91-2217 ORIGINAL
✓
_ � �Q Council File # ' /
__..�
Green Sheet # 17653
RESOLUTION
CITY OF SAINT PAUL, MINNESOTA
Presented By
Referred To Committee: Date
RESOLVED: That application (ID B-01698-004) for renewal of a State Class B
Gambling Premise Permit by Highland Area Hockey Association at
Starting Gate, 2516 W. 7th Street, be and the same is hereby
approved.
Yeas Navs Absent Requested by Department of:
imon /
oswi z
an � License & Permit Division
acca ee 'i
ettman J
une �
By: �/'
Adopted by Council: Date DE C � i99i Form Approved by City Attorney
Adoption Certif'ed by Council se�et ry � ' � /O. �/.�'
C�,:� By: .
.. ,,
By:
' r? F ��.�,,� Approved by Mayor for Submission to
Approved by yor: Date � '�� Council
" ,<<- •�!-��ji�� .
By: . /� - ,� By:
PU�USRED DEC 14'91
�����
✓
DE?ARTMENT/OFFICE/COUNCIL DATE INITIATED
Finance Lic nse GREEN SHEET N° 17653
CONTACT PERSON&PHONE INITIAL/DATE INITIAUDATE
a DEPARTMENT DIRECTOR �CITY COUNCIL
r• _ _ Ag$��N �CITY ATTORNEY p CITY CLERK
NUNBER FOR
MUST BE ON COUNCIL AGENDA BY(DATE) C�t C ler ORDER 6 0 BUDGET DIRECTOR �FIN.&MGT.SERVICES DIR.
O� y1J a MAYOR(OR ASSISTAN� � �,�. ��+� R
—vvQi-rcrr
TOTAL#OF SIGNA URE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE)
ACTION REQUESTED:
Approval of an application for renewal of a State Class B Gambling Premise Permit.
Notification Hearin � s �1/
RECOMMENDATIONS:Approve(A)or Reject(R) PERSONAI SERVICE CONTRACTS MUST ANSWER THE FOLLOWING CUESTIONS:
_PLANNINO COMMISSION _CIVIL SERVICE COMMISSION �• Has this personlfi�m ever wOrked under a contrect fOr this department?
_CIB COMMITTEE _ YES NO
2. Has this person/firm ever been a city employee?
_STAFF _
YES NO
_ DISTRIC7 COUR7 _ 3. Does this person/firm possess a skfll not normally possessed by any current city employee7
SUPPORTS WHICH COUNCIL OBJECTIVE? YES NO
Explain all yes answers on separats ahsst end ettach to grean shest
INITIATING PROBLEM,ISSUE,OPPORTUNITY(Who,What,When,Where,Why):
Mary Michels on behalf of Highland Area Hockey Association requests Council
approval of their application for renewal of a State Class B Gambling Premise
Permit at Starting Gate, 2516 W. 7th Street. Proceeds from the pulltab sales
are used for youth hockey.
ADVANTAOES IF APPROVED:
If Council approval is given, Highland Area Hockey Association will continue
to operate a pulltab booth at Starting Gate, 2516 W. 7th Street.
DISADVANTAQES IFAPPROVED:
DISADVANTAGES IF NOT APPROVED:
RECEIVED C�u���s� F���°'�j,'�, C���er
►vov 2 21g91 N��' 21 1Q91
CITY CLERK
TOTAL AMOUNT OF TRANSACTION S COST/REVENUE BUDGETED(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�FFICE(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.Qrants)
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. Ciry Council
6. Finan�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. City 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 flag
eaCh of these pages.
ACTION REQUESTED
Describe what the project/request 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 private.
SUPPORTS WHICH COUNCIL OBJECTIVE?
Indicate which Council objective(s)your projecVrequest supports by listing
' the key woM(s)ZHOUSING, RECREATION, NEIGHBORHOODS, ECONOMIC DEVELOPMENT,
BUDGET, SEWER SEPARATION). (SEE COMPLETE LIST IN INSTRUCTIONAL MANUAL.)
PERSONAL SERVICE CONTRACTS:
This information will be used to determine the city's liability 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/
charte�or whether there are specific ways in which the Ciry of Saint Paul
and its citixens will benefit from this projecUaction.
DISADVANTAGES IF APPROVED
What negative effects or major changes to existing or past processes might
this project/request 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
approved?Inabiliry 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?
�-9, ����
- � ,�
DIVISION OF LICENSE AND PERMIT ADMINISTRATION DATE /D o2`1 q//
INTERDEPARTMENTAL REVIEW CHECKLIST Appn rocessed/Received by
Lic Enf Aud
- C�S'r.�s�an �al� ts �-mb� �h�)
Applicant �/p� � , Home Address ��.
Business Name � Home Phone ��— ���'3 /p��/ �
S �-f- 'rt
Business Address , S//� Type of License(s) ��� c�Q� �_
Business Phone S'�3d.•,Slf��j'3 (jrQ/Y10�/17q �/f�'17lSP! �2/yy1jT - ��J�'eL/
Public Hearing Date �a- Qs �i � License I.D. � ,B � d�����'DO�
at 9:00 a.m. in the Council Chambers,
3rd floor City Hall and Courthouse State Tax I.D. �� ���7�.�,3
Date Notice Sent; Dealer �� ���'
to Applicant
Federal Firearms �6 /(�
Public Hearing ��
DATE INSPECTION
REVIEW VERFIED (COMPUTER) CO1�iMEENTS
A roved Not A roved
Bldg I & D I
�f�-
Health Divn. I
ti�� (
Fire Dept. �
� ( � I
Police Dept.
��r�c��q� Se�
,� ��� G► ��
License Divn. (
��I�l`! I ��
City Attorney / f
C°l3� �'I I ��
Date Received:
Site Plan ���a 9 �
To Council Research ���ZD^�l�
Lease or Letter Date
from Landlord j v1� �1�
. �cg�--ao?�7
� � FOR BOAFID USE ONLY "
LG214 BASE#
przaq,� .
� PP#
FEE
Miruiesota La:vfuI GambIing CHECK
Premises Permit Application - Part 1 of 2 �NITIALS
DATE
e,.y...,:a::•.y,•,ar}'N.fi:;.MCwuiW%%Yh:^:r}i:{^?Y.+�:.m,v,na�.};.;.yi. r.�i .:JJ.•`%!^'f.?f?�4ti}:{M}?}
............... .Sii:.};.xW..}yi};::::r:::rn}:•:u:..i�iin}iik3.N:.}v;::::.i::':ifi::HfA�:Jr r.v.i:t..^^:�:•:i{n;n;{.w.:}W}Yri:fi.;�: . .. .. .. ... ......:. ':Y. n?.• ..J..
� + L.v•:•v.:�v.::. ,.,,X,'` /.'.;...;;Y.:'.;...n;..:,
•::•S:<:��:�::.......::..... ..X.......:•::.... ..'C':...,-;.;:....;..,.
::.�::::.,.v .•:::::::. ..........:..,.... ......t .::.,•:::::..!#•:.
::.::::::.:........,...............::::........:..�::::::::::.... ....... ::::: r.�,:::.:..::::.::..�::.::•::;;•r:,:;•:+r::o•.•::;a,.:.;:.•,•,:s,:%:•.:.:.a..•::,.a:::•...,.,.....:.::::•,.v.::.....,..5,. ,....:n..�•.,...n:::.'•t::..::.•:::r:
::.... :....:........::.:..::.::.::::�:::.,-.;.,-Y..::::.�::�::.;....n............r...�::::n�::::::::rh.:�•.:.. .............. ...r................................... �......s...........it..........v.�.................:....
;..::.::.:::n 1.....:.: ••.�.:::v:::i i..i::.i:�: .................... n•�:::::n�:::::rr.�:.v:+':.:v:.r.:r�:v:�•i::B::Lirv�4:ii:ibir i%:•:.;r,
+,.;•:{•i:4ii'i{:::..�i..
.......rv.:::n.. :.. . n:.... .........x:::::::: ..r............... M:•n:tiJ:tiSi{{:{r.iii::i+.tiv':ti:�:ti4:'viii:ivi'J.v:hiii:ti�{tii3:i:{:j:{ri}'.•ii}i:ii?
.. ........v:... .:: ......... .......... .�:}:....:...x...:...:.. .......y........:.::.....:...;s,•vx:::v.:v............... }:. .... ...r{.. .:{�........
.......:::nY::::::::.:::w:::::::w:....,....r.v......:.....:....•:� ............n.�..v:::•...rr.r..:h:i:m:n4•:+n•v......r.n•:::xv:::::::7:::::r.•..n. ...yx:::v:Yi:::.`•:
v:F.v:A::-+:r::•n.�•:::::.r. ..}.:y:;J,.v:i;�::.y::::...........
.. . '' '�' :i: .. . :{.i4::{:::.i'.iw::.�::{:.::•:.i'.r::.:.r.:::.::::•y:::::n.:..::::}w::^:.i•::nv....;.
.?.,{•;•;r•:ii:i^.>.•'.�:i•''�.'•ii:i:'{.iiii:�:{:y;:};:}O{ii}:ri:Y<ii::�. . .{.}:r.:i:x•::x.i?Sii}i:ii: .
......... ........ ....................... ........ .si::..ti:?<v::.v..J.........{... .v{�.....{�ti?•?:i:....:...:v...........
> ;; I�CQ�# .:•:::::.::::;•::. .:....:.:.:..:......:.::......................,..:�.........,....:::,:.,:,.:... v
e o A or�.:.:<.:..>::.::::.::<.::::..:,:.:�.:;:.:::�.:::;.::;::.::.>:.;:.;:.;:.::.;:;::;:;:..;:.::::.:v;:.:::.:.::.::�:::.:.:�..
Q Class of premises permit
Re�ewal (check one)
Organization base lioense number �0� q$ � A($400) Pull-tabs,Gpboards,paddlewheels,raffles,bingo
Premises permit number ` ��`� � B(5250) Pull-tabs,tipboards,paddlewheeis,raffles
� New ❑ C($200) &ngo.only
❑ D(StSO) Raffies ony _
• .�,:,..:M•:�,..•...
..�,,.•,:::::,,:.::.,:.:.,.,,..,,....:.:.,::,..,,:,.:,.:::.,..x::•.,:.:.,�•:,�.,..,.,.,::..,,.,...•.,.,...,..,:.,N:.:...,.•:•„ .::. <�...».,.,.a,..�..,<.,:,.<.,:;.,{.:,�.,,:::,,,.;;..::..::•:«�:«�.•...................r:��.,,.;:.,,,,:x,,,,..;«,,;:<:::..;<.r.
:.......................<......................
..............,..................,............::.:.......::......:..,...,....«::::�:.::..,.:.:.::<.::....:,...........,.,,................:.......�
<;.,:,:,::,:::.:.::,<;;.;:<:. .....�;;..;�.:<::;•;;;>;;s. :.:.<r.;:.:�:.:::.:;.::.;:.;:.:.;,.
..::,<.,::•;:;•:;;.K:::-.;;::;:.,,:•:<.::.;:;.:r:;:v.>:;.;:.:<::;s:::;>::z::<:;:::�::>r:>::::><:z::_:.::>::<>.::::::z::>:<:::<::>::»:::<:=::::;:;::
.:..:..:.:..: .::.� ................ .:.:. .........r....
...�,....>..............................
:...-...:... . ..:.:::.::.::::.. .::.::.: ............
:.:f;��•:<
..y. .:..:.:.,:.,..:•..:..::r......;..,.............,<..:...,.>..,.,.,.::<...... .........,
..•:::w.::•;:•;•:.sx.:::.::.;••>:.:;;:.;:.;:;.:<.:;.;:-:::-
::c>;>.;:•..::;:;•.:.::�•;:�•xo:•:>:;x�•;;•::r•:'........t.........�......................
'.:: Q Q� . :,1 . :;:,.:.�::::::::r:..;:..:::;>::s:::r::,::::::•::>::::,y:::::::.•,••::;•::<>'•,r;;r,::.::...,.:..�..:::.:
�::.r:::::::•:::::•::::.�::::::.�:.:�.�::::
Or ruz hon o!�-matz .:;;�.;;;>:.;;:,..::.::.::::::.:::.:.�:;�.:::..,.::::::::::.:..:.;.::.:....:....::.:::.:.:::.,.::....:.........>:....:....:...>:.......:.,:..::>:::.
.:9....:......:.:._,:.: �_:;.:.....::_.
arrt...,.
...... . ............................. .. ........................................,....................................................................:..................,...............:...................................:..:..:....:.... ...
Name o(Organization
TSt�eet+c►-AN� ��2G—l� ��y �56G,
Business Address of Organization-Street or P.O Box(Do not use the address of your gambling manager)
15 y0 /�s�n 10.,;�c� t�'VZ.
City State T.ip Code Counry Daytime phone number
St. t�cu:.� M� 5s►o� a�LSe. cbi� � �-�1G.��
Name of chief executive officer(cannot be your gambling manager) . Tide DayDme phone number
. . ,� � ��� . '.. - ' ' . �;'P�Ix3(.EJE N � -:( l�� y -0�..�
�Bingo O casions . . . � . � . � . �
If app�ying for a class A or C permit. flll in days and beginning&ending hours of bingo occasions:
No more than seven bingo occasions may be conducted by your o�ganization per week.
• Day: . Begln�ing/Ending Hours'.' :::.- paY. . �g�ntng/End1r�6 Hours . : DaY. ' Be�ning/Ending Hours ,
' ' .. . • ���'. t � _ � . . „t �`—.' • : . '. ♦ .•�: . . . .♦�.' • � � .. ;
\V W lV
.. • • � . . . .�r . . _ . .. . .-�� . . . > . - . . . �. . . ' � . .
... . � • ;to , ' . . . 'If b�0�l IIOt�hAIIQ1iC�Cd.C�iCC�hEIO.• � ` . . ' ��
R.cvs':C•.-5:4:4i:"�:. y��:.. .+f.h .'.{;4¢}.•55Y.'N.d::g}SS<+!+tt•::x_ .S�yw'wf,•,:iiY.:i•:•}.`•<:. w' '{+Y;: ,r,•: ..`/F. ' '. i . '+�:?Y?Yb.pC,'...i'nv++W+. itH.•^y.wy� ,c ,ry_ .s:ryp..x:
.: ,...;..... .. ,.:. .. ....:..... ..,:•: _..: ..,, ;..:�::..'Y.,..;.:..:.::..,-.,....:.5..:}3.:::#•::�:.�??Y..;?�?"•?'.>!.;�:>,�,'5,.;,t.,"v,DF;��.,.:::..•..�•i;!::•:•...•,3,;::::.},.;:..,�fi^•'q?�,..:..,,:6::::.,..�:r:.+.t
..•.}:.:;:?.:•.x....yx.y • '+ .v;3.•;.�>:;.:.;•:.y.
..ir%:`:
:>Gam
:.Y:i.;::%c::i'>::;.::::t<
.: ....:
b ::Prem�ses::: or�aa�ian>>::;::�v»»::.:::::.;.::,..::..:r.;<.:<<';<:.>;:::ri,::�,:� .:�..............:....
;.::.,:>::::<.r.::>;:::;:<::,.,.::,:ti.::::�;;>:
,
�::..:....:..�:.:.:..::::.::.. :v.�::.�::..�.::::.:::.�.:.�:.�::::.:.�::::::::::::::.�:...:..:::.:...�...::::w:.n..::.:::.:::w:::.�:::::::::,v,y::.iiti{:iiii:..
IX•:3.r..
'�X�tiii::::::::•::::�:ir.
•'•i:.ti•.•:.:•.:v:iiiY..}}:tiLp,.sv.;r.v..;
. ... .:...:::::ti.:......::.::::...w.:w.ii�.'•ir.:•i:•���i:
............................ ............................. ...:.v:::::.:::......... . . .... . .
.............................................. . ......................................... ............ r•..x•.v.0:3:i... .
.::::...............::.::::::::..:::.::.:�::::....:..:.:.:i:.:::..�::::.:.:::..�::�•::•;'•':!L.:{{.;:.}�:.;;.?;
Name o establishment where gam ing nnl conducted treet ss( not use a post o �ce x num er)
�_-�2.�'i�iC-� �C;��P.� o`ZS 1(o lt�. �'�'!� 5�. �
Is the premises tocated witfpn aty Gmits? L�J Yes �No If no.is township �orpanized � uncxganized O uni�corporated
Ciry and County where gambfing premises i�located OR Township and Counry where 9ambGnp premises ia bcated if outside of aty Gmits
�+.�0..�s , �Zi ,�Sz.� I
Name�nd address oi lepal ovmer of premises Ciy . , State Trp Code
Does your organization own the bu�dng where the gamblinp w�ll be oonducted? p YES NO
If no,attach the fo�owing:
• a copy of the lease(form LG202)wiih terms for at least one year.
' a copy of a sketch of the floor plan with dimenaions,showin9 whst poroon is being leased.
A lease and aketch are not required for Class D applications.
.::.r;,:...;:;.:..,..
..::.:<.:,,:.,:,,..;,.;::•�•;:.:•••• ,...:<.:n. �•�•r$;.:<N.>
.i)C�:.,v,.;.;�.}}y:n r x.;{• •.}yv;v
.}r.}.. •�.n::w::::.v:::n}wuny.irvi?i}ii}w:x: : :r:r.:....,.,..;
4x'ii::y`-ii'x/'....$..�}'N� .'. �? �' n. �v� . •::?H.?•i::?•
v:.+}�i:.r.. x.. r.�...�}..r •r:::}iY:�:i. .v: . .� • ..•'r.•:$�' .. .v . :.�.�i$:f�:'r�'r v.} n� 4 r:j7Y:•:�;v'v,:::'?.: .}
..x:
.r..,::'•::::::nt::r:.•i::::x:::::::.:rv.n�..n....v.itr r:. ....y{... v...v. :u. .. ....5.......v....x..........v...rr...�i.A`.'. �.v.E . .... ♦ vn.n�S.n...nr.:�ri:i:!�:....'�..x..+�i'..
.:. .....:.w.�:.:::;ny. ............:.....:.... x...nE::::4`/.`..� :v... ....n........ . ..........n.r........ ....................... }. .... SJ.r \........�......... ..'C:,x,•.vv.tw:v'i.'•:�}i:�.'•i:i•ii}i::.:.:
:: :: .: ...:..:.....::v. .::...v:...::.::.:..:.v.;.... .........:..r.. . .:. ..... .. ... ....... .:�.:........ ..........:........ .:::C:i':i:>.�.::r}.:r:rh,•n}}v...:}.::?v::.�:.::::'iii:4i::•.'4ii:..:v.•:::::...rJ:w::::v:.�:.�:::::
Xddress of.::sto . e;:s act:::� ; amb ::e meat:��r:�:�r:�$ a::�x��,��::>::�;:::<<::;�<>::»:�x:>;::::>;::::::::�::::::<>:::;:::»
_ ____._... .. .., _ ::_�. _ Iin ..: : .
. , . �
_ .:: ::.:,... .. . .. ..... .. :. ::.:
Address City State Zip code
�so� �'l►���In r� i.1 �v� 5�, �c�.«� �d�.l �r�� 0�1
�,��`����
Mircnesota Lawful Gambiing �
Premise Permit Applicatioa - Part 2 of 2
....:.:::.:.:�>. � :,>,.�.
:: _ , _ .::>:»;:
« . ..:. :.. .: .. . . ...: ......
..,. ......:.:.......,
;:�
,. >;:::;::::»:.:;::.�
1 >B <::� n o : a.tio.
�Gumb in ank ccourtt rm n::::::;<:>::>�::::::<:::;:<>::«<::;:..:><><::>::>::.:::<::.::>::>.:::::::`:"::::>:>;:::::::::<::;:::::««:<:<::::>:::<:::>:;:;::::>:<:::<::><::>:::<:�::;::::::><::::>:::>::>::.;>:::�:::<:::::<><::<::��:::<
_ 9 }� ...................... .... ..... ......... ..... . .. .......
Bank Name Bank Acoount Number
,�'►'1P�.�S ca ri �Ct.��CMC.t X �c��.� �ty �tae� — l(o ( — �I
i o� C-. S'''`'` St. S-t. �a..� f�l� 5��o� - �Q�(�
•,,:`:�`" _ �lar�►�„addressk.�rd�a at .;::.:au�ia�zed� _ �r3�.and��'epo,sr�s ar�c��thdrawals. �' '" {
::::.. �s... .�
,.,:{.�...::.,,:.,:,,,..::::.�:::::.::
.:..,�:r:.:::..,,::,>::.::::.:.::::::>::;:<;<:;:;<:>::>�:»::::>:::;;:;�:>::;:::<.;:.;:....
s:>.
�:.<:<.::.,:.,:::•.;:;<�:.;:�:.>:.:.;:.>:�:;.:
...::. :....;::,;•«.�<.;:.:;;.::.:.::.;.::.::.:::...:..�::..:.:r.:,.: ,�:::::.:.:
::: •� ::
,.........::....:.:.... <.»::::;:::«:>::::>s: ;�r'6aiii'zatrdR�s::bsasur�r:i�x�ot��ta�le�aoarr�ti�irvfundS :; <�
:. <�
_ .. _. . ::
_ __
�+� ame ress Ti e
S�r, Yln_ -Pcx.rzv�c . - �� �'- uJ A-�so� �,v�e: : �xi,ry�b ti nc, I(`'�.c,�r_
��.�-1�e. !�. �Sa 1e � t w.h. �'l r,
�.:.,v..r:::.,>:<:::•.::.:::••:.::.::.::.>:<:.»::::.:w:::?«.::.::.x::•::<.::::::<.:�:.:::.::....::::<:.:::.:
•:.•.,v.,:•::::.:.>x.:::::.:::::..�::.�:::::.�.:::•::•:•r:c•::::::::::.:::.;•;..;.;;::,.::::.�•:•.:.;•,::::,:::::.�::::•::.;:t•r::•:ttt:;a;;,;.;,;.,;.,, •::::.::::.,.:::::::::.::::::::..�::
.. ...:... :.:...:::..:�:::::::::�.::::::............. :•::.....:.:...:::::::::.••::::•:::::..•:.:::::::::.............................y....,..............................................................................,::::::::::::::::::::.�::..,�..;..::
:.f n:�.::<•.......::..:.:........ ..F.........................::...: .
r;.r:�r<:dr;':c:::�::A:::;:�::::;<�i:�::;%�:�::;�k�::�:i:�:.'•::�::�:::��:�::<t:::::i:::�i:�i;:�::»c%�:::<�::;�:::�;:;a:i::c:;;:�::�::::::�:;��;:�:;�::�
...:�•..::�.�:.�•::::..::::.�.:::t•::.:�'•»r.i•i:;•>:::.::.:::::.:::......:....:.......::..v.:::::• r.�:..�:�.�:.,:?•.r;r:>:t;,::•::•:
•i:•••i... ..........n... ..... :..:....:. .........::::::..::..:::::. xv:F:+::;?:;:j{nw:.�:::::::.�i::.:::.
.. .. . .. . . .. . .. ....:.....:•. .........................v::ii:.n..::in:..:::i.}v:: .;•::}i:r��:iii.•::x5::.:rv•:nv:r::::::+.�:r.::..�:.,-..�..
. . . .. ............+...........n........................x:::::::nw:::::n .. ...�................:..::..:.::.:•.{yiiiiiiiiiiiiiiiii:L:i{Liiiiiiiiiiiiviiii}iii}:ii}iiiiiiiiii:4iiiii:Jii:
•.��.�v:.�.�•.Y:v.:�:..:...::a:y:.................:...:y..;.;......,-,-......;...,-;...,-:..........,-...............,-......,-........
.. . ....:......:...v...:.......::�w::wn�::::::::::.�:v::::::•::::::.....r
:v.3...:ti.::::::::::•::::::+v::::::}:...::.i.... . •::A:::.+.v:.:::v:....:..:.�:.�::::::::::n:::.:.::.:..w:.v..•::::n::n..:::..::n�:::::.:::::r{:::.�:x.y:::.::n:::.:i.::i::
:i:!• . �:�..........................:.............:..:.....:w::.•:::::.¢....:.........
Acknowi ement::<::;:::>;>::;:::;::;::><>;;.....:::�::...:::...::.::::.�::::::::::.�:::.:.�.................................................... ................::::::::::::::::<.::::::::.<::.::<..:.:...:.:
...................:............ ...... ...�:.�::..:.:.:..:::.�..:::::..:.:.:::...:::<::...............................fi....................::..:::::............................................
............................�....................................................................................,..,..:::.:::..:.:::::::.::.:::::.:....:..::,..,::::.:::::.::::.:::::::::.::.,:,..,:.:�<:;:.:;>;>;:.>;,::«.;:;:<::�.;:.;::.:::<.:.:.:,:<:.:.
.................................. .................................. .......................................... .
Gsmb g S te Autho on •I am the chief executive offioer of the organization;
I hereby consent that local law enforcement officers,the •I assume fuil responsibil'rty for the fai�and lawful opera-
board or agents of the board,or the.commissioner of ,.:�tion of all activities to be canduded; .... ,
reveriue or pubiic safery;or agents of the oommissioners,• �' ' :�y„ill familiarize'myse1f witFi tf�e lav►�oi Minnesota � '
. .may enter the premises to enforcs:the iaw.,. :�. _ . . . goveming lawful gambling and rules•of the bqard and ,: �
� Baak ReCOrds Informatfnn �` �� � . :agree, 'rf Jice�sed.to.abide by thos�faws and.rules,� • �
. . . • Tho board is:suitioriied.toinsped.thebank.raco�dsci�the:. •�y��ing amendmentato�fiem:• . . . .. �''. . .
gamblin�axour�t.whenever�necessary to fuMill .. � : ' . •� '.any c:hanges in applicatbn+ntotination will ba,8ubmitted. �- :� • : .
requirements of cunent gambling rules and law. to the board and local unit of govemment within 10 days
Oath of the change;and . � � � � �
I dedare that: . . � •I.understand that failure to provide required information
�I have read this application and all informatio�submitted• . , '.� a�providin�falsg�or.�misleading infprrriation m�y resuti in
.� �to ihe board is true, accurate and compleio; ,,°. .•'.;• -��•.tt'io•,dertial�or revocatbn of:the'I'�'nse � • ' �' " '�� �
� •all other required information has been fully disclosed; . � ' � � � '
Signature of chief executive officer Date
�'l�rh f: C� . %'l��'r.f�� .� f�G7�"�l�e�; �%�l
.�...
>.><�::_>:::>:::>:::<:::>:<>.::::�::::»>:::_::::«:::>:::::<:»>:<:>«:�::><::::::::»<:::::::::�:::::�:::::.:::<::::>>:::<::::::<:;:::::>::::::::::;>::>:>::�:::::.;::::<:::<::>::::»:»:::::::>::<:>:::::::::::::::::>::::>:::::::::>::;:>:;::>:::�<::::>:><:>:<::::::>:::�:.»:::>:::::>:::�:>::::::»>::�:::::;>:::>::»:>::»::<>::
:<.::�.::::..;.:::;.:>:::.
: :.;::.:.:.:::.. :.:: .: .... ..:,...:.. .::.: . . . .,. .... ::., .....<.:::�::.:::::.�:::.�::::..::::.;.:
w d e �:«::::::<:>::>;::>::;<>::::::>:>::>::::>:::::::::<:;:<::>:.><::;::>:<>::::_:;>::>::::>;::>:;:::>;:�::<:`;.:><:<��:;:::'::::::';:::::<:<<:::>:>�`:':»:>:<:<><:»»:»::»>:>;><::::>
�:�ca�C Gavernmier�A�kno 1e: g m�n :.::::.:::::.::::::..
4. A coov of the local unit oi aovernment's resolution a�-
1. The city•must sign this application ii the gambling prem- ��this aoolication must be attached to this a�olication.
ises is bcated within aty limits. 5. If this appl'ication is denied by the bcal unit of government,
2. The courrty••AND township••must sign this application ff �should not be submitted to the Gambling Control Board.
the gambling premises is located within a township.
3. The local unit government(city or county)must pass a Tovmshlp: By signature below,the township adcnowledges
resolution specifically approving or denying this application. that the organization is applying for a premises permit within
township limits.
Clt ' or Count *' Townshl "
City or Counry Name Township Name
Signature of person receivinp application Sipnature of person reoeivinp application
Title ( Date Reoeived Title I Date Reoeived
fQ
Refer to the instructions tor required attaehments.
Mail to: GsmbUnp Control Board
Ros�wrood Plasa South,3►d Floo►
1711 W.Counry Road B
Rosevllle�MN 55113 � LG214(Part 2)
�a«�r��►