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Charitable Gambling Control Board Rm N -475 Griggs - Midway Bldg. 1821 University Ave. St. Paul, MN 55104 -3383 (612) 642 -0555 GAMBLING LICENSE RENEWAL APPLICATION For Board Use Only Paid Amt: Check No Date' LICENSE NUMBER: 8 -00465 -002 / EFF. DATE: 04/01/87 / AMOUNT OF FEE: $50.00 1. Applicant -Legal Name of Organization ST JOSEPHS SOCIETY FOR THE LITTLE SISTERS OF THE POOR 2. Street Address 132 Dement Ave E Rot 341 3. City, State. Zip St Paul, M4 55117 4. County Ramsey 5. Business Phone4/3 -a, ( 612) 484 -2659 6. Name of Chief Executive Officer Patricia Pillsbury 7. Business Phone (o, /. )4Lf3 - /-,7 o1/45 8. Name of Treasurer of...peirson Who Accounts for Revenues l e-1 ra- F/f) f(': / (' r 9. Business Phone (e /2) 4< /3 -7,z z:),.. 10. Name of Gambling Manager Lois Blomberg 11. Bond Number 273610 12. Business Phone (6/ 2) 4 P:9- (-W.3 13. Name of Establishment Where Gambling Will Take Place Venetian Inn Little Canada 14. County Ramsey* 15. No. of Active Members 27 16. Lessor Name 2814 Rice St Venetian Inn 17. Monthly Rent: $600 18. If Bingo will be conducted with this license, please specify days and times of Bingo. Days Times Days Times Days Times 19. Has license ever been: ❑ Revoked Dater ❑ Suspended Date: 20. Have internal controls been submitted previously? 21. Has current lease been filed with the board? 22. Has current sketch been filed with the board? AD ❑ Denied Date- L F" Yes 0 No (If "No," attach copy) ❑--//Yes VNo (If "No," attach copy) frees ❑ No (If "No," attach copy) 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. 23. Official Legal Name of Organization ST. JOSEPH'S SOCIETY FOP CH-APITY, INS Signet e (Chief Executiv Officer) Date i Title . CO , ACKNOWLEDGEMENT OF NOTICE BY LOCAL GOVERNING BODY I hereby acknowledge receipt of a copy of this app ication. By acknowledging receipt, 1 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. 24. City /County Name (Local Governing Body) City of Little Canada Township: If site is located within a township, please complete items 24 and 25: Signature of Person Receiving Application: 25. Signature of Person Receiving Application T' r l Date Received (this date begins 30 day period) C1.erk 2/10/88 Title: Nada_ 1 drson Dehveri1i(g��Applicatiorn/ },5moo Local Governing Body: `. 6./ ( er- rn l,- $l4"- C7, - -\ Township Name CG- 00022 -01 (5/87) page -6- White Copy -Board Canary - Applicant Pink -Local Governing Body