5.a) Application for Excluded or Exempt Lawful Gambling Permit, Scandia Women's Softball Meeting Date: 2/6/2008
Agenda Item: % � �
City Council Agenda Report
City of Scandia
14727 209`h St. North
Scandia, MN 55073 (651) 433-2274
Action Requested: Consider application of Scandia Women's Softball for an Excluded or
Exempt Lawful Gambling Permit to conduct Ham Bingo and Turkey
Bingo at the Scandia Community Center
Deadline/ Timeline: Ham Bingo is scheduled for March 7, 2008, Turkey Bingo on
November 21, 2008.
Background: • The Gambling Ordinance (No. 100) requires a local permit to
conduct lawful gambling excluded or exempted from state
licensure requirements.
• The softball association's state Application to Conduct Excluded
Bingo requires approval by the city. Up to four events in a
calendar year may be covered in a single application.
• Prizes given will be 50-$10 hams (March) and 50-$10 turkeys
(November)
� This event has been conducted in past years by this organization at
this location, with no incident or complaint.
• 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.
Attachments/ • Applications
Materials provided:
Contact(s): Linda Capra, Scandia Women's Softball
651 464-0659
Prepared by: Anne Hurlburt, Administrator
(gambling permit womens softball bingo)
Page 1 of 1
O 1/30/08
APPLICATION FOR EXCLUDED OR EXEMPT
LAWFUL GAMBLING PERMIT
Fee: $15.00
City of Scandia, Minnesota
14727 209th Street North, PO Box 128, Scandia, MN 55073
Phone 6511433-2274 Fax 651/433-5112 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 240B,
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 renfal 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: �,t���-, �ti•.��(z i� Phone: �yS � � `'��`i r G�C 5��
Street Address: Z( ��U � u� "� �- f� ��� j� E-Mail: �cct'���a G���'. %"�'' ��� � �-�`~�--
City/ State: '' y �_�� 14�?� �> ��� L `� Zi
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Name: Phone:
Street Address: E-Mail:
City/ State: Zip:
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 notified in writing of the date on which fhe City Council will consider
the permit. The City Council meets on the first and third Tuesday of each month. Applications must be
received not less than 5 days prior fo the meeting date. No application will be considered complefe 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 P��p
Application Fee Received � ��- U C� �AI� 2 3 Z00$
City Council Consideration (Date) CITY OF SCANDIA
Approved Denied
City of Scandia, Application for Excluded or Exempt Lawful Gambling Permit
Page 2, 1/22/2007
6/07
Minnesota Lawful Gambling Page 1 of 2
LG240B Application to Conduct Excluded Bingo No fee
ORGANIZATION INFORMATION
Organization name Previous gambling permit number
� � � S��� 4��, ��
�1 C'c:�� 1 c�i eti 1,�� G���e_,� �__
Type of nonprofit organizatlon. Chedc ('�) one.
❑ Fraternal ❑ Religious ❑ Veterans � Other nonprofit organization
Mailing address City State/Zip Code County
,,�17�v 2I�C:-F�t /� ir� �v ���s �1��k� ��,� �����zs iti��asH
ATTACH A COPY OF ONE OF THE FOLLOWING FOR PROOF OF NONPROFIT STATUS
* Do not attach a sales tax exempt status or federal ID employer number as they are not proof of nonprofit status.
� NonprofitArticles 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
Internal Revenue Servlce-IRS Income tax exemption[501(c)]letter in your organization's name.
Don't have a copy7 To obtain a copy of your federal income tax exempt letter,send your federal ID number and
the date your organization initially applied for tax exempt status to:
IRS, P.O. Box 2508, Room 4010, Cincinnati,OH 45201
Internal Revenue Servfce-Afflllate of national,statewide,or international parent nonprofit organization(charter)
If your organization falls under a parent organization, attach copies of�of the following:
a. IRS letter showing your parent organization is a nonprofit 501(c)organization with a group ruling
b. the charter or letter from your parent organization recognizing your organization as a subordinate.
Internal Revenue Servlce-proof previously submitted to Gambing Control Board
If you previously submitted proof of nonprofit status from the Intemal Revenue Service, no attachment is required.
EXCLUDED BINGO ACTIVITY
1. �No � Has your organization held a bingo event in the current calendar year?
If yes, list the dates when bingo was conducted
2. The proposed bingo event for which we are applying will be:
Y one of four or fewer bingo events held this year. Dates �-,5 7-v� ��" �"D�
OR
_conducted up to 12 consecutive days in connection with a:
_counry fair. Dates
civic celebration. Dates
Minnesota state fair. Dates
3. Person in charge of bingo event ' c����C� �C����-- Daytime phone �5�"`���'������ J /
4. Name of premises where bingo will be conducted ��(-+�ti"�C��C� � ��;7�r'�—� ���`�,� .
5. Premises street address »1 �r' �(� � '�-• �
�
6. City ��'� ���c.,tic����. If township, name of township County U���S N
Bingo hard cards, bingo paper, and bingo number selection devices must be purchased
from a distributor licensed by the Gambling Control Board. To find a licensed distributor, go
to www.gcb.state.mn.us and click on List of Licensed Distributors. Or call 651-639-4076.
Be sure to complete page 2
Page 2 of 2
LG2406 Application to Conduct Excluded Bingo sio�
Chief Executive Officer's Signature
The information provided in this applicatiQn is compl e and accurate to the best of my knowledge.
Chief executive officer's signature ��Z�C�- �—� � �t-�`-- Phone nu�ber)�/�7 "��n��
� �
Name (please print) ���L'�j� � ����Z'� Date C� / ��/ ���
Local Unit of Government Acknowledgment and Approval
If the gambling premises is withfn city Iimits,the city must sign this application.
On behalf of the city, I approve this application/or print city name
excluded bingo activity at the premises located within
the city's jurisdiction.
Signature of city personnel receiving application
Title Date / /
If the gambling premises Is located In a township,both the county and township must sign this application.
For the township: On behalf of the township,
I acknowledge that the organization is applying for print township name
excluded bingo activity within the township limits.
A township has no statutory authority to approve or Signature of township official acknowledging application
deny an application(Minn.Stat.349.213,Subd.2).
Title Date / /
For the county: On behali of the county, 1 approve Print county name
this application for excluded bingo activity at the
premises located within the county's jurisdiction.
Signature of county personnel receiving application
Title Date / /
Mail Application and Attachment(s)
Send the application and proof of nonprofit You will receive a document from the Gambling Control Board with
status to: your permit number for the gambling activity. Your organization must
Gambling Control Board keep its bingo records for 3-1/2 years.
Suite 300 South
1711 W.County Rd.B Questions? Contact the Gambling Control Board at 651-639-4000.
Roseville,MN 66113
This form will be made available in alternative format(i.e. large print,
Or, you may fax it to 651-639-4032. Braille) upon request.
Data Privacy Notice: The information requested on this form Board does not issue you an authorization,all information provided
(and any attachments)will be used by the Gambling Control Board remains private, with the exception of your name and your
(Board)to determine your qualifications to be involved in lawful organization's name and address which will remain public.
gambling adivities in Minnesota. You have the right to refuse to private data about you is available to:Board members,Board staff
supply the information requested;however,if you refuse to supply Whose work requires access to the information; Minnesota's
this information, the Board may not be able to determine your Department of Public Safety,Attomey General; Commissioners of
qualifications and, as a consequence, may refuse to issue you Administration,Finance,and Revenue;Legislative Auditor,national
an authorization. tf you supply the information requested, the and intemational gambling regulatory agencies;anyone pursuant to
Board will be able to process your application. court order; other individuals and agencies that are specifically
Your name and your organization's name and address will be authorized by state or federal law to have access to the information;
public information when received by the Board. All the other individuals and agencies for which law or legal order authorizes a
information will be private data until the Board issues your new use or sharing of information after this Notice was given;and
authorization and the information then becomes public. If the anyone with your consent.
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BUSINESS ORGANIZATIONS INQUIRY -VIEW ENTITY
Filing Number: 650404-2 Entity Type: Non-Profit
Corporation
Original Date of Filing: 10/8/2003 Entity Status: Active
Duration: Perpetual Good Standing: 2007
(date of last annual
filing)
Name: Scandia Women's Softball Association
Registered Office l 529 Broken Oak Ct
Address: Lino Lakes, MN, 55038
Agent Name: Andrea C Golis
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