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Gambling License Application Page 2 Type of Application: PQQClass A 11Class 8 1.1Class C I ICIass D -NYes No 23. Is gambling premises located within city limits? (NYe&L IN° 24. El Yes INNo 25. LYestTJNo 26. Are all gambling activities conducted at the premises listed in 1/19 of this application? If not, complete a separate application for each premises (except raffles) as a separate license is required for each premises. Does organization own the gambling premises? If no, attach copy of the lease with terms of at least one year. g premises? $ /-) J7 Rent r Does the organization lease the entire remises. If rto, attach a sketch of 27. Amount of Monthly the premises indicating what portion is being leased. A lease and sketch S 7 /?p It m E:NT is not required for Class D applications. LXYesCINo 28. Do you plan on conducting bingo with this license? If yes, give days and times of bingo occasions: Days Times Thursday 7:15 & 9:15 p.m. Saturday 1:00 & 3:00.m. LLYes ❑No 29. Has the $ 10,000 fidelity bond required by Minnesota Statutes 349.20 been obtained? Attach copy of bond. 30. Insurance Company Name 31. Bond Number St. Paul Fire & Marine 6631E6045 32. Lessor Name Little Canada Charity Bingo 35. Gambling Manager Name Joan Kosrnalski 38. Gambling Manager Business Phone 612 ) 645 -PETS 33. Address 2940 Rice St. 34. City, State,Zip Little Canada, Mn. 55113 36. Address 1115 Beulah Lane 37. City, State, Zip St. Paul, Mn. 55108 39. Date gambling manager became member of organization: C 1972 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, includin amendments thereto. } 40. Official, Legal Name of Organization 4„1,_ Signature (must i ned'by`C ief E e� tiv Officer) 14ar .,. ' Humane Society of Ramsey County x . _ r-'11 -,G_ ?/-t;:- _ .5 Title of Signer Date Executive Director 5_5_87 ACKNOWLEDGEMENT OF NOTICE BY LOCAL GOVERNING BODY I hereby acknowledge receipt of 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. 42. Name of City or County (Local Governing Body) If site is located within a township, item 43 must be completed, in addition to the county signature. Signature of person receiving application 43. Name of Township X Title Date received (30 day period Signature of person receiving application begins from this date) 44. Name of Person delivering application to Local Governing Body CG- 0001.02 18/861 White Copy -Board X Title Page 18 Canary - /applicant Pink - Local Governing Body