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<br />Charitable Gambling Control Board
<br />". Rm N-4,75 Gri9
<br />, gls-Mid�way I Bldg.
<br />1821 University
<br />St. P II, MN 551 4-,3 83
<br />(612) 64,2-0555
<br />GAMBLING LICENSE REM EW'A,L APPLICATION
<br />For Board Use Only
<br />Paid Amt.
<br />check NO.
<br />Dale:
<br />LI'CENIS�E NUMBER: A-01485001 / EFF. DATE:
<br />09/1 23187
<br />/AMOUNT-
<br />OF FEE: Mose@
<br />1., Applicant— Legal Name of Organization
<br />2. Street Addlress,
<br />......
<br />NORTH SU'BURBAR YOUTH ASS'OC'IATION ROSEVILLE
<br />PO Box, 13253
<br />3. City, State, Zip
<br />kseViller KA 5 15 1, 1, 3
<br />4. County
<br />wmlh�
<br />5. Business Phone
<br />R alsey
<br />61 633-0156
<br />( 11
<br />.Name of Chief Executive Officer
<br />7. Business Phone
<br />1, Roblert Ka,tson
<br />8�. Name, of Treasurer or Person Who Accounts, for Revenues
<br />9. Business Phone
<br />Dale Kar,is�tuto
<br />612 ) 298-2582
<br />1101., Name of Gamblin�g Manager
<br />11. Bond Num�ber
<br />I
<br />12. Business Phone
<br />Bob Katson
<br />RPS316933
<br />13. Name of Establishment Where Gambling Willl Take Place
<br />114. County
<br />15. No. of Active Members
<br />Falk Place Inn RosIieville
<br />Raitsey,
<br />238
<br />16. Lessor Name
<br />Fluls place Ian
<br />17. Monthly Rent:
<br />$1
<br />-1
<br />18. If Bingo will be conducted with this licenlse,, please specify days and times of Bingo.
<br />Times
<br />11
<br />Ti IrmMe
<br />bas Times
<br />19. Has license ever beem:
<br />EJ Revoked Date: 11 Suspended Da
<br />91 Cate:
<br />0 Denied Date-
<br />20. Have internal controls been submitted previously?
<br />21. Has current lease been filed wlithl the board?
<br />Wyss El No (if '"No," attach copy)
<br />1WYes 11 No (If '"No," attach copy)
<br />22., Has current sketch been filed with the boiard? 191 Yes 0 No (it "No," attach copy)
<br />'11 GAMBLING SITE AUTHORIZATION
<br />By my signature, below,, local law enforcement officers or agents of the Board are hereby authorized to enter upon the site, at any lime, gambling is
<br />A C
<br />beinig conducted, to observe the gambling andto 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 olf't'he General Gambling Bank Account whenever necessary to
<br />fulfill Iregluilrernernts of current gambling, rules and law.
<br />I hereby declare that: OATH
<br />1. III have read this apipticatioln and all information submitted to the Board;
<br />2. All information submitted is true, accurate and colrnple,te;
<br />3. All other required information has been fully disclosed;,
<br />4.. 1 am the ichilet executive officer of the organization;
<br />5. 1 assume full responsibility for the fair and, lawful operation of all activities to be conducted;
<br />6. 1 will familiarize myself! with the laws of the State of Minnesota respecting garribling, and rules of the board and agree, if licensed, to abide by those
<br />laws, an�id rules,, including amendments thereto.
<br />23. Official Legal Name of Organization
<br />I� 1z. CJ4A&cw"N'
<br />:-utive Officer) Date I
<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 1hatthis application will
<br />be, reviewed by the Charitable Gambling Control[ Board and if approved by the Board, will become effective 30 days from the date of receipt (noted
<br />below), unliess 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 30 days of the below noted date.
<br />24,. City/Cou Name (Loca]L Govern
<br />Signature of Person hecely'ng Appli(
<br />ing Body) Township: If site is located within a township, please complete items 24
<br />1 t 11 r=`" I and 25:
<br />Time Date eived (this date begins 30 day period)
<br />11 4-1 P
<br />ILL AV'I Cc Irt R, 0
<br />Name of IPellrsorn Delivering Application to Local Governing Body:
<br />251., Signature of Person, Receiving Application
<br />Title:
<br />Township Name
<br />CG-0002201 (5187) White Copy—Board Canary —Applicant Pink—Local Governing Body
<br />
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