5.f) Application for Excluded or Exempt Lawful Gambling Permit (Friends of Scandia Parks and Trails-Bingo) Meeting Date: 07/17/2012
Agenda Item: �' - �
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City Council Agenda Report
City of Scandia
14727 209�' St. North
Scandia, MN 55073 (651) 433-2274
Action Requested: Approve the application of the Friends of Scandia Parks and Trails for
an Excluded or Exempt Lawful Gambling Permit to conduct bingo
during the annual Taco Daze celebration.
Deadline/ Timeline: The event is scheduled for September 8, 2012.
Background: • The Gambling Ordinance (No. 100) requires a local permit to
conduct lawful gambling excluded or exempted from state
licensure requirements.
• The value of all prizes to be given is $300.00.
• The organization and the event appear to meet all the requirements
of the city's ordinance.
• The Scandia Marine Lions Club included this activity in their
Special Event Permit for the parade and the rest of their Taco Daze
events.
Recommendation: I recommend that the Council approve the permit.
Attachments/ • Application
Materials provided:
Contact(s): Mike White, 651 433-3579
Prepared by: Anne Hurlburt, Administrator
(Bingo Friends of Scandia Parks)
Page 1 of 1
07/11/12
APPLICATION FOR EXCLUDED OR EXEMPT
LAWFUL GAMBLING PERMIT
Fee: $15.00
City of Scandia, Minnesota
14727 209th Street North, Scandia, MN 55073
Phone 651/433-2274 Fax 6511433-5112 Web http:/Iwww.ci.scandia.mn.us
This application form is for use to request City approval of a local permit for lawFul gambling required to be registered with
the Minnesota Gambling Control Board. In addition to this form, applicants shall submit to the City the original, signed and
completed application to the Gambling Control Board (forms LG220, Application for Exempt Permit, or LG 2406,
Application to Conduct Excluded Bingo)with copies of all required attachments.
1. Name and address of organization: D �j�� Z �"�
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2. Name and address of premises where event will occur: (a copy of the rental or leasing arrangement,
if any, including rental to be charged to the organization must be attached to this application.)
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3. Date(s) of gambling occasion:
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4. Estimated value of prizes to be awarded:
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5. Names and addresses of o�cers and persons accounting for receipts, expenses and
profits for the event:
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Street Address: E-Mail:
City/ State: �/�.��}�fj ZiP�
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Street Address: E-Mail:
City/ State: ���� t � Zip:
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ACKNOWLEDGEMENTS: I hereby acknowledge and certify that the organization and the activity
for which this application applies will be conducted in accordance with the all regulations and
requirements of Minnesota Statutes and the rules of the Minnesota Gambling Control Board, and the
City of Scandia, including:
a) The organization is a non-profit organization with non-profit status from the IRS or the Minnesota
Secretary of State.
b) The organization has been in existence in the City of Scandia for at least three consecutive years
prior to the date of this application.
c) The organization has at least 15 active members.
d) This is the only organization conducting exempted or excluded lawful gambling activities on the
premises.
e) This permit is valid only for the occasion(s) for which it is issued.
6. Applicant Signature(s) Date:
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Upon receipf of this application you will be notified in writing of the date on which the City Council will consider
the permif. The City Council meets on the third Tuesday of each month. Applications must be received not
less than 5 days prior to the meeting date. No application wil!be considered complete until the fee has been
paid. After Council action, the City Clerk will sign and return form LG220 or LG2408 to you.
For City Use Only
Application Fee Received
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City Council Consideration (Date) / � � �'" ��-- CITY OF SCANQIA
Approved Denied
City of Scandia, Application for Excluded or Exempt Lawful Gambling Permit
Page 2, 7/11/2012