HomeMy WebLinkAbout[04c] Gambling Permit - St. Joseph Lionsc~~ ciN s~ dc~H,rt~
MEETING DATE:
AGENDA ITEM:
SUBMITTED BY:
Council Agenda Item '"C~
June 18, 2009
Gambling Permit -Requested Action: Accept the Gambling
Application of the St. Joseph Lions for an event to be held on
September 12, 2009 at the St. Joseph Meat Market.
Administration
BOARD/COMMISSION/COMMITTEE RECOMMENDATION:
PREVIOUS COUNCIL ACTION:
BACKGROUND INFORMATION:
BUDGET/FISCAL IMPACT:
ATTACHMENTS:
Application to conduct off-site gambling
REQUESTED COUNCIL ACTION: Gambling Permit -Requested Action: Accept the Gambling
Application of the St. Joseph Lions for an event to be held on September 12, 2009 at the St. Joseph Meat
Market.
Minnesota Lawful Gambling slog
LG230 Application to Conduct Off-Site Gambling No Fee
Organization name____~T.__.T6,~PN____ L/Q~[~ _____________________ License number O Z OZ /
License expiration date __~ __I_ 31 __/___/ O_
Gambling Premises
1. Name of establishment or function where gambling activity will be conducted~L~Q~__~~~T_~Ii~IP~.ET____
2, Street address and city __~_~/~_____~ ~r_~U~~_____ST_~Q~~~1~1Jrv1 __ 5,,74___________
• Do not use a post office box.
• If no street address, write in road designations. Example: 3 miles east of Hwy 63 on County Road 42.
3. Does your organization own the gambling premises?
____ Yes If yes, a lease is not required.
_~_ No If no, a lease agreement must be attached. Use LG224 Lease for Off-Site Gambling Activity.
A lease is not required for raffles._
Gambling Activity
1. Check (1~) the gambling activity your organization will be conducting.
___pull-tabs ___bingo ___tipboards raffle ___paddlewheel
2. Date of single day event ______________ . 4 separate days allowed per calendar year.
3. Dates of up to 12 consecutive days in connection with a-county fair, state fair, church festival, or civic
celebration. Begin date ~'[i~l~ ~Ieo9End date _~~~o~____ 1 event allowed per calendar year.
Acknowledgment
• The person signing this application must be the CEO of your organization and have their name on file with the
Gambling Control Board.
• If the CEO has changed during the term of your license and the current CEO has not filed a
LG200B Organization Officers Affidavit with the Gambling Control Board, he or she must do so at this time.
I have read this application, and all inform ti n is tru ~eccurate, and complete.
. -,,
Chief executive officer signature _ ____ _ ~&„~.~______________________ Date __~ / ~ ~ /_ v~
Print name _~EN____3jQd'1ME~_ .~ ~ ___ Daytime phone __ ~-~ '_ -}` %,~_-_ ~,~'/~
Application and Required Attachments
1. LG230 Application to Conduct Off-Site Gambling. Mail to: Gambling Control Board
There is no application fee. Suite 300 South
2. Resolution of approval from the local unit of 1711 West County Road B
government (city or county) Roseville, MN 55113
3. Copy of the lease agreement. Or, fax to 651-639-4032
No lease is required if only a raffle will be
conducted or your organization owns the premises. Questions? Contact a licensing specialist at
651-639-4000.
This publication will be made available in
alternative format (i.e. large print, Braille) upon
request. The information requested on this form
(and any attachments) will be used by the
Gambling Control Board (Board) to determine
yourqualifications to beinvolved inlawful gambling
activities in Minnesota, and to assist the Board
in conducting a background investigation of you.
You have the right to refuse to supply the
information requested; however, if you refuse
to supply this information, the Board may not be
able to determine your qualifications and, as a
consequence, may refuse to issue you a permit.
If you supply the information requested, the
Board will be able to process your application.
Your name and address will be public
information when received by the Board. All
other information you provide will be private
data about you until the Board issues your
permit. When the Board issues your permit,
all information you provided will become
publicexceptforyourSocial Security number,
which remains private. If the Board does not
issue you a permit, all information you
provided remains private, with the exception
of your name and address which will remain
public. Private data about you are available
to following: Board members and staff
whose work requiresaccesstotheinformation;
Minnesota's Department of Public Safety;
Attorney General; Commissioners of
Administration, Finance, and Revenue;
Legislative Auditor; national and international
gambling regulatory agencies; anyone
pursuant to court order; other individuals and
agencies specifically authorized by state or
federal law to have access to the information;
individuals and agencies for which law or legal
order authorizes a new use or sharing of
information after this Notice was given; and
anyone with your consent.