � � ' '-° � -- • a copy of a sketch of the floor plan with dimensions, showing what portion is being leased. �°--� " - . . y �" "•A lease and sicetch are.not required for Class D appticaritlons. = � � - - �- -- - _._ _ . _. _ .. _. ._. .. . _. _._. . ... . _ � ., .... ._._ ., ._... ._.... _ _... - . ... ._._ . . Y.. `Rent' , ~-�.- _:. : = �-rv.�: ,..... �,: - - �--�- m;;�.. :� - _ . . _._ .. ..,.. . �.: , ._ . _, ... _ _ _ _.�.� ...� .. ... _, .,... � . ... .._ ,. � . ._ ;-- ..__ .. :._ For gambiing with bingo, _. $ � � �� . Total square footage leased - ` , , . . ._ � _ ... ,. . . � : . . $�.. ._ , . _. . --_ . ._ . , . . ... • __ ;. .__:. �_..w. F_.-- For gambiing without bingo _ _-�3��..�`2�0_. :__-.�Total square footage leased . - -� _ � , � _ �a Address of storage space of gambling equipment . - - ., :, . _.. _ _ . ___ .. _ _ . . _ _ ,. : , . - _- ... , Address . _ ._City _ _ .___.__ .._ State .-.� :� ;-_. _ Z�p code . .._ _ ,- � _ . __.__ - ; _ ; _ .. .:::::::: ;::: _:<;<: ..,:.:.;�.;�.>.;.;:..;..:.<.;:.;:::::.:..;:...:.:...:.. ..:.,.::.:;:�•.= ...ti...:�::.;�;�� :.,.::.,.,:�.,� -�� ... :.. i.�y..:� :._ ...;�I7 . �1�7��.. '.7�kk..i'S.�}4: . .3:��'.,....,..r.,..�,.,.��;}?�.•. �. :•.w•�.. ��4'" �'.3�+��}'i..}�+St'4s;;o;?e'3i�.:t;�.. .�t�y����r.�r3 �':ti;#`� .. • � � �.' ... �� ..'.:; �.-vi��is?fi;_., •• ,. .....Se*..s.'v.•io �> ::�at' �<i'�'ca.'..iia... nx�x y,.� ;;<�,;a�.�.��",.�,�.��'.°.��;,.. ••�..:•.. sr,':.>y,.;. .,.�..� ..,. ... .;•:. :.. • 5 . 1Y�:w::.l��::;.�:;>::::>:::•::.:..:r: .K..::nr . ... . ,. ••"RC���.�''c+'...,. '-^�`... Y"'.x`,..v, ._ :.;..>... (e�������psmr A�gambi ng promrses must avs a aeparats chec ng axount) - . Bank Nams " � • , : Bank Aaeount Number . - . .. � . . � , , ,, . _. �,,r : . ��'/'n.�Psot-�ac �Ca,� �/5�,,.C. �"/CV�1.��'" � � - Bank Address Ciry - - Staoa _ ZP i ..<�i .��.<!T . -�j� , ^'���, '� . r..�^�r �,�(�,.�•w ,( +- L. - �' ,'`+� , . � - ._'"�"'��'��QC��:�,6���� �'^�w�'�1�1��.��'-.•:: �°-�.t:i.. ',�.�..�-��jt(�r.I= �'��.�_`�w�� . -� - � _ ;: _�. Name,address.and aBe of persons auUrorized ro sign dredcs�d make daposns and wid►aBrawals :;_. '-: ` ; . .� ._ - ,.__. _ ., . _: � _ � : : . . _ �ne _ '..:. _ .. -� . _ . . _ .. . _ - - d/ �r .j�,�/��z�' �. SSi�o3 �- �� _ : .,_ ,.. _ _ , _ v . .. . _... ". . ... . � �w :._ .-� . . . _. .- _ � . . . :- � _. . .. . M_ _- -:. !?� r`I.� �-� _. . ., �. , �... ,., - . . ..'"." - ���'�, r,. .���. ..,� -.�. . '�..N � _ `� . � �c.:�� ;. � _ . , _. „ . �;,� -�-ti. . � -� : . '-: � .; - ' _ - . , . _ . _ .�,.._ �- a- . . ..Y^�.`r-,,,.�.._. ., a _ ... �aa:_.. . . ...... .,�_.::.�-- ._.,.�_._:. ��i __. ..,::: .. .....:_._ _.....:. _.,. �., .__...,_ _..�.�.s:� .. . _ .i +..... - . _. . _ �n.n.� � ... ��. �: . ::.. .- r - ._ _..' .:.' ... :, .�� . .. . . . ... ._. � _ � _ �, . _ �.. ; . . . � .. " .-' ' ' "' . _ . ,�: � � ::. �__.. . �. _ '�. .:..- y�...� .,.. '_ t �_: �:- . .�_,�-.�:-���_�_..tfuz'. .nr...,�. .•.:.: ...�.,.��. . . .-.._ _,. ..i:. ..«., -,::.: . _..:.r .'.�<_ +/,�'VC^ • �-m.v.2-'w _. .- _ . .. . �. _ --,?_._ - . .tidb:_ _. . _ ' _.::w. � .