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<br />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 />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. Psal Midway Lions Club, Inc.
<br />Business Address c/o L. L. Ewy
<br />3050 SandyHook Drive '
<br />City, State, Zip ,..
<br />St. Paul, MN 55113
<br />County
<br />Ramsey
<br />Business Telephone Number
<br />(12 )484 -4379
<br />Federal I.D. Number ,.
<br />41- 6038017E
<br />type of Organization
<br />❑ Faternal ❑ Veterans
<br />❑ Religious ❑ Other Nonprofit Organization
<br />Type of Organization Charter - 1,)
<br />❑ .International ❑ National . ❑ State
<br />Number of Years in
<br />Existence (in Minnesota)
<br />April 10,1978
<br />Number of Articles of
<br />Incorporation (if 'incorporated)
<br />F 48 pg 152 ' ;`
<br />Locat'on Where Articles are Filed
<br />Secretasy of State -State of Minnesota
<br />Yes
<br />X
<br />No
<br />1. Does organization have a dues structure?
<br />If yea, number of active members 11F
<br />City, State, Zip'. , .! / ;. �,
<br />Little Canada 55113
<br />X
<br />2. Has organization been previously.
<br />by the Board? If yea, give date '
<br />City, State, Zip.:.
<br />St. Pauli , MN 55104
<br />-`X
<br />3. Has license ever been denied, suspended:
<br />or revoked? If yea check all that apply':
<br />❑Denied ❑Suspended ❑Revoked `-
<br />X
<br />4. Is organization exempt from payment of.
<br />U.S. income tax ? If yes, attach copy of
<br />letter declaring exemption.'
<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 />4 + "- "-
<br />281. is r t .
<br />City, state, zip- :Li.ftle. Canada
<br />... . mi loX
<br />County'
<br />Ramsey
<br />Yes
<br />Xa
<br />No
<br />,6
<br />/( '
<br />1
<br />1. Are all gambling activities conducted at
<br />2 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 />Ellsworth L. Ewv - Secty.;7reas.
<br />2. Is site located within city /town limits?
<br />X
<br />3. Does organization own the site where
<br />gambling activitywill"be conducted ?' If
<br />' no, attach copy of the lease for the
<br />site.
<br />Lessor Name /if lease or rent)
<br />. VFNFTTAN TNN `
<br />Address
<br />2814 Rice Street
<br />City, State, Zip'. , .! / ;. �,
<br />Little Canada 55113
<br />Gam6 ng Manager. Name
<br />Gregory: Kne {sl' '1
<br />Address
<br />1789 Selby Avenue
<br />City, State, Zip.:.
<br />St. Pauli , MN 55104
<br />The $10,000 fidelity bond required by Minnesota
<br />Statut4 349.09 has been obtained.
<br />" Company Name ix,' • Bond Number
<br />St. Farm Ins. 1). 93 -11 -7544
<br />Name of Organization's Officers and Titles
<br />a. Thomas Farrell - Oresident
<br />c.
<br />Eugene Arnal2nd Vice President
<br />b. Richard Kedrowski - 1st Vice President
<br />d.
<br />Ellsworth L. Ewv - Secty.;7reas.
<br />CC- 00001 -01 (12/84)
<br />Continued on Page 2
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