CCP 03-26-1990 - Laserfiche WebLink

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, . Gambling License Application Type of Application: 9!I~lass A D Class B D Class C D Class D [JlcYes D No 22. Is gambling premises located within city limits? ~Yes 0 No 23. Are all gambling activities conducted at the premises listed in #18 of this application? If not, complete a separate application for each premises (except raffles) as a separate license is re uired for each premises. o Yes ~No 24. Does organization own the gambling premises? If no, attach copy of the lease with terms of at least one year, and attach a sketch of the premises indicating what portion is being leased. A lease and sketch are not require for Class 0 applications. 25. Amount of Rent Per I \e 26. 00 you plan on conducting bingo with this license? If yes, give days and times of bingo occasions. D.4cl..c.t.h or Bingo o,-,~L:." Day _ Time Day Time Day Time I $ (D 00<::' ,,~'\...+ I 1\ v..."-6<\.""'" -. .. 0" 1'ue.~;.:.d..O-.o..-\' ~ t. 00 , DYes No 27, Has the $10,000 fidelity bond required by Minnesota Statutes 349,20 been obtained? 28. Insurance Company Name (not agency name) 29, Bond Number 30. Lessor Name 31, Address L(!)C[/S WALS 371{" C"'N G. '-I.. '{ S5'1 / ~ 33. Gambling Manager Name 34, Address Jim Winiecki 4471 Hi hwa 10 2 36. Gambling Manager Business Phone 37. Date gambling manager became Year 612 633 7706 member of organization: Month DYes 0 No 38. Has the license termination form been completed? Attach copy, DYes 0 No 39. Has the compensation schedule been approved by the organization? Attach copy. 40 List the day and time of the regular meetin of the oraanization. Day Time 41. Bank Name 42, Bank Address 43. Bank Account Number GAMBLING SITE AUTHORIZATION By my signature below, loca! law enforcement officers or agents of the Board are hereby authorized to enter upon the site at any time gambling is being conducted to observe the gambling and to enforce the law for any unauthorized game or practice. . BANK RECORDS AUTHORIZATION By my signature below, the Board is hereby authorized to inspect the bank records of the gambling bank account whenever necessary to fulfill requirements of current gambling rules and law. I hereby declare that: OATH 1, I have read this application and all information submitted to the Board; 2, All information submitted is true, accurate and complete; 3, All other required information has been fully disclosed; 4, I am the chief executive officer of the organization; 5, I assume full responsibility for the fair and lawful operation of all activities to be conducted; 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 laws and rules, including amendments thereto; 7, Membershi list of the or anization will be available within seven days after it is re uested by the board. 44. Official, Le~al Name of Organization 45. Signature (mu t be sig by Chief Executive Officer) Lady S11pper Chapter ABWA X ~ Title of Signer '70 President ACKNOWLEDGEMENT OF NOTICE BY LOCAL GOVERNING BODY I hereby aCknowledge receipt of a copy of this application. By acknowledging receipt, 1 admit having been served with notice that this application will 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 below) unless a resolution of the local governing body IS passed which specifically disallows such activity and a copy of that resolution is received bv the Charitable Gamblinq Control Board within 60 days of the below noted date. 46. Name of City or County (Local Governing Body) If site is located within a township, item 47 must be completed, in addition to the county signature. If township is not organized, _~_M~ county must sign Signature of person receiving application 47. Name of Township X ,,-"-_._- Title Date received (60 day period Signature of person receiving application . begins from this date) X -.---- 48. Name of person delivering application to Local Governing Body Title CG~0001 ~03 (3/891 White Copy-Board Canary-Applicant Pink.Local Governing Body Page 2 of 2