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Pr^'; ":`T+\ Charitable Gambling Control Board (. �,•� Rm N -475 Griggs- Midway Bldg. ii'7 •.'� .":! 1821 University Ave. r St. Paul, MN 55104-3383 (612) 642 -0555 GAMBLING LICENSE RENEWAL APPLICATION For Board Use Only Paid Amt: Check No. Date: LICENSE NUMBER: 8-11393 -113 / EFF. DATE: 15114188 / AMOUNT OF FEE: 1. Applicant -Legal Name of Organization SERVANTS Of NARY 2. Street Address 2941 Rice St 3. City, State, Zip St Paul, NN 55113 4. County Ramsey 5. Business Phone (612 ) 483 -1213 6. Name of Chief Executive Officer Celeste Houle 7. Business Phone (612 ) 738 -2331 8, Name of Treasurer or Person Who Accounts for Revenues Donna Bauman 9. Business Phone xis3 - ( 612 ),324-491S / a 03 10. Name of Gambling Manager Jan Sherman 11. Bond Number 2115866 12. Business Phone (co /a)k83 - /<aG3 13. Name of Establishment Where Gambling Will Take Place Bradys St Paul 14. County Ramsey 15. No. of Active Members 31 16. Lessor Name James Tolgren 17. Monthly Rent: $44)44 500. °= 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: 0 Revoked Date: 0 Suspended Date: 20. Have internal controls been submitted previously? E " es 21. Has current lease been filed with the board? GAes 22. Has current sketch been filed with the board? Cd'ces 0 Denied Date: ❑ No (If "No," attach copy) O No (If "No," attach copy) ❑ 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. 1 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 Servanfis of Mary 4-nc. Signature (Chief Executive Officer) Date Title C ACKNOWLEDGEMENT OF NOTICE BY LOCAL GOVERNING BODY I hereby acknowledge receipt of a copy of this app ication. By acknowledging receipt, I admit having been serve with notice that this application will be reviewed by the Charitable Gambling Control Board and if approved by the Board, will become effecti says from the date of receipt (noted below), unless a resolution of the local governing ody is passed which specifically disallows such activity an a copy of that resolution is received by the Charitable Gambling Control Board withi 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 3ay period) Ale Date Received (this date begin�o u Cler - 1/20/89 6.0 Title: f 4.}son plication Local Governing Body: ,l.G,or/ 1� -' 2 - rt%LLGAc. -4 Township Name CG-00022-01 (5/87) White Copy -Board Canary- Applicant Pink -Local Governing Body PAGE -2-