2018-04-25 Set Agenda & Packet - Laserfiche WebLink

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MINNESOTA LAWFUL GAMBLING I 1 LG220 Application for Exempt Permit Page I of 2 Auesempt permit may be issued to a nonprofit Application Fee (non-refundable) organization that: !Ica on I b f t]e re Applications are processed in the order received. If the application 'a • concl=b;tearful gambling on five or fewer days,and on' 1 $50 P n is postmarked or received 30 days or more before the event,the • awards less than $50,000 in prizes durning a calendar application fee is$100; otherwise the fee is SIGN. re year. Due to the high volume of exempt applications, payment of If total raffle prize value for the calendar year will! be $1,500 or less,contact the Licensing Specialist assigned to additional fees prior to 30 days before your event will not expedite calling 651-539-1,900. your unty service, nor one telephone requests for expedited service accepted, coby ORGANIZATION INFORMATION ------------------------------- -------------- Previous Gambling AAU�, r. X92403 Permit Numbs ............... .................................................................... ----------------- .............................. Minnesota Tax ID Federal Employer ID Number, if any: ------------------------ Number(FEIN), if any. ..........:.:.............................................................."I'l""I'll""I'll'll""I'll""I'll",'ll"'ll................................................................................- pity. I rnct�t --- State: MR Zip- 55446 County.� Hennepin -ty— ----------------------- -----------— Name of Chief Executive Officer(CEO); Rich Berg,President -------------------------- CEO Daytime Phone:763-286-0507 CEO Email: RBerg3710@aol,com (permit will he emailed to this email address unless otherwise indicated below) Email permit to (if other than the CEO):rpmcmn@yahoo,com —--------------- NONPROFIT STATUS Type of Nonprofit Organization (check one): rraternal Religious Veterans other Nonprofit Organization _________w_ -------------- Attach a copy of able of the following showing proof of nonprofit status, --------- ----------------- _______.w (Do NOr attach a sales tax exempt status or federal employer ID number,as they are not proof of nonprofit status.) _=.tedbel w) ................j NO PROFIT STATUS 0 IT Type of N (In profit Organization Erate 7 al .......... .. A current calendar year certificate of Good Standing Don't have a copy? Obtain this certificate from: MN Secretary of State, Business Services Division Secretary of State andwate,phone numbers: 60 Empire Drive, Suite 100 ww-w—so-s—sig-Le--milama St. Paul, NO 55103 651-296-2803,or toll free 1-877-551-6767 IRS income tax exemption (501(c))letter In your organizations name Don't have is copy? To obtain a copy of your federal income tax exempt letter, have an organization officer contact the IRS toll free at 1-877-829-5500. IRS-Affiliate of national,statewide,or International parent nonprofit organization (charter) If your organization falls under a parent organization,attach copies of BDIb,of the following: 1. IRS letter showing your parent organization is a nonprofit 501(c)organization with a group ruling; and 2. the charter or letter from your parent organization recognizing your organization as a subordinate. GAMBLING PREMISES INFORMATION ------- ---- i Name of premises where the gambling event will be conducted (for raffles, list the site where the drawing will take place): Rumble House ------------ 'a subordinate. ---- ...................................... ...................a Physical Address(do not use P.O. box): _4031)Msin sfhol ............"I1111111111111111111111-,--I------------------ .................................................................... -----------------Z.......................................... Check one: city-.S�ante no -------—----- -—----------------- zip: 55038 County: Anoka Township: --—-°-__________ Zip: '11-11-..."I'll I Countyv Date(s)of activity (for raffles, indicate the date of the drawing): Elul Y2�,2Q'I4_..--------------------- Check each type of gambling activity that your organization will conduct, E]Bingo =Paddlewheels =Pull-Tabs =11pboards EZ1 Raffle Gambling equipment for bingo paper, bingo boards,raffle boards, paddlewheels, pull-tabs,and tipboards must be obtained from to distributor licensed by the Minnesota Gambling Control Board, EXCEPTION, Bingo hard cards and bingo ball selection devices may be borrowed from another organization authorized to conduct bingo. To find a licensed distributor,go to oniver.garowevIgueb and click on Decratutors under the List of Licensees tab,or call 651-539-1900. ---------------- 76