HomeMy WebLinkAbout2006-12-27 CC - Set Agenda
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CITY COUNCIL MEETING
Wednesday, December 27, 2006
6:30 p.m.
Set Agenda = Red
COUNCIL MEETING
I. CALL TO ORDER
1. Roll Call
ll. PUBLIC HEARINGS
llI. APPROVALOFAGENDA
IV. APPROVAL OF COUNCIL MINUTES
1. December 7, 2006 City Council Work Session Meeting Minutes (page 1)
2. December 13, 2006 City Council Work Session Meeting Minutes (Page 2)
3. December 13, 2006 City Council Meeting Minutes (page 3-20)
V. CONSENT AGENDA
1. City ofCenterville December 14, 2006 through December 27,2006 Claims
(Page 21 & 2la)
2. Centennial Fire District Expenditures through December 13, 2006 (page 22)
3. Centennial Lakes Police Department Expenditures 11/10-12/14/06 (Page 23-
25)
4. Centerville Lion's Request for Temporary Gambling Permit (Rame) &
Special Event Permit for Ice Fishing Contest - Saturday, February 17, 2007
- Centerville Lake Subject to Filing of Appropriate Documents (Page 25a)
5. Successful Performance Review - City Clerk, Ms. Teresa Bender (From
Grade 6, Step 7 to Step 8)
60 Approval of Massage Thfloapist License & Sauna(s) or Massage Parlor(s)
l.kenS(' \ls. l.isa h.it'\dho!'\,l (SUbjl'tt to Suc('-{'"sflll Criminal Background
Check)
VI. A W ARDS/PRESENTATIONS/APPEARANCES
VII. OLD BUSINESS
1. Joint Powen Agreement (CSAH 14) (Page 25b-25k)
vm. NEW BUSINESS
1. Precision Excavating Closeout & Final Payment - $132,384.50 - (Block 7)
(Page 26-29)
2. Labor Agreement (January, 2007 - December 31,2009) (Page 30-53)
3. North Anoka Meals on Wheels Request for Letter of Support (Page 54)
4. Press Publications Request to be Appointed/Designated as the City's Legal
Paper (Page 55)
5. Anoka County Integrated W ute Management Agreement for Residential
Recycling Program 2007 & Recommended Language Modification (Page 57
-64)
6. Policies
a. Sidewalk/Trail Inspection (Page 65-67)
b. Pothole Repair (Page 68-69)
c. Snowplowing (page 70-72)
d. Street Sweeping (Page 73-75)
7. District Memorial Hospital Board Dissolution (page 77-82)
8. Res. #06-0xx. - Appointment Committee/Commission Guidelines (Page 83-
84)
9. Council Appointments (Capra)
10. Res. #06-05X - Operating Transfers of Funds (Page 84a)
11. Facility Use Agreement (Church of St. Gen'slMet. Transit/City) (Page 84b)
IX. ANNOUNCEMENTSIUPDATES
. 1. City Administrator, Mr. Dallas Larson
2. CSAH14 JPA (Update)
3~ Downtown Redevelopment - Draft Development Agreement (Page 85-123)
4. Centerville Sesquicentennial
a. LaCompany
6. Correspondence to Anoka County Integrated Waste Management (page
124-125)
7. Centennial Lakes Police Department Update (Pat Aldrich) (Page 126-127)
X. ADJOURNMENT
**REMINDERS**
Happy New Year - January 1,2007 (City Hall Closed in Observance)
Planning & Zoning Commission - January 2,2007 - 6:30 p.m. Council Chambers
Parks & Recreation Committee - January 3, 2007 - 6:30 p.m. Council Chambers
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'Esta 6fisfi ed' 185'(
Name
10100 MAIN STREET BANK
Paid Chk# 021992 AVlIC
Paid Chk# 021993 CWo HOULE, INC.
Paid Chk# 021994 LARSON, DALLAS
Paid Chk# 021995 MCPHERSON, JOEL
Paid Chk# 021996 NATIONWIDE RETIREMENT
Paid Chk# 021997 PRESS PUBLICATIONS
Paid Chk# 021998 QWEST
Paid Chk# 021999 UNIVERSITY OF MINNESOTA
Paid Chk# 022000 US BANK'
Paid Chk# 022001 XCEL ENERGY
CITY OF CENTERVILLE
12/27/063:34 PM
Page 1
*Check Summary Register@
UPDATE
Check Date
DECEMBER 2006
Check Amt
12/28/2006
12/28/2006
12/28/2006
12/28/2006
12/28/2006
12/28/2006
12/28/2006
12/28/2006
12/28/2006
12/28/2006
Total Checks
$624.07 DEF COMP W/H 12-28-06
$3,658.00 INSTALL BIT TRAIL
$27.68 REPLACEMENT BATTERYS FOR SECUR
$136.00 REIMBURSE FOR BOOT ALLOWANCE
$356.38 DEF COMP W/H 12-28-06
$352.00 AD FOR PART-TIME RINKATTENDAN
$322.45 429-3232 - SERV THRU 1-15-07
$300.00 J. MCPHERSON 1-3 & 1-4 & 1-8 R
$131.06 CALENDARS
$1,046.00 1880 MAIN STREET - SERV THRU 1
$6,953.64
2/0-1
11>15. ~
APPUCAnON PORMASSAGE TBEltAPIST CERTD'lCATIONILICENSE
CITY 01' CENTERVILLE
1I- ;JJ. -0(,
Date
MASSAGBLOCATION/ADDRESS ~\<A.\)\n ~\ roprG\.(,;\-c~
HOURSIDAYSOFOPBRA11ON fll-~ ( . 1./- 7
NAMEOFAPPLICANT LIsA KA~l.ln K:ese\horst.
(first) (1IIidcIIe) J' (last)
DATE OF BIR.m 1- J.S -(0 S" HOME 'lELEPBONB f#: ~..., --<..S-?> II( ~ '6
SCHOOL ATI'ENDED ANDDBGRBESItECEIVBD: ~6h R~~~(\J ~j'",~~e... S~ )'00 \ ~ rntl~ ~
1\ .J.. "r ~ .1 m '-11_ ..L.. p." 71to11l(J5c>Y) ~ J:. ~ lJ,so
L.~~tT~~ l..!..J(J.~~ II\O~~~ ~ f~ tnw ~/fI
usr QUAUFlCATIONS REQUIRED TO PRACl1CB MASSAGE: '1 ~ fwu.u,~ ~ O-",d Uw1d. ofl
~~~ v..\"Id. ~~ ~ b1 ~n'~ \)fcL.~~'~~.
USTTHRBB CHARACTHRRBFBRENCES ~rr AND JgTHDATE): Pc,.: ~ 000
l\J(J.n~ ~h/\~-DOC5 7-"-$2. ~~ ~(O ,2.-70-1 f l.lS-l .t- J.j.illli .l,2-r-S3
'<"Li~ ~~ ''''~P''y) ~l ~u{k.-rlil) ~
, _ qlt.' ( - - 0 - LJ90-
HAS ~8EEN CONVICIED OF A CRIMB. arBER THAN A TRAFFIC VIOLADON?
YES NO ~ ~ - C.SI - 7f,'j -4l1T"
I~' (l)CA~n~t
. &.(\ \t.~\J, IIR.. m~~
lP YES, PLEASE GIVB ANBXPLANA1ION ON A SEPARATE PIECE OF PAPER, JNa.UD1NG TJMB, PLACE AND
NA1URE OF SUCH CRJMB OR. OFFBNSB AND DISPOSmON THEREOF.
TUB APPUCANT SBAU. PllOVIDE TBB FOLLOWING INFORMATION:
A. EVIDENCE OF APPLICANTS EDUCA1ION INCLUDING CONTINUING EDUCATION lP APPLICABLE.
B. EVIDENCE OF APPLICANTS QUALIFlCA110NS AND CHARACI'ER RBFBRBNCES. .
C. EVIDENCE IN THE FORM OF A CURRENT CERTIFICAlE FROM A UCBNSES PHYSICIAN
PRAcnClNG IN MINNBSOrA INDICATING mAT SAm MASSAGE THERAPIST WAS EXAMJNBD
AND IS FREE OF ANY COMMUNICABLE DISEASE THAT WOULD DISQUALIFY THE APPLICANT
FROMBNGAGING INTBBPRACDC OFMASSAGB.
A RENEWAL CERTIFICATE WILL DB REQUIRED ~CH CALBNDAR YEAR, ALONG WITH A PHYSICAL
EXAMINATION CERTlPlCA'IB. COMPLB'IED APPLICA110N AND RENEWALFEB OF $50~ APPUCANTS WILL
STRICI'LY COMPLY Wl1H ALL REGULATIONS PROMULGATBD BY THE cnY COONeR. OF THE CITY OF
CEN'lERVILLE AND AlL ORDIANCES OF SAID MUNICIPALITY..
I hereby certify that I have read the foregoing~. . as and that the BDSWeI'S to said questions are true
oI'my ownkDowlodae- . ~DJ'--1
. . 0 Applicant
Subscribed BDCl swomto before me
j
This ~ day of 'D.,.1L-
~ SV.JlR.N<-,
Notary Public 5tg1'Afllre
My Commission Expires ~,D
. 2006
~ ~". -
KRIS SWEENE';
NOTARY PUBLIC. MINNESOTA
Mr CllmmIssIoIl Expiles.lan. 31, 201 0
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_m2 fax (651).429-8629
CElVEllOF 2845 AMOUNT.
Usa K1eselhort $85.00
.
FOR;
MS888ae Therapy Ucense CHECK tJ 7161
SURCHARGE
BY 'I 'e/'eBfl
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December 8. 2008
Thank you for your business.
RecelPt# 2845
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. OCC1JRRENCE COVERAGE
ABMP (q..I)ues Uabllity Program
..
JNSVRf.D ~ AOORESS:
A8iiCJdatect~ &; Massage Pi'ofesslonaIa
and lDcItvIdiW Members In Good StandIIIg
1271 Suprbush Drive
l:vew~CO ~766
P01JC\f ICL _110802 EVANSTON INStJRANCE co.
PRODUCER:
MIdwest Genel'a1 Agency
AGENTJBROKER:
Midwest GenA Agency
MASTER POUCY t;tl'U~ DAm 1/1/2806
~ Ilforded to ~ 1II8II1bersb:Y lhI8 poBcy Is applicable for a perlod
ollZ -..tbs Irom tile date Ibli i;leiDber 1si1dde4 by~t or until the
IDdlvIduaI_ber'8 -. Is aaceIIed or tbeyceue to be 811 ectM,:. ~
DftJIt~
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LIABILITY LIMlTS(per__) .
COMMERQAL GENERAL LLUIUI'V .
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GENERALA~~,~_._._....__..-._..._....._....._.._......S3.000.000
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. EACH oc::clfflRENq:~~;;'~~';;~j:--~~...,........_....._.._........._.$2,OOO.OOO
FIRE DAMAQ:(any OM fire) .~_._._.;__...._...._._.......__......$IOO.OOO
To verify ~rmatlOD, contactABMP. Tel: (3()3)614--8~78..~ (303) 674-0859
ThIs c:ertific;ate provldes proof t:lf coverage:for the lndivldllal namlid certlflCate boIder(memberlOnlJ;Tbts certlfIcate DOES NOT prcWkIe
proof of coveta(e for llRY em~. ItIdependerit I!ODtracttlrs, and/en: lIlI)' other ~y1~ aQlIlate4'lVitb the IUlIDed certificate holder. Ead1
lNOMDUAL Insured ABMP melllber Is Issued their own certl8ca1e of IrISurmce. Coverages are valid rrom.tbe membership inception date to the
membershll' expiration da~ ... . . . .. . .,
ADDITIoNAL INSURED: (1Dilh inceptiOn Date)
CO\'ERA.GES . . ..
'THIS IS TO CERTIFY THAT 1Itt POUCY Of'lI'lllUIWa LlSI'ED AII01IE HAS 8la91S9l/1D 10 'l'HElNSUIlIlD
NAIlED IIFLOW fOR nil! I'OUcY PitRIOD 1IIDlCA'l'ED. NO'IWI11ISTANDIiIG AllY 1IF.QUlRf;MENT, 'lTNA 01\ .
CONIimON Of' """ COI'lJ1IACT OR 0'\1lER ~ wmt.1lElII'ECT TO WHICIi THIS CI!KI1I-1CATE MAY
IIElSSWD 01\ MAY PEJn'AIN, 11l! INSUaANI:E ~ BY 11 IE I'OUCY DEScRIlIm HEBEJN l8!UIIJECT
TO AU. lIlE 1J;IlMS. EXQ.I.J5lONS. AICD CONIlI1lQ!IS OF SUOl PO\.ICY. LIMI'JlI!HO\Yfl NAY HAW 8III!N
RDIuaD BY ci.Aaa PAID. CX)pY OFI'OIJCY AVA/lAIILE IlI'ON /If!QUE$T (lJlUIO OWIGE). . .
TIde..allc:ale Iillauild.... _ of III/ar=IIaD IIIII1ll111coa1.n IIDdgtlb.,.Mttlie eertIIIc8Ie 1IoIcIer.
TIde C1lIdlcale ~ .. emend, 1lIllend. or _!be........ atIardell by ilia poUqo ABOVE.
UJCI.u-1CATE HOLDER
(AcIive Regiflered Membel1 are on file IDi1h the ABMP Membel1hlp Chofrman.)
Member Name: Lisa Kieselbont
Membenbip I.D. #: 835160
Lo)'ai M'em~ Since: SeptePlber 30, 2006
(dOe!IlIOt relied p8lIIIfbIe IaWTuptieD efillSllJ'llllCe)
M..nbershlplPoUey
Term Eqllratioa:
fssoeJ)-=
September 2S'. 2007
September 3D, 2006
CAl\lC!!U.A~ $Joulof....~clMcribitIlf,..., IIecuceJlcd.iIcIDre.lIlcl.1II;IIndIoII dele
d......t, tbe1auloa CGIIIJIIIIl7w11t ___10 _10.,. 'orJlUilil iitIt!ce IGr _ ..,.... or 30'"
wrIIleD IlIlIk:efiit.., ........."..10 dlaterllll<BlB....... -.ed ......lIut IoIluIe 10 lIIIIIeadl ~
ahd!nlJi\lie l!O.~or.UaidUtJ of eqj.~ upaIl the~,'" ...........~
Per form ME iJo!i (4/99)
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CITY OJ' CENTERVILLE
'.
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APPLICATIoN I'ORM I'OR SAUNA(S) OR MASSAGE .,ARLOR(S) DaNSE
~ -:iL & li-k
TllADE NAME
:x~ 01 - .\Lf'\ ()~
UCBNSING PERIOD
L,'~ ~~~ ~t~~~t
FULL NAME OF APPLICANT
OWNER IF INDIVIDUAL
11$ Bru.l(\ ~('
ADDRESS
7 -~.) - (o~-
DATE OF BIR.11I
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DATE OF APPUCATION
~ !Q."S( - (QS"O" f1>Db
PHONE NUMBER
~51- (g"S3 CGC4Qq
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CITY STATE
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PIA! OF BlRnI
ADDRESS OF BU~S
LOCATION o.v i () ~\~ Pffi.l\+it-
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LIST OWNERS OF Bun.DING OR PREMISE TO BE UCENSED:
NAMES
Lo.j~ \)~, \ \if\?s
ADDRESSES
DATE OF BIRTH
MANAGER'S NAME
~~ k)/,,"
ADDRESS
PHONE
OPERATOll'S NAME
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ADDRESS
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PHONE
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NAME
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'4ft E."t'h4 M pic h ijt.d...- (os- / - rs<f - }. e 10
~''Sb ~ '$l-...P~ h'\1V ~/1~
HAS APPUCANT/OWNER IDSIHER. DESIGNEE EVER BEEN CONVICTED OF A CRIME,
OTHEll THAN A TRAFFIC VIOLATION?
PHONE
trI=q -/),2-~~t.\..
DYES ~
IF YES, GIVE EXPLANATION ON A SEPARATE SHEET OF PAPER, INCLUDING TIME,
PLACE AND NATURE OF BACH CIUME OR. OFFENSE AND DISPOSlTION'IlIEREOF.
UST ALL CREDITORS INVOLVED IN THE CONSTRUcnON AND MAINTENANCE IN ANY
WAY PROVIDING DEBT OF EQUITYFlNANCINO TO SAID OPERATION:
UST CORPORATE OR PARTNERSHIP TITLE, IF ANY ~
CORPORATE OR PARTNERSHIP ADDRESS: rll~
UST AIL OFFICERS, MANAGERS OR. DIRECTORS, IF CORPORATION:
NAMBS
ADDRESS
DATE OF BIRTH
Please submit accurate 8Dd complete business records showing II8IDe8 and addRsses of aU individuals
having an interest in business including partners, officers. owners and crediton fumisbing credit for
est8b1isbmeDt acqJliRition 8Dd maintenance and tbmishing of said businfl!lHl.
Please furnish ~ documentation establishing the interest of the applicant and any other person
having interest in the premises upon which the building is proposed to be J.ocated or tbmished thereot:
The dooumentation shall be in the fonn of a lease, deed, contract for ~ mortgage deed, etc. and any .
other documents establiAhiqg interest orthe applicant or any other person in the operation.
Please. provide bIuepriDts, diagrams. layouts, etc. sbowiDg CODSIruCtion and or ~1i1tg to the
premises and specifically showing the layout of the Nathi'-8 and rad:lu()m fiIcilities to be used.
Applicants and hisIher associates will strictly comply with all regulations prormllpJed by the City
Council of City ofCenterville and aU ordinances of said municipality.
I hereby certify that I have read the fOlea0i48 questions and that the BDSWeI'S to said questions are true
of my own knowledge. I further understand that an investigation fee, not to exceed 5250.00 shall be
dJoqjod 811 appIiaat by die City. r<f _ d<... . I t..J-
~
Subscribed and sworn ~
This J~ day of .2006
~~<I.zJ ~~
Notuy Public sigDature
My Commission Expires 131 fD
}" eal)reRESA BENDER
., _MY~, ":"~,!ESOTA
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1880 ~ Strat. ~ ']tf!H sso3B
(6511429-3232 fu (651)429-8629 .
R OF 2853
Usa Kelselhorst $270.00
IFOR:
IADDlIcatIon Fee for Massaae CHECK II 5877
Establishment Ucense SURCHARGE NA
December 1&, 2006
Thank you for your business.
Recelpt# 2853
. .
-" - ._---" - --- -_.. -. ~
6-
'TL~"~tervi{{e
.. . .... 'L<ta6li.<iid IS),
Centerville
Special Event Permit Application
1. TITLE, PURPOSE, AND BRIEF DESCRIPTION OF EVENT: 2007 Centerville and Lino
Lakes Lions Ice Fishing Contest
New Application: X
Renewal of or Change in Application:
CONTACT PERSON: Greg Kieselhorst
TELEPHONE: 612-221-9122
OR 651-653-1833
2 IDENTIFYING INFORMATION:
Attach a written communication from the organization(s) in whose name the event will be advertised which
authorizes you, the applicant to apply for this special event permit on its/their behalf.
Applicant's N ame: ~ Greg Kieselhorst
Address: 7155 Brian Drive Centerville, MN 55038
Mailing Address: Same as above
Affiliation: Centerville Lions Club
Day Phone: 612-221-9122 Evening Phone:
Emergency Phone: 612-221-9141
Title: Lions Secretary
651-653-1833
3. EVENT PRINCIPALS:
Following, please list the names, addresses and telephone numbers of all the principals involved in any of the
proposed special event. Include professional event organizers, event promoters, financial underwriters, commercial
sponsors, charitable agencies for whose benefit Ihe event is being produced. the organizalion(s) in whose name the
event is being advertised, and all others administratively. financially and organizationally involved as principals in
the production of the proposed special event. Make additional copies of the following as needed to include as of the
principals involved in the proposed special event.
Name: Centerville Lions and Lino Lakes Lions Clubs
Organization/Business! Agency! Affiliation: V olunteer Organization
Is this a non-profit organization?
X Yes
No
If you arc making application under non-profit status. Droof of non-profit status must be attached to this application
* Should be on file with the City of Centerville from the Minnesota Secretary of State, if not it will be provided.
Mailing Address: Same as above Day
Phone: Same Evening Phone: Same
Title and functional responsibility with regard to the event: Centerville Lions Secretary. As part
of said duties, event permits and Lion insurance add-ons etc.
Page 1 of 10
4. REQUESTED EVENT COMPONENTS:
Date requested: _02-17-2007 Alternate date: 02-24-2006
Requested hours of operation: _11am (a.m./p.m) To: _3pm (a.m./pm)
Set up beginning date and time: 02-15-2006,8am
Complete dismantle date and time: 02-26-2006, 8pm
Describe the number and type of animals (if any) to be used in this event: N/ A
Attach a draft of the entry form for participants and/or spectators.
Anticipated number of participants: 300 to 2,500 Spectators: Very few
5. INSURANCE: *TJ Adams Group Ins. has been applied for, with the City ofCenterville, Anoka
County Sheriff as add-on's. Attach to this application either an insurance policy or a certificate
of insurance including the policy number, amount, and the provisions that the City of Centerville
is included as an additional insured. (Please note that insurance requirements depend upon the
risk level of the event. Also, if your event can be classified as first amendment expressive
activity, insurance requirements can be waived under certain circumstances.)
6. SANITATION: *The Lions will provide trash and recycling bins for use, and remove after.
Attach your "Plan for clean-up/Material Preservation"'. Include number, type and location of trash containers to be
provided for the event. Indicate who and how man will be responsible for emptying and cleaning up around
containers during the event. Indicate who and how many will be responsible for cleaning up after animals if they are
present during the event. Indicate who and how many will be responsible for cleaning up after the event. Describe
the number, type and location of portable toilets to be provided for the event (or permanent toilets to be used in the
event.) Include any other plan you have for ensuring post -event cleanliness and material preservation of city
facilitics, equipmcnt. prcmiscs and strcets. A deposit of $500 will be required fOl' clean-up and restoration. H
premises are left in satisfactorv condition, this dellosit will be refunded in full following insPl.'Ction. *Plcasc
waive, a lettcr of good standing ean be provided from Mainstrcet Bank if needed. Six Porta-Pots will be rented. Lion
members will pick-up aHleft behind articles and trash.
LOCATION: Centerville Lake and or Peltier Lake
Please attach a map of your event land design. Check off below items that apply to your event
and indicate them on the attached map. Use, where necessary, a "to scale" drawing.
A. If a route is involved, the beginning and finish area with arrows.
B. If a route is involved, the places where buses, autos or other motorized vehicles need to
be considered.
C. If a route is involved, attach separate maps giving two or more alternate routes.
D. Entertainment or stage locations (grandstand operators should provide you with a
"to scale" drawing.)
E. _ Alcoholic beverage concession area.
F. X Non-alcoholic concession area.
G. X Food concession area.
H. General Merchandise concession areas.
Page 2 of 10
I. _X_Portable toilet facilities (indicate number).
1. _X_Event participant and/or spectator parking areas.
K. _X_Event organizer's command post.
L. First aid facilities.
M. _ Fireworks or pyrotechnics site.
N. _ Vehicle fuel handling sit.
O. _X_ Cooking areas.
P. _ Electrical sources to be used for cooking.
Q. _ tables, enclosures, etc.
R. _ Temporary or permanent structures constructed for the event.
S. _ Site of electrical wiring to be installed for the event.
T. _X_Trash receptacles (indicate number)
U. _X_Other - Please describe. _Contest Area - Centerville Lake, In front of Waterworks
7. AVAILABILITY OF FOOD, BEVERAGES AND/OR ENTERTAINMENT:
If there will be music, sound amplification or any other noise impact, please describe, including
the intended hours of the music, sound or noise: Sound amplification system. for
announcements.
Will alcoholic beverages be served? Yes
No X
PLEASE NOTE THAT SALES OF LIQUOR/ALCOHOL IS PROHffiITED IN CITY
PARKS UNLESS THE EVENT IS A CITY CELEBRA nON AND PRIOR APPROVAL
AND APPROPRIATE LICENSES ARE OBTAINED BY CITY CQUNCIL ACTION.
If yes, describe what system will be used to ensure that alcoholic beverages will be consumed by
persons 21 years and older:
If yes, describe how, where, when and by whom the alcoholic beverages will be served:
If a casino party, a dance, or live entertainment is part of your event, please describe:
Please describe all of the activities of your event for which a license is required, for example: a
cabaret license, etc. Attach all required licenses to this application. Please note that certain
licensin2: may be reauired by City. County and State a2:encies. such as a Lar2:e Assembly
License for 2:atherin2:s over 1.000 people. some types of food handlin2: Iicensin2:. Gamblin2:
License. Cabaret License. etc. It is your responsibility to check with the City Clerk or local
authorities to determine what Iicensin2: is reauired prior to submittin2: this application.
Page 3 of 10
Will food and/or non-alcoholic beverages be served? Yes _X_ No
If yes, describe sanitation measures, food handling procedures and the nature of the food (such as
pre-packaged foods, hot dogs, pre-mixed soda, unpeeled fruit, raw meats, vegetables, fish or
peeled and cut fruit.) Will be done as per stated Anoka Community Health guidelines.
If yes. YOU will need a permit from the Anoka County Department of Environmental
Health. Please attach a copy of the permit to this application. Permit applied for through
Anoka County. Granted Permits usually arrive day of event. with inspector.
8. SECURITY AND SAFETY PROCEDURES:
Describe your proposed procedures for set up, operation, internal security and crowd control:
Vehicles on the Lake could be a issue. should ice be too thin. If so, no parking signs and
barricades will be posted. Contestants would have to park and walk on and off the Lake.
If the event is to occur at night, describe how you are going to light the event area in order to
increase the safety of participants and spectators coming to and leaving the event: _ N/ A
If your event includes vehicles or animals, describe the minimum and maximum speeds of the
event and the minimum and maximum intervals of space to be maintained between units:
10' between parked vehicles and other rows.
Attach to this application a copy of your building permit(s) if you are installing any electrical
wiring on temporary or permanent basis and/or if you are building any temporary or permanent
structures such as bleachers, scaffolding, a grandstand, stages or platforms.
Attach a copy of your fire department permit(s) to this application if you will use parade floats;
an open flame; fireworks or pyrotechnics; vehicle fuel; cooking facilities; enclosures (and tables
within those closures); tents, air supported structures, canopies, or fabric shelters.
Give the name, address and phone numbers of the agency or agencies which will provide first aid
staff and equipment if required. Attach additional sheets if necessary.
Name of agency: Anoka County Sheriff - Water Patrol
Name of Representative: Deputy Sink
Address: 1530 Bunker Lake Blvd. NW
Day phone: _763-754-4545 Evening phone:
Page 4 of 10
Indicate medical services (if required) that will be provided for this event:
Ambulances:
Nurses:
Doctors:
Paramedics:
9. VENDORS OR CONCESSIONAIRES:
Describe what vendors/concessionaires you will allow in conjunction with the event, and the
purpose of these concessions: Lions Concession Trailer. to make available Hot Chocolate.
Pop. Hot Dogs. Chili etc. to the Contestants.
Describe how you intend to regulate, monitor and control the type, number and quality of
vendors/concessionaires whom you may permit to operate in conjunction with the event: N/A
10. CITY SERVICES/EQUIPMENT:
Describe city services and/or equipment requested for this event: City barricades, cones, signs,
picnic tables and other equipment which may be borrowed on an as-available basis. You should
make advance arrangements to pick up and return this equipment. If you or any volunteers
cannot pick up and return this equipment, please attach a letter requesting these services and
explaining why your organization cannot perform them. This will be reviewed, then approved or
denied by the public works foreman.
Parking Cones and Street Barricades
11. OTHER PERTINENT INFORMATION:
Please list below any other miscellaneous information you feel would be important and have a
bearing on the approval of this Special Event Permit request:
12. FEE STRUCTURE / EVENT CHARGES:
If there is a fee or donation required as a condition of attendance or participation of this event,
please describe the amounts to be collected from various categories of participants or spectators:
Ticket price is $5.00 a hole. to fish in the contest.
13. If a donation is requested on a purely voluntary basis, describe how you intend to inform
participants/spectators or others that they may participate in the event whether they make a
donation or not:
Page 5 of 10
Centerville
Special Event Permit
NAME AND TYPE OF EVENT:
DAY, DATE AND TIME:
1. PARKS AND RECREATION DEPARTMENT
FINAL APPROVAL AND SIGN OFF
Signature
Title
Date:
Please check or use N/A (not applicable) where appropriate:
1. _ Final check has been made of application requirements.
2. _ Event is approved by City Council.
3. _ All required permits are issued and on file.
4. _ Refundable clean up fee has been paid.
5. _ Insurance Certificate is on file with City Clerk
6. _ Surety Bond is on file to secure payment for applicant's obligation to the
City.
7. _ Application is complete.
8. _ Special conditions are attached.
REVOCATION: Upon mutual consent, the City Council may revoke a special event permit if
the conditions set fourth in the permit application are not being followed.
Permit is hereby revoked:
Signature
Title
Date:
Reason(s) for revocation:
TO BE REVIEWED/APPROVED AND SIGNED BY AFFECTED
CITY DEPARTMENT HEADS
Page 6 of 10
2. PARKS AND RECREATION DEPARTMENT
Special Events Coordinator:
Date:
InitiaV sign-off:
3. POLICE DEPARTMENT
Approved by:
Signature
Title
Date:
1. _ Emergency vehicle access.
2. _ Traffic/safety street closures.
3. _ Appropriate barricades. (# Required)
4. _ Police personnel required/available.
5. _ Portable toilet facilities. (# Required)
6. First aid facilities.
7. _ Internal security and crowd control.
8. _ Nighttime lighting.
9 . _Other provisions as may be required by this department.
4. LICENSING AND INSURANCE
Approved by:
Signature
Title
Date:
1. Dance and/or live entertainment.
List types or permits or licenses required:
2. _ Alcoholic beverages.
3. Peddlers.
4. Noise abatement.
5. _ Other provisions as may be required:
Page 70fl0
INSURANCE: Your insurance coverage must be reviewed and approved by the
City's insurance carrier.
1. _ Public liability insurance naming City of Centerville and other public agencies
additionally insured is required.
2. Hold harmless forms executed and failed.
3. _ List and approve/disapprove other insurance coverage as may be required.
5. FIRE DEPARTMENT
Approved by:
Signature
Title
Date:
1. _ Emergency vehicle access.
2. _ Use of fireworks, pyrotechnics, vehicle fuel, open flame.
3. _ Cooking facilities.
4. _ Occupancy and spacing of tables, enclosures.
5. _ Parade, floats.
6. _ Tents, air supported structures, canopies.
7. _ Other provisions as my be required by this department:
6. BUILDING DEPARTMENT
Approved by:
Signature
Title
Date:
Electrical:
1. _ Plan check/inspection of any wiring installed on a temporary or permit basis.
2. _ Permit(s) attached.
Structural Plan:
1. _ Plan check/inspection of any temporary or permanent structures, including
bleachers, scaffolding, grandstand, reviewing stands, stages, or platforms.
2. _ Permit(s) attached.
3. _ Other provisions as may be required by this department:
Page 8 of 10
7. PARKS AND RECREATION DEPARTMENT
Approved by:
Signature
Title
Date:
1. _ Park permit(s) required. (to be attached)
2. _ Ballfield Usage Permit.
3. _ Beach permit required. (to be attached)
4. _ Trash containers required. (# )
5. _ Portable toilets required. (# )
6. _ Applicant's plan for cleanup, site restoration and material preservation
(recycling) required and attached.
7. _ Other provisions as may be required by this department:
8. PUBLIC WORKS DEPARTMENT
Approved by:
Signature
Title
Date:
1. _ Trash containers required. (# )
2. _ Portable toilets required. (# )
3. _ Special animal clean up required.
4. _ Barricades provided, as available. (# )
5. _ Cones provided, as available. (# )
6. _ No parking signs provided, as available. (# )
7. _ Applicant's plan for clean up and material preservation (recycling) required
and attached.
8. _ Other provisions as may be required by this department:
9. STATE, COUNTY AND CITY HEALTH DEPARTMENT
Approved by:
Signature
Title
Date:
Page 9 of 10
1. _ Food and/or beverage served.
2. _ Permit( s) attached.
3. Food cooked.
4. Permit(s) attached.
5. _ List other health licensing obligations as may be require:
Page 10 of 10
~ 12/2fi/8fi 89:89:51
DEFAUL res ID -)
Pdge BBI
ACORD CERTI FICA TE OF LIABILITY INSURANCE DATE i...."VOD!\'V)
December 26, 2006
PROOUCER(800)316-6705 i=AX (800)316-6705 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
T. J. Adams Group, a Hilb Rogal & Hobbs Company ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND EXTEND OR
333 E. Butterfield Rd., Suite 500 ALTER THE COVERAGE AFFORDED BY THE POlICIES BELOW
Lombard, IL 60148 INSURERS AFFORDJNG COVERAGE
"."u,.,,:u INSURER A ACE American Insurance Comoanv
Centerville Lions Club INSURER B
Minnesota INSURER C
INSURER D
INSURER E
COVERAGES
THE POLICiES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
ANY REQUIREMENT TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THiS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE SEEN REDUCED BY PAID CLAIMS.
:~ TYPE OF iNSURANCE POclCY ~IUMBER ~,;!~1MM'iDD/YYI rokT'E. ti",MlODNY,. LIMITS
GENERAL LlABILlTV EACH OCCURRENCE $ 1 000 000
, I-- FIRE DAMAGE (Anyon" lire) 1 000.000
X COMM(;RCII\L GENERAL I..JAIl/lITY $
I-- CLAIMS I.IAOE 0 OCCUR !.lED EXP (Any OM ."""on) S 1.0001
A ~ HDOG21732679 & 09/01/2006 09/01/2007 PEASON,oL &. ADV rNJUFIY $ 1 000000'
~ CSZ0302505
GENERAL AGGREGATE $ 2 000 000
Gi:N'L AGGREGATE LIMIT APPLIES PER PRODUCTS. COMP/OP AGG i 2 000 000
" POUCY nPROJECn LOC 1
.
ALJTO~10BILE LIABILITY COMBINED SINGLE liMIT $ Included 1n Above
- (Par .ccidanl)
ANY AUTO
- HDOG21732679 &
ALL OWNED AUTOS BC:JILY INJURY
- CSZ0302505 ; 09/01/2006 09/0112007 (Par person) S
SCHEDULED AUTOS i
A- T HIRED AlITOS OWNED AUTOS NOT COVERED
BODlL Y INJURY
T NON-OWNED AUTOS (?~r .cc'dant) S
-
- PROPERTY DAMAGE t
(Per ..cciden1)
GA ~AGE LIABILITY AUTO ONLY. EAACCIDENT .
ANY AUTO NOT COVERED OTHER THAN 'E." ACe
- AUTO ONLY
AGG I
EXCESS LIABILITY eACH OCCURRENCE S
- o CLAiMS MADE AGGREGATE
OCCUR $
- NOT COVERED
- $
DEDUCTIBLE i
- RETENTION $
s
WORKERS COMPENSATION ANO ! ~c~,~~~.;. I OTHER
EMPLOYERS' LIABILITY NOT COVERED
i E 1.. EACH ACCIDENT S
I E L OrSEASE . EA EMPLOYEE S
E L. DiSEASE. POLICY LIMIT ! s
DESCRIPTION OF OPERATION$!LOCATIONSIVEHICLES/EXCLUSIONS ADDED BV ENDORSEMENT/SPECiAl PROVISIONS
rovisions of the policy apply to tbe Centerville Lions Club for their conducting an Ice Fishing Contest at the Centerville Lake in .b..noka
County on February 27, 2007 (or on any other dates during the policy period).
City of Centerville and Anoh County Sheriffs Office are an additionalinsured(s), but only with respect to liability arising out of the use of
premises by the Centerville Lions Club and not out of the sole negligence of said additional insured.
ROVISIONS OF THE POLICY DO NOT APPLY TO THE SALE OR SERVING OF ALCOHOLIC BEVERAGES.
CERTIFICATE HOLDER
ADDmONAL INSURED; INSURER LETTER
L
City of Cent~vil1e
1880 Main Street
Centerville, i\1N 55038
SHOULD ANY OFTHE ABOve DESCRIBED POLICIES BE CANCELED BE."DRE THE!
EXPIRATION DATIiTHER60F, TI1E 1SSUING COMPANY WILL ENDEAVOR TO MAIL
-1Q...QAYS WRITTEN NOTICE TO TME CERTIFICATe HOLDER NAMED TO THE ~i=T.
BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVes.
AIJTHORIZED REPRESENTATIVE
John E. Adams, C.P.C.U.
e. :Admrr.b
ACORD CORPORATION 198B
Minnesota Lawful Gambling
LG220 Application for Exempt Permit
Page 1 of 2 2/06
Fee $50
For Board Use Only
Fee Paid
An exempt permit may be issued to a nonprofit organization
conducting lawful gambling activity on five or fewer days, and
awarding less than $50,000 in prizes durings a calendar year.
Organization Information
Organization name
Check No.
L~3
Previous lawful gambling exemption number
County
A,..J p?A
L-~ i..:J
Street
(77 32-+N ::::::~-wli
Name of chief executive officer (CEO)
First name
~~ ~(;6-'~
Type of Nonprofit Organiza ion
Type of nonprofit organization (check one)
D Fraternal ~9ious
D Veteran ..k1 Other nonprofit organization
Type ..9f-proof of nonprofit status - attach a copy (see instructions)
~onprofit Articles of Incorporation or Certificate of Good Standing - Minnesota Secretary of State's Office
~ternal Revenue Service
JZ] _ Affiliate of parent nonprofit organization (charter)
-)Z( Proof previously submitted and On file with the Gambling Control Board
Last name
Daytime phone number
b.;?..- ~ 2--:?-f - 9 i 2-2-
Gambling Premises Information
Name of premises where gambling activity will be conducted (for raffles, list the site where the drawing will take place)
L <: U1(;'j:2.v ~
Address (do not use PO box)
L-A~r
City
c::-.:c~;A} l~ L-It:>r-J
Zip Code
U.sld~-"\~
Date(s) of activity (for raffles, indicate the date of the drawing)
.L.....^_.
~I'
~e'~Dvf\i2
-.- It 2-- u'
~ Pi~,.Jt. ~
County
9?t>'3~
t>tLA-
Check the box or boxes that indicate the type of gambling activity your organization will be conducting:
D *Bingo ~ffles D *Paddlewheels D *Pull-Tabs D *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 (Le.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 and and your organization's name
and address will be public information when
received by the Board. All the other information
that you provide will be private data about you
until the Boa rd issues your permit. VIh1en the
Board issues your permit, all ofthe 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 remain public.
Private data about you are available only to
the following: Board members, staff of the
Board whose 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 L,".,...J"Ii?~~ l..-\ct->.?
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.
Check the action that
the city is taking on this application.
O The city 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 city denies the application.
Print name of city
Signature of city personnel receiving application
Title
Date_'_'_
Page 2 of 2
2'06
~ws
r
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 county is taking on this application.
O The county approves the application with no
waiting period.
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 county denies the application.
Print name of county
Signature of county personnel receiving application
Title
Date_'_'_
TOWNSHIP: On behalf of the township, I acknowledge that
the organization is applying for exempted gambling activity
within the township limi1s. [A township has no statutory
authority to approve or deny an application
(Minnesota Statute 349.213, subd. 2).]
Print name of township
Signature of township official acknowledging application
Title
Date--1_'_
Chief Executive Officer's Signature
The information 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 the Gamblin . ontral Board within 30 days of the date of our
gambling activity.
Name (please print)
Date /,}- I i)- i..- I c' Cc.
Complete an application for each
gambing activity:
. one day of gambling activity
. two or more consecutive days of
gambling activity
. each day a raffle drawing is held
Mail Application and Attachments
Send
. the completed application,
. a copy of your proof of nonprofit status, 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
tervi{{e
~stab[islied 1857
1880 'Main Street . Centervi[[e, 'M:J{ 55038
(651) 429-3232 . Pa:{(651) 429-8629
STATE OF MINNESOTA
COUNTY OF ANOKA
CITY OF CENTERVILLE
RESOLUTION #06-05X
BE IT RESOLVED that the Finance Director of the City of Centerville is authorized to make the following
operating transfers of funds in the general ledger accounts of the City:
Joint Police Station GO Bond
General Fund
GO Bond Series 2004B
General Fund
Hunters Crossing I GO Bond
General Fund
Park Fund
General Fund
Total
$ 78,500.00
$ 78,500.00
$102,000.00
$102,000.00
$ 400.00
$ 400.00
$ 25,000.00
$ 25,000.00
$205,900.00
$205,900.00
PASSED AND ADOPTED by the City Council this 27th day of December, 2006.
Attest:
City Clerk, Teresa Bender
Mayor, Mary Capra
~4~
Facility Use Agreement
1. This agreement is by and between the Church of St. Genevieve, the City of
Centerville, MN, a municipal corporation, and the Metropolitan Council, a
public corporation and political subdivision of the State of Minnesota. This
agreement is mutually entered into and supersedes any other agreement, whether
written or oral.
2. The Church of St. Genevieve agrees to allow the Metropolitan Council the
use of 50 parking spaces in the Church of St. Genevieve parking lot closest to
Centerville Road located at St. Genevieve's Parish Community Center, 6995
Centerville Road, for the purpose of Met Council's Park and Ride Program. The
dates of this agreement are from December 15, 2006 - December 15, 2009. Either
the Church of St. Genevieve or the Metropolitan Council may terminate this
agreement with a written 60 day notice for any reason.
3. The Metropolitan Council agrees to pay the Church of St. Genevieve 35% of
the cost toward the removal of snow and sanding of the parking lot surface in
return for the use of 50 parking area spaces.
4. The City of Centerville, MN agrees to provide general liability insurance
coverage in an amount not less than $1,000,000.00 for any injuries, damages,
and/or claims related to the Park and Ride Program use of the parking area.
This insurance coverage shall be primary to any other insurance. The City of
Centerville, MN shall provide the Church of St. Genevieve with a certificate of
insurance, naming the Church of St. Genevieve and the Metropolitan Council
as additional insured with respect to the Park and Ride Program.
5. The City of Centerville, MN agrees to hold harmless, indemnify, and defend
the Church of St. Genevieve for any and all injuries, damages, and/or claims
related to the Park and Ride Program, except for any injuries, damages, and/or
claims caused solely and directly by the gross negligence of the Church of St.
Genevieve. The City of Centerville, MN limits its indemnification to the
monetary limits of Chapter 466. This Section 5 shall survive the termination of this
Agreement.
The Church
of St. Genevieve
City of Centerville, MN
a municipal corporation
Metropolitan Council
a political subdi . ion of
the e of 'nne ota
~f
s~gnat~re
V~-'tL
Title
~~old.clDDb
I
Date
Signature
Ignature
~/d'AJA-1 Ad.mlnI8.f.t~ R.
tie
Title
Date
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Date
Drafted
He
!1h
Sergeant Aldrich # I 04
Centennial Lakes Police Department
54 North Rd
Circle Pines, MN 55014
(763) 784-2501
December 26, 2006
To: Dallas Larson
Re: Bi-weekly review of Centerville activity
Dallas,
This report is for the whole month of December. I am working on December 27,
so I plan on attending the council meeting.
Aside from the obvious incident, there really has not been much activity occurring
in Centerville. That was the third reported fight at a bar in your city within a month, and
second at Sager's. The only theft reported was a break in to vehicle at the elementary
school, while school was in session. Officers encountered juvenile activity at the
elementary school resulting in three juveniles getting citation for miscellaneous status
offenses.
A Lino Lakes officer conducted in a traffic stop, which resulted in the arrest of a
male for stealing Christmas ornaments from Centerville. Officer Bill Jacobson was able
to assist in investigating, and the return all of the items to the rightful owners. I located
two vehicles driving through the mud in the new construction area off the 7000 block of
21 st Ave. The driver's were cited for exhibition driving and for driving around a
barricade. There was a large juvenile drinking party reported, and several citations were
issued. There were no DWI arrests made in Centerville in December, and there was one
"not a drop" minor arrested.
The officers stepped up stationary radar on Mill Rd. There were 3 citations for
speed written, and four verbal warnings to speeders. There were over two hundred traffic
stops which produced over 40 miscellaneous citations.
The CSO's continued to be extremely productive in ordinance enforcement. Their
efforts assisted in keeping the quality of life higher in the city of Centerville.
Alcohol and compliance checks were conducted in December. No businesses
failed the alcohol compliance, and one business failed the tobacco checks.
1$
I am not sure if this was specifically what you were looking for. If you would like
a different style of report, need more details, or presented in an alternate manner, please
let me know. Like I said, I should be meeting with you and the rest of the council on
Wednesday. Thank you for your time.
Pat
IL1