Agenda - Council - 10/25/2005 - Laserfiche WebLink

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Mirme$o~ Lawful Gambling 8/o5 LG215 Lease for Lawful Gambling Activity of2 ' ' ~,~, I 'License number Daytime phone NameoHeasedpremise~ j ' Streetadd'ress C~ i State i Zip Da~timephone__, Name o~l~alownerofpremises Business~street addm~~C~/ State Zip . D~p~hane Hame of loser (if sam~ as legal Busines~street addre~ C~ S~te j Zip Da~ime phone owner, write in 'SAME") Check all a~i~iti~ that ~ill be conduced: ' v"Pud-~bs ~Pull-~ with dispensing device ~pboards ~Paddlewheel ~Paddlewheel wi[h ~ble ~8ingo Pull-~b, Tipboard, and Paddlewheei Rent (No ~... requir~ for Booth ope~don - sal~ of gambling equipment by an employee Bar opera,on - sales of gambling equipment wi~in a leased (er volun~r) of a lic~ns~ organization w~in a 5epa~e enclosure pr~mb~ by an employee of~e lessor ~om a common ar~ where that ~ di~n~ from ar~s where food and beve~g~ are so~. food and ~verages are a~o sold. F ~ ~ ~ D~s your organiza~on OR any o~er organiza~i~ conduct gambling from a booth o~r~on at ~is IocaUon? ~ . Yes No bas~ on ~e ~llo~ng combina~ons of open,on: based on ~e ~llo~ng combina~ons of ope~on: - Boo~ o~on Bar ope~ Boo~ operahon and pull-~b dispensing device Bar open,on ~ pOll-~b dispensing devic~ BooSt open,on and bar ope~bon Pull-~b dispensing device only Boo~ open,on, bar open,on, and pull-~b dispensing device The maximum rent allow~ may not ~c~d $1,750 in to~l ~e maximum rent allo~d may n~ ~ceed $2,500 in ~1 per month ~r all organi~ons at ~is premises, per mon~ for all organJzaaons at this premis~.. Camplete one op~on: Complete one op~on: Op~on A: 0 to 10% ortho gro~ profim per mon~. Op~on A: 0 ~o 20% ortho gross profi~ per month. Percen~ge ~ be paid . % Percen~ge to be paid % Op~on B: When gross profi~ are $4,000 or le~ per mon~, $0 to Op~on B: When gross profi~ are $1,000 or $~0 per mon~ may be paid. Amount ~ be paid $ ~ $200 per mon~ may be paid. Amount~.~ paid $ .. Op~o, C: $0 to $~0 per month may be paid.on ~e ~ $4,000 Op~on C: $0 to $200 per month may be paid on ~e fi~t $~,000 :~fgrossprofit. Amount ~ be paid $ ~~Pius0%to ofgro~pmfi~. :Amount to be paid $. Plus0%to ].0% of ~e gross profi~ may be paid per ~on~ on gro~ profi~ 120% of~e gross profi~ may be paid per mon~ on gross profi~ over$4,90O. Percen~ge to be paid /~ % .over$L,000. Pe~en~ge to be paid % · Bingo Rent (~mplete one option) Op~o. D: 0 to [0% of~e gross profi~ per month from all la~l Op~on F: ~r bingo only - No rent may be gambling a~vi~ heJd dunng bingo oc~sions, ~duding bar bingo, paid ~r bingo conduced in a bar. Percen~ge to be paid % Op~on E: A ~te based on a co~ per square ~ot not ~ ~c~d of a compa~ble co~ per square ~ot for leased space, as approved.by the dire~or of~e Gambling Con~ol Boa~. No rent may be paid ~r bar F ~r an~ new bingo a~viW n~ previou~ty bingo. Rate to be paid $ . per square ~ot. J includ~ in a Premis~ermitApplica~on, The lessor mu~ a~ach doc~men~don, verified by ~e organi~on, to confirm ~e compa~ble ~te and all applicable co~ ~ be ~id by ~e j a~ch a sepa~te s~eet of paper listing ~Qays and hou~ ~at bingo ,~11 be conduced. orgamzation ~ ~e le~r. A mend~ If ~is is an amended lease showing cha~ges ~cumng dunng ~e term of~e curren~ premis~ permit, bo~ pa~es · at sign~ ~e lea~ mu~ ini~al and date all change. ~ang~ mu~ be submi~ ~o ~e Gambling ~n~ol Board Lease at I~st ~O days prior to ~e change. Wr~e in ~e date ~a~ ~e chang~ will be e~ve Only L~sor Date ~ O~anizaBon Date~ -117-