09-09-1987 Council Agenda - Laserfiche WebLink

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Minnesota Charitable Gambling Control Board Room N475 Griggs- Midway Building 1821 University Avenue St. Paul, MN 55104 -3383 (612) 642 -0555 LAWFUL GAMBLING EXEMPTION FOR BOARD USE ONLY INSTRUCTIONS: 1. Submit request for exemption at least 30 days prior to the occasion. 2. When completing form, do not complete shaded areas. 3. Give the gold copy to the City or County. Send the remaining copies to the Board. The copies will be returned with an exemption number added to the form. When your activity is concluded; complete the financial information, sign and date the form, and return to the Board within 30 days. ?LEASE TYPE Organization Name Suburban Area Liitle Canada ad .i _•hts Ch -mb- o C.mmerc- Div.Chamb- .f Cate- license it currently or pre wustylicenuel - Address 2489 Rice Street City, County, Roseville. State, Zip Code Ramsey MN 55113 Manager's Name Tim Block Phone Number 483 -L313 Chief Executive Officer's Name Eugene R. Strommen Phone Number 483 -1313 Type of Organization If Other Nonprofit Organization ICheck One) O IRS Designation El Incorporated with Secretary of State 0 Affiliate of Parent Nonprofit Organization ❑ Fraternal • Veterans ❑ Religion Other Nonprofit Organization Name of Premises Where Activity Will Occur The Venetian Inn Premises Address 2814 Rice Street, Little Canada, MN 55113 Datelsl of Activity Sunday. October 18, 1987 Profit Games Yes No Gross Receipts Value of Prizes Expenses Bingo X Raffles X Paddlewheels Tipboards X Pull -Tabs Use of Profit X X Distributor From Whom Gambling Equipment Acquired Distributor's License No I affirm all information submitted to the Board is true, accu rate, and complete. Chief Exe(ykive Officer Signature ¢=5771110^�) 9 -1 -87 I affirm all financial information submitted to the Board is true, accurate, and complete. Date Chief Executive Officer Signature Date ACKNOWLEDGMENT 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 will become effective 30 days from the date of receipt (noted below) by the City or County, unless a resolution of the local governing body is passed which specifi- cally 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. CITY OR COUNTY TOWNSHIP Name of Local Governing Body (City or County) City of Little Canada Township Name (Must be notified when County is the approving body) Sgnnaa- t�u�re�of Person Receiving App anon ✓Tile 7/ Clerk — Treasurer Joseph G. Chlebecf' Date Received 9 -1 -87 Signature of Person Receiving Application Title Date C3- 00020.01 14/861 White — Board Canary — Board returns to Organization to keep Pink — Organization Gold — City or County Page 1