02-13-1989 Council Packet - Laserfiche WebLink

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RI?rFIVEOf'OV2ll9e3 Charitable Gambling Control Board Rm N-475 Griggs-Midway Bldg. 1021 University Avo. St. Paul, MN 55104-3383 (612) 642-0555 GAMBLING LICENSE RENEWAL APPLICATION For Board Use Only Paid Amt; _______ Check No________ Data: ___________ / AMOUNT OF FEE:tSMI 1. Applicant-Legal Name of Organization I01TIPU SCIEIOSIS SOCIETT NORTH STIR CHAPTER 2. Street Address 23M Hlcilltt 3. City. State. Zip Nlmiiiolis. NR SS4M 4. County NtnniDln 5. Business Phone ( 812 ) 821-lSII 6. Name of Chief Executive Otficer HillarO RuitQtr Jr 7. Business Phone ( 812 ) 871-lSH 8. Name of Treasurer or Person Who Accounts for Revenues Elianor Nsvik 9. Business Phone ( 812 ) 878-1S08 10. Name of Gambling Manager R S Siciity Uaym Nsvik 11. Bond Number S88226I 12. Business Phone 13. Name of Establishment Where Gambling Will Take Place Jiiiit't lotinfli Rivirrt 14. County Ninnepin 15. No. of Active Members 20081 16. Lessor Name Jiuit's louitQt 17. Monthly Rent: 8600 Times Days Times Days Times 19. Has licer.se ever been:□ Revoked Date:. 20. Have internal controls been submitted previously? 21. Has current tease been Hied with the board? 22. Has current sketch been filed with the board? □ Suspended Date:_________ P^Yes □ No (II “No." attach copy) 6^ Yes □ No (If “No." attach copy) ^ Yes □ No (If “No." attach copy) □ Denied Date: GAMBLING SITE AUTHORIZATION By my signature below, local law enforcement officers or agents of the Board are hereby authorized to enter upon the site, at any t'me, gambling is being conducted, to observe the gambling and to enforce the law for ary unauthorized game or practice. BANK RECORDS AUTHORIZATION By my signature below, the Board is hereby authorized to inspect the bank records of the General Gambling Bank Account whenever necessary to fulfin requirements of current gambling rules and law. OATH I hereby declare that: 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 bo conducted: w 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. ______________________________ 23. Official Legal Nar ^^^ o c./y Signature (Chief Executive Officer) Date Title ACKNOWLEDGEMENT OF NOTICE BY LOCAL GOVERNING BODY I hereby acknowledge receipt of a copy of this application. By acknowledging receipt, I 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 specifics!'y disallows such activity and a copy of that resolution is received by the Charitable Gambling Control Board within 60 days of the below noted date. Sign re of Person Receiving ity Name^Local Governing Body) iving ApfSiication: fat^ Received^is (^te begins 60 day^ei^d) /9<k^ if Person DeliverincLApplication tq^ocal Governing Body: Township; If site is located within a township, please complete items 24 and 25: 25. Signa' jre of Person Receiving Application Title: Township Name CG-00022-02 (8^)White Copy-Board Canary-Applicant Pink-Local Governing Body