4.c) Scandia Elementary PTO, Application for Excluded Raffle Permit . � -
Meeting Date: 2/8/2011
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 Scandia Elementary PTO for an Excluded
Raffle Permit to conduct a raffle.
Deadline/ Timeline: The event is scheduled for March 26, 2011.
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 $2,000.00.
• The organization and the event appear to meet all the requirements
of the city's ordinance.
Recommendation: I recommend that the Council approve the permit.
Note: Staff is requesting that the Council make an exception in this
case to consider an action item at a work session meeting. The PTO
missed submitting their request in time for the January regular
meeting. The Council just changed the schedule to eliminate the
meeting on the first Tuesday of the month. Waiting until February 15
would create a hardship as the state must still approve the permit and
tickets must be printed. Without earlier action, the PTO might not
meet their goal of having tickets to sell by March 1.
Attachments/ • Application
Materials provided:
Contact(s): Mike Goeken, 651 433-2172
Prepared by: Anne Hurlburt, Administrator
(gambling permit scandia elem PTO)
Page 1 of 1
O 1/24/11
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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://www.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:
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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 officers and persons accounting for receipts, expenses and
profits for the event:
Name: ��`� G'G��� Phone: ��.�-3W'��
StreetAddress: l`���t ��'°"�� �`� � � E-Mail: t����) �� ���'�`��'`'"�"��
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City/ State: ��GA�iM � � Zip: �����
Name: �rt��- v��G^��� Phone: ,3�_�!'��
Street Address: 2��1�� a�g,"�� �'�, E-Mail: ��,t,lG���'�a•��t��y�Kti I�l � c��
City/ State: �C�*�r��i �'\'� Zip: ,)�G��`
Name: Phone:
Street Address: E-Mail:
City/ State: Zip:
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 receipt of this application you will be nofified in writing of the dafe on which the City Council will consider
the permit. The City Council meets on the first and third Tuesday of each monfh. Applications must be
received not/ess than 5 days prior to the meeting date. No application will be considered complete until fhe
fee has been paid. After Council action, the City Clerk will sign and return form LG220 or LG2408 to you.
For City Use Only
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Application Fee Received � i �n � I l
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City Council Consideration (Date) � O� ��
cITY QF SCANDIa
Approved Denied
City of Scandia, Application for Excluded or Exempt Lawful Gambling Permit
Page 2, 1/20/2011