1m. Chan Lion Club Gambling App 1 int,.
• CITY OF --
1 .,
1040.-- 690 COULTER DRIVE • P.O. BOX 147 • CHANHASSEN, MINNESOTA 55317
1 (612) 937 -1900 • FAX (612) 937 -5739
1 MEMORANDUM
1 TO: Don Ashworth, City Manager "
FROM: Scott Harr, Public Safety Director
1 DATE: March 3, 1993
1 SUBJ: Chanhassen Lions Club Gambling Application
1 This memo is to respond to the license application for gambling from the Chanhassen Lions
Club. The background investigation I have conducted reveals no reasons that the license
should be denied. The application does meet the requirements of our city ordinance
I regarding gambling within Chanhassen. I have provided the Lions Club with a copy of our
ordinance regarding local requirements.
1 Attached is a resolution approving the permit. It is the recommendation of staff that this
permit be approved.
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1 to PRINTED ON RECYCLED PAPER
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City of Chanhassen
Carver and Hennepin Counties, Minnesota
' DATE: RESOLUTION NO:
MOTION BY: ` SECONDED BY:
1 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 for their location at 401 W. 78th Street.
NOW, THEREFORE, BE IT RESOLVED by the Chanhassen City Council that the
gambling permit application as submitted by the Chanhassen Lions Club is hereby approved.
Passed and adopted by the Chanhassen City Council this 22th day of March, 1993.
1 A "1'FEST:
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Don Ashworth, City Clerk /Manager Donald J. Chmiel, Mayor
YES NO ABSENT
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FOR BOARD USE ONLY
LG200A
Rev. (7/28/92)
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Minnesota Lawful Gambling
Organization License Application - Part 1
Organization Information .
Legal Name of Organization Other names used
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L -/ c/4S c c. c/6 0 F C f-tfl- rJ HASSC!v / ,
Business Address of Organization - Street or P. 0. Box (Do not use address of gambling manager) (IBusiness iD Numessiast sw.+ Use Tax Parrot)
PO LC 4 ? L f 1 .. /1347i t
CV Stale Zip Cone County Business phone number I
t- - /■, / i, •/:.f t % ,4 k v = R. ( ) —
Name of chief executive officer Tide I Date of birth Business phone number
Last Name First Name Middle Name Maiden Name
CIA.iS AC- H c D /4R2) Lec Pis /Deiv ; 'fY) ?3i l 1 e c 1
Address of chief executive officer - Street or P. 0. Box Date CEO attended Gambling Manager Seminar
7 -3r/ LvnVG-V e c' e %1ii-v' /1 ,r;2, / °I 3
City State Zip Code County
Name of treasurer or person responsible for organization's other revenues Title Date of birth Business phone number
Last Name First Name Middle Name Maiden Name
/ 4 0 t 3 i C,Ai C- vK7"1s CAr:L 7 t t s X 6 K 3 // / ( 2 1 r44 , a
Type of Nonprofit Organization: G Fraternal 0 Veterans 0 Religious X,ptiher nonprofit
Number of years organization has been in existence as a nonprofit organization t
I
Attach a copy of a certificate of good standing as a nonprofit organization from the Minnesota Secretary of State's office and/or a letter from
the IRS declaring income tax exemption. (Do not send a sales tax permit or Federal employer identification information)
Number of Active Members 't J (must be age 18 and older). Attach a membership list to this application.
When does your organization hold regular meetings? Day (s) 4 /7 - Al (,..74.)ft CI t " : f " ' C • r"=-f Hours 6 + 3 AA - ?;..30 ftti
Type of Application
Class of Organization License
Check the boz that most
❑ Class A — Bingo, Raffles, Paddlewheels, Tipboards, Pull-tabs accurately summarizes the
IS Class B — Raffles, Paddlewheels, Tipboards, Pull -tabs gambling at all of your premises.
❑ Class C — Bingo only The organization license must
❑ Class D — Raffles only reflect all forms of gambling
conducted by your organization.
Status of License - check one:
X Organization has never been licensed.
❑ Previously expired license — Fill in complete license number
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Refer to the Instructions for the required attachments. REMINDER: The organization's chief executive officer and I
treasurer must complete the Organization Officer Affidavit, form LG200B.
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Minnesota Lawful Gambling
Organization License Application, LG200 A - Part 2
' Lawful Purpose Expenditures (Minn. Statute 349.12 Subd.12)
Please list the lawful purpose expenditures for which your organization will expend gambling funds. (Refer to Minn. Statute
349.12 Subd.25.) Give specific examples.
' L 0 G f} L Pr1A KS l`T / 4) PL F, Y o vA/>_s
F (g E p c ice. 7)E,A -K2 7 /N/E TS
' I'v J77-1 A-774 LET! CS
Sc oc A,. s i- i PS
Gambling Manager
er 9
Name of organization's gambling manager Address City State Zip Code
, k.hA i 5 E , q3 6o (< 172,4 is Ci4-4nI µ ,4SSC: J Mn „.l'3 (7
Organizational Income and Activities (Attach additional sheets if
' List other activities through which your organization raises funds.
O cTC Bei F6ST
-r vgi\je
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' In comparison with funds you raise as a nonprofit organization, what is the percent of funds you will raise through lawful
gambling? - 7 U
What other activities does your organization engage in (not fundraising activities)? C.4 0A/ /T SC A V /C‘
Acknowledgement
I declare that:
1 • I have read this application and all information submitted to the board;
• All information is true, accurate and complete;
• All other required information has been fully disclosed;
• I am the chief executive officer of the organization;
• I assume full responsibility for the fair and lawful operation of all activities to be conducted;
• I will familiarize myself with the laws of Minnesota governing lawful gambling and rules of the board and agree,
if licensed, to abide by those laws and rules, including amendments to them;
• A membership list of the organization is attached to this application;
• Any changes in application information will be submitted to the board and local government within 10 days of
the change; and
• A termination plan will be submitted to the board within 15 days of termination of all premises permit(s).
• 1 certify that the gambling manager is bonded and licensed as required per Minnesota Statute.
• Failure to provide required information or providing false or misleading information may result in the denial or revocation of
the license.
S'�re of Chief ecutive • r Date
c a / //‘/r .
Mail to: Gambling Control Board
Suite 300 S.
1711 W. County Road B
Roseville, MN 55113
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I LG202
(10/28/92)
Minnesota Lawful Gambling
i Lease Agreement
Premises Information . .
1 flame and Address of Lessor Address C /Zip Cod Phone
I "Li.s 611k fR es oPt nh",i' c--, W, 7tTH ST, c ( ct 1 93 y-, 303 0
Name of Legal Owner of Gambling Premises Address City/Zip Code Phone
C4 "r i 118 6 -a. O S I
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f-tE�!l2Y A- r ,%i -,' ft/JcFFoQ Pa 'Air RD. Hcr2� 6 z ( ) qa
Name and Address of Leased Premises Address 7Zlp bode
1 Name of Organization Leasing the Premises (lessee) License Number, if known
L40/4S CcvB of ct.tot,Jrtftss6 ,0 /,Jc-. 4-Ph_t D fo4.
1 Gambling Activity
The lawful gambling activity which the organization will conduct is (check all that apply):
1 = bingo C] raffles 0 paddlewheels pull - tabs CD tipboards
Rent Information (See Rules 7861.0060, Subp 2D)
Class A and C premises permits: Class B and D premises permits:
Rent for bingo and all other gambling activities conducted Rent for gambling activities not including bingo
during that bingo occasion may not exceed: is a maximum of $1000 per month.
$200 for up to 6,000 square feet;
I $300 for up to 12,000 square feet; and
$400 for more than 12,000 square feet.
Rent to be paid per bingo occasion $ Rent to be paid per month $ t o DO, O 0
1 Rent may not be based on a percentage of receipts, profits from lawful gambling, or on the number of
participants attending a bingo occasion.
I An organization may not pay rent to itself or to any of its affiliates for space used for the conduct of lawful gambling.
Premises Description
The area(s) leased within the premises are / / feet by /'- feet, for a total of /C. A'' square feet.
feet by feet, for a total of , square feet.
I feet by feet, for a total of square feet.
I Combined total square feet
I Sketch
Attach a sketch which shows the location and dimensions of the leased areas.
Effective Dates . _.
I The lease will go into effect at 12:01 a.m. on _VI 19 73 , and will end at 12:00 a.m. on 3 3j. _/-
19 (1- ,: for a period of at least one year. .
Times and Days of Bingo Activity. (tf none,andicate WA) N/A
The bingo occasions will be held (a maximum of 7 bingo occasions per organization):
from (hours) ( a.mJp.m.) to r •-_� ( a.mJp.m.) on (days of week) + • .. .
from (hours) . : ( a.mJp.m.) to „,„,,_ _ . . ( a.mJp.m.) on (days of week) — '
1 from (hours), • _ (a.mJp.m.) to r ( a.mJp.m.) on (days of week) `
from (hours) , • ta.mlp.m.) to ( a.mJp.m.) on (days of week)
1 from (hours) (a.m. /p.m.) to ( a.mJp.m.) on (days of week)
from (hours) (a.mJp.m.) to (am /p.m.) on (days of week)
1 from (hours) (a.m. /p.m.) to ( amJp.m.) on (days of week)
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By agreeing to the terms of this lease, it is mutually agreed that:
• When leasing from a licensed bingo hall, the lessor must be legal owner of the property. 1
• The owner of the property or the lessor may not manage gambling at the premises.
• The lessor of the premises, his or her immediate family, and any agents or employees of the lessee may not
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participate as players in the conduct of lawful gambling on the leased premises.
• The lessor and the lessee do not have a direct or indirect financial interest in the distribution or manufacture I
of gambling equipment.
• The lessor of the premises will allow the Board or agents of the Board, the Commissioner of Public Safety or
agents of the commissioner, or the Commissioner of Revenue or agents of the cornmissioner, and law
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enforcement personnel to inspect the premises at any reasonable time, and permit the organization to
conduct lawful gambling at the premises according to the terms of this lease. The lessor may not impose any
conditions on the organization regarding distributors of gambling equipment, services, or the use of profits.
• The organization must obtain an organization license, gambling g manager license and a premises permit from the
Gambling Control Board. The organization will be responsible for complying with the laws and rules of lawful
gambling.
• The organization must have, at the gambling premises, a current inventory of gambling equipment, a sketch with
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dimensions of the premises available for review, and a clear physical separation or divider between the lessee's
gambling equipment and the lessor's business equipment.
• The organization will be responsible for ensuring that the lessor's business activities are not conducted on the
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leased premises.
• The lease shall be terminated immediately for any gambling, liquor, prostitution or tax evasion violations occurring
on the premises.
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• The lessor of the premises shall provide the lessee access to the licensed premises during any time reasonable
and necessary to conduct lawful gambling on the premises and as agreed upon in this lease. I
• (Write in any other conditions or restrictions that will be included as part of the lease. Attach additional sheets if
necessary)
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This lease is the total and only agreement between the lessor and the organization conducting lawful gambling activities.
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There is no other agreement and no other consideration required between the parties as to the lawful gambling and other
matters related to this lease. Any changes in this lease must be submitted to the Gambling Control Board within 10 days
of the change. __ _. _ _ _
Signature • f L = - sop ' sate Sig - ture of or • = nization icial (le , _) Date I
L ..r. / 4' 2 4 49 1/i / id' iit' A. ' _,., �. CD 99
Title" , �� 7 Tttl / - ' - / /
A cony of this lease and sketch with dimensions must be submitted with the premises permit application renewa or when
changes in the lease occur to:
- Gambling Control Board I
1711 W. County Road B, Suite 300 S
Roseville, Minnesota 55113 I
(10/28/92)
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FOR BOARD USE ONLY
LG214 BASE*
(7/2241) PP # 1
FEE
Minnesota Lawful Gambling CHECK
INITIALS
Premises Permit Application - Part 1 of 2 I
DATE
I:K.::: ' - -- .:K. - % .:- ... .::: , ...*..:s:::::-.::::•Eminr , ?-* , :-..f:.,, :x:::-::::::::::::::: - — - 1
P 0.tApPaccelitcgi2101:2,1161111iiiiiiillindigia..;:::::!:
Cass of premises permit
E l Renewal (check one)
Organization base license number 0 A ($400) Pull-tabs, tipboards, paddlewheels, raffles, bingo
Premises permit number 0 B ($250) Pull-tabs, tipboards, paddlewheels, raffles
New
i t C ($200) Bingo only 1
El D ($150) Raffles only
Organization 14:t0r*:4#014
Name of Organization
‘-teAf-s c-Lyg O, C4441.1i I AssEtv , IA 1 c-,
Business Address of Organization - Street or P. 0 Box (Do not use the add of your gambling manager)
e 0 00x (
City State Zip Code County Daytime phone number
C 1
- t4 A /■/ H ASS A/ A/ A ,r,r3 (7 cA-levEg ( ) ---
Name of thief executive officer (cannot be your gambling manager) Title Daytime phone number
6 z-, G ,A.er 1)6 NI 417.4 /3r—itc1
Bingo Occasions
If applying for a class A or C permit, fill in days and beginning & ending hours of bingo occasions:
No more than seven bingo occasions may be conducted by your organization per week.
Day Beginning/Ending Hours Day Beginning/Ending Hours Day Beginning /Ending Hours I
to to to
to to to
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— to If bingo will not be conducted, check here I:2i
i -Oaniti)frg t 7: .... ..:.:,;;;„... :17 .::::.::::::. 1 .... , I
Name of establishment where ambling will be conducted ..... .... Street Address (do not use a PosfaffiPe i
PAIII—Y=S gale 4 - gegrAURA"Pr, 0 /4C. 4 7 1 0( (Ai , 7$711 Cr, e ileltiH 11-o/ . .r.r..3 /7
Is the premises located within city Omits? j'iti Yes C3 No If no, is township Erj organized i= unorganized = unincorporated
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City and County where gambling premises is located OR Township and County where gambling premises is located if outside of city limits
CHAIJ tiet5Serj 7C Rit.V6/Z.. I
Name and address of legal owner of premises City State Zip Code
te ' , i • 1/1 •
, , , ....,
Does your organization own the bu ding where the gam • sng 'II be conducted? C=3 YES pt NO
If no, attach the following:
• a copy of the lease (form LG202) with terms for at least one year.
• a copy of a sketch of the floor plan with dimensions, showing what portion is being leased.
A lease and sketch are not required for Class D applications.
•:•
Address of storage iiiPsee gl.niblititttitiitimeniit:*iitotitikiiiii06 :::
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Address City State • Zip code
7 0 fol )giVE CeAtsi fit+ cSe i /1//%1. ,r,r 17
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Minnesota Lawful Gambling
Premise Permit Application - Part 2 of 2
Gambling Bank: Accoun :T jb at
Bank Name -r-e R �f NR t c RN' T C.. ,i W' 4' Bank Account Number
a wNt C-4 9.v44ssin, aeia5/ 1p o/ca 3
Bank Address City State p Code
00 NES 7 F ff S7 EET 0--,t4 J MSSE� Mn/ f.r3 /7
��rr� �j •.. ,. !3 3:.:. PI
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. ...... ....... Orvarrrzabaxss bsastnsr::rnat!• not .lraritJle. b�+¢fu�ds:. .:. • :� ::: >: <;•: >:;: >: < •:,.: ::,. .
N ame Address Tide
ED w z L, G, Nis bk.-F-( 738 / 44146 -VtEa taccE, t Ff4N Hose Al PRes,i
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JAM 6 5 -OSS 73(, K/ (44,14 7M-rL, C f ,i NffASSE.N 6 "/V 4 i t4 ' fi4
PAtJ(..- 3, . 3) iFFEn 77 :24 F riE4TRki�,cHA,•iffoctsst ,4 6.AlWJG /46
Acknowledgement .. :...
Gambling Site Authorization
.1 am the chief executive officer of the organization;
I hereby consent that local law enforcement officers, the
.1 assume full responsibility for the fair and lawful opera -
board or agents of the board, or the commissioner of tion of all activities to be conducted;
revenue or public safety, or agents of the commissioners, .1 will familiarize myself with the laws of Minnesota
may enter the premises to enforce the law, governing (awful gambling and rules of the board and
Bank Records Information agree, if licensed, to abide by those laws and rules,
The board is authorized to inspect the bank records of the including amendments to them;
gambling account whenever necessary to fulfill •any changes in application information will be submitted
I requirements of current gambling rules and law. to the board and local unit of government within 10 days
Oath of the change; and
I declare that: .1 understand that failure to provide required information
I .1 have read this application and all information submitted or providing false or misleading information may result in
to the board is true, accurate and complete; the denial or revocation of the license. •all other required information has been fully disclosed;
Signatu e of chief executive officer Data i
1 4).e..-e7, . / �/' "/Z 7/4
:Local Government icknoiu!edg ...:..;>,.....::. t: :.:: .' " " ;.. - ... -...
II 4. A coov of the local unit of government's resolution ao-
1. The city *must sign this application if the gambling pram- provina this application must be attached to this application,
ices is located within city limits. 5. if this application is denied by the local unit of government,
I 2. The county AND township" must sign this application if should not be submitted to the Gambling Control Board.
the gambling premises is located within atownship. It
3. The local unit government (city or county) must pass a Township: By signature below, the township acknowledges
resolution specifically approving or denying this application. that the organization is applying for a premises permit within
1 township limits.
City` or County** Township'•
• City or County Name r Township Name
C ffAJ H ASS E,J
Signature of person receiving application Signature of person receiving application
1 , e • �, . Date Received Title Date Received
1 R to the instructions for required attachments.
I Mail to Gambling Control Board
Rosewood Plaza South, 3rd Floor
1711 W. County Road 8
Roseville, MN 55113 LG214(Part 2)
(Rw7r25'91)
LG2.I2 FOR OFFICE USE ONLY
(Rev. 7/2/92) BASE UC #
SEO #
Minnesota Lawful Gambling FEE
Gambling Manager Application CHK
DATE
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New Give date that the two -day gambling manager seminar was completed. _L/ � SI
Location of training g O SE V i t-_ E I
(city)
❑ Renewal Give date of training received within three years prior to the date of the application for renewal. / / 1
Location of training
:::Garnbfing Mal'iager oflfta oti .:::.::::.:: ::;<:.:: :..: ::::.;::::;;::<; :::.:;:: .;; >:::::.:.:.::.:: >::::; `> :. >::a:: ;:< :;:':: =- .:: >:<.> ;:...:::.. - .:::..
LAST NAME FIRST NAME MIDDLE NAME MAIDEN Date of Birth Soc. Security Number
.71-OSS jf4tiiE'5 E DwkAD 7 -27- 7z - /ritz
Address State Zap Code Daytime Phone
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q36 K'oc.vf{ TEA- /L CHAAI MSSEnf 11/14 ff3 /7 (6/1+ e.-2..e -1446. o
MEMBERSHIP: Date gambling manager became a member of the organization ( I /_ig Sex : Male ❑ Female
tgcrdiat Ori. I4formaticiit:.::-:..:::.........;:<.:.,:.::.::.-...._... :..: :.......;.... :::..;:: :: :....::....:::;::- >: »; ::::..... .;:..,:-:_:.......: :.....:..
Name of Organization se Number
Uo Js CL- Ca o c h
14A lJ,+S
SEnJ (nJc_. P LIED R4.: 1
Address City /State Zip Code Phone
PC 2 0 X F c4,111/4i t-i-tFssc tJ , Mn1, f , r 3 i 7 ( ): 1
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- - A $10,000 fidelity bond in favor of the organization must be obtained for the gambling manager.
v t 0. A Pip /Lt .
Name of insurance company (do not use agency name) �J1) s Q � � Bond Number
:.:::..... .:
I declare that
• I have read this application and all information submitted to the board; 1
• 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 will familiarize myself with the laws of Mnnesota governing lawful gambling and rules of the board and agree, if licensed, to 1
abide by those laws and rules, including amendments to them;
• any changes in application information will be submitted to the 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 information may result in the denial or revocation of the 1
license.
Sign lure of Gambling Manager Date
Send the completed application and alt required attachments to:
Gambling Control Board
Suite 300 S.
1711 W. County Road B
Roseville, MN 55113 1
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1 LG213 Minnesota Lawful Gcunbling
(Rev. 6112/92) Gambling Manager Affidavit
(Attach to the Gambling Manager Application. Form LG212)
1 STATE OF !l / ^/ ^Jc o - ) AFFIDAVIT OF QUALIFICATION
) s.s. FOR GAMBLING MANAGER LICENSE
I COUNTY OF C- ,qg t/EI ) AND CONSENT STATEMENT
(Pursuant to Minnesota Statute 349.16 Subd. 2(e)
and Minnesota Rule 7861.0030,Subp.129(3))
1 I J A nI Es 6, SL O SS , under oath state that:
(type /print name)
1 1. I have never been convicted of a felony.
1 2. I 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. I have never been convicted of a criminal violation involving fraud, theft, tax evasion,
1 misrepresentation, or gambling.
4. I have never been convicted of assault, a criminal violation involving the use of a firearm,
1 or making terroristic threats.
5. I am not an assistant gambling manager for any other organization.
1 6. I am not a gambling manager for any other organization.
I 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
1 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
1 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 swom to before me this - 9.-- /C.-eve
1
//o / day of 7o,2�u -cam 19 '--3 ature of applicant - gambling manager)
4.7 c .4/B o
1
GtlAtn1f7 .rSEA / / N G
(Name of organization)
Cot, i 4.4 0 AL /C Ii2
1 i(l - {—Z_. License number
Notary Public
My commission expires / ,2 , ; , ' "_ _IN M. GALLU5
' ,• ,•- NOTARY PPJBLIC • MINNESOTA
1 :'"i ht, HENNEPIN COUNTY
` M y Commission Expires ten. 21, 1994
1 Xtryy .
SECTION N ON REIC EvE qS E E �D�
SECION RRS
Section
Public Otl•rial 1
Fidelity 3 ehfv 2 Weste Surety Cornpany
v Individual ❑
Referee. R Receiver. etc. 4
Court 5 Partnership ❑
License 6 Form 10
Lost Securities 7 Corporation IR
APPLICATION FOR BOND —ANY KIND
Applicant 1For pnrtnership give full names of partners and trade names) Please print Taxpayer 1 D � o j r S.S # Age Married l
- f- -101.5 C1- � CH�IN1kAS I C.. yi' l - 1o� OO67 Single ❑
Address (�v. BOX Lt6 C t� qN FtASS[,kI MN 553i 7
(Street and Number) (City) (State) (Zip) I
Occupation or business How long so engaged? Previous Surety ❑ Yes No If yes, give name and reason for change
_.( — Pre F cT 1 f�
• �z.P e
Type of Bond Amount of Bond Effective Date
I
— GAMgLI,J$ #9QC g _0NPt $ 1O,000.00
- Complete name and address of Obligee 1111 W . Co.'' P.m() Bt
MIwNtSoIA G4.4 et- ING_ C..4 fret, RoAaD S '4Ife.3cc, 5 . _R05e.QIt_t...&_, M SSI13
I
FINANCIAL STATEMENT as of urJe 3os, I R et?.
Check applicable section on the reverse to see whether a financial statement is necessary.
ASSETS LIABILITIES I
Cash (List Banks) Accounts Payable
Taxes due —Gas
-- .- - - -. -- Taxes due & accrued —Other
Stocks +Bonds— Describe Notes Payable to Bank
-- - - - - -- Notes Payable to Others (Describe)
Notes Receivable— Describe_ i Mortgage on Real Estate A
Merchandise or Material in Stock Mortgage on Real Estate B '
Accounts Receivable Other Liabilities — Describe
Real Estate. Homestead— A
Real Estate. Investment_ B TOTAL LIABILITIES I
Furniture and Fixtures_ Capital Stock (Paid in)
Other Assets — Describe NET WORTH OR SURPLUS
TOTAL ASSETS TOTAL Liabilities and Net Worth
Gross Sales - Tlto Years Ago_— Last Year Net Income • Two Years Ago Last Year
INDEMNITY
The undersigned nrpheant and mdrmnitnrs hereby r - 1 .-.- •Re.tern Surety Company Rhe - Company ) to become surety for the shove bond The undersigned hereby certify the truth of •1 statements
in the npplirnnon. author'', 'he Company to verilc •his iriormat,on and to obtain additional informaunn from any source. and jointly and severally agree:
t II To pay the usual r• in.-furling renew al pr.•n'um<
I
t 20 To romplet,•Is I110F.`•1\•IFl the Compam from and scales, any liability. loss. coat. attorneys )ere and expenses whatsoever which the Company shall st any time sustain as surety or by reason
of having been surety nn this bond or any nther herd issued for applicant. or (nr the enforcement nl this agreement. or in obtaining a release or evidence of termination under such bonds.
t 1) To furm-.h the Cnrrpanv with setirfsctory and conclusive termination evidence that there in no further liability on this brim! or any other bond issued for applicant,
1 ii O'pon demand I.3. the Company for any reason a hat .never to deposit current funds with the Company in an amnunt sufficient to satisfy any claim against the Company by reason of such suretyship.
15, Tha' the C..mpsnv shall have the right to handle or settle any claim or suit in good faith. An itemized statement of loss and expense incurred by the Company, mown to by an officer of the
C•'mpnn shall he prima facie ev:drnrr of 'he fact and extent of the liability of the undersigned to the Company.
t 61 Than die C "mra, mss decline to hec.mr surer, on any bond and may cancel or amend any hund without cause and without any liability which might arise therefrom,
I 71 That the Compnnt shad without not're Iinne the nicht to alter the pennito. terms and conditions of •no bond issued for undersigned. and this agreement shall apply to any such altered bond.
1 al That if o contract or perlormanee bond i. issued herrander. the undersigned hereby assign to the Company any mnmes now due or hereafter becoming due under the contract. including all deferred
payments and rr...ned eerrrntage supplies 'o,ds piarts equipment and materials due or i sad on the contract. and
t 91 51 the 1 .mpar. • discretion. this •ndem . niry net. em nr shall he governed in all respects bv the laws of the State of South Dakota and the undersigned applicant and indemmtors consent to the
1or:sd•. • ion nl the roots of the Stare of South Dakota and the llnrted States District Court for the District of South Dakota in all actions or proceedings arising from or relating to this indemnity
agreement.
l tot Dori this indemmts mo be cancelled an 'o subsequent liability by an indemnitnr upon written notice to the Company at Sioux Falls. South Dakota 57192. affective ten (10) days after the earliest
dr.• tho•eaft •' • 'r.,r wh..-h the Company could has,. °anrelled o11 hnnds in Inree for applicant
t I I In the e. ..1 Inv pat nient by the Company re pee the Company interest on p �
such nm nt the highest legal rntr frnnt the date such payments err made Signe( thi _—day of _.19 [
Agency _SC1.{N E IOER AG -ENG`? 1 aC . _ _ 7••
-
Agent's 'Code —
Address 402 - 1 03•2_5T 7 Q th 5TRee...-r
Street
CAA
_. e 1►J HA SSE/. M.) 553i7 Note• Personal indemnitors should sign their names and add the wprd "indemnitor" in
City State Zip their own handwriting, e.g. ..,-.4 i t'.r - i. ...•ne.
AGENT'S RECOMMENDATION
Your recommendation will be helpful and may be the difference between getting a refusal or having the bond written. Tll us what
you know and think of the applicant 1
AGENT: Check here if this correspondence was previously faxed to WSCo. I � I
•
Form 10 -9 -90 c WSCo '990
OFFICIAL 1 Annually? for term?
BOND — —
NO FINANCIAL S'1'AI'F"MENT
NECiiSSAltI Annual Solar R ill applicant sign 1s countersignature required? ❑ Yes ❑ No Regular audits? ❑ Yes ❑ No
checks? ❑ Yes Q No Hy whom? By whom?
Are bank nceounts reconciled by someone not authorized to deposit Ever discharged from any employment? ❑ Yes No Why?
FIDELITY
BOND
or withdraw from the accounts? I' Yes ❑ No
Last position held'? StAStaU1$0P OF Sueit.DiAI9y How long in present Applicant's net worth
NO FINANCIAL S') Y1'EMENT Reason for loacing p position $
NECESSAli _ ÷ Gf'o cat S �p�NA `�1gf_IC �HCOLS fo bX at, Ars
Name of deceased (Ward) Date of death Date of appointment Is applicant indebted to the estate
or trust? 0 Yes 0 No (If yes,
explain.on an atta sheet)
1 Name and address of attorney (If none, do not write the bond;
submit it to our underwriters.) Will the attorney remain involved throughout
the duration of this estate? 0 Yes ❑ No
Assets of estate or trust (describe)
1 Name and age of Applicant s relationship to Applicant's net worth
❑ minor(s) DI deceased $
PROBATE D incompetent ❑ w•ardis)
BOND Are guardianship funds to be used for support of w is the source of the guardianship funds? (If an insurance
minor(st'' 0 Yes Nn (If so, send copy of court settlement, do not execute the bond; instead refer it to an under -
i 1
NO FINANCIAL STATEMENT order authorizing monthly expenditures.) writer )
NECESSARY Who are the heirs of this estate'?
HAVE PRINCIPAL SIGN
THIS APPLICATION.
1 Will anv business of the estate be continued by fiduciary? Is this bond required on the demand of an interested person?
(if so, send a copy of court order ) ❑ Yes ❑ No ❑ Yes ❑ No Who?
Narnc and address of court
1 What is the applicants experience in handling fiduciary responsibilities'?
❑ REFEREE'S
❑ RECEIVER'S Plaintiff Name and address of principal's attorney
❑ TRUSTEE'S
BOND Defendant — Name and location of Court Applicant's net worth
NO FINANCIAL S'I'1'rF'91ENT —
$
N(:r;('ES t'LCSC,vtl
HA\ E PRINC'IP1L SIGN
THIS APPLICATION
COURT BOND Name and location of Court Name of Defendant
OTHER THAN
15
3 AND 4 Name and address of attorney If an Injunction or Restraining Order bond, does appli•
FINANCIAL S'1',1 "1 EVENT' cant anticipate a foreclosure or collection action against
NECESSA RN him? n Yes n No If so, submit for underwriting
HA\ E PRINCIPAL SIGN Expl -yin purpose of bond (submit copy of relevant documents)
THIS APPLICATION.
LICENSE AND
IIP PERMIT BOND N worth J I'uhlicliabffltvinaurance carried? Yes Nn Pro rt dame a insurance carried'? ❑Yee ❑ No
FINANCINI. Sr1T NT ❑ ❑ Property damage
SSARS R iIr.R1 STATE g (Give limits) (Give limits)
IS THE 0131.1(31 - - - - - �.
HAVE Pi11 NCIl" L SIGN
THIS APPLICATION.
LOST Serial Number and description (Please submit a copy or Date of instrument Payable to applicant only? ❑Yes D No
sample of the form it was on.) If not, who is it payable to?
SECURITIES -
BOND Are securities endorsed? Describe manner of loss Has notice of loss been given? ❑ Yes ❑ No
FINANCIAL STATEMENT
0 Yes ❑ No When? To Whom?
NRCESS\Rl
HA\ E PRINCIPAL SIGN If registered. in whose name'' if a check, has payment been stopped? If a deed of trust or note, has either been involved in a law -
THIS APPLICATION 0 Yes ❑ No If so, when? suit? 0 Yea 0 No Was a judgement obtained? 0 Yes ❑ No
Of
Western Surety Company
HOME OFFICE:
1 P.O. Box 5077
S ioux Falls, South Dakota 57117 -5077
(800) 331 -6053
FAX 1 (605) 335 -0357
1 •
1
BOND NO. 58551443
Effective Date: January 4, 1993 1
GAMBLING MANAGER'S BOND
1
KNOWN ALL MEN BY THESE PRESENTS: That we, James E. Sloss
as Principal and the WESTERN SURETY COMPANY,
a corporation authorized to do business in the State of Minnesota, as Surety,
are held and firmly bound unto Lions C] nh c,f Ch al,ha
, in the sum of not to exceed TEN THOUSAND DOLLARS
($10,000.00), for payment of which, well and truly to be made, we bind ourselves
and our legal representatives, jointly and severally, by these presents.
THE CONDITION of the above obligation is such that WHEREAS said Principal
has been designated Gambling Manager and is required to give this bond by virtue
of 349.17. MSA.
NOW, THEREFORE, if said Principal shall faithfully perform his duties as
Gambling Manager, then this obligation to be void; otherwise to remain in full force
and effect.
This bond may be cancelled by WESTERN SURETY COMPANY, as to future liability,
by giving written notice by Certified Mail, addressed to the Principal and the Licensing
Authority, and thirty (30) days after the mailing of said notice by Certified Mail,
this bond shall oe null and void as to any liability thereafter arising, conditions
and provisions of this bond for any and all acts covered by this bond up to the
date of such cancellation.
Dated this 5th day of January 19 93 1
' 1
P cipal 1
COUNTERSIGNED: W STERN SURETY COMPANY
L. Stoltz,. A$51. S 1
B z Vic, •eecIt 9 BY
MINNESOTA RESIDENT AGENT Surety 1
•
r 1
1
1
1 LG200 B
(7/28/92)
Minnesota Lawful Gambling
Organization Officers Affidavit
1 STATE OF " 1 / .N N ES OT /4 ) AFFIDAVIT OF QUALIFICATION
) s.s. OF OFFICERS FOR
ORGANIZATION LICENSE
I COUNTY OF C A . E e ) AND CONSENT STATEMENT
(Pursuant to Minnesota Statute 349.16, Subd. 2e)
I I, 0/ R D L-• G /W5'8 4 c ff , 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 felonX,or gross misdemeanor.
I 2. I have never been convicted of a crime involving gambling.
I 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.
I 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
1 Minnesota.
By signature of this document, the undersigned authorizes the Department of Public Safety to conduct a criminal
I 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-
lion of the license.
I
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.
1 ,
..L - Z, A i:1-1 4 e/. . 1 .T- 4 2 4 t 2 - ' ; 1
I (signature of applicant)
NOTARY PUBLIC INFORMATION APPLICANT INFORMAT ION
Notary Public Seal must be current and correct.
1
Seal may »4i be altered. Chief Executive Officer0 Treasurer
Effective date of officer change 1 / 1 / 9z--
I Horne Address
Subscribed and sworn to before me this 133/ t J G V f E. J G( R O L E
City
�j L c CfriA14{-t�SSE. ni
1 day of - -( <« 19 , 3 State Zip
M Ai f r 3 / 7
Phone ( /Z) 13!- q? 9 7
I /z / L z , — /% ,� ' - L & c � Date of Birth '+J
`..�J -2V
XAAA 4.14.IA
< , :1;; CA1 HLEEN M GALLUS Name of Organizadon.
� NOTARY RU3'_'C OU NE50TA a o ,AIS C v 6 C F
1 � ; HENfJE. iv COUNTY G Ht4f Yt`A'SS ENr / N C C.
- s . 1 . . My Cammission EsG res Jan. 21, 1994
xrn► License ber ti .q, ,
1
(7/28
(7281922
)
Minnesota Lawful Gambling
Organization Officers Affidavit
STATE OF /"l / . +/A) G-1 0 f� ) AFFIDAVIT OF QUALIFICATION
) s.s. OF OFFICERS FOR
�, _ i,, ORGANIZATION LICENSE
COUNTY OF C fT V ) AND CONSENT STATEMENT
(Pursuant to Minnesota Statute 349.16, Subd. 2e)
g
C T (S C, -o e j USo r 1
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. 1
2. I 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, asr°e and hereby irrevocably consent that suits and actions relating to the subject matter of the 1
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 1
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.
�-- h / .ei , + )
(signature of applicant)
NOTARY PUBLIC INFORMATION APPLICA1NT INFORMATION
Notary Public Seal must be current and correct
Seal may Dat be altered. Chief Executive Officer ❑ Treasurer,
Effective date of officer chance 1 / ( / 9 Z'
Horne Address
Subscribed and sworn to before me this ° W E ST - 1 5
City
r C i-f� Mme+ 4A SS
E
11 day of TES 4) 19 13 State 1,3 Zip 65-311
Phone ( 6 (Z) ; 44 _ 1
Date of Binh 3// C J 7
Notary F, blic /
Name of Organization, F ..
I. r.� ; ;C A A � ;���! ., yQ �iS c -LV'e o.
C 11AniHASSc N /A; C-
-
, Tinny
T �. C_- -S.: t 7 t License ;)ju P' g
1 LG201
( ev 7/24191) Minnesota Lawful Gambling
1 Gaming Operations Internal Controls
Name of organrzaaon License nurrner Date
I C A4N1Ass ' ,`1 C /44 �'ivc. 4 nkJ F:;'? J - /t S3
Acaress Cry State Zip code
0 .D. i33 x y 8 y G4 q r•/ h A-SS,s N 1v(A/ 3`S / 7
1 Fill in the name and title of the person responsible for each action listed below.
1 Inventory Acquisition and Control
Responsibility of: Title: Action
1 1
JA Mks SASS LL M Purchases gambling equipment and supplies from distributors licensed by
the Garrcnng Control Board. Verifies license number of distributors.
I 2. J S V M Receives equipment or supplies, initials and dates he invoice, and verifies
the quantity received.
3 . \ 5 • Verifies that a Minnesota State registration stamp has been affixed to all
gambling equipment and supplies by the licensed distributor.
' s J 5 C AI Compares all games received, by serial number and state registration stamp
number, to the distributor's invoice Reconciles any differences before
placing the games into play.
I „ J 5 G M Completes inventory records for all items received. Records should verity
that all purchases were properly authorized, received, and put into play
ci 5 G M Secures ail gambling equipment in a locked storage area.
1 7 J - G M Maintains control and custody of the keys to the storage area.
E 3 3 L M Maintains a list of persons who have access to the storage area and
I updates the list as necessary
g 3 S G /✓) Counts and records items taken from inventory on the inventory record.
10 J S G M Takes a physical count of inventory at the end of each month.
I t 4 S G M Maintains a list of persons authorised to purchase gambling equipment and
supplies
1 Cs rrt irtg Operations Control
I 1 3 .S G M Maintains a list of persons authorized by the organization to conduct lawful
gambling sales at a licensed location.
2. 3 S G M Counts and verifies starting cash.
I 3 S A=/le4 Posts the are (pull - tabs), or the master flare (paddlewheels and tipboards)
with the correct serial number, and with the state registration stamp affixed.
4 J S Cv M Posts the house rules.
1 5 5 E / /4k' Puts entire deal into a receptacle other than the container in which the deal
was received.
I E 5 5/iO41' Begins play in accordance with gambling rules
S / /E? Closes tr e deal when skid out or major winners are awarded, whichever
house rues indicate.
1 E S0 //SR Defaces and retains ail winning tickets
S 5V/0? Recores winners valuec at $50 or greater pnze receipt form)
1
J S_ .. 14r.4 au_ S /6rs
Gaming Operations Internal Control (continued) I
Responsibility of: Title: Action
10. _ J _S G M Removes and retains any unsold and defective tickets.
11 56 / /F•? Counts total rash in the cash drawer separating the normal starting bank
I from the net balance.
12. J S G /v1 Deposits and records net balance cash or secures it until it can be
deposited.
13. 50 //ER Removes receptables and stores them in a secure area at the dose of the
day.
14. S6 //FR 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
1. J S G M Audits all dosed games and records inforration on schedule B for the
monthly tax report
Fund Control and Record - Bingo
1 Fills out bingo report forms for each occasion
2. Conducts bingo according to the rules. Complies with prize limits.
3 Verifies that one or more checkers are used for each bingo occasion.
1
4 Verifies and records serial number of winning bingo card for prize of $100 or
more.
Accounting —Monthly Reports
(treasurer of organization may not account for gar•blir.g fundsl
1 J .5 ( M Maintains gambling bank accounts .
1
2. J S G M Signs all checks from gambling checking account.
3 J - V m Maintains deposit records.
1
4 J S G M Maintains expense records.
5 J S G M Reconciles and maintains monthly bank statements
I
6 J S G M Prepares monthly tax returns for each site (Schedule A: Site Accounting)
and a combined tax retum for all locations.
7 . ) S Ca M Prepares and presents monthly reports to members
1
8 JS (M 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
I
9 3 -S G ni Records authorization in the minutes of the organization.
10 'J S G M Investigates variances and documents reasons for these variances.
I
REQUIRED ATTACHMENT -- Administrative Controls
1. Indude 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.
I
2. Indude a narrative explanation of how the administrative duties are separated and explain the responsibilities of each individual in the
organizational chart.
I, _ ' , , . ; • • , , - ' / , chief executive officer of . - , / / >" , Q L L ' ' }— I
signature) (name o org - . tzabon)
verify that the above information conforms in all respects to the objectives of intemal control as outlined by state law and Gamblino 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
I