1d Temp Gambling Permit/St. Hub
CITY OF
CHANHASSEN
7700 MarkalBoulevard
PO Box 147
Chanhassen, MN 55317
Admlnisllation
Phone: 952.127.1100
fax: 952.127.1110
Building Inspections
Phone: 952.127.1180
fax: 952.127.1190
Engineering
Phone: 952.127.1160
fax: 952.127.1170
Finance
Phone: 952.227.1140
fax: 952.227.1110
Park & Reerealion
Phone: 952.127.1120
fax: 952.227.1110
RecreationCenler
2310 Couller Boulevard
Phone: 952.127.1400
fax: 952.227.1404
Planning &
Nalural Resources
Phone: 952.127.1130
fax: 952.227.1110
Public Works
1591 Park Road
Phone: 952.227.1300
fax: 952.227.1310
Senior Cenler
Phone: 952.227.1125
fax: 952.127.1110
WebSlle
WOIffl.ci.chanhassen.mn.us
icL
MEMORANDUM
TO:
Todd Gerhardt, Acting City Manager
FROM:
Karen J. Engelhardt, Office Manager
DATE:
March 27, 2002
SUBJ:
Approval of Temporary Gambling Permit Request, St. Hubert's
Church, May 4, 2002
St. Hubert's Church has submitted an application for a temporary gambling
permit for a fundraising event. They will be having a dinner and raffle on
May 4,2002. The proceeds from the raffle will be donated to St. Bernard's
Church and School as a part of St. Hubert's outreach program. Law
Enforcement has completed a background investigation on the applicant and did
not find any negative comments. Bruce Koprucki from St. Hubert's will be in
the audience on Monday night if the Council has any questions of him.
RECOMMENDATION
Staff recommends approval of the application as submitted.
The Cily 01 Chanhassen . A growing communily wilh clean lakes, qualily schools, a channing downlown, Ihriving businesses, winding lrails, and beaulilul parks. A g~al place 10 live, work, and play.
Page 1 of 2 3101
Fee - $25
or
n
Fee Paid
Check No.
Previous lawful gambfing exemption number
~MJ tl. I ððo ,
~IJ
Name of chief executive offICer (CEO)
~ name 0 last name
~~ ~"'rJ R,\c..
Name of asurer
irst name
Check 1he box 1hat best desc~'b s your organization:
o Fraternal eligious
o Veteran Other nonprofrt organization
Check 1he box 1hat indicates 1he type of proof your organization attached to 1his application:
o IRS letter indicating income tax exempt status
o Certificate of Good Standing from the Minnesota Secretary of State's Office
charter showing you are an affiliate of a parent nonprofit organization
roof previously submitted and on file wfth the Gambling Control Board
Gamblin Premises Information
Na f premises wh g'f"bUng activity wHl be co~t¡td (for ralf)'". Us! the sfte where the drawing will take place)
;r~ V ~ 1 "- tw/u '"
~ttusePt\~;N V\VII t~I.~.-J i1;ro~"3 c~ IJ~
Dale(s)
of Ihe drawln~
ctðO ~
xes thai indicate the e of gambUng activity your organization wiN be conducting:
o 'Bingo Raffles (cash prizes may not exceed $12,000) 0 'Paddlewheels 0 'PuN-Tabs 0 *Topboards
'Equipment for these actMties must be obtained from a licensed distributor.
This form will be made available in Your name and and your organization's
alternative format (I.e. large print, BraUle) name and address wi be pubUc information
upon request. The Information requested when received by the Board. AU the other
on this form (and any attachments) will be information that you provide wDI be private
used by the Gambling Control Board data about you until the Board Issues your
(Bo.ard) to d?termine your qualifICations to permit. When the Board issues your
be llvoived n lawful gambUng activities in permit, all of the information that you have
Minnesota. You have the right to refuse to provided to the Board In the process of
supply the information requested; however, applying for your permft wil become public.
i! you refuse to supply this information, the II the Board does not issue you a permft,
Board may not be able to determine your all the information you have provided in the
qualifications and, as a consequence, may process of applying for a permft remains
ref,,:,e to issue you a permtt. II you supply private, wfth the exception of your name
the nformation requested, the Board will and your organization's name and address
be able to process your application. which will remain pubUc.
Private data about you are available only to
the foHewing: Board members, staff of the
Board whose work assignment requires
that they have access to the information;
the Minnesota Department of Public Safely;
the Minnesota Attorney General; the
Minnesota Commissioners of
Administration, Finance, and Revenue; the
Minnesota Legislative Auditor, national and
international gambUng 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 wfth your consent.
Organization Name ________________
Local Unit of Government Acknowledgment
If 1he gambling premises Is within city limits, the
city mus1 sign this application.
On behalf of 1he cfty. I acknowledge 1his application.
LG220 - Application for Exempt Permit
Check the action that
the city is taking on this application.
O The cfty approves 1he application with no
waiting period.
O The cfty approves the application wfth a 30 day
wafting period. and allows the Board to issue a
penmft after 30 days (60 days for a first class
city).
o The city denies the application.
Print name ofc"Y_____________________________
(Signature of city personnel receiving application)
T~e__________________________________
Date_____I____I______
Chief Executive Officer's Signature
The infonmation provided in this application' co
Page 2 of2
3/01
----
If 1he gambling premises Is located in a township, both
1he county and townshIp mus1 sign 1hls application.
On behalf of the county, I acknowledge this application.
Check the action that
the county is taking on this application.
O The county approves 1he application wfth no
wafting period.
o The county approves the application wfth a 30 day
wafting period, and allows the Board to issue a
penmft after 30 days.
o The county denies the application.
Print name of county ________________
(Signature of county personnel receiving application)
Tftle _____________________________
Date____'-__'-___
TOWNSHIP: On behalf of the township, I acknowledge that
the organization is applying for exempted gambling activity
wfthin the township limfts. [A township has no statutory
authority to approve or deny an application (Minn. Stat. sec.
349.213, subd. 2).]
Print name of township ________________
(Signature of township official acknowledging application)
Tftle___________________
Date______I__I_
to the best of my knowledge.
Date'ô '3. I~I ð
Name (please print)
Mail Application and Attachments
At least 45 days prior to your scheduled activfty date send:
the completed application,
, a copy of your proof of nonprom status, and
, a $25 application fee (make check payable to "State of Minnesota").
Application fees are not prorated, refundable, or transferable.
Send to: Gambling Control Board
1711 West County Road B, Suite 300 South
Roseville, MN 55113
If your application has not
been acknowledged by 1he
local unft of government or
has been denied, do not
send 1he application to the
Gambling Control Board.