HomeMy WebLinkAbout[04f] Gambling PermitCITY i)F 14T. ~I>,SF VH
MEETING DATE:
August 20, 2009
Council Agenda Item 4f
AGENDA ITEM: Gambling Permit -Requested Action: Accept the Gambling
Application of the St. Joseph Jaycees for an event to be held on
October 3, 2009 at the Stonehouse Tavern.
SUBMITTED BY:
Administration
BOARD/COMMISSION/COMMITTEE RECOMMENDATION: None
PREVIOUS COUNCIL ACTION: None
BACKGROUND INFORMATION: The application included in the packet has not been executed by
the Jaycees, but due to timing issues, we have agreed to process the application with the understanding
that they will submit the executed application and required fees prior to the meeting on Thursday night.
BUDGET/FISCAL IMPACT:
ATTACHMENTS:
Application to conduct off-site gambling
REQUESTED COUNCIL ACTION: Accept the Gambling Application of the St. Joseph Jaycees for
an event to be held on October 3, 2009 at the Stonehouse Tavern.
pat;ir 1 of 7. 7/09
Minnesota Lawful Gambling
LG230 Application to Conduct Off^Site Gamktling N~t~ Fee
Organization name 5t Joseph Jaycees Lim ne;e number 03Q11
Address PO Box 755 City st Joseph MN Zip code rb37~4
Gambling manager name Rose Janssen payti~ne phone 320-2 ~~
.~
Gambling Activity
1. Four off-site events are allowed each calendar year. Dates for each event, Wert to exceed 3 days.
October 3, 2009 . _____ ,~
2. Check the gambling adivity that will be conducted.
® raffle pull-tabs bingo ,~tipboards _(~paddlewheel
Gambling Premises
3. Name of location where gambling activity wiN be conducted Storehouse Tar~~ern
4. Street address and city 2010 Co Rd 75 E, St Joseph
• Do not use a post office box.
If no street address, write in road designations. Example: 3 miles east c>~` Hwy 63 on County Road 42.
5. Daes your organization own the gambpng premises?
Yes If yes, a lease is not required.
No If no, the lease agreement below must be completed, and signetN by the lessor.
Let~lse Agreement for off-site Activity (A lease agreement is not required for raffles:)
6. Rent to be paid for the leased area $ If none, write "0."
7. All obligations and agreements between the organization and the lessor are listed below or attached.
Arty attachments must be dated and signed by both the lessor and lessee:.
• This lease and any attachments is the total and only agreement between the lessor and the
organization conducting lawful gambling activities.
Other terms, ff any
8. Lessor's signature ..- Date'
Print lessors name
CON'I1T31.7T: TO t'AC+I^.'2
LG230 Application to Conduct Qff.•Site Gambling
Local Unit of Government Resolution of Approval
CITY APPROVAI. for a gambling premises located
within city limits
City name
The city counGl has approved this appligtion by
resolution within 90 days of the date of signature below,
Signature of ~ personnel
P»>;~r' 2 of 2 7109
COUNTY APpROVAI, for a gambling preml,a,es
located In a townshlll
County name
The county board has t,pproved this application by
resolution within 90 day s of the date of signata_ire below.
Signature of couhty pert 7nnel
Title Date ! / I Title
bate /
Chief Executive Officer (CEO) Aicknowledgment
9.
The person signing this application must be your organization's CEO and have their name on file ~nnth the
Gambling Control Board. If the CEO has changed and the current CEO has 11nt filed a LG200B Orgalnizatlon
Officers Affidavit with the Gambling Control Board, he or she must do so at this tune,
70. !have read this application, 9nd a!1 information is true, accurate, and complete; and if applicable, agr>'e to
tl~ lease terms as stated !n this application.
CEO signature _ Gate
t1. Print name Daytime phone ~ -I~
M I
or fax to:
Gambling Control Board
1711 Weft County Road B, Suite 300 South
Rosevellt?, MN 55113
FAX; .667-639-4038
No sttachments requllyM.
This publication will be nvrde »vauable in allemative fomwt (i.e. large print, Braille) upon request. The Information re9uP.sted tin this
form (and any attachments) will he u9ed by the Gambling Contrd Board (Board) to determine ~yMUr quallfkaitlons to be irmvcdved in
lawful gambAng acdvltles In Mlnnosota, and to »ssist the Board in conducting 2 backgraind investl ~ atlon of you. You have the right to
rofuae to suppty the Information requcstotl; however,rf you refuse to supply this information, the Eb' x+rd may not be sable to de~,ermine
your qualifications and, as a consequence, may refuge to issue you a pem,it. If you supply the inf~mm>atlon requested, the eo,~rd wit
be able to process your »ppliration. Your name and addre_aa will be public informaton when ~ceived by the Board. All other
Infommatlon you provide wip be Private data about you until the Boats issuos your permR. 1Alhr~t the Board issuos your per~mi~ ell
intormatlon you provided will become public ezccpt for your Social Security number, which rerrrglne private, K the Board deers not
issue you a permit, all information you provided remains private, with tho exoepfion of your nacre and »ddress which wltl i~smein
public, Private dada about you are av»il»ble to following: Board members and staff whose work rsqulms acceaa to the irmtorenatlon;
Minnesota's department of t'ublic S»fety; Attorney General; Commissioners of Aorninistralion, F inancc, and Revenue; Leglslatlve
Auditor, natlonal and intemetlonat gambling regulatory agenGcs; anyone pursuant to court order; other lnd{v-duels and ac_iencea
specificaky au[horizad by state or federal Inw to have access to the Ir-formstian; individuals end as~rnCeg for which law or lep¢u order
alrthoNzos a nErw use or sharing of informatlon after this Notice was given; end anyone Ndth your ah~senk
Resr~i~ , rrti `print ~bl ~~'::::.xl