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· ';:~-'-'~?:::'='..c;,'.' ' GAMBLING LICENSE RENEWAL APPLICATION
<br /> ": LICENSE NUMBER: Y~'-1~,2t$-It1 / EFF, DATE: t7/22J$9
<br /> 1. Applicant--Legal Name of Organization 2. Street Address
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<br />I 3. City, State, Zip 4. County
<br /> '":-' I~aa~eyl lin ~315 ...... An(,I,a
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<br />; ' 6. Name,of Chief Executive Officer
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<br />I'~' 8. Name of Treasurer ~)r Person Who Accounts for Revenues
<br /> - CP..cx3 -
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<br /> 10. Name of Gambling Manager 11, Bond Number
<br />I Hamlet 32518~
<br /> Jerry
<br /> 13. Name of Establishment Where Gambling Will Take Place 14. County
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<br /> Jlemy I~s Am Cafe
<br />16. Lessor Name
<br /> S3S
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<br />A:loLa
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<br />JFor Board Use Only .
<br /> Paid Amt:
<br /> Check No.
<br /> Date:
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<br />/ AMOUNT OF FEE:
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<br />18. If Bingo will be conducted with this license, please specify days and times of Bingo. - - Days Times Days Times
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<br />" 15.
<br /> 17.
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<br />Days
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<br />Business Phone . _~,.,
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<br />Business Phone ,. g ~.~._~
<br />~;~ ) ,~-~4ff
<br />Business Phone ~
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<br />Business Phone ,'
<br />No. of Active Members
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<br />.- ff5
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<br />Monthly Rent:
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<br /> Times
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<br /> 19. Has license ever been: [] Revoked Date:
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<br /> 20. Have internal controls been submitted previ(~usly?
<br />:~.2~l:_.Has current lease been filed with the board?
<br /> 22. Has current sketch been filed with the board?
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<br />[] Suspended Date: [] Denied Date:
<br /> X Yes [] No (If "No," attach copy)
<br /> [] Yes ~No (If "No," attach copy)
<br /> ID Yes ~i(No (If "No," attach copy}
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<br />I' GAMBLING SITE AUTHORIZATION
<br /> · By my signature below, local law enforcer~ent officers or agents of the Board are h~reby authorized to enter upon the site, at any time, gambling is
<br />I:~ 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. .................... OATH ~
<br />i"-.:.:i he~;eby decl~r~ ihat:I. ': ::-. '" ' -.'
<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 />I 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 taws 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.
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<br />i 23. Official Legal Name of Organization Signature (Chief Executive Officer) Date Title
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<br /> ACKNOWLEDGEMENT OF NOTICE B/~ LOCAL GOVERNING BODY
<br />I 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 resoiution is received by
<br /> the Charitable Gambling Control Board within 60 days of the below noted date. "
<br />I 24. City/County Name fLocal Governing Body) If site is located within
<br /> Township:
<br /> a
<br /> township,
<br /> please
<br /> complete
<br /> items
<br /> 24
<br /> C. I'T''~' O ¢- ~--~k,~--.f"('~ ~ ~ ~ and 25:
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<br /> Signature of Person Receiving Application: 25. Signature of Person Receiving Application
<br />I ~/, "~, - xk
<br /> / / :,'.,,'. : ; , .~(.,. ? ....,.':. · ~,:_>,' . '
<br /> T~e,. '...," ~.. '/
<br />I ';' ..¢,',::;:' ' '."'-~"~"/I.',
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<br /> Date Received (this date begins 60 day period)
<br />N~h~e of p~rson Delivering Application to Local Governing Body:
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<br />Title:
<br />
<br />Township Name
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<br />ICG-00022-01 (4/89) White Copy--Board Cana~--Applicam Pink--Local Governino Body
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