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Gambling License Application Type of Application: IXClass A ❑Class B ❑Class C L ]Class D Page 2 WYesL IN° 23. Is gambling premises located within city limits? [Yes t,No 24. Are all gambling activities conducted at the premises listed in //19 of this application? If not, complete a separate application for each premises (except raffles) as a separate license is required for each premises. . Yes iXNo 25. Does organization own the gambling premises? If no, attach copy of the lease with terms of at least one year. ClYes No 26. Does the organization lease the entire premises? If no, attach a sketch of 27. Amount of Monthly Rent the premises indicating what portion is being leased. A lease and sketch Ls_ not required for Class D applications. 1, 630.95 XYesLINo 28. Do you plan on conducting bingo with this license? If yes, give days and times of bingo occasions: Days Times Saturday 9.15 - 11•QQ Sunday 9:15 -11:00 7.15 - 9•QO DO Yes No 29. Has the S 10,000 fidelity bond required by Minnesota Statutes 349.20 been obtained? Attach copy of bond. 30. Insurance Company Name State Surety Co, 31, Boi d Number 273610 32. Lessor Name Movers Warehouse, Inc. 33. Address 2233 N. Hamline Ave. #220 34. City, State,Zip St. Paul, MN 55113 35. Gambling Manager Name Lois Blomberg 36. Address 132 Demont Ave, E. #341 44..Na 2e,6f Pern.delivezfeig,applicatioryryfo Local Governing Body 37. City, State, Zip Little Ca nada, MN 551 Gambling Manager Business Phone @12 ) 484 -2659 39. Da member e gambling manager became of organization: L..- _ m GAMBLING SITE AUTHORIZATION By my signature below, local law enforcement officers or agents of the Board are hereby authorized to enter upon the site, at any time, gambling is being conducted, to observe the gambling and to enforce the law for any unauthorized game or practice. BANK RECORDS AUTHORIZATION By my signature below, the Board is hereby authorized to inspect the bank records of the General Gambling Bank Account whenever necessary to fulfill requirements of current gambling rules and law. OATH I hereby declare that: 1. I have read this application and all information submitted to the Board; 2. All information submitted is true, accurate and complete; 3. All other required information has been fully disclosed 4. I am the chief executive officer of the organization; 5. I assume full responsibility for the fair and lawful operation of all activities to be conducted; 6. I will familiarize myself with the laws of the State of Minnesota respecting gambling and rules of the Board and agree, if licensed, to abide by those laws and rules, including amendments thereto. ' 40. Official, Legal Name of Organization 41. Signature' /usf be signed by Chief xecutive icer) St. Joseph's So iety for Charity, Inc. Titlf. �ijner Date ACKWOWLEDGEMENT OF NOTICE BY LOCAL GOVERNING BODY I hereby acknowledge receipt Kf a copy of this application. By acknowledging receipt, I admit having been served with notice that this application will be reviewed by the Charitable Gambling Control Board and if approved by the board, will become effective 30 days from the date of receipt (noted below), unless a resolution of the local governing body is passed which specifically disallows such activity and a copy of that resolution is received by the Charitable Gambling Control Board within 30 days of the below noted date. 6 /17 42. Name of City or County (Local Governing Body) City of Little Canada If site is located within a township, item 43 must be completed, in addition to the county signature. Signature of person receiving application X 43. Name of Township Title Date received (30 day period begins from this date) Signature of person receiving application X 44..Na 2e,6f Pern.delivezfeig,applicatioryryfo Local Governing Body Title CG- 0001 -02 (8/86) White copy-Board Page 15 Canary - Applicant Pink-Local Governing Body 7