|
~~'"L'D;~rtment of ~e"- Gaming Divisbn; :':-:'";:'-'iii'~:':::'::~'.i ::.i:~:;.!;ii'!;~:;'": .'::':~ ::"-
<br /> Mall Station 3315~:::, .4' ,.::.. ~. ':::'. ".i'L;:-".'- ..... ':'..'¶' _4.' f ';". ,- ~ ,:-..~?: :~-.:,:;:-:'.~'~.;T*~.:. :-: ~:-: -::~%'h! ~-.:-~: Fo~ Board U~e Only
<br />
<br /> St. Paul, MN 55146-3315 ,~ ~.'...~ ,. .... ' t ..... / ..... ' ......... :"'-"it ':"': .... -...-. ~ Paid Amt:
<br /> {6i2) 297-5300 ". ~.::. :;'~?:. ": ":!' ~' ':?~_::!: ".' .:".-' ...;':;~'~' :.: "::: .'-': .'-;:; ;:~ ::::: ~'~,~'::/: ?,::'i::~!::~.: Check No:
<br /> ::'.::.:,.~ .':.:-' '..' '.:i::.:;~,iL:~:.,.. :~, t-i:: :. "- .':. +"-'-;': ............. Data:-
<br /> · "%"'" '"::"" "" GAMBLING LICENSE RENEWAL APPLICATION '
<br />
<br />LtCENSE NUMBER:
<br />
<br />/ EFF. DATE: fllllI~' /AMOUNT OF FEE:
<br />
<br />1. Applicant--Legal Name of Organization
<br /> CYSTIC flIlOS]$ FOUMD~IIO# MIMM CI(APT
<br />
<br />:' 3. City, State, Zip :
<br /> · IlJnnmapolJl, MI~' 55~13-
<br />
<br />'~::;::,: 6. Name of Chief Executive Officer ,.
<br /> ~".": Si, iron' Cbiti~m .......
<br />
<br /> 8. Name of Treasurer or Person Who Accounts for Revenues
<br />. .:- Ir,hr Illckey'
<br />
<br />10. Name of Gambling Manager
<br />· -4.,~=~ '~ .A,,~ ~., ~.~_!
<br />13. Name of Establishment Where Gambling Will Take Place
<br /> Jlts I~lsey
<br />
<br />2. Street Address
<br />
<br /> 4. County ., 5.
<br /> Henneptfl '
<br /> 7.
<br />
<br />11, Bond Number 1~.
<br />
<br />14. County 15.
<br /> Anoka
<br />
<br />Business Phone
<br />&12) 87~-14~2
<br />Business Phone
<br />612) 87~-6462
<br />
<br />Business Phone
<br />612) 334-45~
<br />
<br />Business Phone
<br />
<br />No. of Active Members
<br /> 3GII
<br />
<br />16. Lessor Name 17. Monthly Rent:
<br /> Mike Medina $2211
<br />
<br /> 18. If Bingo will be conducted with this license, please specify days and times of Bingo.
<br /> Days Times I Da~vs Times Days
<br />
<br /> I
<br /> 19. Has license ever been: [] Revoked Date:.
<br />· ?.-. 20. Have internal controls been submitted prevk~usly?
<br />
<br /> :: 21. Has current lease been filed with the board?
<br />~,':-~"'22. H~ current sketch been filed with the board?
<br />
<br />Times
<br />
<br />[] Suspended Date: [] Denied Date:
<br />
<br /> [] Yes [] No (If "No," attach copy)
<br /> [] Yes [] No (If "No," attach copy)
<br /> [] Yes [] No (If "No," attach copy)
<br />
<br /> ~ !: :"~ ' :' · GAMBLING SITE AUTHORIZATION
<br /> '"' By my signature below, local law enforcement officers or agents of the Board are hereby authorized to enter upon tl~e 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 />~ -.: .... ·::': '- OATH
<br /> . I hereby declare that:~. 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, incJuding amendments thereto.
<br />
<br /> 23. Official Legal Name o( Organization Signature (Chief ,Executive Officer) Date [ T~le ~
<br />
<br /> · -~, . ~. , ~/~/,/'" .. , . · / . I//~../~// / /" . / .. ,. ~
<br /> ' _ ¢/." c .
<br /> AC NO. EOGEME, NOT,CE B', LEDA,- GOVER.,.G .o0 , .., ,,. ,-, ¢
<br /> I hereby acknowledge receipt of a copy of this a)gplication. By acknowledging receipt, I admit having been s . ed wittt'zfotice that this application will
<br /> be reviewed by the Charitable Gambling C, entel Board and if approved by the Board, will become effective/~ days fr~m the dat~ of receipt (noted
<br /> below), unless a resolution of the local goYerning body is passed which specifically disallows such activity ~d a copy of that resolution is received by
<br />
<br />the Charitable GambUng Control Board witch 60 days of the below noted date.
<br />
<br />24. Ci!y/County Name (Loc.al Governing Body)
<br />
<br />Signature Cd-person Receiving Application: '
<br />
<br />Title Date Received (this date begins 60 day period)
<br />
<br />Name ef-'Person. Delivering Application to Local Governing Booy:
<br />
<br />Township: If site is located within a township, please complete items 24
<br />and 25:
<br />
<br /> 25. Signature of Person Receiving Application
<br />
<br />Title:
<br />Township Name
<br />White Copy-Board Canary-Applicant
<br />
<br />Pink--Local Governing Body
<br />
<br />
<br />
|