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Charitable Gambling Control Board <br />St. Paul, MN 55104-3383 <br /> <br />FOR BOARD USC ONLY <br /> <br />IType of Application: <br />~ Class A - Fee $100.00 (Bingo, Raffles, Paddlewheels, Tipboards, Pull-labs) <br />[-] £]ass B - Fee $ 50.00 (Raffles, Padd]ewheels, Tipbosrds, Pull-Tabs) <br /> [] Class C - Fee $ 50.00 (Bingo only) <br /> M~ke checks payable tn: Minnesota Charitable Gambling Contro{ Board. <br /> <br /> GAMBLING LICENSE APPLICATION <br /> (CJass A, B, or 0 <br /> <br />INSTRUCTIONS: ]. PR]NI OR <br /> 2. Bring co~p}eted application to lous] governing body, obtain ~ignature and date un ali copies, <br /> and ]caw ~ c'opy. Applicant keeps ~ copy and sends remaining copies to <br /> address. <br /> ). Chanqes in.application information must be submitted withir, lO dav~ after ~be change, <br /> <br /> RENEWAL <br /> <br />License Number <br /> A-01203-01 <br /> <br />Applicant (Official, legal name of organization) <br />Ramsey Lions Club <br />Business Address <br />P.O. Box 771 <br />City, StaLe, Zip <br />Ramsay, MN 55303 <br />County <br />Anoka <br />Busi'ness Telephone NL~erIFederal I.D. N~ber <br />i(612) 441-1630 J 22-2698068 <br />lype of Organization <br />I~ Fraternal El Veterans <br />[] Religious El Other Nonprofit Organization <br />lype of Organization Charter <br />~ International El National [~ State <br /> N~rnoer of Years in Number of Articles of <br /> [xistence (in Minnesota) Incorporation (if incorporated) <br /> 1Z4 years <br /> <br /> Location Where Articles are Filed <br /> <br /> Yes No I. D~es organization have s dues structure? <br /> X Y e s number of active members 41 <br /> 2. Has organization bee~ previously licensed' <br /> X by the Board? Ir yes, 9ire date.6/JD/8-' <br /> 3. Has license ever been denied, suspended <br /> or revoked? If yes check all that apply: <br /> X [~Denied OSuspended ORevoked <br /> ~. Is organization exempt from payment of <br /> U.S. incase tax? If yes, attach copy of <br /> X letter dec]arin~ exemption. <br /> ~. is organization tax exempt from payment <br /> X of Minnesota tax? If yea, attach copy of <br /> letter dec]srin~ exemption. <br /> <br />Site Address <br />6937 N.W. Highway 10 <br />iCity, State, Zip <br />Eamsey~ MN 55303 <br />£~Jnty <br />Anoka <br /> Yes No 1. A~ all gambling activities conducted at <br /> the above site? If no, complete a sepa- <br /> rate application form for each site ss a <br /> X separate license is issued for each site. <br /> X 2. Ia site located within city limits? <br /> ~.Does organization o~n the site ~here <br /> gambling activity will be conducted? If <br /> X no, attach copy of the lease for t~ <br /> site. <br />Lessor Name (if lease or rent) <br />Jimmy B's American Cafe & Lounge <br />Address <br />6937 N.W. Highway 10 <br />City, State, Zip <br /> Ramse[, MN 55303 <br />~ambling Manager l~ne <br />Jerry R. Hamlet <br />9335 173rd Avenue N.W. <br />£ity, State, Zip <br />Ramsey, MN 55303 <br />The $10,OO0 fidelity bond required by Minnesota <br />Statutes 349.20 has been obtained. <br />Company Name Bor~N~er <br />Western Surety Company 58171826 <br /> <br />Name of Organization's Officers and Titles <br /> <br />David I. Bawden, President c. Gary Suchy, Treasurer <br />Gary Albrecht, Secretary d. <br /> <br />CC-OO00I-OI (12/8~) Continued o~ Paoe 2 <br /> <br /> <br />