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~.~...:~g~..;~;;~,: Department of Revenue - Gaming Division
<br /> ; "~.~ Mail Station 3315 .." .,
<br /> .:i i~.~,!~)~ St. Paul, MN 55146-3315
<br />i: ( 2) 97-53o0 .' :.'b.'. '
<br />
<br />m :.;. LIcENsE NUMBER:· )-l)~)t'lll '
<br /> 1. Applicant--Legal Nam~ of Organi~tion
<br />
<br /> '. 6. Name of Chief Executive Oflicer ,!'~. ~. ~
<br />
<br /> 8. Name of Treasureror Person W~o Acco~nt~Gr R,
<br />
<br /> 10. Name of Gambling Mh~ager ' , ,
<br /> VJct0r lufl~s . -" ' ,
<br /> 13. Name of Establishment Where Gambling Will Take
<br /> HcPuffs Raasey"'
<br /> 16. Lessor Name ' ~' ~ ~, c t. -
<br /> RRH Enterpr[~t~ lnc ~ ' ,' ---- :
<br /> 18. If Bingo will be conducted with this license, pleas~
<br /> Days . . ~.' Times :' ':":
<br />
<br /> 19. Has license ever been: ~ Revoked Date:
<br /> 20. Have internal controls' been submitted previ~usl~ ~
<br /> 21. Has current lease been filed with the board?
<br />
<br /> 22. Has current sketch been filed with t~e board? '
<br />
<br /> By my si gnature belo~ ')c a ~r 01 :e
<br /> being cc nductec, to c ,~ e la ~ in
<br />
<br /> By my signature belo~ ~ I i~ h ~r~
<br /> '.fulfill requiremer t~ of ren bi % .n
<br />
<br /> ~' I hereby declare that: ..... ' ~.
<br /> ' 1. II
<br /> 2.
<br />
<br />GAMBLING LICENSE RENEWAL APP.LICATION
<br />
<br />For Board Use Only
<br />Paid .Amt:
<br />Check No,
<br />Date:
<br />
<br />/ EFF. DATE:
<br />
<br />6. Name of Chief Executive Officer , .!';~. ~. ~
<br />
<br />8. Name of Treasureror Person Who Acco~Jnt~'~or Revenues
<br />
<br />2. Street Address
<br />
<br />4. County
<br /> A~ka
<br />
<br />/ AMOUNT OF FEE:
<br />
<br />10. Name of Gambling Mii'llager ' ,~'W//'~.~ ("/~ ! 11. Bond Number Co,~, ,~,~ '" ~'
<br /> Victor Bun. · ' '¢,2V'~,:5"/~'~ (/'/) S~88179
<br />13. Name of Establishment Where Gambling Will Take Place / 14. County~
<br /> ,,,, Anoka
<br />
<br />12.
<br />15.
<br />17.
<br />
<br />18. If Bingo will be conducted with this license, please specify days and times of Bingo.
<br /> _D. _a~y_s Ti m e s
<br />
<br />Days
<br />
<br />M25,11
<br />
<br />5. Business Phone
<br /> (612 )427-9919
<br />7. Business Photo ..... ~
<br />
<br />9. Business Phone
<br /> H2 ) ~27-99~9'
<br />
<br />Business Phone
<br />612 ) 475-1273
<br />No. of Active Members
<br /> 6~3
<br />Monthly Rent:
<br />
<br />Times
<br />
<br />[] Suspended Date: [] Denied Date:
<br />
<br /> [] Yes [] No (If "Noi"'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 enfm:cement 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 requirementi~ of current gambling .rules and law.
<br /> OATH
<br />
<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 /> "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 /> 23. Official Legal Name of Organization~ v~ IJ /~! I Signature (Chief Executive Officer).,- / / Date J Title
<br /> . .. ~ ~ . ~ .f r~. i...
<br /> / ~./ //1 ' - . .
<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 this application will
<br /> be reviewed by the Charitable Gambling Control Board and if approved by the Board, will becomb-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 />
<br />24. Cjt~y/County Name (Local Governing.Body)
<br /> , -~, ,.? /
<br />Signature of Person~:~.eceiving Application: ,.
<br />
<br />Tit~e , ~ .~ate ~eceived (this date begins 60 day period)
<br />
<br />Name of Person Deliv~ng Application to Local Governing Body:
<br />
<br />CG*00022-01 (4/89) ':..-.~:
<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 />
<br />Township Name
<br />
<br />White Copy- Board
<br />
<br />Canary-Applicant
<br />
<br />Pink--Local G~ng Body
<br />
<br />
<br />
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