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Gambling License Application
<br />Type of Application: ~j~Class A [] Class B []Class C
<br />
<br />[] Class D
<br />
<br />"T' [~Yes I-I No
<br />
<br />22. Is gambling premises located within city limits?
<br />
<br />[]]Yes [] No
<br />
<br />23. Are all gambling activities conducted at the premises listed in//18 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 />
<br />Yes [~No
<br />
<br />24. Does organization own the gambling premises? If no, attach copy of the lease with terms of at least one year, and
<br /> attach a sketch of the premises indicating what portion is being leased. A lease and sketch are not required for
<br />Class D applications.
<br />
<br />25. Amount of Rent Per 26.
<br /> Month o~,B~;ID~2]~'~i~ I
<br />
<br /> 600,00
<br />
<br />Do you plan on conducting bingo with this license? If yes, give days and times of bingo occasions.
<br /> Day Time Day Time Day Time
<br />~.,?L (_'!Jl_:J~_~_k~T:"_' 'f':,Q ~(-~'_P I~VF AWY PT.~,N,c T() CONTW~Ct'I
<br />
<br />~,Yes DNo 27. Has the $10,000 fidelity bond required by Minnesota Statutes 349.20 been obtained?
<br />
<br />28. Insurance Co,m, pany Name (not agency name)
<br />STATE SURETS. CO.KPAN¥
<br />
<br />30. Lessor Name
<br />?,. E, M, ENTEKPF, ISF,.~, '~,.~C,
<br />33. Gambling Manager Name
<br /> JERF. Y h. t-{AI'ILET
<br />36. Gambling Manager Business Phone
<br /> ( 612 ) 441-1630
<br />
<br /> 31.
<br /> Addres.,s , .~,, e
<br /> 16659 N.W. ST. FI-.A,.,CIc. BLVD.
<br /> 34. Address .
<br /> 9335 173R~ AVENUE N.W.
<br /> 37. Date gambling manager became
<br /> member of organization: [ Month !0
<br />
<br />[~Yes [~No 38. Has the license termination form been completed? Attach copy.
<br />[~Yes I-INo 39. Has the compensation schedule been approved by the organization? Attach copy.
<br />
<br />29. BondNumber ,,,~
<br /> ~50o6
<br />
<br /> 32. City, State,Zip
<br /> P,~2-',.SI':Y~ NN 5530o
<br /> 35. City,,State, Zip
<br /> R$~SE~ ~ I,',N 55303
<br />
<br />Year 82 [
<br />
<br /> 40. List the day and time of the regular meeting of the organization. Day Time
<br /> 41. Bank Name [ 42. Bank Address 43. Bank Account Number
<br />
<br /> I
<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
<br /> ----time,.gambling is 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 gambling bank account whenever
<br />~i~ ~necessary to fulfill requirements of current gambling rules and law.
<br />
<br /> ' I hereby declare that: OATH
<br /> 1. I have read this application and all information submitted to the Board;
<br /> 2. AIl~nformation 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
<br /> licensed, to abide by those laws and rules, including amendments thereto;
<br /> 7.Membership list of the organization will be available within seven days after it is requested by the board.
<br /> 44. Official, Legal Name of Organization 145. Signature (must be signed by Chief,Executive Officer)
<br />
<br /> Date .... ..
<br /> Title of Signer
<br /> i~idgSIDE~;T } 20 :E/~.CP~ 1989 ...
<br />
<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
<br />this application will be reviewed by the Charitable Gambling Control Board and if approved by the board, will become effective
<br />60 days from the date of receipt (noted below) unless a resolution of the local governing body is passed which specifically
<br />disallows such activity and a copy of that resolution is received by the Charitable Gambling Control Board within 60 days of the
<br />below noted date.
<br />
<br />46. Name of City or County (Local Governing Body) If site is located within a township, item 47 must be completed, in
<br />Ci~ OF ]',~d,',SEY addition to the county signature. If township is not organized,
<br /> county must sign. ~
<br />Signature of person receiving application 47. Name of Township
<br />
<br />Title ~;" I Date received (60 day period
<br /> I
<br /> begins from this date)
<br />
<br />48. Name of person delivering application to Local Governing Body
<br />JERP, Y K. HAi.:I, ET
<br />
<br />Signature of person receiving application
<br />X
<br />
<br />Title
<br />
<br /> Canary-Applicant Pink-Local Governing Body
<br />
<br />CG-O001-03 (8/88) White Copy-Board
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