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Gambling License Application Type of Application: ;XClass A EClass B ❑Class C :_Class 0 Page 2 X,Yes. :No 23. Is gambling premises located within city limits) :Yes.=No 24. Are all gambling activities conducted at the premises listed in 4'19 of this application? If not, complete a separate application for each premises (except raffles) as a separate Iicense is required for each premises. LYes iNo XXYes ":No 26. Does the organization lease the entire premises? If no, attach a sketch of the premises indicating what portion is being leased. A lease and sketch is not required for Class D applications. 25. Does organization own the gambling premises? If no. attach copy.of the lease with terms of at least one year. 27. Amount of Monthly Rent $ ..iYes ENo 28. Do you plan on conducting bingo with this license? If yes, give days and times of bingo occasions: Days Times Saturday Night 7:15 and 9:15 p.m. iCYesENo 29. Has the $ 10,000 fidelity bond required by Minnesota Statutes 349.20 been obtained? Attach copy of bond. 30. Insurance Company Name Jnited Fire and Casualty Cartoany 31. Bond Number 51- 061577 32. Lessor Name Movers Warehouse, Inc. 33. Address Suite 2233 N. Hamlin Ave., 220 34. City,State,Zip 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 e gambling manager became member of organization: • October, 1976 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. !d ��yyy 40. Official, Legal Name of OrganizationNorth SD1JUrb2S1 41.�ign: u5'"l ief Executive Officer) Developmental Achievement Center, Inc. X Title of Signer Date Executive Director June 10, 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) If site is located within a township, item 43 must be completed, in addition to the county signature. City of Little Canada Signature of person receiving application X G( —C Ti Clerk— Treasurer Date received (30 day period begins from this date) 6/ 10/87 43. Name of Township Signature of person receiving application X 44. Name of Person delivering application to Local Governing Bocy Title CG•0001 -02 t8.86) White Copy-Board Canary.APPlicant Pink-Local Governing Body