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Gambling License Application
<br />Type of Application: OCIass A 16ICIass B OClass C OClass D
<br />Page 2
<br />LAYes ONo 23. Is gambling premises located within city limits?
<br />6(Yes0No 24. Are all gambling activities conducted at the premises listed in 4119 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 />OYesNNo 25. Does organization own the gambling premises? If no, attach copy of the lease with terms of at least one year.
<br />Oyes XNo 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 . S MOW t
<br />is not required for Class D applications.
<br />OYesNo 28. Do you plan on conducting bingo with this license? If yes, give days and times of bingo occasions:
<br />Days Times
<br />uired by M
<br />nnesota Statutes 349.20 been obtained? Attach copy of bond.
<br />y.; ,c, L,,.., .,. , ,,, .. .. _
<br />30. Insurance "C�ompan- Name /'7
<br />0 1 a t`C p,,..bl l.. tvs Ct,,.•1n cc l_O •
<br />31. Bond Number
<br />S�, .S. 36933
<br />32. Lessor Name I
<br />1 fiL 3
<br />I�< �tUjytisrtil 1/
<br />33. Address
<br />S
<br />aSO4 N, l�rtG. ��.
<br />34. Cit State,Zip
<br />L,tfl� 3
<br />�,.s.,ii �I'�I,n, ��f)
<br />35. Gambling Manager Name
<br />13 m]"�soti.
<br />36. Address
<br />J-fntt L7-cIIWeoc�
<br />37. City, I State, Zip
<br />Res. ,11,. Mr. S S H3
<br />38. Gambling Manager Business Phone
<br />1iiI1 1 C33-6I56
<br />39. Date
<br />member
<br />gambling manager became
<br />of organization: 1 ci 3
<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. 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 />1 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 amendments thereto.
<br />40. Official, Legal Name of rga,rnrizatiiR n 41. S�'�� /r}t�t ( u t be,sig Chief Executive Officer)
<br />N „It. SWWKrb1v. y0•ji-, Act v, , %t IV L�
<br />Date
<br />Title of Signer ,
<br />Ex L-.1t.•cc701-
<br />(0 -19 8-7
<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) If site is located within a township, item 43 must be completed, in
<br />addition to the county signature.
<br />City of Little Canada
<br />Signature of person receiving applica •n
<br />X
<br />43. Name of Township
<br />T
<br />- Date received (30 day period
<br />Clerk- Treasurer begins from this date)
<br />I0-20--87
<br />44. Name of Person delivering application to Local Governing Body
<br />Signature of person receiving application
<br />X
<br />Title
<br />CG- 0001 -02 18/861
<br />White Copy-Board Page 83
<br />Canary - Applicant Pink -Local Governing Body
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