Agenda - Council - 07/14/2015 - Laserfiche WebLink

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1{R-29-2015 20:48 FROM:DAVIS SALES & SERVIC 507-642-3562 mis ■�• <.G220 Application for Exempt Permit TO:17634339898 P.1/1 5/15 Page 2of2 LOCAL UNIT OF GOVERNMENT ACKNOWLEDGMENT (required before submitting application to the Minnesota Gambling Control Board) CITY APPROVAI. for a gambling premises located within city limits The application in acknowledged with no waiting period. application is acknowledged with a 30 -day waiting period, and allows the Board to issue a permit after 30 days (60 days for a 1st class city). The application is denied. City Name: C--`,. COUNTY APPROVAL for a gambling premises located in a township The application Is acknowledged with no waiting period. ____The Print Signature The application is acknowledged with a 30 -day waiting period, and allows the Board to Issue a permit after 30 days. The application is denied. Print County Name; of City Personnel: Signature of County Personnel: Title: _ -- .P',.. ` Date: Title:_ Date: TOWNSHIP (if required by the county) On behalf of the township, t 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, per Minn, Statutes, section 349.2134 Print Township Name: _ ._. The city or county must sign before submitting application to the Gambling Control Board. Signature of Township Officer: ___... . . Title: Date: CHIEF EXECUTIVE OFFICER'S SIGNATURE (required) The information report Chief Print provided in this application is complete and accurate to the best of my knowledge. I acknowledge that the financlal will be completed and returned to the Board within 30 days of the event date, Executive Officer's Signature' Date: (Signature must be GEO'5 signature; designee may not sign) Name: REQUIREMENTS • MAIL APPLICATION AND ATTACHMENTS Complete a separate application for: • all gambling conducted on two or more consecutive days, or • all gambling conducted on one day, Only one application Is required If one or more raffle drawings are conducted on the some day, Financial report to be completed within 30 days after the gambling activity is done; A financial report form will be mailed with your permit. Complete and return the financial report form to the Gambling Control Board, Your organization must keep all exempt records and reports for 3-1/2 years (Minn. Statutes, section 349.166, subd, 2(f)). Mail application with; a copy of your proof of nonprofit status, and application fee (non-refundable). If the application Is postmarked or received 30 days or more before the event, the application fee is $100; otherwise the fee Is $150. Make check payable to State of Minnesota. To; Gambling Control Board 1711 West County Road B, Suite 300 South Roseville, MN 55113 Questions? Call the Licensing Section of the Gambling Control Board at 651-539-1900. Data privacy notice: The Information requested on this form (and any attachments) will be used by the Gambling Control Board (Board) to determine your orgenizatIon's qualiflcations to be Involved in Iawtul gambling activities in Minnesota. Your organization has the right to refuse to supply the Information; however, If your organization refuses to supply this Information, the Board niay not be able to determine your organization's qualifications and, es o consequence, may refuse to issue a permit. If your organization supplies tie Information requested, the Board will be able to process the application, Your organization's name and address will be public Information when received by the Board, All other Information provided will be private data about your organtxatlon until the Board Issues the permit. When the Board Issues the permit, all Information provided will become public. Ir the Board dens not Issue a permit, all Information provided remains private, with the exception of your organization's name and address which will remain public. Private data about your organization are available to Board members, Board staff whose work requires access to the Information; Minnesota's Depart- ment of Public Safety; Attorney General; Commissioners of Administration, Minnesota Management & Budget, and Revenue; legislative Auditor, national and international gambling rrajulatoryagencies; anyone pursuant to court order; other Individuals and agencies specifically authorized by state or rederal law to nave 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 written consent. This form will be made available in alternative format (i.e. large print, braille) upon request.