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Minnesota Charitable Gambling Control Board <br />900 Summit State Bank Building <br />310 4th Avenue South <br />Minneapolis, MN 55415 <br />(612) 341 -7676 <br />FOR BOARD USE ONLY <br />GAMBLING LICENSE APPLICATION <br />(Class A, B, or C) <br />INSTRUCTIONS: 1. PRINT OR TYPE. <br />2. Bring completed application to local governing body, obtain signature and date on all copies, <br />and leave goldenrod copy. Applicant keeps pink copy and sends remaining copies to above <br />address. <br />3. Changes in application information must be submitted within 10 days after the change. <br />Type of Application: <br />❑ Class A - Fee $100.00 (Bingo, Raffles, Paddlewheels, Tipboards, Pull -Tabs) <br />)❑X Class B - Fee $ 50.00 (Raffles, Paddlewheels, Tipboards, Pull -Tabs) <br />❑ Class C - Fee $ 50.00 (Bingo only) <br />Make checks payable to: Minnesota Charitable Gambling Control Board. <br />Applicant (Official, legal name of organization) <br />St. Joseph's Society for the Little Sisters <br />Business Address of the Poor <br />132 Detnont Avenue E. 1041 <br />City, State, Zip <br />St. Paul, MN 55117 <br />County <br />Ramsey <br />Business Telephone Number <br />(612 ) 484 -2659 <br />Federal I.D. Number <br />41- 1388606 <br />Type of Organization <br />0 Faternal ❑ Veterans <br />® Religious ❑ Other Nonprofit Organization <br />Type of Organization Charter <br />❑ International ❑ National ® State <br />Number of Years in - <br />Existence (in Minnesota) <br />34 <br />Number of Articles of . <br />Incorporation (if incorporated) <br />2111213 / 396302 <br />location Where Articles are Filed <br />Ramsey County <br />Yes <br />No <br />x <br />1. Does organization have a dues structure? <br />If yes, number of active members <br />X <br />Gambling Manager Name <br />Jan Sherman <br />2. Has organization been previously licensed <br />by the Board? If yes, give date 3 -18-85 <br />City, State, Zip <br />St. Paul, MN 55117 <br />X <br />3. Has license ever been denied, suspended <br />or revoked? yes check all that apply: <br />�Iyf <br />',Denied Suspended Il Revoked <br />° <br />X <br />4. Is organization exempt from payment of <br />U.S. income tax? If yes, attach copy of <br />letter declaring exemption. On file <br />X <br />5. Is organization tax exempt from payment <br />of Minnesota tax? If yes, attach copy of <br />letter declaring exemption. <br />Site Address <br />201 E. Little Canada Road <br />City, State, Zip <br />St. Paul, MN 55117 <br />County <br />Ramsey <br />Yes <br />X <br />No <br />1. Are all gambling activities conducted at <br />the above site? If no, complete a sepa- <br />rate application form for each site as a <br />separate license is issued for each site. <br />Patricia Pillsbury, Treasurer <br />X <br />2. Is site located within city /town limits? <br />X <br />3. Does organization own the site where <br />gambling activity will be conducted? If <br />no, attach copy of the lease for the <br />site. <br />Lessor Name (if lease or rent) <br />CORDIE S PLACE <br />Address <br />201 E. Little Canada Road <br />City, State, Zip <br />St. Paul, MN 55117 <br />Gambling Manager Name <br />Jan Sherman <br />Address <br />2442 North Rice Street 11152 <br />City, State, Zip <br />St. Paul, MN 55117 <br />The $10,000 fidelity bond required by Minnesota <br />Statutes 349.09 has been obtained. <br />Company Name Bond Number <br />Alexander & Alexander 8645389 <br />CG- 00007 -01 (12/84) <br />001 <br />Continued on Page 2 <br />Name of Organization's Officers and Tltien <br />a. <br />Lois Blomberg, Chief Exec. <br />Officer <br />c. <br />Patricia Pillsbury, Treasurer <br />b. <br />Jan Sherman, President <br />d. <br />Ruth Hendrickson, Secretary <br />CG- 00007 -01 (12/84) <br />001 <br />Continued on Page 2 <br />