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HomeMy WebLinkAbout[04c] Gambling PermitC[TV OF NT. JINKPH MEETING DATE: Council Agenda Item 4 C February 4, 2010 AGENDA ITEM: Gambling Permit — Requested Action: Accept the Gambling Application of the St. Joseph Volunteer Firefighters Relief Association for an event to be held on April 9, 2010 at the 400 Supper Club. SUBMITTED BY: Administration BOARD /COMMISSION /COMMITTEE RECOMMENDATION: PREVIOUS COUNCIL ACTION: BACKGROUND INFORMATION: The City is required to accept all applications for lawful gambling within the City Limits. BUDGET /FISCAL IMPACT: ATTACHMENTS: Gambling Application REQUESTED COUNCIL ACTION: Accept the application of the St. Joseph Volunteer Firefighters Relief Association for an event to be held on April 9, 2010 at the 400 Supper Club. Minnesota Lawful Gambling LG220 Application for Exempt Permit Page 1 of 2 3/01 For oar se On y Fee - S' ,<n - r — Organization Information rea rasa Check No. Organization name Previous lawful gambling exemption number Street (rrxL; I/noraelclr"s City State/Zip Code County O 1 + `-I S- . �� vs /'kP '71 Name of chief executive officer (CEO) First name Last name Daytime phone number of CEO 0LV'C9►. ee de- .,� o+^ 3� ) 9 So -- 3 q 95 Name of treasurer F st name Last name Daytime phone number of treasurer: Type of Nonprofit Organization Check the box that best describes your organization: ❑ Fraternal ❑ Religious ❑ veteran ❑ Other nonprofit organization Check the box that indicates the type of proof your organization attached to this application: IRS letter indicating income tax exempt status Certificate of Good Standing from the Minnesota Secretary of State's Office (n%u,5+ 6a cu.rrcrX ❑ A charter showing you are an affiliate of a parent nonprofit organization ❑ Proof previously submitted and on file with the Gambling Control Board Gamblina Premises Information Name of premises where gambling activity will be conducted (for raffles, list the site where the drawing will take place) t10 5LAeW Climb Address (do not use PO box) City State/Zip Code County a5l5t? L-u14 U 5*- c o,s Date(s) of activity (for raffles, Indicate the date of the drawing) q-9—/o Check the box or boxes that indicate the type of gambling activity your organization will be conducting: ❑ 'Bingo Raffles (cash prizes may not exceed $12,000) ❑ 'Paddlewheels ❑ "Pu&Tabs ❑'Tipboards "Equipment for these activities must be obtained from a licensed distributor. This form 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 your qualifications to be involved in lawful gambling activities in Minnesota. 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 and your organization's name and address will be public information when received by the Board. All the other Information that you provide will be private data about you until the Board Issues your permit. When the Board issues your permit, all of the Information that you have provided to the Board in the process of applying for your permit will become public. If the Board does not issue you a permit, all the information you have provided in the process of applying for a permit remains private, with the exception of your name and your organization's name and address which will remain public. Private data about you are available only to me ronowing: Board members, staff of the Board whose work assignment requires that they have access to the information; the Minnesota Department of Public Safety; the Minnesota Attorney General; the Minnesota Commissioners of Administration, Finance, and Revenue; the Minnesota Legislative Auditor, national and international gambling regulatory agencies; anyone pursuant to court order; other individuals and agencies that are specifically authorized by stale 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. LV220 Application for Exempt Permit r C Page 2 oft �t . -b5 *k Uy i u o k Pf -F Il �(.+� 3/01 Organization Name � i �S 4 �+ Local Unit of Government Acknowledgment If the gambling premises is within city limits, the city must sign this application. On behalf of the city, I acknowledge this application. Check the action that the city is taking on this application. j city approves the application with no o 4� waiting period. The city approves the application with a 30 day 4.J waiting period, and allows the Board to issue a permit after 30 days (60 days for a first class city). The city denies the application. Print name of city JD (Sig a re o p rsonnet eceiving application) Title 11h i S a Date / I / 10 If the gambling premises is located in a township, both the county and township must sign this application. On behalf of the county, I acknowledge this application. Check the action that the county is taking on this application. The county approves the application with no waiting period. The county approves the application with a 30 day waiting period, and allows the Board to issue a permit after 30 days. The county denies the application. Print name of county (Signature of county personnel receiving application) Title Date TOWNSHIP: On behalf of the township, I acknowledge that the organization Is applying for exempted gambling activity within the township limits. [A township has no statutory authority to approve or deny an application (Minn. Stat. sec. 349.213, subd. 2).] Print name of township (Signature of township official 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. Chief executive officers Name (please print) . /P �� �a u t�� � ✓� �� / �g Date / Mail Application and Attachments At least 45 days prior to your scheduled activity date send: • the completed application, • a copy of your proof of nonprofit status, and • a $25 application fee (make check payable to "State of Minnesota ") Application fees are not prorated, refundable, or transferable. Send to: Gambling Control Board 1711 West County Road B, Suite 300 South Roseville, MN 56113 If your application has not been acknowledged by the local unit of government or has been denied, do not send the application to the Gambling Control Board.