|
Department of Revenue - Gaming Division
<br />Mail Station 3315
<br />St. Paul, MN 55146 -3315
<br />(612) 297 -5300
<br />GAMBLING LICENSE RENEWAL APPLICATION
<br />For Board Use Only
<br />Paid Amt:
<br />Check No
<br />Date.
<br />LICENSE NUMBER:
<br />A -11174 -112
<br />/ EFF. DATE:
<br />11/11189
<br />/ AMOUNT OF FEE:
<br />1. Applicant -Legal Name of Organization
<br />LAKE OWASSO RESIDENCE VOLUNTEER COUNCIL X
<br />2. Street Address
<br />211 North Owasso Blvd
<br />3. City, State, Zip
<br />Shoreview, NM 55126
<br />4. County
<br />Ramsey
<br />5. Business Phone
<br />( 612) 484 -2234
<br />6. Name of Chief Executive Officer
<br />Janet Thul
<br />7. Business Phone FI-Of
<br />( 612) 3M- rr317. f.C4 -S,
<br />8. Name of Treasurer or Person Who Accounts for Revenues
<br />Joan Jenkins
<br />9. Business Phone
<br />( 612) 641-6834
<br />10. Name of Gambling Manager
<br />Betty Strohbeen
<br />11. Bond Number
<br />511667117
<br />12. Business Phone
<br />( 612) 483 -1213
<br />13. Name of Establishment Where Gambling Will Take Place
<br />little Canada Bingo Hall Little Canada
<br />14. County
<br />Ramsey
<br />15. No. of Active Members
<br />21
<br />16. Lessor Name
<br />Hovers Warehouse
<br />17. Monthly Rent:
<br />i qgd /YC9*A
<br />18, If Bir)go will be conducted with this license, please specify days and times of Bingo. .5 ae'L'a i S N-' A.4.0,
<br />N9�"�'Ill q Days 7:L5_Tt Days Days /q I0 Times,/ m P-
<br />t,�a�. boa � �r� Y 1990 Times 3coer,s:oA �.,� . yDa i
<br />ldartaa) K.9l6in -I/ :ot, ? .iolgo- 1:00- 9/BP4- loo- 7s- lte0Ir; ell /DiJvnm- Ieop,,, 9 :�P`,,,- /Pee
<br />R,slaid iday Foru)and e0 el, y 0NPh
<br />19. Has license ever been: ALTO ❑ Revoked Date: ❑ Suspended Date: ❑ Denied Date*
<br />20. Have internal controls been submitted previously? A Yes ❑ No (If "No," attach copy)
<br />21. Has current lease been tiled with the board? aYes ❑ No (If "No," attach copy)
<br />22. Has current sketch been filed with the board? f$ Yes ❑ No (If "No," attach copy)
<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, at any time, gambling is
<br />being conducted, to observe the gambling and to enforce the law for any unauthorized game or practice.
<br />BANK RECORDS AUTHORIZATION
<br />By my signature below, the Board is hereby authorized to inspect the bank records of the General Gambling Bank Account whenever necessary to
<br />fulfill requirements of current gambling rules and law.
<br />I 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, if licensed, to abide by those
<br />laws and rules, including amendments thereto.
<br />OATH
<br />23. Official Legal Name of OrganiA ation
<br />o, tee- Ow ,S ‘' 6 /C es ;demce
<br />Luhl ?Fen Pc lAn7C ;L
<br />Signature ( hief utive Officer) Date
<br />04-L• 3 -IS -9
<br />O
<br />a(j÷ oaat,LLAQ
<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 notice that this application will
<br />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
<br />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
<br />the Charitable Gambling Control Board within 60 days of the below noted date.
<br />24. City /County Name (Local Governing Body)
<br />Township: If site is located within a township, please complete items 24
<br />and 25:
<br />.
<br />nature of Person Receiving Application:
<br />c L t^. \ \)
<br />25. Signature of Person Receiving Application
<br />'
<br />,ice
<br />Till
<br />Date Received (this date begins 60 day period)
<br />4..,.- 7,.y4- ,. .,,4. /n, -c4 /,T', /990
<br />Title:
<br />of Person Delivering Applicatio7 Local Governing Body:
<br />6-(
<br />Township Name
<br />CG- 00022 -01 (4/89)
<br />White Copy -Board
<br />Page 46
<br />Canary- Applicant Pink -Local Governing Body
<br />
|