07-22-1998 Council Agenda - Laserfiche WebLink

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Minnesota Lawful Gambling Application to Conduct One -Day Off -Site Gambling - LG230 Licensed Organization Information (please print all information) For Board Use Only Organization Name St. 9„..t License Expiration Date 7 / 2 I / 9 es(� Name of Chief Executive Officer S f c License Number (5 digits) O Li 1 6 Class of Organization License (A, B. C, or 0) 0 Daytime Phone Number( : I ) • 9 O (Do not list the gambling manager) Gambling Premises Information Name of establishment where -r .t- gambling activity will be conducted I IN e- U e r DT I c -� L n h Street Address and City 1 6 i `i L) , 2 : c c Sk • L `it/ K C ;'^ a. 24._ h') NJ S 1 / /3 (Do not use a post office box. If no street address, write in the road designations. Example: 3 miles east of Hwy. 63 on County Road 42) Does your organization own the gambling premises? 0 If yes, no lease is required. ® if no, a lease agreement must be attached (you may use lease form LG224, available from the Board). However, no lease is required if the only gambling activity to be conducted is a raffle. Check the box(es) which indicate(s) the type of gambling activity your organization will be conducting for this one -day off -site activity. 0 Bingo ❑ Paddlewheels 0 Pull -Tabs III Raffles ❑Tipboards NOTE- You may only conduct activity authorized by the Gass of your organization license. Date of one -day off-site activity: r-i / / 9 g If you are conducting a raffle, enter the date of the raffle drawing- The gambling activity conducted on this day may not exceed 12 hours. Local Unit of Government Acknowledgment Ifthe•gambiingipremisemi wiihimcitydli- mrtshthatuty -must•siggtmthisapplicattor=: On behalf of the city, I acknowledge that this application will be forwarded to the appropriate city officials, the city must pass a resolution specifically approving' or denying this application, and a copy of the resolution will be forwarded to the applying organization. Printna • - •f city TT1_. hs wit (Si. atureofcity personnel receiving application) Title (MU51U "47 Wte f771 1 5qC ifttislambling ;premises;islocated.itia; township„ bottrtimcotmtyIZtowrtshi {rmiisCsigrcthisapplicatibn°^ For the township" On behalf of the township, I acknowledge that the organization is applying for one -day, off-site gambling activity within the township limits. A township has no statutory authority to approve or deny an application (Minn. Stat. sec. 349.213, subd. 2). Print name of township (Signature of township official acknowledging application) Title Date / For the county. On behalf of the county, I acknowledge that this application will be forwarded to the appropriate county officials, the county must pass a resolution specifically approving or denying this application, and a copy of the resolution will be forwarded to the applying organization. Print name of county (Signature of county personnel receiving application) Title Date / Chief Executive Officer (CEO) Oath I have read this application, and all information is true, accurate, and complete. CEO S; nature Submit this application at least 30 days prior to the date your scheduled activity. Attach the resolution of approval from the local unit of government and a copy of the lease agreement, if required. Mail to: Gambling Control Board Suite 300 South 1711 West County Road 8 Roseville, MN 55113 Date 7 / 7 / !b' Questions on this form should be directed to yourlicensing specialis at the Board at (612) 639-4000. Hearing impaired individuals using a TTY may call the Minnesota Relay Service at 1-800-627-3529 and ask to place a call to (612)639-4000. This publication will be made available - in alternative format (Le. large print, Braille) upon request. The information requested on this farm will become public information when received by the Board, and will be used to determine your compliance with Minnesota statutes and rules governing lawful gambling activities. 11/97 Page 7