Agenda - Council - 09/26/1989 - Laserfiche WebLink

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~ ;:~:~; 1. ApplicantmLegal Name of Organization ~.~ : 2. Street Admess ~'~;'=~- 3 Ct State Zip-- ' ': 4 County 5 6usiness Phone ~ - J~:~¥:"' 6 Name' of Chief Executive Officer ': . - 7. Business Phone ~ ~[~:~':'~ 8 Name of Treasurer or Person Who Accounts Ior Revenues . 9. Business Phone " ~:~:.;~.~- 10. Name of Gambling Manager '- · . 11. Bond Number ~ - 12. Business Phone ~ ] :.:'~" ?;; 13 Name of Establishment Where Gambling Will.Take place 14. County 15. No. of Active Members ~lfl~::.:,'-. , The Super 8ovI N~sey Anok4 ~ ~.:"... ' ?&. Lessor Name '.. ~7. Uonthly Rent: .: 18. If Bingo will be conducted with this license, please speci~ days and times of Bingo. ) ~-:- '" - Days Times Days Times Days Times , :_;_ ~0 D Suspended Date: ~ ' ~ ~ n su v ? ~Yes D No (If "No," attach copy) ~1. H~ ~urrent lease bee~ filed wit~ the board. ' D Yes ~No (If "No,' attach copy) . ~"~ .: 22. Has current sketch been filed with the board? ~Yes D No (If "No," attach copy) ~ r.>:.'~. , By'~y signature below, local ia~ enforcement officers or agents of the Board are hereby authorized to enter upon the site, at any time, gambling is ~ ~ -'. being conducted, to obse~e the gambling and to enforce the law for any unauthorized game or practice. ~ '~ ': ...-.v-; .... ~;" BANK RECORDS AUTHORIZATION ! :..' By m~ignature below, the Board is hereby authorized to inspect the bank records of the General Gambling Bank Account whenever necessa~ to ~-'-.;-::~)' fulfill requirements of current gambling rules and law. "" ;' I hereby declare that: .::;.' · . - ~. ~ have re~ this application nnd nil information submitted to the Board; . ~ ~. :-; .. 2. All information submitted is true, accurate and complete; " ~... · ~. All other required inlormation has been fully disclosed: 4. I nm the chief executive officer of the organization; 5. I assume full fesponsibility for the fair nnd In~ul operation of nil activities to be conducted; --' G. I will familiarize myself with the laws of ~he ~tnle of ~innesotn respecting gambling and rules of the board and agree, if licensed, to abide by thc · ~- laws nnd rules, including.amendments thereto. i ~ ~ 23. Official Legal Name of Organization 5i~pn~ure (Chief ~xeoutive Officer) Date Title ACKNOWLEDGEMENT OF NOTICE BY LOCAL GOVERNING BODY ~ I hereby acknowledge receipt of a copy of this application. By acknowledging receipt, I n~mit having ~en se~ed with notice that this npplionlion will ~ .... be reviewed by the Ohnritnble Gambling Oontrol Bonr~ nnd if approved by the Board, will become effective &0 days from the date of receipt (note~ below), unless a resolution of the local governing body is passed whio~ speoifi~lly disallows such notivi~ nn~ n copy of that resolution is reoeive~ by ~ the Ohnritnble Gambling Control Board within &0 days of the below no~eddnte. 24. Oity/Oounty Name (Local Governing Body) "' ~- Township: If site is located within n township, please complete items 24 ~ Signnlure of Person Receiving Application:. 25. ~ignnture of Person Receiving Application ? ~ ': Name of Person Delivering Application to Local Govern;ng Body: Township Name ?' CG-00022-01 (4/89) White Copy--Board Cana~,--Applicant Pink-Local Governing B