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Home My WebLink About[04e] Gambling Permit - CSB/SJU Ducks Unlimited~~ crra= a~ sr JcxsH NH MEETING DATE: October 1, 2009 Council Agenda Item 4e AGENDA ITEM: Gambling Permit -CSB/SJU Ducks Unlimited SUBMITTED BY: Administration BOARD/COMMISSION/COMMITTEE RECOMMENDATION: PREVIOUS COUNCIL ACTION: BACKGROUND INFORMATION: BUDGET/FISCAL IMPACT: ATTACHMENTS: Application for Exempt Permit REQUESTED COUNCIL ACTION: Gambling Application -Accept the Application for Exempt Permit for the CSB/SJU Ducks Unlimited for an event to be held at Sal's Bar on October 20, 2009. l` Minnocnta 1 awfi~/ a^amh/inn Page 1 of 2 7/09 '-""""'" --- -~ -- "" "" -~"""~"""'~ LG220 Application for Exempt Permit Application fee If a lication ostm rked or received: An exempt permit may be issued to a nonprofit organization that: - conducts lawful gambling on five or fewer days, and I ~~ a ~ less than 30 days before the event $100 more than 30 days before the event $50 GP -awards less than $50,000 in prizes during a calendar year. ~ ,~. RGANIZATION INFORMATION Check # $ Organization name P evious ambling permit nu r Type of nonprofit organization. Check one. a Fraternal a Religious Veterans ~ Other nonprofit organization Mailing address City State Zip Code County ~ ~ ~1i3~ Cali ~i ~ `~ 3a~ ~ ~~s . Name of chief executive officer (CEO) Daytime phone number Email address yes e~ ~ !~- gl6 " ~Q; ~ I~S"r-~ r fix' Attach a copy of f 11,E of the following for proof of nonprofit status. Check one. Do not attach a sales tax exempt status or federal ID employer numbers as a,ey are not proof of nonprofit status. a Nonprofd Articles of Incorporation OR a current Certificate of Good Standing. ' Don t have a copy? This certificate must be obtained each year from: Secretary of State, Business Services Div., 180 State Office Building, St. Paul, MN 55155 Phone: 651-296-2803 IRS income tax exemption [501(c)] letter in your organization's name. Don't have a copy? To obtain a copy of your federal income tax exempt letter, have an organization officer contact the IRS at 877-829-5500. IRS -Affiliate of national, statewide, or international parent nonprofit organization (charter) If your organization falls under a parent organization, attach copies of both of the following: a. IRS letter showing your parent organization is a nonprofd 501(c) organization with a group ruling, and b. the charter or letter from your parent organization recognizing your organization as a subordinate. IRS -proof previously submitted to Gambling Control Boats '-~`~' If you previously submitted proof of nonprofd status from the IRS, no attachment is required. GAMBLING PREMISES INFORMATION Nam of premises where gambling activity will be conducted (for raffles, list the site where the drawing will take place) " I~ ~ / Address ( not use PO box) City Zip Co d e County ~ ~ ( ~ lr ' fi ~ I h Date(s) of activity (for raffles, indicate the date of the drawing) O heck the box or boxes that indicate the type of gambling activity your organization will conduct: Bingo* ®Raffles ~Paddlawheels* ~Puil-Tabs' ~Tipboards* * Gambling equipment for pull-tabs, bingo paper, tipboards, and paddlewheels must be obtained from a distributor licensed by the Also complete Gambling Control Board. EXCEPTION: Bingo hard cards and bingo Page 2 of this form. number selection devices may be bornowed from another organization authar¢ed to conduct bingo. Fill-itti & PrintForm To find a licensed distributor, go to www.gcbstate.mn.us and click on List Reset Form of Licensed Distributors, or call 651-639-4076. ~~ ~- C LG220 Application for Exempt Permit Page 2 of 2 7/09 LOCAL UNIT OF GOVERNME KNOW LEDGMENT If the gambling premises is w' city limits If the gambling premises is located in a township, a a aty official must check the action tha city is county official must check the action that the county is taking taking on this application and sign the application. on this application and sign the application. A township official is not required to sign the application. _The application is acknowledged with no waiting period. The application is acknowledged with no waiting period. _The application is acknowledged with a 30 day waiting The application is acknowledged with a 30 day waiting period, and allows the Board to issue a permit after 30 period, and allows the Board to issue a permit after 30 days (60 days fora 1st class aty). days. _The application is denied. The application is denied. Print aty name ~ Print county name On behalf of the county, I acknowledge this application On behalf of the cr , 1 acknow/ed Phis applicafion. . Signature of county official receiving application Si o I receiving application Title Date / / (Optional) TOWNSHIP: On behalf of the township, I Title Date ~ 1 ~-~ / B 9 acknowledge that the organization is applying for exempted gambling activity within township limits. [A township has no statutory authority to approve or deny an application )Minnesota Statute 349.166)) Print township name Signature of township officia I acknowledging application Title Date / / CHIEF EXECUTIVE OFFICER'S SIGNATURE The information provided in this application is complete and accurate to the best of my knowledge. !acknowledge that the financial report will be completed and re a tot rd within 30 days of the date of our gambling activity. Chief executive officer's signature Date 9- Z f 9 Complete a separate application for each gambing activity: Financial report and recordkeeping required Cb one day of gambling activity, -two or more consecutive days of gambling activity, A financial report form a nd instructions will be sent with your permit, or use the online fill-in form available at - each day a raffle drawing is held www.gcb.state.mn.us. Within 30 days of the activity date, Send application with: complete and return the financial report form to the - a co ofd sta Gambling Control Board. -application fee for each event. Questions? le to "State of Minnesota." Calt the Licensing Section of the Gambling Control To: Gambling Control Board Board at 651-639-4076. 1711 West County Road B, Suite 300 South Roseville, MN 55113 Fill-in & Print Foam Reset Form: Data privacy. This form Mnlt be made avagable in aftemative format (i.e. large prim, Braille) upon request. The information requested on this form (and any attachments) wit be used by the Gambling Cordrol Boats (Board) to determine your qualifications to be invotvedai lawful gambling activities in t,Aimesota. You have the right to refuse to supPN ~ information requested; however, if you reir~e to ~+PPIY this information, the Board may not be able to determine your quatificattorrs and, as a consequence, may refuse to issue you a permit. If you suppry the iMommation requested, the Board w~l be able to process your appNcation. Your name and and your orgarrzation's name and address wtll tae public information when received by the Board. AN the other informatan you provide will be private data urt~ the Board issues your perrrrit. YVhen the Board issues your perrr~, aY of the k-formatan provided to the Board w8 become public. If the Board does not issue a pemrt, aH infomration provided remains private, with the exception of your name and your organ¢atton's name and address which wiH remain pubkc. Private data are available to: Board members, Board staff whose work ins aooess ~ the irrfom'ration; Minnesota's Department of Public Safety; Attorney General; Commissioners of Admtrrsiration, Fnance, and Revenue; tegialative auditor, r~tiorral and international gamMxrg regulatory agencies; anyone pursuant to court order, other individuals and agencies that are specificaNy authorized by state or federal law to have acxa::ss to the information; individuals and agencies for which taw or legal order auttwrses a new use or sharing of iMormation afkerthis Notice was given; and anyone WTIt your consent.