1f. Chanhassen Lion's Club-Approve Gambling Permit Request1
1
1
1
1
1
1
1
1
1
1
1
CITY OF
CHANHASSEN
690 COULTER DRIVE • P.O. BOX 147 • CHANHASSEN, MINNESOTA 55317
(612) 937 -1900 • FAX (612) 937 -5739
MEMORANDUM
TO: Mayor
City Council
Don Ashworth, City Manager
FROM: Scott Harr, Public Safety Director . i'
DATE: November 14, 1994
SUBJ: Chanhassen Lion's Club Gambling Application
Action by City Adminiotr? tot
Endorse
�t i. Z _ .
Deee
Date S ^e o C %,. ❑cff
In order to continue their charitable gambling operations in the City of Chanhassen, the Lion's
Club has submitted their renewal application. The background investigation conducted reveals
no reason that the license should be denied.
Attached is a resolution approving the permit, which staff recommends.
g:\,safety\shVions. gam
CITY OF CHANHASSEN
CARVER AND HENNEPIN COUNTIES, MINNESOTA
RESOLUTION
Dated: November 28, 1994 Resolution No.
Motion By: Chmiel Seconded By:
A RESOLUTION APPROVING THE GAMBLING PERMIT APPLICATION
OF THE CHANHASSEN LIONS CLUB
WHEREAS, the Chanhassen Lions Club has submitted an application for a Lawful
Gambling Permit at Pauly's Bar, Inc. at 401 West 78th Street.
NOW THEREFORE, BE IT RESOLVED, by the Chanhassen City Council that the
gambling permit application as submitted by the Chanhassen Lion's Club is hereby approved.
Passed and adopted by the City Council of the City of Chanhassen, this day
of . 1994.
ATTEST:
Don Ashworth, City Clerk/Manager
Yes
No
Donald J. Chmiel, Mayor
Absent
STATE OF MINNESOTA
GAMBLING CONTROL BOARD
PREMISES PERMIT RENEWAL APPLICATION
LG214PPR PRINTED:10 /13/94
LICENSE NUMBER: B- 03959 -001 EFFECTIVE DATE: 04/01/93
NAME OF ORGANIZATION: Lions Chanhassen Club
I
FOR BOARD USE ONLY
AMT PAID
CHECK NO.
DATE
EXPIRATION DATE: 03/31/95
GAMBLING PREMISES INFORMATION
NAME OF ESTABLISHMENT WHERE GAMBLING WILL BE CONDUCTED
Paulys Bar & Restaurant
401 W 78th St
Chanhassen 55317
COUNTY Carver
IS THE PREMISES LOCATED WITHIN THE CITY LIMITS ?: Y
7
DOES YOUR ORGANIZATION OWN THIS SITE ?: No
IF NO, LIST THE LESSOR:
Russell Pauly
1031 Carver Beach Rd
Chanhassen MN 55317
NAME OF PROPERTY OWNER (WHEN NOT LESSOR):
Henry Pauly
SQUARE FEET PER MONTH: 168
SQUARE FEET PER OCCASION: 0
LESSOR INFORMATION I
AMOUNT PAID FOR RENT PER MONTH: 1000 '
AMOUNT PAID PER OCCASION: 0
BINGO ACTIVITY
BINGO IS CONDUCTED ON THIS PREMISES: No IF YES, REFER TO INSTRUCTIONS FOR REQUIRED ATTACHMENT '
STORAGE ADDRESS
7800 Park Dr '
Chanhassen MN 55317
Americana Community Bank
600 W 78th St
Chanhassen MN 55317
GAMBLING BANK ACCOUNT NUMBER: 600163
BANK INFORMATION
ON THE LINES PROVIDED BELOW LIST THE NAME, ADDRESS AND TITLE OF AT LEAST TWO PERSONS
AUTHORIZED TO SIGN CHECKS AND MAKE DEPOSITS AND WITHDRAWALS FOR THE GAMBLING ACCOUNT.
THE ORGANIZATION'S TREASURER MAY NOT HANDLE GAMBLING FUNDS.
A
S
(BE SURE TO COMPLETE THE REVERSE SIDE OF THIS APPLICATION)
THIS FORM WILL BE MADE AVAILABLE IN ALTERNATIVE FORMAT (I.E. LARGE PRINT, BRAILLE) UPON REQUEST'
1
7
r
LG202
(08/26/94)
Minnesota Lawful Gambling
LEASE AGREEMENT
Property Owner/Lessor Information
Name of Legal Owner of Property Street Address City Zip Daytime Phone
F , W Rr A 19NCA,4 —IOL? R,-R4 e"PUr ,(47 -c S 41 9 2 Q,'8') 692 -2 as - /
Name of Lessor Street Address City Zip Daytime Phone
(This may or may not be the same as the Legal Owner of the Property)
(4 1 1) 931/ - 303
Name of Leased Premises Street Address City Zip Daytime Phone
u 1 V S QAr? + Res /LA uR,* .m t yo / w 71' GXgAAAss6, ss - a n (G 12 ) g3.1 -do3
Name of Lessee (Name of Organization Leasing the premises) GCB License # of Organization Daytime Phone
oNS C A4 4 S 0 3969 -00
Gambling Activity and Rent Information
Type of gambling activity that will be conducted at this gambling premises (Check all that apply to this gambling premises)
[D Bingo 0 Raffles Q Paddlewheels [OPull -tabs 0 Tipboards
Rent Information (See Rule 7861.0060, Subp 2D) Indicate the rents paid by your organization to the lessor.
Class A and C premises permits rent per bingo occasion: Class B and D premises permits rent per month:
Rent for bingo and all other gambling activities conducted Rent for forms of lawful gambling activity other than bingo
during that bingo occasion may not exceed: may not exceed a maximum of 51000 per month.
S200 for up to 6,000 square feet;
$300 for up to 13,000 square feet; and
5400 for more than 12,000 square feet.
Rent to be paid per bingo occasion 5 F 7Rnt to be paid per month 5 / 0011, O O
Rent may not be based on a percentage of receipts from lawful gambting or attendance at a bingo occasion .
An organization may not pay rent to itself or to any of its affiliates for space used for the conduct of lawful gambling.
Effective Date for Amended Lease Agreements
Please list the effective d ate on w hich the amendments to the original lease will take place.
List dimensions of all areas leased by your organization for gambling activity on this premises:
The leased areas are: feet by / 1, feet for a total of 9 square feet.
feet by feet for a total of square feet.
_ feet by feet for a total of square feet.
feet by feet for a total of square feet.
Combined total q square footage
Submit a sketch (drawing) of the gambling premises. This must show the location of your organizations leased areas for the
conduct of lawful gambling including areas leased for storage of your gambling product on this gambling premises. Be sure to
write the dimensions of the leased areas on the sketch. THE DIMENSIONS ON THE SKETCH MUST BE THE SAME AS ABOVE
Times and Days of Bingo Occasions (for Class A or C pmmLses permits). If you checked bingo activity above, you must fill in
the bingo days and times below. Circle a.m. or p.m. after each beginning and ending time. A bingo occasion must continue for at
least 1 -1/2 hours (90 minutes) but cannot exceed four (4) consecutive hours and at least 1S bingo games must be held at each
occasion. An organization (as a whole) may not conduct more than seven (7) bingo occasions each week.
Begins At:
(a.m. "p.m.) Ends At:
(a.m.:`p.m.) On Day of Week
Begins At:
(a.m. /p.m.) Ends At:
(a.m. /p.m.) On Day of Week
Begins At:
(a.m.'p.m.) Ends At:
(a.m. /p.m.) On Day of Week
Begins At:
(a.m. p.m.) Ends At:
(a.m.!p.m.) On Day of Week
Begins At
(a.m.!p.m.) Ends At:
(a.m. /p.m.) On Day of Week
Begins At:
(a.m. /p.m.) Ends At:
(a.m. On Day of Week
Begins At:
(a.m.-p.m.) Ends At:
(a.m. /p.m.) On Day of Week
LG213 Minnesota Lawful Gambling
(Rev. 6!12/92)
Gambling Manager Affidavit
(Attach to the Gambling Manager Application, Form L,G212)
STATE OF _ A4 //O ) AFFIDAVIT OF QUALIFICATION
S.S. FOR GAMBLING MANAGER LICENSE
COUNTY OF GAiP uv ) AND CONSENT STATEMENT
(Pursuant to Minnesota Statute 349.16 Subd. 2(e)
and Minnesota Rule 7861.0030,Subp. 12B(3))
J
I, AMC_ 5 r= S , under oath state that:
(type/print name) '
1. 1 have never been convicted of a felony.
2. 1 have not, within five years, committed a violation of law or board rule that resulted in the ,
revocation of a license issued by the Lawful Gambling Control Board.
3. 1 have never been convicted of a criminal violation involving fraud, theft, tax evasion, '
misrepresentation, or gambling.
4. 1 have never been convicted of assault, a criminal violation involving the use of a firearm, ,
or making terroristic threats.
5. 1 am not an assistant gambling manager for any other organization.
6. 1 am not a gambling manager for any other organization.
In addition, I understand, agree and hereby irrevocably consent that suits and actions relating to the subject '
matter of the attached gambling manager license, or acts or omissions arising from such application, may
be commenced against my organization and I will accept the service of process for my organization in any '
court of competent jurisdiction in Minnesota by service on the Minnesota Secretary of State of any summons,
process or pleading authorized by the laws of Minnesota.
By signature of this document, the undersigned authorizes the Department of Public Safety to conduct a I
criminal background check or review and to share the results with the Lawful Gambling Control Board.
Failure to provide required information or providing false or misleading information may result in the denial
or revocation of the license.
'
,
Subscribed and sworn to before me this
( .nature
day of nue� 1994
( of applicant - gambling manager)
'-
/—/ ; , "V s CA'4
(Name of organization)
Count
6 G 3 9S9 -oa i
License number
ry Public
My commissio
�JAMES C. HAUGEN
NOTARY PUBLIC — MINNESOTA
HENNEPIN COUNTY
CorW. Expires Sept. 16, 1997
STATE OF MINNESOTA FOR BOARD USE ONLY
GAMBLING CONTROL BOARD AMT. PAID
GAMBLING MANAGER LICENSE RENEWAL APPLICATION CHECK # _
LG212GMR PRINTED: 10/13/94 DATE
LICENSE NUMBER: G -03959 001 EFFECTIVE DATE: 04/01/94 EXPIRATION DATE: 03/31/95
' NAME OF ORGANIZATION: Lions Chanhassen Club
l
' James Edward Sloss
9360 Kiowa Tr
Chanhassen MN 55317
DAYTIME PHONE NUMBER: 612 - 928 -1460
MEMBER SINCE: 12/01/90
DATE OF BIRTH: 07/27/44
SEX: M
LAST DATE YOU ATTENDED A GAMBLING MANAGERS SEMINAR /CONTINUING EDUCATION CLASS: 01/11/93
BOND INFORMATION
BOND COMPANY NAME: Western Surety BOND NUMBER: 58551443
ACKNOWLEDGMENT
I DECLARE THAT:
• I HAVE READ THIS APPLICATION AND ALL INFORMATION SUBMITTED TO THE GAMBLING CONTROL BOARD;
• ALL INFORMATION IS TRUE, ACCURATE AND COMPLETE;
• ALL OTHER REQUIRED INFORMATION HAS BEEN FULLY DISCLOSED;
• I AM THE ONLY GAMBLING MANAGER OF THE ORGANIZATION;
• I HAVE BEEN AN ACTIVE MEMBER OF THE ORGANIZATION FOR AT LEAST TWO YEARS;
• I WILL FAMILIARIZE MYSELF WITH THE LAWS OF MINNESOTA GOVERNING LAWFUL GAMBLING AND RULES OF
THE GAMBLING CONTROL BOARD AND AGREE, IF LICENSED, TO ABIDE THOSE LAWS AND RULES,
INCLUDING AMENDMENTS TO THEM;
' • ANY CHANGES IN APPLICATION INFORMATION WILL BE SUBMITTED TO THE GAMBLING CONTROL BOARD AND
LOCAL UNIT OF GOVERNMENT WITHIN 10 DAYS OF THE CHANGE;
• AN AFFIDAVIT FOR GAMBLING MANAGER HAS BEEN COMPLETED AND ATTACHED; AND
• I UNDERSTAND THAT FAILURE TO PROVIDE REQUIRED INFORMATION OR PROVIDING FALSE OR MISLEADING
INFORMATION MAY RESULT IN THE DENIAL OR REVOCATION OF THE LICENSE.
I SIGNATURE OF GAMBLING MANAGER
n
DATE
/ /-- a- - / 9 `r y
REFER TU THE CHECKLIST FOR REQUIRED ATTACHMENTS
MAIL TO: GAMBLING CONTROL BOARD
1711 WEST COUNTY ROAD B, SUITE 3005
ROSEVILLE, MINNESOTA 55113
I THIS FORM WILL BE MADE AVAILABLE IN ALTERNATIVE FORMAT (I.E. LARGE PRINT, BRAILLE) UPON REQUEST.
GAMBLING MANAGER INFORMATION
(e) Issue quarterly or semi- annual statements to
each member for dues and other financial obli-
gations owed to this club, collect and turn the
same over to the club treasurer and obtain a
receipt therefor;
(f) Give bond for the faithful discharge of his /her
office in such sum and with such surety as deter-
mined by the board of directors.
(5) TREASURER: He /she shall:
(a) Receive all monies, from the secretary and
otherwise, and deposit the same in a bank or
banks recommended by the finance committee
and approved by the board of directors;
(b) Pay out monies In payment of club obligations
only on authority given by the board of direc-
tors. All checks and vouchers shall be signed
by the treasurer and countersigned by one other
officer, determined by the board of directors;
(c) Have custody and keep and maintain general
records of club receipts and disbursements;
(d) Prepare and submit monthly and semi- annual
financial reports to the International office of the
association and the board of directors of this
club;
(e) Give bond for the faithful discharge of his/her
office in such sum and with such surety as deter -
mined by the board of directors.
(6) LION TAMER: The Lion tamer shall have charge
of and be responsible for the property and parapher-
nalia of the club, including flags, banners, gong, gavel,
song books and button board. He /she shall put each
in its proper place before each meeting and return the
same to the proper storage area after each meeting.
He /she shall act as sergeant -at -arms at meetings, see
that those present are properly seated, and distribute
bulletins, favors and literature as required at club and
board meetings. He /she shall give special attention to
assure that each new member sits with a different group
at each meeting so that he /she can become better ac-
quainted.
no member shall be fined more than twice at any one
meeting. The tail twister may not be fined except by
the unanimous vote of all members present. All monies
collected by the tail twister shall be Immediately turn-
ed over to the treasurer and a receipt be given therefor.
(8) MEMBERSHIP DIRECTOR: The membership
director shall be the chairman of the membership com-
mittee. The responsibilities for this position shall be:
(a) Development of a growth program specifically
for the club and presented to the board of direc-
tors for approval.
(b) Regular encouragement at club meeting to bring
In new quality members.
(c) Ensuring proper recruitment procedures.
(d) Preparation and implementation of orientation
I sessions.
(e) Reporting to the board of directors on ways to
reduce the loss of members.
(f) Coordination with other club committees In fulfill-
ing these responsibilities.
(g) Serving as a member of the zone level member-
ship committee
ARTICLE VIII
Board of Directors
Section A. The members of the board of directors
shall be the president, Immediate past president, the
vice presidents, secretary, treasurer, Lion tamer, tail
twister and all elected directors.
Section B. Regular meetings of the board of direc-
tors shall be held monthly at such time and place as
the board shall determine.
Section C. Special meetings of the board of direc-
tors shall be held when called by the president, or when
requested by five (5) or more members of the board
of directors, at such time and place as the president
shall determine.
(7) TAIL TWISTER: He /she shall promote harmony, Section D. The presence in person of a majority of
good fellowship, life and enthusiasm In the meetings its members shall constitute a quorum at any meeting
through appropriate stunts and games and the judicious of the board of directors. Except as otherwise specifical-
Imposition of fines on club members. There shall be ly provided, the act of a majority of the directors pre -
no ruling from his /her decision In im osin a fine, pr - t arting� boall t� act
00 h64What � sh ed Wts, ion 67717e entire oard 6T dFrectors.
M MM M M M M M s M M M m m m M M No am
returned, and all right to the use of the name "LIONS,"
the emblem and other insignia of this club and this
association have been surrendered.
ARTICLE VI
Forfeiture of Membership
Section A. The secretary shall submit to the board
of directors the name of any member who fails to pay
any Indebtedness due this club within 60 days after
receipt from the secretary of written notice thereof. The
board shall thereafter decide whether the member shall
be dropped from or retained on the roster.
Section B. Any member may be expelled from the
club for cause by a two- thirds vote of the entire board
of directors.
Section D. DUTIES.
(1) PRESIDENT: He /she shall be the chief executive
officer of this club; preside at all meetings of the board
of directors and this club; Issue the call for regular and
special meetings of the board of directors and the club;
appoint the standing and special committees of this
club and cooperate with chairmen thereof to effect
regular functioning and reporting of such committees;
see that regular elections are duly called, noticed and
held; and cooperate with, and be an active member of,
the district governor's advisory committee of the zone
In which this club is located.
(2) IMMEDIATE PAST PRESIDENT: He /she and the
other past presidents shall officially greet members and
their guests at club meetings and shall represent this
club in welcoming all new service- minded people in the
community served by this club.
Section C. The name of any active member who shall
absent himself /herself from four consecutive regular
meetings of the club, without acceptable cause being
given to the attendance committee chairman or the club
secretary, shall be submitted to the board of directors
by the secretary at the board meeting next following
the fourth such absence, and the board of directors
shall direct the attendance committee to investigate the
reasons for the absences and report Its findings to the
board. The board shall thereafter decide whether the
member shall be dropped or retained.
ARTICLE VII
Officers
Section A. The officers of this club shall be a presi-
dent, immediate past president, first vice president, se-
cond vice president, third vice president, secretary,
treasurer, Lion tamer, tall twister and all directors.
Section B. No person shall be eligible to hold office
In this club unless he/she is an active member in good
standing.
Section C. No officer shall receive any compensa-
tion for any service rendered to this club in his /her of-
ficial capacity with the exception of the secretary,
whose compensation, if any, shall be fixed by the board
of directors.
(3) VICE - PRESIDENTS: If the president is unable to
perform the duties of his /her office for any reason, the
vice president next in rank shall occupy his/her posi-
tion and perform his /her duties with the same authori-
ty as the president.
Each vice president shall, under the direction of the
president, oversee the functioning of such committees
of this club as the president shall designate.
(4) SECRETARY: He /she shall be under the super-
vision and direction of the president and the board of
directors and shall act as the liaison officer between
the club and the district (single or sub- and multiple)
in which this club is located, and the association. In
fulfillment of this, he /she shall:
(a) Submit regular monthly and other reports to the
international office of the association on blanks
provided by it containing such information as
may be called for therein and otherwise by the
board of directors of the association;
(b) Submit to the district governor's cabinet such
reports as it may require Including copies of
regular membership and activities reports;
(c) Cooperate with and be an active member of the
district governor's advisory committee of the
zone in which this club is located;
(d) Have custody and keep and maintain general
records of this club, including records of minutes
of club and board meetings; attendance; com-
mittee appointments; elections; classifications
(if any); addresses and telephone numbers of
members: members club accounts-
2. Include a narrative explanation of how the administrative duties are separated and explain the responsibilities of each individual in the
I, chief executive officer of
(sig ture) (name of organization)
verify that thi i above information conforms in all respects to the objectives of internal control as outlined by state law and Gambling Control Board rules.
Attach to the Organization License Application or submit within 10 days of any change in information.
Gambling Control Board
Rosewood Plaza South, 3rd Floor —1711 W. County Road B
Roseville, MN 55113 '
Gaming Operations Internal Control (continued)
Responsibility of:
Title:
Action
10. J AM aS S ly SS
G M
Removes and retains any unsold and defective tickets.
11. gMgr SASS
co /✓
Counts total cash in the cash drawer separating the normal starting bank
from the net balance.
'
12.
G Nf
Deposits and records net balance cash or secures it until it can be
deposited.
13. . P, It Tp
Removes receptables and snores them in a secure area at the dose of the
,
day.
14. 11 794 .Se //e
S
Checks serial numbers on a winning ticket to the game being played.
If the serial numbers do not match, does not pay the winner.
,
Fund Control and Record
I. J R M 'eS
Audits all closed games and records information on schedule B for the
'
monthly tax report
Fund Omtroi and Record - Bingo
'
1.
Fills out bingo report forms for each occasion.
_
2.
Conducts bingo accordng to the rules. Complies with prize limits.
Verifies that for bingo
'
3.
one or more checkers are used each occasion.
4.
Verifies and records serial number of winning bingo card for prize of $100 or
more.
'
Accounting — Monthly Reports
I. J AM '-S SA SS
(treasurer
M .
of organization may not account for gambling funds)
Maintains gambling bank accounts.
'
Id
4ACj'- S'pA In y
2. 14,60 ZS S& s
Signs all checks from gambling checking account.
3. ) AM ES SAars
G M
Maintains deposit records.
'
4. J AM e-5 S1
G M
Maintains expense records.
5. 4,994,'5 Sle S
C 14
Reconciles and maintains monthly bank statements.
'
6. J a A-16tS S /o rr
G Aef
Prepares monthly tax returns for each site (Schedule A: Site Accounting)
and a combined tax return for all locations.
j
7. JAM BS SA r S
Prepares and presents monthly reports to members.
,
8. Ca M 6 L o Gc •r+ ,wff& - c
G C
Prepares and presents list of proposed allowable expenses and lawful
purpose expenditures to members for authorization. Prepares Schedule C and D
for monthly tax report.
'
9. AM8 S _ 7�
Se C - 4
Records authorization in the minutes of the organization.
10. Ja m x S S, S'S
G M
Investigates variances and documents reasons for these variances.
'
REQUIRED ATTACHMENT
-- Administrative Controls
1. Include diagram or illustrated flowchart showing how your organization is structured. This organizational chart should show who reports to
whom and how the chain of command is set up.
2. Include a narrative explanation of how the administrative duties are separated and explain the responsibilities of each individual in the
I, chief executive officer of
(sig ture) (name of organization)
verify that thi i above information conforms in all respects to the objectives of internal control as outlined by state law and Gambling Control Board rules.
Attach to the Organization License Application or submit within 10 days of any change in information.
Gambling Control Board
Rosewood Plaza South, 3rd Floor —1711 W. County Road B
Roseville, MN 55113 '
LG200B
(7126192)
Minnesota Lawful Gambling
Organization Officers Affidavit
' STATE OF M/ Arw ,e-so T/1 ) AFFIDAVIT OF QUALIFICATION
S.S. OF OFFICERS FOR
ORGANIZATION LICENSE
COUNTY OF C!4 V .�%? ) AND CONSENT STATEMENT
(Pursuant to Minnesota Statute 349.16, Subd. 2e)
/?c b rN s a .. i , under oath state that within the previous
' (type/print name) five years:
1. I have not been convicted in a federal or state court of a felony or gross misdemeanor,
2. I have never been convicted of a crime involving gambling.
n
LI
3. I have not had a license issued by the Lawful Gambling Control Board or Director revoked for a
violation of law or board rule.
In addition, I understand, agree and hereby irrevocably consent that suits and actions relating to the subject matter of the
organization license application, or acts or omissions arising from such application, may be commenced against my
organization and I will accept the service of process for my organization in any court of competent jurisdiction in
Minnesota by service on the Minnesota Secretary of State of any summons, process or pleading authorized by the laws of
Minnesota.
By signature of this document, the undersigned authorizes the Department of Public Safety to conduct a criminal
background check or review and to share the results with the Lawful Gambling Control Board.
Failure to provide required information or providing false or misleading information may result in the denial or revoca-
tion of the license.
FURTHER AFFIANT SAYETH NOT, except that this Affidavit and Consent Statement are submitted in support of the
application for an organization license from the Lawful Gambling Control Board.
NOTARY PUBLIC INFORMATION
N otary Public Seal must be current and correct.
Seal may = be altered.
Subscribed and sworn to before me this
day of M 04"11.x -1 19
Notary Public
JAMES C. HAUGEN
NOTARY MIC MINNESOTA
HENNEPIN COUNTY
MY Comm. Expires Sept. 16, 1997
of app licant)
APPLICANT INFORMATION
Chief Executive Officer ❑ Treasurer
Effective date of officer change 7 / 1 / 94
Home Address
202 WEST 77TH STREET
City
CHANHASS
State Zip
M1 55317
Phone
612 ) 934 -6069
Date of Birth
3 -10 -37
Name of Organization
LIONS CLUB OF CHANHASSEN
License Number
LG205
(Rev. 6/1 1/92) Minnesota Lawful Gambling
Lawful Gambling Compensation Schedule
Name of organization License Number
416 Avs GAS /1; 9
bus ine s addr organization not use address of gambling manager
Street City State Zip Code
/y U, L l G A 1411 4 A
Name of chief executive officer Title Business phone number
.)1 mil; S i I dl J_ G Q - •/G 4q
The following compensation schedule has been approved by the organization. If employees are volunteers, indicate $0.
Position Amount to be paid
Per bingo occasion QR Per hour QH Other
Indicate rate of pay,
E� month
� week
year
E: other
Gambling Manager $
Assistant Gambling Manager, $
if any
BINGO Caller
Checker(s)
Sales -paper
Collectors (hard cards)
Other (identify)
OTHER THAN BINGO
$
$ /0_00 $
a
0 .
Signature of chief ex Live o cer Da
" 7
q
Attach to the Organization icense Appl anon or submit within ten days of any change in information. Mail to:
Gambling Control Board
1711 W. County Rd B, Suite 300S
Roseville, MN 55113
t
Q1Nl/V 9 !`r�El�
C
o b-
u
gX i
J
rF= -------------
oQ
T
Scenario I Exhlbli F
a
I
U
LG200 B
(7/28/92)
Minnesota Lawful Gambling
Organization Officers Affidavit
,
STATE OF AFFIDAVIT OF QUALIFICATION
S.S. OF OFFICERS FOR
ORGANIZATION LICENSE
COUNTY OF _dip v E/i' ) AND CONSENT STATEMENT
(Pursuant to Minnesota Statute 349.16, Subd. 2e)
nn r
I, J a L/ 's 4 a Yi R , under oath state that within the previous
(typelprint name) five years:
1. I have not been convicted in a federal or state court of a felony or gross misdemeanor.
2. 1 have never been convicted of a crime involving gambling.
3. I have not had a license issued by the Lawful Gambling Control Board or Director revoked for a
violation of law or board rule.
In addition, I understand, agree and hereby irrevocably consent that suits and actions relating to the subject matter of the
organization license application, or acts or omissions arising from such application, may be commenced against my
organization and I will accept the service of process for my organization in any court of competent jurisdiction in
Minnesota by service on the Minnesota Secretary of State of any summons, process or pleading authorized by the laws of
Minnesota.
By signature of this document, the undersigned authorizes the Department of Public Safety to conduct a criminal
background check or review and to share the results with the Lawful Gambling Control Board.
Failure to provide required information or providing false or misleading information may result in the denial or revoca-
tion of the license.
FURTHER AFFIANT SAYETH NOT, except that this Affidavit and Consent Statement are submitted in support of the
application for an organization license from the Lawful Gambling Control Board.
NOTARY PUBLIC INFORMATION
N otary Pubbc must current and correct.
Seal may = be altered.
Subscribed and sworn to before me this
day of 19
Notary Public
(signature of applicant)
APPLICANT INFORMATION
Chief Executive Officer Treasurer ❑
Effective date of officer change
Home Address
a 9t.
City
/''/ /"/ N Z7f 1 r
State Zip
W A -1
Phone ( /)—)
Date of Birth 7
�7
Name of Organ zati on
License N ber
0 0 act S
CHANHASSEN LIONS ROSTER
Sz �.gS�
i
1 JULY 1994
'
1
Last
First
Spotse
Street
9!Y-
ST
ZIP
Nome
ofrk
Anniv
Sponsor
Q Benson
Harry
7101 Tecumseh La.
Chanhassen
Mn
55317
4748746
Mar92
JVOght
?Bongard
Wayne
Cindy
8831 Audubon Rd.
Chanhassen
Mn.
55317
448 -6339
474 -5282
Nov88
Charter
4 Borg
Gene
Doreen
6897 Chaparell La.
Chanhassen
Mn.
55317
434 -5954
934 -8530
Nov88
Charter
- QBoyle
Gary
Kay
7214 Frontier Tr.
Chanhassen
Mn.
55317
934 -7617
540 -7529
Nov88
Charter
� Brown
Gary
1831 Koehnen Circle
Excelsior
Mn.
55331
474 -2437
934 -2155
Nov88
Charter
Chadderdon
Ozzie
Joan
760 Cree Dr.
Chanhassen
Mn.
55317
474 -4064
Oct89
P.DiKerding
Coffee
Charlie
Bonnie
7474 Saratoga Dr.
Chanhassen
Mn.
55317
934 -6757
844 -5000
Nov88
Charter
Congdon
Jim
Cindy
1079 Bluff Point Dr.
Chaska
Mn.
55318
448-6156
937 -8736
Nov88
Charter
P Cook
-1° Daniel
Brian
John
Barbara
6539 Countryside Dr.
Eden Prairie
Mn.
55346
934 -4619
844 -7657
Mar92
C.Robinson
Char
7478 Saratoga Dr.
Chanhassen
Mn.
55317
934 -0206
Nov"
Charte
� Differding
Erickson
Paul
Ellen
7228 Frontier Tr. 4,5-7,5_1V-, Chanhassen
Mn. 55 17
V CM
932 -2608
Nov88
Charter
Earl
Judy
Mn.'
_
Nov90
E.Ginsbach
Ginsbach
Ed
Lirxla
7381 Longview Circle
Chanhassen
Mn.
55317
934 -4897
938 -1900
Jan89
Charier
Gossard
Phil
Beyerly
901 Carver Beach Rd.
Chanhassen
Mn.
55317
474 -5629
934 -0789
Nov88
Charter
P Gunn
Bill
Laurie
1490 Haron Dr.
Chanhassen
Mn.
55317
368 -3880
Jan90
Transfer
Haugen
James
Kama
Americana Bank 600W791h St.
Chanhassen
Mn.
55317
443 -3288
937 -9596
Feb93
J.Spakiing
Q Hectome
Dan
Barbara
491 Indian Hill Rd.
Chanhassen
Mn.
55317
474 - 1507
645 -3988
Jan89
Charter
.� Herbst
Dan
Karen
7640 Crimson Bay
Chaska
Mn.
55318
4745031
Nov88
Charter
Janahosky
Bill
Jean
8105 Dakota Lane
Chanhassen
Mn.
55317
934 -5558
937 -8192
Jan94
J.Sloss
Killian
Jim
Debbie
2010 Wbodstone Dr.
Victoria
Mn.
55386
443 -2397
Nov90
G.Boyle
Larson
Ken
6911192nd Ave. W.
Eden Prairie
Mn.
55346
949 - 9394
Oct90
J.Daniel
.Q Lillie
Pete
George Ann
9355 Klowa Tr.
Chanhassen
Mn.
55317
496
496 - 0714
0082
Transfer
MacAlpine
Mal
Lois
7187 Frontier Tr.
Chanhassen
Mn.
55317
934 -4210
Nov88
Charter
Masterson
Steve
Roste
8031 Erie Ave.
Chanhassen
Mn.
55317
934- 3187
544 -6463
Mar92
J.Wright
.� McCallum
Wes
Cheryl
418 Oak Hill Rd.
Chaska
Mn.
55318
448 -6535
934 -5705
Dec93
C. Robbins
Q Meuwissen
Howard
Jean
406 Highland Dr.
Chanhassen
Mn.
55317
934 -8120
Dec88
Charter
Moore
Terry
Lynn
15811 Village Woods Dr.
Eden Prairie
Mn.
55347
937- 8078
544 -9533
Feb93
G.Borg
Murray
Robert
Nora
Festival Foods 7900k4arketOlvd
Chanhassen
Mn.
55317
861 -7854
934 -1010
Feb93
E.Ginsbach
,"Osi
Chuck
Sharoyl
16461 Ellerdale Ln.
Eden Prairie
Mn.
55346
949 -2482
Jan89
Charter
, Peterson
Randgaard
Bob
Jerry
Pat
Jennie
18226 Cascade Dr.
Eden Prairie
Mn.
55347
934 -2286
Nov88
Charier
408 Dal Rio Dr.
Chanhassen
Mn.
55317
994 -7386
546 -9000
Nov88
Charter
-Q Robbins
-Q Robinson
Charlie
Curl
Jean
7340 Longview Circle
Chanhassen
Mn.
55317
934 -0209
4?1 — rp Nov88
!�
Charter
Nancy
202 W77 St.
Chanhassen
Mn.
55317
934 -6069
U
Aug89
J.Wrighl
Roos
Roman
Peggy Jo
1727 Greencrest Dr.
Victoria
Mn.
S5386
443 -3206
41 f47&3
Nov88
Charter
Somerville
Steven
Hied
392120th Av. S.
Minneapolis
Mn.
55407
729 -5042
934 -4500
Jut 94
R.Roos
Sj Siegel--
Bob
Judy
411 Highland Dr.
Chanhassen
Mn.
55317
934 -4713
Jan93
J.Spakiing
Sloss
Jim
Jean
9360 Klowa Tr.
Chanhassen
Mn.
55317
445 -0970
928 -1460
Dec90
P.LiNIe
Spalding —
Jack
Carol
2501 County Rd 92
Minnetrisia
Mn
55359
418 -1649
Nov88
Charier
Stedman
Dents
Mary
415 Santa Fe Circle
Chanhassen `
Mn.
55317
934 -5570
Aug91
G.Boyie
Tester
David
MaryAnne
3897 Lone Cedar Lane
Chaska
Mn.
55318
474 -6527
934 -7990
Nov88
Charter
Townsend
Joey
8043 Erie Av. S.
Chanhassen
MN.
55317
937 -6060
470 -3580
Jut94
P.Liilie
i
r r�r r r r r r r r r r r r r r r r am ON
� 'y ^ �'G., l.. �. . �.._ ,, i` �'tr4. r
CHANHASSEN
LIONS ROSTER
1 JULY 1994
Vetter
Lowell
Judy
404 Highland Dr.
Chanhassen
Mn.
55317
934 -9301
934 -6397
Jan93
J.Spalding
Sl Vik
Brian
Buffy
18632 Jaques Cl.
Eden Prairie
Mn.
55346
934 -7881
449 -2010
JU94
D.Hectorne
f! Vohs
Jim
Pam
9576 Crestwood Terr.
Eden Prairie
Mn.
55347
934 -5500
Aug91
J.Spalding
Wallentiny
Paul
Mary
7030 Alpine Tr,
Eden Prairie
Mn.
55347
937 -2994
937 -2994
Jan89
Charier
Way
Jim
Jean
6641 Minnewashta Pky
Excelsior
Mn.
55331
474 -6310
944 -8040
Nov90
S.Danlel
Weidner
Erich
Judy
7031 Red Wing Ln.
Chanhassen
Mn.
55317
470 -1309
Jun90
P.DfPferding
Q Westbrock
Jack
7335 FrontlerTr.
Chanhassen
Mn.
55317
937 -0478
Nov88
Charter
Wright
John
Nan
64aol;ass44�-
Mn.
5fY -
93+&+e-7
441 -3121
Jan89
Charter
u` eSs Arl� ]�r.
�r'.
✓`'3`NF
g7S 18��
� /23
,�(evt
� 'y ^ �'G., l.. �. . �.._ ,, i` �'tr4. r
Minnesota Gambling Control Board
Worksheet for Lawful. Gambling Expense Calculations
For expenses incurred beginning June 1, 1991
Fonn G•1W Include total expenses from all silos oporntod by your organization. Put negative numbers In parentheses.
Organization name TTM License number
G 4 A-+,1%,�x5 -5 E"1J L - DZ 9 S4
A
B
C
D
E
F
G
H
I
J
month
and
year
net receipts
from
line 10 c
monthly return
multiply
column B
by
.5 150 'y.
net
bingo receipts
from fine 1 c
monthly return
multiply
column D
by
.04 4%
add
column C
and
column E
allowable
expenses
from line 35
monthly return
subtract
column G
from
column F
amount from
column J
for
last month
add
column H
and
column I
q4
q 4-
006 ��
5 030 s -�
S ID
So3o
1?
3 !
-1
Ft 4 . So
RA-
a9
3 � s
^_ 3S� rr
3 9bgs%
— Ss� s =
I f q
7I6
3 S�o -
(o ,F(fl ° �
- 3aFt`�
-r4 0
4ao�ao
So �a '
�S�'l w
541 S �
4 ao�
4qs_°-
36 7 =
0
46 �3- _
Q6 ?3 .-
4� 9v °�
- /ob s
4- 7 4-�js °
x}643 �-
(oo 0, 51)
X ��
l4 --
/sd s
46
57q y
4
S
1
i
If the first month you ors roporting on this form is June 1991, IN In the amount for May 1991 here (from column L of your previous worksheet).
Mall this worksheet together with your application for renewal of your lawful gambling license to:
Minnesota Gambling Control Board
1711 Wool County Road n, suite 30o s, nosevllle, MN 55113
11002030 (dg..` Do not mail to P of nevenue
a
_ ' nnesola�'a`mbling Control D d M M M M M MW aft
•Worksheet for Lawful Gambling Expense Calculations
For expenses incurred beginning June 1, 1991
Form G - Include total expenses from all sties operated by your organizadon. Put negative numbers In parentheses.
Organization name License number
—.� 9 s 4
E
i
Z
y
l
A
B
C.
D
E
F
G
H
month
and
year
net receipts
from
line 10 c
monthly return
multiply
column 0
by
.5 50%
net
bingo receipts
from line 1 c
monthly return
multiply
column D
by
.04 4`y.
add
column C
and
column E
allowable
expenses
from Nne 05
monthly return
subtract
column G
from
column F
amount from
column J
for
lest month
add
column H
and
column I
67 8s 00
33ga.50
33 N. So
Sa I ov
�l ��8.s0
-'
�lv /o•
!�
7,
3Q3� ° —°
3�1 .3� v—G-
3gvs'
33. °
Sb
1 �q8_
Sam
l�'6S —
9
Y�53 —
4ia6 S
416
SJJ �°-
t70/ ✓
i86SS�
3567 —
1q3
!3-565
12- �°
Soog =
!7 72 S'
3567 s1
/7 3 So
13,-44=
66aa�
66da
S4QS=
/1�7%
/793
�66 �o
I q
14(,07 0
72 d3 =°
- 73 d .? S °
s 3 (tD =
ya3 s -=
666""
/
��9-�
(,an�
Poo4�
�ob4°O
06
°
d4
3fi10 °—'
'I l q,3
I a- "7Sa -
6376
4376
534-1 "
�oSS=
3
+ FMS .=
00
6 4.6
4,?6S —'
6 !
a 0 —
6DDS
6 a o.S... °
SSS 3 D°
4-6 oL °=
6
L) I 4—
I
t►9
aboS
=4
530-
S30 s
+7 a7
5767
6bSo=
7a4S -
rq 4 -
J,, 6 3 �°
ss�i so
P
s S � 1 S°
q -7 �°
70 ? =° 1
7 4 aS
Mall this worksheet together with your application for renewal of your lawful gambling license (o:
Minnesota Gambling Control Board
1711 West County Road B, Sufis 000 S, Roseville, MN 55110
OD02030 (b101)) Do not mall to Department of nevenve
i
N
4.