Laserfiche WebLink
Charitable Gambling Coinitroil Board <br />Room N-475 Griggs - Midl way Building <br />1821 1Uni versity, Avenue <br />St. Paul, Minnesota E55,104-3383 <br />(612)1642-055,5 <br />GAMBLING LICENSE APPLICATION <br />FOR BOARD USE ONLY <br />PAID <br />AMT <br />CHECK# <br />DATE <br />i <br />4. Applicant (Officlai, legal name, of organization) 5. Business Address of Organization <br />NORTH, SUBURBAN YOUTH, ASSOCIATION P., 041 BOX 13253 <br />6. City, State,,, Zip <br />ROSEVILLE , MN' 5151.113 <br />7. County <br />RAMSEY <br />8. Business Phone Number <br />( 612 ) 633-0156 <br />11 4., Number of active members <br />15., Number of years in existence <br />ME= <br />16. Name of Chief Executive Officer (Cannot be <br />Gambling (Manager) <br />R., Robert Matson <br />Title <br />Executive Director <br />Note: Attach evidence of <br />three years existence. <br />17. Name of treasurer or person who accounts for other revenues <br />of the organization lCannot be Gambling Manager) <br />Title <br />Business Phone Number I Business Phone Number <br />18. Name of establishment where gambling gill be <br />conducted <br />Chlop Stick Inn <br />20. City, Staste, Zip <br />Roseville,, MN 55113 <br />Whiite Clopy-Board <br />19. Street adidlress (not RO. Box Number) <br />1744 Lexington Ave. <br />21., County (where gambling premises is located) <br />Pag�e 1 of 2 <br />Canary-Applicant <br />Pink-Local Governing Body <br />