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Gambling License Application <br />Type of Application: ❑Class A PIClass B ❑Class C ❑Class D <br />Page 2 <br />OYes ]No 23. Is gambling premises located within city limits? <br />C3cYesDNo 24. Are all gambling activities conducted at the premises listed in #19 of this application? If not, complete a separate <br />application for each premises (except raffles) as a separate license is required for each premises. <br />OYeskiNo 25. Does organization own the gambling premises? If no, attach copy of the lease with terms of at least one year. <br />CXYes No 26. Does the organization lease the entire premises? If no, attach a sketch of 27. Amount of Monthly Rent <br />the premises indicating what portion is being leased. A lease and sketch <br />is not required for Class D applications. <br />$ 800.00 <br />OYesDNo 28. Do you plan on conducting bingo with this license? If yes, give days and times of bingo occasions: <br />Days Times <br />LIYes ONo 29. Has the S10,000 fidelity bond required by Minnesota Statutes 349.20 been obtained? Attach copy of bond. <br />30. Insurance Company Name <br />Fidelity Bond Company - United Fire & Casuality Co. <br />If site is located within a township, item 43 must be completed, in <br />addition to the county signature. <br />31. Bond Number <br />51 -56888 <br />43. Name of Township <br />32. Lessor Name <br />Jacobsen Memorial Aux. Unit 487 <br />Date received (30 day period <br />begins from this date) <br />August 3, 1987 <br />33. Address <br />423 Eli Road <br />44,/( Name of Person deliv r 'g b licatipn to Local Governing Body <br />7 /Q,7-o //0// A /Y1, ,,,' /.1 . <br />34. City, State,Zip <br />Little Canada, MN <br />5511' <br />35. Gambling Manager Name <br />Mrs. Pamela Darsow <br />36. Address <br />123 Canterbury Road <br />37. City, State, Zip <br />Circle Pines, MN <br />55014 <br />38. Gambling Manager Business Phone <br />( 612 ) 484 -2234 <br />39. <br />Da <br />member <br />e gambling manager became <br />of organization: <br />August 1978 <br />GAMBLING SITE AUTHORIZATION <br />By my signature below, local law enforcement officers or agents of the Board are hereby authorized to enter upon the site, <br />at any time, gambling is being conducted, to observe the gambling and to enforce the law for any unauthorized game or <br />practice. <br />BANK RECORDS AUTHORIZATION <br />By my signature below, the Board is hereby authorized to inspect the bank records of the General Gambling Bank Account <br />whenever necessary to fulfill requirements of current gambling rules and law. <br />OATH <br />I hereby declare that: <br />1. I have read this application and all information submitted to the Board; <br />2. All information submitted is true, accurate and complete; <br />3. All other required information has been fully disclosed <br />4. I am the chief executive officer of the organization; <br />5. I assume full responsibility for the fair and lawful operation of all activities to be conducted; <br />6. I will familiarize myself with the laws of the State of Minnesota respecting gambling and rules of the Board and agree, <br />if licensed, to abide by those laws and rules, including amendmen s thereto. <br />40. Official, Legal Name of Organization 41. Si 'ture (must 'e signed Chie E ecutive Officer) <br />Jacobsen Memorial Auxiliary Unit 487 X C0. %" . , . // L <br />Title of Signer Date <br />President of Unit <br />ACKNOWLEDGEMENT OF NOTICE BY LOCAL GOVERNING BODY <br />I hereby acknowledge receipt of a copy of this application. By acknowledging receipt, I admit having been served with <br />notice that this application will be reviewed by the Charitable Gambling Control Board and if approved by the board, will <br />become effective 30 days from the date of receipt (noted below), unless a resolution of the local governing body is passed <br />which specifically disallows such activity and a copy of that resolution is received by the Charitable Gambling Control <br />Board within 30 days of the below noted date. <br />42. Name of City or County (Local Governing Body) <br />If site is located within a township, item 43 must be completed, in <br />addition to the county signature. <br />Signature of person receiving app li ation <br />X <br />43. Name of Township <br />le <br />Cl e k /Treasurer <br />Date received (30 day period <br />begins from this date) <br />August 3, 1987 <br />Signature of person receiving application <br />X /� <br />44,/( Name of Person deliv r 'g b licatipn to Local Governing Body <br />7 /Q,7-o //0// A /Y1, ,,,' /.1 . <br />Title' A1-8-4'_. <br />7_. <br />CG- 0001 -02 (8186) <br />White Copy -Board Page 21 Canary - Applicant <br />Pin Local Governing Body <br />