11-09-1988 Council Agenda - Laserfiche WebLink

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Gambling License Application Type of Application: ❑ Class A %Class B ❑ Class C ❑ Class D Yes ONo 22. Is gambling premises located within city limits? Yes ONo 23. Are all gambling activities conducted at the premises listed in #18 of this application? If not, complete a separate application for each premises (except raffles) as a separate license is required for each premises. OYes No 24. Does organization own the gambling premises? If no, attach copy of the lease with terms of at least one year, and attach a sketch of the premises indicating what portion is being leased. A lease and sketch -are not required for Class D applications. 25. Amount of Rent Per Month or Bingo Occasion S 26. Do you plan on conducting bingo with this license? If yes, give days and times of bingo;occasions. Day Time Day Time Day; y `� 'FF,--O! Time 'es ONo 27. Has the S10,000 fidelity bond required by Minnesota Statutes 349.20 been obtained?‘ CKY ` adz. 28. Insurance Company Name (not agency name) 29. Bond Number \.:, " \, 30. Les or Nam .� 1 enemy `L HK 3 1 . Address C lq Rice Ji ree7L 32. Ci Stet�ip - 4i% e srirr /7-, • 33. Gambling Manager Name ^�- T A, $nc y r `/ r-, 34. Addr ss ,,�� //�� ?OX left f2q e 6 rf 'art 3c iD ity, State, Z/ii�p' //,�/ /i/� (/4cdat,, // lili�' / I, 36. Gambling Manager business Phone ( oo /Z 1 ��to - �'�3 G 37. Date member ✓✓ gambling manarj¢r became / / of organization: Month Year Feb r,:tar y `/ OYes ONo 38. Has the license termination form been completed? Attach copy. OYes ONo 39. Has the compensation schedule been approved by the organization? Attach copy. 40. List the day and time of the regular meeting of the organization. Day y 3rr/ T fwr d ime _ 41. Bank Name p [, °Sett/ge C. it /\ 42. Bank Address 43. Bank Account Number ../00 /`t0 .>re /inti- �173s Ro5ev %l /N / /,r 537/ 3 7 77 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 gambling bank account whenever necessary to fulfill requirements of current gambling rules and law. I hereby declare that: OATH 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 ga • -ling and rules of the Board and agree, if licensed, to abide by those laws and rules, including amendments thereto; 7. Membershi• list of the organization will be available within seven da s: ter it is ru_uested b t e •oar.. 44. Office I, Le•.I Name of Organization IMAM 466 err 41._ WrIe •r q e5e 5 f4 ,oa5 Title of Signer Date PPC SrQ ' 11 p /0 3G O ACKNOWLEDGEMENT OF NOTICE BY LOCAL GOVERNING BODY thereby 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 60 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 60 days of the below noted date. 46. Name of City or County (Local Governing Body) I If site is located within a township, item 47 must be completed, in Signature of person receiving application 4 47. Name of Township T' D Date ceived (60 day period S Signature of person receiving application 48. Name of person delivering application to Local Governing Body T Title ,.r- CG- 0001 -03 (8/88) White Copy -Board PAGE -2- Canary - Applicant Pink -Local Governing Body