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Gambling License Application Type of Application: IXClass A ❑Class B OCIass C OCIass D Page 2 IXYes ONo 23. Is gambling premises located within city limits? EXYes G No 24. Are all gambling activities conducted at the premises listed in P19 of this application? If not, complete a separate application for each premises (except raffles) as a separate license is required for each premises. OYes EkNo 25. Does organization own the gambling premises? If no, attach copy of the lease with terms of at least one year. LXYes ENo 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 is not required for Class D applications. $ 2,816.54 I$YesON° 28. Do you plan on conducting bingo with this license? If yes, give days and times of bingo occasions: oay0ne day per week 7:15 antdt:15 p.m. EXYes ONo 29. Has the S10,000 fidelity bond required by Minnesota Statutes 349.20 been obtained? Attach copy of bond. 30. Insurance Company Name United Fire and Casualty Company 31. Bond Number 51- 061577 43. Name of Township 32. Lessor Name Movers Warehouse, Inc. Signature of person receiving application x 33. Address Suite 2233 N. Hamline Ave. 220 34. City, State,Zip i St. Paul, MN 55113 35. Gambling Manager Name Mary Wegwart 36. Address 891 Cobb Road 37. City, State, Zip St, Paul, MN 55126 38. Gambling Manager Business Phone ( 612 ) 484 -7000 39. Da member e gambling manager became of organization: Ortohpr, 197 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 Minne . . -sp-cting •arnbl' and rules of the :oard and agree, if licensed, to abide b those laws and rules, includin• a endme • •'th•retr. _ 40. Official, Legal Name of Organization North �' i Exec tive Officer) Suburban Developmental Achievement Ctr.Inc, �'��i Title of Signer Fven,ttive Director D. e June 24, 1987 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) 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 City Clerk Date received 130 day period begins fi / 94h)s date) Signature of person receiving application x 44. Name of Person delivering application to Local Governing Body Title CG-0001-02 18186) White Copy-Board r Canary-Applicant Pink -Local Governing Body