5.d) Gambling Permit, Gammelgarden Meeting Date: 6/21/2011
Agenda Item: �( ��
City Council Agenda Report
City of Scandia
14727 209�' St. North
Scandia, MN 55073 (651) 433-2274
Action Requested: Approve the application of Gammelgarden Museum for an Excluded
or Exempt Lawful Gambling Permit to conduct a raffle.
Deadline/Timetine: The event is scheduled for September 10, 201 l, immediately prior to
the Taco Daze parade.
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.
• The Museum will sell chances on the "Running of the Meatballs"
which will occur on Oakhill Road starting at Elim Church, down
the hill (to the east.) Special golf balls will be rolled down the hill
and prizes awarded based on when the balls cross a finish line.
• A Special Event Permit will be needed for this activity. The
Scandia Marine Lions Club may decide to include it in their
application for the parade and the rest of their Taco Daze events.
If not, a separate permit should be applied for. Any conditions
that might be necessary to address the logistics and/or safety of the
event will be recommended at that time (most likely at the July
Council meeting.)
Recommendation: I recommend that the Council approve the permit.
Attachments/ . Application
Materials provided:
Contact(s): Dianne Johnson, 651 470-3724
Prepared by: Anne Hurlburt, Administrator
(gambling permit gammelgarden)
Page I of 1
06/1 S/11
APPLICATION FOR EXCL�UDED OR EXEMPT
LAWFUL GAMBLING PERMIT
Fee: $15.00
City of Scandia, Minnesota
14727 209th Street North, PO Box 128, Scandia, MN 55073
Phone 651/433-2274 Fax 6511433-5112 Web http:llwww.ci.scandia.mn.us
This application form is for use to request City approval of a �ocal 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 �nd address of organization: �'��,1in�� �� ,����,,�I /�� v��.u i�►-� �
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2. f�ame and addres� of premises where event will occur: (a copy of the rental or leasing arrangement,
if any, including renta/fo be charged to the organization must be attached to this application.) �
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3. �ate(s) of gambling occasion: �S�P_i. /G, � a � �
4. Estimated value of prizes to be awarde�: ;,?��c� o�.� � � ja T�2,z f s
5. Names and addresses of officers and persons accounting for receipts, expenses and
profits for the event:
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Name: ,�/{�N �. �J��j--t�)5G� , (Lmn'��i���. Phone: � /� 7
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Street Address: � � X ��� C��2 E-Mail: �--� 1�1����u�- �
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City/ State: ���ST (�c � Zip: ��� �
Name: Sv� ��,' 7 f-�-� ��-- � C�cA-Si,%QF�- Phone: (o S'J _ 5[�3 --�c��S
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City/ State: �.�}-�;��q- 7�1 ►..� Zip: S�SZ���
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Name: ��iN�, ]���i Z�.� � ��� .� ,�'r.i�:r�r� Phone: G;S I-��� ��y�f�
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Street Address: j����y ��'� �`�S�f• �` E-Mail: ��?�- ��m�,c�.;�Pr£-�E�1��w��� °J
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City/ State: ��.�`5 I ��(�t �`� Zip: ���, , �
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ACKNOWLEDGEMEIVTS: 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) Dat :
�,�� � � � �� ��2, �oi I
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Upon receipt of this application you will be notified in writing of the date on which the City Council will consider
the permit. The City Council meets on the �rst and third Tuesday of each month. Applications must be
received not less than 5 days prior to the meeting dafe. No application wi/l 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
Pa«
Application Fee Received �I' � �� � � � t t.5:,` �; � i;;,�
, �_ .
/ ���. ov
City Council Consideration (Date) �8 Jo�� � � CITY OF SCANDIA
Approved Denied
City of Scandia, Application for Excluded or Exempt Lawful Gambling Permit
Page 2, 1/22/2007
/�linnesota Lawfu!Gambling Page 1 of 2 5i��
L���(� A��tication for Exernpt Perrnit ApPiication fee
If 'c i n tm rk r r ive :
An exempt permit may be issued to a nonprofit organization that: less than 30 days ore than 30 days
- conducts lawful gamblin9 on five or fewer days, and before the event before the event
- awards less than $50,000 in prizes during a calendar year. $100 S��
ORG�4,1'�t�ZATION IPEFORMATIOt� Check# I I $ S�!)
Organization name Previous gambling permit number
Gammeigarden Museum, Scandia Elim Church �l,4
Minnesota tax ID number, if any Federal employer ID number, if any
410718379
Type of nonprofit orgenization. Check one.
� Fraternal r Religious � Veterans � Other nonprofit organization
Mailing address City ` State Zip Code County
20880 Olinda Trail No, PO Box 67 Scand,� �LiT;i�14 MN 55073 Washington
Name of chief executive officer (CEO) Daytime phone number Email address
Kevin �lickelson, Board Pres 651-433-5482 djdiannek@aol.com
�ttach a ca�sy a�fat�E a�the foEtowing fa� praaf af nan�rofit �tatus.
Do not attach a sales tax exempt status or federal employer ID number as they are not proof of nonprofit status.
�lonprofit/4rticfes of Incarporation Oti a current Certificate af Good fitarsding .
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 exemptiort [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.
IItS-/�ffiiliate of national,sYatewide,ar international parent rtonprofit organization (charter)
If your organization falls under a parent organization, attach copies of 124th of the following:
a. IRS letter showing your parent organization is a nonprofit 501(c)organization with a group ruling,and
b. the charter or letter from your parent organization recognizing your organization as a subordinate.
GQ►MBLI(�!G PREMISES INFORMATIQ(�E
Name of premises where the gambling event will be conducted. For raffles, list the site where the drewing will take place.
City of Scandia , prior to Taco Days Parade on Oakhiil Rd N
Address (do not use PO box) City or township Zip Code County
20880 Olinda Trail No Scandi� 55073 Washingtan
Date(s) of activity (for raffles, indicate the date of the drawing)
September 10, 2011
Check the box or boxes that indicate the type of gambling activity your organization wilf conduct:
Bingo* � Raffles . Paddlewheels* • Pu�l-Tabs* Tipboards*
`1J '� ,fl �(it`� lr�.Qt 18 A L't-S U4/ 'G' � 5
* Gambling equipment for pull-tabs, bingo paper, tipboards, and
paddlewheels must be obtained from a distributor licensed by the
Gambling Control Board. EXCEPTION: Bingo hard cards and
bingo number selection devices may be borrowed from another
organization authorized to conduct bingo.
To find a licensed distributor, go to www.gcb.state.mn.us and click
on List of Licensed Distributors, or call 651-639-4000.
LG220 Application for Exempt Permit Page 2 of 2 5n�
LOC/lL UNYT OF GOVERNMENT ACKI�OWLEDGMENT
If the gamtsling premises is within city limits, If the gambling premises is located in a township, a
a city official must check the action that the city is county official must check the action that the county is
taking on this application and sign the application. taking on this appfication and sign the application.
h tawnship officiat is not required to sign the
application.
The application is acknowledged with no waiting The application is acknowledged with no waiting
period. period.
The application is acknowledged with a 30 day
_The application is acknowledged with a 30 day waiting period,and allows the Board to issue a
waiting period, and allows the Board to issue a permit after 30 days.
permit aRer 30 days (60 days for a 1st class city). The application is denied.
The application is denied. , Print county name
Print city name ��lJ L��� On behalf of rhe county, I acknowledge this application.
Signature of county personnel receiving application
On behalf of the city, 1 acknowledge this application.
Signaiure of city personnel receiving application
Title Date
Title Date (Optionial) YOWNSHTP: On behalf of the township, I
acknowledge that the o�ganization is applying for exempted
gambling activity within the township limits. [A tow�ship has no
statutory authority to approve or deny an application [Minnesota
Statute 349.166)]
Print township name
BigRatur� of township official acknowledging application
Titie Date
CHIEF EXECI�fIYE QFF�CER`S SIG[�A�TIfFt� Print form and have CEO sign
The information provided in this application is comp/ete and accurate to the best of my knowledge. I acknowledge
that the financial report will be completed and returned to the Board within 30 days of the date of our gambling
activity. �,y ���_ Date �"� 2 Q " 1 C
Chief executive officer's signature
Complete a separate application for each gambling event: Financial report and recerdkeeping
• one day of gambling activity required
• two or more consecutive days of gamb{ing activity A financial report form and instructions will
• each day a raffle drawing is held be sent with your permit, or use the online
fill-in form available at
Send application with: www.gcb.state.mn.us. Within 30 days of the
• a copy of your proof of nonprofit status, and activity date, complete and return the
• application fee for each event financial report form to the Gambling
Make check payable to "State of Minnesota." Control Board.
Questions?
To: Gambling Control Board Call the Licensing Section of the Gambling
1711 West County Road B, Suite 300 South Control Board at 651-639-4000.
Roseville, MN 55113
This form will be made available in alternative format(i.e. large print,Braille)upon request.
Data privacy notiee: The information Your organization's name and private data about your organization are available
requested on this form (and any address will be public information to: Board members, eoard staff whose work
attachments) will be used by the Gambling when received by the Board. All requires access to the information; Minnesota's
Contro! Board (Board)to determine your other information provided will be Department of Public Safety;Attorney General;
organization's qualifications to be involved private data about your Commissioners of Administration, Minnesota
in lawful gambling activities in Minnesota. organization until the Board Management &Budget,and Revenue; Legislative
Your organization has the right to refuse to issues the permit. When the Auditor, national and international gambling
supply the information; howeve r, if your Board issues the permit, all regulatory agencies; anyone pursuant to court
organization refuses [o supply this information provided will become order; other individuals and agencies specifically
information, the Board may not be able to public. If the Board does not authorized by state orfederal law to have access
determine your organization's qualifications issue a permit, all information to the information; individuals and agencies for
and, as a consequence,may refuse to issue provided remains private,with the which law or legal order authorizes a new use or
a permit. If your organization supplies the exception of your organization's sharing of information after this noUce was given;
information requested,the Board will be name and address which will and anyone with your writtem m�sent.
able to process your organization's remain public.
application. �83@t FOf'R1