1p St Hubert Gambling Permit
CITY OF
CHANHASSEN
7700 Market Boulevard
PO Box 147
Chanhassen, MN 55317
Administration
Phone 952.227.1100
Fax 952.227.1110
Building Inspections
Phone 952.227.1180
Fax 952.227.1190
Engineering
Phone 952.227.1160
Fax. 952.227.1170
Finance
Phone 952.227.1140
Fax 952.227.1110
Park & Recreation
Phone 952.227.1120
Fax 952.227.1110
Recreation Center
2310 Coulter Boulevard
Phone 952.227.1400
Fax 952.227.1404
Planning &
Natural Resources
Phone 952.227.1130
Fax. 952.227.1110
Public Works
1591 Park Road
Phone 952.227.1300
Fax 952.227.1310
Senior Center
Phone 952.227.1125
Fax. 952.227.1110
Web Site
www.cl.chanhassen.mn.us
1--4:
MEMORANDUM
TO:
Todd Gerhardt, City Manager
FROM:
Karen Engelhardt, Office Manager e«ç
March 9, 2005 .~
DA TE:
SUBJ:
Approval of a Temporary Charitable Gambling Permit Request,
St. Hubert Catholic Community
Attached please find a request for a Temporary Charitable Gambling Permit
from St. Hubert Catholic Community. They would like to conduct a raffle as a
part of their annual Spring Fling fundraiser that will be held on April 23, 2005 at
the school, 8201 Main Street.
RECOMMENDA TION
Staff recommends approval of St. Hubert Catholic Community's request as
submitted.
The City of Chanhassen · A growing community with clean lakes, quality schools. a charming downtown, thriving businesses, winding trails, and beautiful parks A great place to live work, and play
Minnesota Lawful Gambling
LG220 Application for Exempt Permit
An exempt permit may be issued to nonprofit organizations
conducting lawful gambling activity 0/1 five or fewer days. and
awarding less than $50,000 In prizes dUring a calendar year.
Organization Information
~a/1iZatlOn ill name , Previous licens
¡ii;:e:F~- tLl~ .. <:~G.tf~J¡(6,y(fl!"'M" "'-~
~@ ¡ /{1t/1Il S{g~"Il_Œ-,J~Açç~ V
Name of chief executive officer (CEO)
F~name Sre ç I'J D
Fee $50
Page10f2 11/04
For Board Use Only
Fee Paid
Check No.
or exemption number, if any
/ð tJO I
Last name
U I A. Ie. I(
County
Vc.1L-
Daytime phone number
- · 3 · q {O ~
Type of nonprofit organization (check one)
D Fraternal S Religious
D Veteran 0 Other nonprofit organization
Type of proof of nonprofit - attach a copy (see instructions)
D Nonprofit Articles of Incorporation or Certificate of Good Standing - Minnesota Secretary of State's Office
D Internal Revenue Service
D Affiliate of parent nonprofit organization (charter)
Gambling Premises Information
N~í premlSejWhere gambling activity will be conducted (for raffles. list;he site where the drawing will take place)
Add,;;:~ ook;,*~~~--- C[~~h___~ '" ~T ;?;,;;;; County-
_39LfI 1\ ;N__~ -:-r_ ._,~"" L" t~""-__ __n_ ~ .s-3J~JCÀ fV ~ r'L _
oate(Af ~ct;~t\for raffle~n3cate the date=Wing)
_.__' ftÎ C; ,--.---.---d----.---.---. .._.___..____.____.__.____.____________.__
Check t~boxes that indicate tile type of ga.mbling activity your organization will be conducting
o 'Bingo ~Raffles 0 'Paddlewheels 0 'Pull-Tabs 0 'Tipboards
-Gambling equipment for pull-tabs, tipboards, paddlewheels. and bingo (bingo paper, hard cards, and bingo ball
selection device) must be obtained 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-651-639-4000.
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 dnd and your organization's name
and address will be public information when
received by tile 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 pennit. 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 rernalll public.
Private data about you are available only to
the following Board members, staff of the
Board wl10se 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 state 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.
LG220 Application for Exempt Permit
Organization Name
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.
Page 2 of 2
11/04
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 city is taking on this application.
O The city approves the application with no
waiting period.
Check the action that
the county is taking on this application.
O The county approves the application with no
waiting period.
O The city approves the application with a 30 day
waiting period. and allows the Board to Issue a
permit after 30 days (60 days for a first class
city).
o The county approves the application with a 30 day
waiting period, and allows the Board to issue a
permit after 30 days.
o The city denies the application.
o The county denies the application.
Print name of city
Print name of county
Signature of city personnel receiving application
Signature of county personnel receiving application
Title
Title
Date_/_I_
Oate_/_I_
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
(Minnesota Statute 349213, subd. 2).]
Print name of township
Signature of township official acknowledging application
Title
Oate_I__I_
Chief Executive Officer's Signature
The Inforrnation provided in this application is complete and accurate to the best of my knowledge. I acknowledge that the
financial report will be completed and returned to e Gambling Con 01 Board ithin 30 days of the date of our gambling
activity
Chief executive officer's signature
Oate~/-3-1 oS
Name (please print) R. S./..e 'P k p tJ
Mail application and attachments
Complete an application for each
gambling activity:
· one day of gambling activity
· two or more consecutive days of
gambling activity
· each day a raffle drawing is held
Send:
· the completed application,
· a copy of your proof of nonprofit status (see instructions), and
· a $50 application fee. Make check payable to "State of Minnesota".
To: Gambling Control Board
1711 West County Road B, Suite 300 South
Roseville, MN 55113