06-10-1987 Council Agenda - Laserfiche WebLink

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Gambling License Application Type of Application: ; :Class A L ;Class B ❑Class C ]Class D Page 2 NYes liNo 23. Is gambling premises located within city limits? XYes!._1No 24. 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. f /Yes LAVo 25. Does organization own the gambling premises? If no, attach copy of the lease with terms of at least one year. [Wes 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. J )<Yes LINO 28. Do you plan on conducting bingo with this license? If yes, give days and times of bingo occasions: Day Times �1 /114 : 7 " / - roe ��, `/ i5 / /,'d & F� / • 7 /c r.- q-0457 s- // )o/3,•.31 X'Yes [ !No 29. Has the S10,000 fidelity bond required by Minnesota Statutes 349.20 been obtained? Attach copy of bond 30. Insurance Company Name S t-c 5q rte± Co. 33. Address - �?szv R1cc_ St 31. Bond Number �G� 11 r 34. City, State Zip ti/ ��t11e- Ccr /4aJ, 37. Cit fate, Zip 0 _ .5 i.e. C?L /p/�/4SJ 32. Lessor Name i"Overs LDc re_ GI n�f.5ec 35. Gambling a a`,fer Name 36. Address _ �i�</2 P!GC /312. `1cj!Ig )fi r CI 38. Gambling Manager Business Phone (& /a I i / /3- /`Rs/ 39. Da member e gambling manager became of organization: / - 7ci 1 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 Narne of Organization) 41. - Signature Imust be si nod by Chief Executive Officer) eroc m- s o-f /t /kel°y - -I-11C • x� ,C�z.Er /��. L.. : (0. Date Title of Signer 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 43. Name of Township Clerk /Treasurer Date received (30 day period Signature of person receiving application begins from this date) 6 -4 -87 44. Name of Person delivering application to Local Governing Body CG 0001 -02 18/861 White Copy-Board x it1e Page 13 Canary- AppliuL Pink -Local Governing Body