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Home My WebLink About2007-06-13 CC Set Agenda & Handouts CITY COUNCIL & WORK SESSION MEETING COUNCIL MEETING Wednesday, June 13,2007 6:30 p.m. w/Work Session to follow Red = Set Agenda L CALL TO ORDER 1. Roll CaD n. PUBLIC BEARINGS 1. Mr. Sambath Cheath, 7323 Deer Pass Drive, Request for Reduction in Easement to Allow Construction of a Deck (Pages 1-2) m. APPROVAL OF AGENDA IV. APPROVAL OF COUNCll.. MINUTES 1. May 23, 2007 City Coodl Closed . Session Meeting Minutes (page 3) 2. May 23, 2007 City CoocD Work Session Meeting Minutes (page 4) 3. May 23, 2007 City CoocD Meeting Minutes (pages 5-12) V. CONSENT AGENDA 1. City of CenterriUe May 24, 2007 through Joe 13, 2007 Claims (page 13 & 13a) 2. Centennial Fire Department Claims through Joe 7, 2007 (page 14) 3. Encroachment Agreement, 1636 Dupre Road - Fence Construction in DrainagelUtiIity Easement (pages 15-22) 4. Encroachment Agreement, 6851 Beaver Pond Way - Fence Construction in DrainagelUtiIity Easement (pages 23-30) s. Arehaeologieal Research Services - $1,220 (Grant Requirement) (pages 31- 32) 6. Res. ##07-XXX - Authorizing the Mayor" City Administrator to Exeeute the CDBG Partnenhip Program Coop. Agreement (Previously Motioned to Approve... March 28, 2007, Housekeeping) (page 33) 7. St. Genevieve's Catholic Churcb Request for Rame Permit (August S, 2007) (pages 33a-33b) 8. St. Genevieve's Catholic Church Request for Special Event Permit, Temp. 3.2 Malt Liquor License, Bingo, Rame, Paddlewheel, Pull- Tabs & Tipboards & 1694 Sorel Street Parking for Annual Chicken Dinner (August 19, 2007) (pages 33c-33p) . 9. Navratil Request for Special Event Permit for Celebration of Life for Ms. Crystal Schneider (pages 33q-33z) 10. Mr. .William Klein, Massage Therapist License Request (Serenity Now - 7031- 20th Avenue, Suite #105) (pages 33i-33v) 11. Mr. Dale Runkle, Pheasant Manh Request for Letter of Credit Reduction (page 33vi) VI. AWARDSIPRESENTATIONS/APPEARANCES 1. Mr. John Golden, 1654 Lakeland Cirele, Request for Eneroaehment Agreement .Associated with Construeted Pool in Easement (Pages 34-39) VU. OLD BUSINESS 1. Res. #07-XXX - Appointing of EDA Members (Pages 40) 2. Parks & Reereation Committee's Reeommendation for Bid Options & Resident Coneerns - mdden Spring Park, 1601 LaMotte Drive (Pages 41- 45) vm. NEW BUSINESS 1. Res. #07-XXX - Vaeating Part of Drainage/UtiIity Easement on Lot 5, Bloek 1, Deer Pass (7323 Deer Pass Drive) (page 46) 2. Consider Option Agreement for Purehase of2085 Cedar Street Building **Available Prior to Meeting or at Meeting'" IX. ANNOUNCEMENTSIUPDATES 1. City AdminiMtrator, Mr. Dallas Larson 2. Commemorative Items for Sesquieentennial (Update) 3. Summer Meeting Sehedule X. ADJOURNMENT COUNCIL WORKSESSION MEETING I. CALL TO ORDER 1. RoD CaD II. ITEMS OF DISCUSSION 1. Developers Agreement (Downtown Re-development - Beard Group) m. ADJOURNMENT * * REMINDERS * * Parks & Recreation Committee - June 26, 2007, 6:30 p.m. Council Chambers - Rescheduled from July 4, 2007 Council Meeting - June 27, 2007,6:30 p.m. Council Chambers Planning & Zoning Commission - July 3,2007,6:30 p.m. Council Chambers -- --- ----- -- - - - - -------------- - -- - - UPDATE CITY OF CENTERVILLE 06/13/07 1:36 PM Page 1 *Check Summary Register@) Name 10100 MAIN STREET BANK Paid Chk# 022433 AVLIC Paid Chk# 022434 BRADLEY & DEIKE, P A Paid Chk# 022435 CITY OF ST. PAUL Paid Chk# 022436 CONSTRUCTION BULLETIN Paid Chk# 022437 GOPHER STATE ONE CALL INC Paid Chk# 022438 INSTRUMENTAL RESEARCH Paid Chk# 022439 LAND MAINTENANCE Paid Chk# 022440 LEE HOMES, INC. Paid Chk# 022441 MENARDS - FOREST LAKE Paid Chk# 022442 METROCALL Paid Chk# 022443 METROPOLITAN COUNCIL Paid Chk# 022444 NATIONWIDE RETIREMENT Paid Chk# 022445 OFFICE MAX Paid Chk# 022446 PERA Paid Chk# 022447 QWEST Check Date 6/1312007 6/1312007 6/1312007 6/1312007 6/1312007 6/1312007 6/1312007 6/1312007 6/1312007 6/1312007 6/1312007 6/1312007 6/13/2007 6/1312007 6/1312007 Total Checks JUNE 2007 Check Amt $606.00 DEF COMP WIH 6-14-07 $840.00 MAINSTREET - DOWNTOWN $825.14 ASPHALT - STREET REPAIR $153.87 AD FOR BID FOR OLD MILL ROAD S $145.15 SERVTHRU MAY $38.00 MAY 2007 WATER TESTING $3,537.08 CITY HALL - LAWN MOWING - MAY $5,000.00 6787 BEAVER POND WAY- 06-100 - $26.19 SUPPLIES $8.05 ON CALL PAGER THRU 8-31-07 $6,633.00 MAY 2007 SAC $450.92 DEF COMP 6-14-07 $241.84 SUPPLIES $2,408.51 PERA WIH 6-14-07 $55.51 PHONE SERV THRU 6-30-07 $20,969.26 /3~ 81MeSOta Lawful Gambling LG220 A IlcatIon for Exern An exempt permit may be issUed to a nonprofitorganlzatlon conduc1ing lawfUl gambling activily on five or fewer days, and awardinQ lessthan $5(),OOO inprizescSurinpa calendar year. 'ORtMlIIIR ,', '_ ,,- c- : ' , -, - - _' , ", -" '. - , . ,'_ " -- ~,--'-,.:,_ .' ,,~- :. -,',- , Page 1 of 2 4Kf1 For Board Use 0nIJ Fee PaId CheckNo. .. Organlza1lon name St. ~eV"t.vi, C~O\I(. c.hwch Type of nonprofit organization. Check ( one. o Fratemal 131 Religious 0 Veterans 0 Other nonprofit organization MalUngaddJeS1l Y.IlY lQ<&l b-01f.fon Rcl- tertervlll>> Name of chief exec:utlve ofticer (CEO) om ~ uaJd PROOFQF:Nc)ttflttQt$".TQ.' PreYlouslawful gambling exemption number 9~OOcg Chec:k one of the following and attach a copy of your proof of nonpr.aftt ....... NOTE: Sales tax exempt status or federal ID employer numbers are not proof of tncome tax exempt status. _1. NonprofltAltlclesof .J 2. ......alRevenueServlce-natlonalorganlzatlon InoorpOratIon ~ Check if proof previouSly submiIled to GarnbIlI1a Control Board. OR OR certltlcate of Good Standing. _ Attach a copy of the IRS incoma 1ax exemption [501 (e)] letter in your organ1zatIon's name. To obtain a copy of your federal \ncom8 tax exempt letter. send your feclerallD number and the date your organization initially applied for tax exempt status to: IRS P.O. Box 2508. Room4010 Cinclnnati, OH ~1 Attach a copy of your organization's Nonprofit ArtIcles of Incorporation OR current Certificate of Good standing. _3. Internal Reveftue8erVlce-Afftllateofparentnonproftt organization (charter) _ Check if proof previously submitIBd to Gambllng Control Board. OR _ If your organization fa1ls wtder a national organ\Z8tion, attach both of the following: a. a copy of the IRS letter showing that your national organization has been a regist&red nonprofit 501 (e) organlzation and carries a group ruling, and b. a copy of the charter. or IetlBr from your national organization. raccgnlzing your organization as a subordlnate. f.JAIIBU,.g~l_lSI'INFORMAnON<. Name of ~ .gamb!!ng actMty VfBl be conduct8d. (for ra~ list the site where ~ drawing wlll1ake place) ..~ VlJ~ toro""un,. ... c.. ldro ,it t Address do not PO box) , nx. Zip Code ~ I\ll Qd- Ltn+e.rVI\l.o .....ru "~03cg Date(s) of ~ (for rafl\eS, indicate the date of the drawlng) ~~ 0 '1 Check 1he boX or boxes 1hat Incicate the type of gambllng activity your organization wftI be conducting: o "'Bingo "Sl Raffles 0 "PaddI8whaele 0 *Pull-Tabs 0 "1lpboards "GamblIng equIpnaent for puII-tabs, tIpboards, paddIewheeIs. and bingo (bingo paper, hard cards, and bingo runber seIedion devICe) must be obtained from a d1stributDr IItenSed by the GamblIng ContrOl Board. To find a Bcensed dIstributDr, go to www.gcb.sla1e.mn.us and click on lISt of uc:ensed D\strIbutOrS. Or call 65Hi39-4)OO. ThIs certificate must be obtained each year from: Secretary of State BusIness Services Div. 180 S1ate Office Building St. Paul, MN 55155 Phone: 651-298-2803 330--/ ---------- - -~~-~--------~-~-~---~------- -- -~~- ~------ ----- . .. LG220 Application for Exempt PermIt Page 2 of2 4If17 If the gambling premises Is within city Dmlts. the city must sign this application. Cheok (~ the action tbat the oily Is taking 011 this application. The appIk:a1ion Is acIcnowIedged with no waiting period. The appllca1ion Is acIcnowIedged with a 30 day waiting period. end allows the BoertI to issue a permit after 30 days (60 days tbr a 1st class cI1J). The eppIication Is denied. If the gambling premises Is located In a township, both the county and tDwnshIp must sign this ~ Check (~the action tbattheaountr Is taking on tIlls~ _The epplIcetIon is adcnowtodged with no welting period. _The eppIIc8tlon is ecIcnow!edged with a 30 day waiting period. end allows 1he BoertI to Issue a permit after 30 days. _The appIlcation Is denied. Print name of city On behelfofthe ~ I adtnowIedge this eppI1r.alion. S\gn81LIre of cI1J p8I8OM8I rec:eivlng applIoation Print name of countv On beheIIofthe ~ I edmowledge this eppf1Galion. SIgnalur8 of countv personnel receiving application TItle 08t8---1---1_ TltIe Dale_' ,- TOWNSHIP: On behlllfoflhe townsIJIp,/adcnowIedgeth8tthe organization Is applying forexempted gambling adIvIly wIlhIn the township 1Im\l8. [A township has no statutory authorily to approve ordeny an appIIca1Ion(MlnnesOta Statute 349.213, subd. 2).] Print name of township Signature of township oflidal acknowIadging application TItle Dale _'---1- Name (please print Complete an application for each gambIng adMty: .. ona day of gambling actMty .. two or more consecutive days of gambUng aclivity .. each day a raftIe drawing Is held Send with 1he compIel8d application: .. a copy of your proof of nonprofit status. and .. $50 appIlca1Ion fee. Make check payable to "Slate of MInnesota". Date Db I.fJ..1JE financial report and recordkeepln9 required A financial report form and inslructions will be sent wilh yoW' pennIt WIhIn 30 days of your date of ~ 1he fil'l8l'\Clial report form must be compIetBd and returned to the Gambling Control BoertI. Questions? Call the UcensIng Section of 1he Gambling Control Board at 651~78. To: Galllblq Control Board If you use a1TY. c:all1he BoertI by using the MInnesota Relay 1711 West CoW'lty Road 8, SUite 300 South ServIce and ask to pIac:e a caD to 651-639 1000. Or. check Rose. UN 65113 our web site at ww.:.gcb.stata.mn.us. Data ~ Thlstblm". nBCIe avaIIabJD In Your Il8m8 and 8111I your ~A.dk..ls Il8IIIl Board IIIllIdIeJ8. ... of the Board -- WDIk fomIIt (Le.1aIge print. BraIlle) upon and addfess wID be public information wilen ~".lllIIlRlqUlnlslhattheyhlM llOCllIiStDthe RlqUIIl 1h8 Wc.....a.n ........ on IIlIs tbIm I8CIIIVed br the I3DaId. NJ the oIher rnr......6.n tub......; the M!nrIIIIJta ~rlhlllllt of PubIlc (and any atlaGllrnelllS) wiD be used by the Ihat you provide wi be pdvate dlIIa about you Safety; the MInneSota A1lomay General; the 0llIlInlI8DaId(Baanl)to.......ih.your unIII the Board .... your pemIIt. Wten tha MInnesota CrH..,dulclners of AdmbM.&un. tD belJwolwd In IawruI gambling Board Issues your pem8. aD of the Itdi:...QIIon FInanoa.andRevenue;thaMlmesalaLeglslldlve klMInrleBaIa. Youhawtha"refuse lhatyouhIMprovidecItotheBaardlnthepnlCl8SS Audllor. national and international gambling suppIf the hM,1ldIon aqulsli ~ hDWlMlr, If of ~ forJOW' ptldwll bllcDrI'I8 public. If reguIatDIy agencies; .... puISUIIlt tD court refuse to ..1hI8 1t1fcA....... the Baard the Board does not Issue you a pmrit, aD tha order; o1h8r IndMdvaIs and agencies that are IIIIY not be abI8 to .....,1Im your qI,...dlR..A"\S IrfonnItIDn you have plQ'IIded In the pIQC8SS of specIIIcaIIJ auIJtoItIed .. &tat8 or federal law to as a consequenca. may __ tD Issue you ~ for a penrit remains private. with tha have 8Oll8S8 tD the 1nformdIDn: IncIIvIdI.BIs 8111I a penriL If you supply the ~"olIlIon AIql~ excepIIDn of your Il8II8 8111I your _iddIDtI's agenIlIlls for Wdch law or IBgaI Older llUlttorilIIBs Board" be abI8 to JIl'OCIlS8 your awl.alloh. narrra8l1lladdnlss........l8I'IIIinpublc. PItvaID a new use or sharing of 1td'"...l1IlIon after this dlIIa are available to the NotIl:e was . 8111I with consent. 33b ------------ ----- ------------------- ----- - -- ------------ ------------ .. CenterviUe Special Event Permit Application 1. ~LE, PURP~SE'~dRIE;F D~RlPTION OF EVENT: klAlI//; (!. ~ell '(1/{/ ~ y. FU//ILJ 7(~l5tL New Application: v Renewal of or Change in Application: -&~ R CONTACT PERSON: TELEPHONE: ~ 6/- ? 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'SName:~. Ti~6,~ Address: b9~5 . "I'__ta:Jtl&'7 7V/ Mailing Address: 'C) B' . Affiliation: L-4'11.;~ Oay Phone: 1#57- '155- J' ~ 5 (p Evening Phone: Emergency Phone: 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 the event is being produced, the organization(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: Sf ~ &~ Organization/Business/ Agency/Affiliation: ",., Yes No Is this a non-profit organization? If you are making application under non-profit status, proof of non-profit status must be attached to this apDlication Page 1 of 10 3j~ --- - --- - -- - -- -- - - - 4. REQUESTED EVENT COMPONENTS: Date requested: ~ J 'I ~ Alternate date: Requested hours of op lion: /f;.' ~ ~p.m.) To:. :: Set up beginning date and time: 8//9 () ~A7n Complete dismantle date and time: ' 9. 19 / ~ Describe the number and type of animals (if any) to be used in this event: (a~ Attach a draft of the entry form for participants and/or spectators. Anticipated number of participants: Spectators: 5. INSURANCE: ~ ~ ~ P a51-~ ~/ 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: Attach your "Plan for clean-uplMaterial 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 facilities, equipment, premises and streets. A deoosit of $500 will be reauired for clean-no and restoration. If oremises are left in satisfactorv condition. this deoosit will be refunded in full followin!! insoeetion. 7. LOCATION: ~~ 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. ~ Non-alcoholic concession area G. v Food concession area H. ~ General Merchandise concession areas. I. v Portable toilet facilities (indicate number). J. ~ Event participant and/or spectator parking areas. K. _ Event organizer's command post. Page 2 of 10 33d - ----- -----~----------------- --- ------- ----- -- - ---------- --- L. First aid facilities. M. _ Fireworks or pyrotechnics site. N. _ Vehicle fuel handling sit. O. _ 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. _ Trash receptacles (indicate number) u. Other - Please describe. 8. 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: ~ /?~.J Will alcoholic beverages be served? Yes V No PLEASE NOTE THAT SALES OF LIQUOR/ALCOHOL IS PROHIBITED IN CITY PARKS UNLESS THE EVENT IS A CITY CELEBRATION AND PRIOR APPROVAL AND APPROPRIATE LICENSES ARE OBTAINED BY CITY COUNCIL ACTION. If yes, describe what system will ~ ensure that alcoholic beverages wiIl be consumed by persons 21 years and older: (i :::r /; 5 If yes, describe how, where, when and by whom the alcoholic beverages will be served: 'tJJ~ td~~ tHrt/l- e2J /I If a casino party, a dance, or live entertainment is part of your event, please describe: l)}r$ ~ ~ dfJ/J~kM- , v Page 3 of 10 33L - -- - ---- -- -- ---- - ---- - -- - - --- ---- -- -- -- ----.--- - -- Will food and/or non-alcoholic beverages be served? Yes t/ No If yes, describe sanitation measures, food handling procedures and the nature of the food (such as pre-packaged foods, hot dogs, _ pre-mixed ~ unpeeled fruit, rayv meats, veg~~les, fish or peeled and cut fruit.) ~/L~~~ 6~ '~~~ . If es on will need a ermit from the Anoka Conn De artment of Environmental Health. Please attach a cOPV of the permit to this application. 9. SECURITY AND SAFETY PROCEDURES: Describe your proposed procedures for set up, operation, internal security and crowd control: - 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: 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: 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: cJfJW tJJ~ ~~~ ~ Name of Representative: ' Address: Day phone: Evening phone: Indicate medical services (if required) that will be provided for this event: Page 4 of 10 33f --~-------~----- -------- ---- ---- --- - -- - ------ -- ---- Ambulances: Nurses: Doctors: Paramedics: 10. VENDORS OR CONCESSIONAIRES: Describe what vendors/concessionaires you will allow in conjunction with the event, and the purpose of these concessions: \.J{l..01\1L, 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: 11. CITY SERVICESIEQUlPMENT: 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. ~ 12. 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: 13. 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: ULO 14. 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: .J{\-O Page 5 of 10 33J - ----------- - --------- --------- Centerville Special Event Permit NAME AND TYPE OF EVENT: DAY, DATE AND TIME: 1. PARKSANDRECREATIONDEPARTMENT 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 10 331 2. PARKS AND RECREATION DEPARTMENT Special Events Coordinator: Date: Initial/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: INSURANCE: Your insurance coverage must be reviewed and approved by the City's insurance carrier. Page 7 of 10 33~ - - - -- ---------------- 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 r~quired. 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. BUll.,DING 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 3Jj --- ---- -- -- -- - -- -- ----- -- 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: 1. _ Food and/or beverage served. 2. _ Permit(s) attached. Page 9 of 10 33~ -- -- -- -- ~----------- - ---~ -- - - --------.-------- - -- ---- -- , ~ 3. Food cooked. 4. _ Permit(s) attached. 5. _ List other health licensing obligations as may be require: Page 10 of 10 33( -- ------~--------~-----~-------- 1880 !Main Street . eenteroifk, '.M9i 55038 (651) 429-3232 . ,.~ (651) 429-8629 CITY OF CENTERVlLLE .,3, ~ ~;(r APPLICATION FOR A 1 TO 40AY1'EMPC)RARVII5V ON SALE LlQUORUCENSE (0FganIzatI0n or loC8lfOrt UmIted~ 3p8nn~~1l,~12 month period) Type or Print InformatIOn wm the applicant contract for intoxicating Uquor services? It 80, give the name and address of the Ucense the service. N APPROVAL' APPUCATIONMU8TBE AIIPROVEDBYCIlYCOI....PRIORTO ~TO UQUORCON1ROL ... CITY OF cE:NTERVILLE DATE APPROVED FEE AMOUNT $ LlC,ENSE DATES DATE FEE PAID Clerk NOTE: SUbmIt to the CIty of eentervIIIeat .... thirty (30) days prior to event. SIgnature of Applicant ~/ZI ~7n~ 33;; .. ~ -~------~------- -- ~---- -------------------- - ------ ----- - -- - --~- -- - ---- Page 1 of 2 4107 For Board Use Only Fee Paid Check No. Minnesota Lawful Gambling LG220 Application for Exempt Permit An exempt permit may be issued to a nonprofit organization Fee 50 conducting lawful gambling activity on five or fewer days, and awarding less than $50,000 in prizes durings a calendar year. for each event ORGANIZATION INF()Ri\ftATIO.N Previous lawful gambling exemption number o Other nonprofit organization ~ lJLJ Check one of the following and attach a copy of your proof of nonprofit status. NOTE: Sales tax exempt status or federal ID employer numbers are not proof of Income tax exempt status. _1. NonprofltArtlcles of Incorporation OR Certificate of Good Standing. Attach a copy of your organization's Nonprofit Mides of Incorporation OR current Certificate of Good Stanaing. This certificate must be obtained each year from: Secretary of State Business Services Div. 180 State Office Building St. Paul, MN 55155 Phone: 651-296-2803 ~ 2. Internal Revenue Service - national organization ~Check if proof previously submitted to Gambling Control Board. OR _Attach a copy of the IRS income tax exemption [501 (c)] letter in your organization's name. To obtain a copy of your federal Income tax exempt letter, send your federallD number and the date your organization initially applied for tax exempt status to: IRS P.O. Box 2508, Room 4010 Cincinnati, OH 45201 _3. Internal Revenue Service - Affiliate of parent nonprofit organization (charter) _ Check if proof previously submitted to Gambling Control Board. OR _If your organization falls under a national organization, attach both of the following: a. a copy of the IRS letter showing that your national organization has been a registered nonprofit 501{c) organization and carries a group ruling, and b. a copy of the charter, or letter from your national organization, recognizing your organization as a subordinate. . ,..' ,_..'---- .'- -. . -. .--.... - . -, . G. :AMBLlN<3.'PREM'.ISESINFORMATIO.N.. . ~. _. ,_ ,_ >"".' ._.":".,,,___.4_''i~,''',.'''''''____'_:'_''_- - '.-. A' ..~.,=~>...I,-;- --. - ... C~ Check the box or boxes that indicate the type of gambling activity your organization will be conducting: ~ *Bingo [0" Raffles [EI *Paddlewheels tl2J *Pull-Tabs 10' *Tipboards *Gambling equipment for pull-tabs, tlpboards, paddlewheels, and bingo (bingo paper, hard cards, and bingo number 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 dick on Ust of UcensedDlstrlbutors. Or call 651-639-4000. 331) --- - --------- - - -- - ---- ----------- ------- J"'\ LG220 Application for Exempt Pennit Page 2 of 2 4107 L~AL UNIT OF GOVERNIIIENTA~KNQWLED~N1J:NT . . .H . ., . ...... If the gambling premises Is within city limits, If the gambling premises Is located In a township, both the city must sign this application. the county and township must sign this application. Check c-"> the action that the city Is taking on Check <,J> the action that the county Is taking on this application. this application. _The application is acknowledged with no waiting period. _The application is acknowledged with no waiting period. _The application is acknowledged with a 30 day waiting ~The application is acknowledged with a 30 day waiting period, and allows the Board to issue a permit after 30 period, and allows the Board to issue a permit after 30 days (60 days for a 1st class city). days. _The application is denied. _The application is denied. Print name of city Print name of county On behalf of the county, I acknowledge this application. On behalf of the city, I acknowfedge this appUcation. Signature of county personnel receiving application Signature of city personnel receiving application Title Date_I----1- Title Date I 1- TOWNSHIP: On behalf of the township, I 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 (Minnesota Statute 349.213, subd. 2).] Print name of township Signature of township official acknowledging application Title Date I I CHieF EXJ=CUTIVE: OFFICERiSSIGNATUR.E '. :. . ..... ....<:. ..... , '. ..'. ','.<'>. .... , . 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 Board within 30 days of the date of our gambling activity. Chief executive officer's signature Name (please print) Date J I Complete an application for each gambing activity: Financial report and record keeping required . one day of gambling activity A financial report form and instructions will be sent with your . two or more consecutive days of gambling activity permit Within 30 days of your date of activity the financial . each day a raffle drawing is held report form must be completed and retumed to the Gambling Send with the completed application: Control Board. . a copy of your proof of nonprofit status, and Questions? . $50 application fee. Make check payable to Call the Licensing Section of the Gambling Control Board "State of Minnesota". at 651-639-4076. To: Gambling Control Board If you use a TTY, call the Board by using the Minnesota Relay 1711 West County Road B, Suite 300 South Service and ask to place a call to 651-6394000. Or, check Roseville, MN 55113 our web site at www.gcb.state.mn.us. Da1a privacy. ThIs form wBI be made avaDabIe In Your name and and your organization's name Board members, staff of the Board whose work aJtemalive format Q.e. large print. BraIDe) upon and address will be public information when assignment requires that they have access to the request. The information requested on this form received by the Board. AD the other Informallon 1nfonnatIon; the Minnesota Department of Public (and any attachments) will be used by the that you provlde wBI be private data about you Safety; the Minnesota Attorney General; the . GambBng Control Board (Board) to determlneyour untO the Board issues your permit. When the Minnesota Commissioners of Administration, . qualllicatlons to be JnvoIvedIn IawfuJ gambling Board Issues your permit, aD of the lnfonnallon Anance, and Revenue; the MInnesota legislative acIlviIiesin MInnesota. You have the rlghtto refuse that you have proWled to the Board In the process Auditor, national and international gambling . to supply the Jnfonna1lon requested; however, If of applying for your pennit wm become pubDc. If regulatory agencies; anyone pursuant to court you refuse to supply this lnfonnation, the Board the Board does not Issue you a pennlt, aD the order; other Individuals and agencies that are may not be able to detennlne your qualifications information you have provlded In the process of speciflcaBy authorized by state or federal law to and, as a consequence, may refuse to Issue you applying for a permit remains private, with the have access to the information; individuals and . a permit. If you supply the lnfonnation requested. exception of your name and your organization's agencles for which law or legal order authorizes the Board wm be able to process your application. nameandaddresswhlchwBIremalnpubllc.Prlvate a new use or sharing of Information after this data about YOU are available onlY to the foIIowIr1Q: Notloe was alven' and anyone wi1h vour consent 33D --------~--~----~--~------ RECEIVED JUN 0 8 2007 CENTERVILLE, MN 1747 Meadow Lane Centerville, MN 55038 July 7, 2007 Dear Mayor, Members of the Centerville Council and City Administer: My name is Brian Nelson and I am responsible for the parking at St. Genevieve's Parish Picnic, which will be held August 19,2007. Parking and safety at the church and on the adjacent neighborhood streets are always a concern to me on this day. The old Park and Ride lot was used last year, this was efficient and a great help to the success of our picnic. I hope that the parish may use utilize the old Park and Ride again. We also set up no parking zones on the south side of Sorel Street and the west side of Goiffon Road to insure the safety of pedestrians and allow emergency vehicles to the site, or to neighbors, if needed. I have also contacted the Centennial Lakes Police Department and Fire Department to ensure that they are also fully aware of the situation and so things run safely and orderly that day. If this is feasible or if you have further questions for me please contact me at home (651) 653-4324. Thank you very much. I look forward to hearing from you in the near future. You are all warmly welcomed to join us for a day of fabulous food, fun and festivities. Sincerely, Brian L. Nelson ---~-----~~ 33,P ---,-l' { , ~ Centerville Special Event Permit App6eation 1. 4~S~B1;DE~OF~T~l'#;h~ New Application: V Renewal of or Change in Application: CONTACT PERSON: f\,u~!~A f\/~v~. ( . TELEPHONE: OR IRS"' '-'1{) 1.-oS-~ (~~ I rZ- 71--(.,'f 'll/l 2. IDENTIFYING INFORMA nON: 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. I Applicant's N"""'~ (.i S5... N", V .-.c:t..' Address: ~ ou.-v- f ~ Mailing Address: Affiliation: Day Phone: US-~Dl-D~ Emergency Phone: Title: ~.A'-(-1 ~ Evening Phone: 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 the event is being produced, the organization(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: _~ ",,- ~tL; Organization/Business/ Agency/Affiliation: Is this a non-profit organization? Yes No If you are making application under non-profit status, proof of non-profit status must be attached to this apnlication Mailing Address: Day Phone: Evening Phone: Title and functional responsibility with regard to the event: Page 1 of 10 33~ ~ I 4. REQUESTED EVENT COMPONENTS: Date requested: ~ t if 1 D I Alternate date: Requested hours of operation: q -- AAid.CM ~.Ip.m.) To: Set up beginning dare and time: ~ . Complete dismantle date and time: ~A IIu1.t ./ Describe the number and type of anhnals (if any)'\., be used in ~ent: (a.m.lp.m.) Attach a draft of the entry form for participants and/or spectators. Anticipated number of participants: {f?O-- {'fj; Spectators: 5. INSURANCE: 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: Attach your "Plan for c1ean-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 facilities, equipment, premises and streets. A deposit of $SOO will be reauired for dean-uD and restoration. If premises are left in satisfaetorv condition. this deposit will be refllnded in run foDowin2 insoeetion. 7. LOCATION: 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. Non-alcoholic concession area. G. Food concession area. H. General Merchandise concession areas. I. _ Portable toilet facilities (indicate number). J. _ Event participant and/or spectator parking areas. K. _ Event organizer's command post. Page 2 of 10 I 3J" I ---- -- --~-------~---------------- --- --------- ------ , 1- L. First aid facilities. M. _ Fireworks or pyrotechnics site. N. _ Vehicle fuel handling sit o. _ 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. _ Trash receptacles (indicate number) u. Other - Please describe. 8. 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: Will alcoholic beverages be served? Yes ~ No PLEASE NOTE THAT SALES OF UQUORlALCOHOL IS PROHIBITED IN CITY PARKS UNLESS THE EVENT IS A CITY CELEBRATION AND PRIOR APPROVAL AND APPROPRIATE LICENSES ARE OBTAINED BY CITY COUNCIL ACTION. If yes, describe what system 1~ur~at alcoholic "lreverages will be consumed by persons 21 years and older: ~v~ 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 lieensine: may be required by City. County and State ae:encies. such as a Lame Assembly License for ~atherinl!S oyer 1.000 DeOple. some types of food handling licensE. Gambline: License. Cabaret License. etc. It is your responsibility to check with the City Clerk or local authorities to determine what licensE is required prior to submittine: this application. Page 3 of 10 33si"" T'. - -- - -----~---~-------- -------~----- ------ ----------~----- ~ .'1 Will food and/or non-alcoholic beverages be served? Yes 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.) If Yes. YOU will need a oermit from the Anoka County Deoartment of Environmental Health. Please attach a COOy of the oermit to this aoolication. 9. SECURITY AND SAFETY PROCEDURES: Describe your proposed procedures for set up, operation, internal security and crowd control: _ 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: 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: 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 staffand equipment if required. Attach additional sheets if necessary. Name of agency: Name of Representative: Address: Day phone: Evening phone: Indicate medical services (if required) that will be provided for this event: Page 4 of 10 J3t -- ----- - -------- ------ ---------------- -- -- --- -- --------- --- ..~1 ~ Ambulances: Nurses: Doctors: Paramedics: 10. VENDORS OR CONCESSIONAIRES: Describe what vendors/concessionaires you will allow in conjunction with the event, and the purpose of these concessions: 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: 11. CITY SERVICES/EQUlPMENT: Describe city services and/or equipment requested for this event: City barricades, cones, signs, picmc 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. ~5 --tv bLud..- 10 euf -M..--~ tlo/t- ~ 12. 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: 13. 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: 14. 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: PageS ofl0 33LL-'~- ---~-----------~--- ----~- {--- .~ Centerville Special Event Permit NAME AND TYPE OF EVENT: DA Y,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 I I I I I J3v I I - ( -" --- -"- ---------'---- ~------------- - ----- - -- ----"'\., t- 2. PARKS AND RECREATION DEPARTMENT Special Events Coordinator: Date: Initial/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. Alc<>holic beverages. 3. Peddlers. 4. Noise abatement. 5. Other provisions as may be required: INSURANCE: Your insurance coverage must be reviewed and approved by the City's insurance carrier. Page 7 oflO 330 --------- ---- - - ---- - --------- I""'"'"--- .' 1. Public liability insurance naming City ofCenterville.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. s. 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 che~k/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 ;(3 v'. X --- ~--- - - ~ ------- ~ , 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: Approved by: Si Dale: o/t4'61 1. Trash containers required. (# ) 2. _ Portable toilets required. (# ) 3. _ Special animal clean up required. 4. Barricades provided, as available. (# ) 5. 2. Cones provided, as available. (# t t;' ) 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: Title 8. PUBLIC WO 9. STATE, COUNTY AND CITY HEALTH DEPARTMENT Approved by: Signature Title Date: 1. Food and/or beverage served. 2. _ Permit(s) attached. Page 9 oflO 3d'y -.-------- ------------------------ --~ ------------ '~-- "' 3. Food cooked. 4. Permit(s) attached. 5. List other health licensing obligations as may be require: Page 10 of 10 33:z- --- ---------------------------- -- -- -- -- -- ------ - -- -- --- -- ----- -- -- -- - ------ - ~ I,UKI II: I JCF: 0 ';0 r i ',II: 'iT: ~ V,' 1::"1' 'T',;r::! FI:: I 1 ~ ! : .l; l' l! " ! ql '" 1 ,l,,! : : ~! CENTENNIAL LAKES POUCE DEPT. MNOO203OO *' "0"7' T"'"3' 4' 8'8"'"3' *" I' 7747 MMEI 6.. ROBERT A ToI8I Y8Iu8 8IDI8n ~ I $O.GO I ~ 11720 : IVIMIIU: -- I $O.GO I 08I121ZOO7 08:20 PM 1720 1748 Tcd8I V8lu8 Damaged (PnlpBrlr): 0811212007 0&:20 PM I 0811212007 8:20 PM TalIII Value ~.. (PllIpBrIJ): I SO.OO I Apt: GIld: 7031 20Ih AVE S Center"JIIIe, MN &5038- #10& 06-06 MOO Code: CIa88IIIcdon: . incident NanaIve 1 On the above date and approximate times, this officer reviewed the application for a massage therapist In the CIty of Centerville. The applicant identified below as William Klein had no criminal record and there was no other information that would prohibit him from obtaining this license. This Information was returned to the CIty of CentervlIIe. NAME tXJDE8. A _ AdUIlArrested. AC. An8sIIng CIIz8n, C. CoI~18nt, D. DrIver. F. F8mIl;JP8nInt. G. GuanIlan. J. JuvenlIB An8lIted, M - Meldlaned. MP - MIsslng PenIGn, 1- 0IIl8I' \nvaIVed, 0 - 0rmIr. P - P U I P. PT - Peo....dtG/. R - Repar1Be, S - SUspeat, v - VIaIIm, W - WIIne8s . Per80n NJIU: --ciiiIi: o BusJnes8 A M KleIn, WIllIam Jacob . , CIty, --. ..",. Apt: U8\'8 Ol' II rm: I=': Race: 482A Elm DrIve N Hugo. UN 15038- 4 1112011880 t1IIlgm: WeigtIt --. ep CDIar: ,-- 812-887-8108 o Person MJ/U: coae: N8IIt8: ~ o Bus\neSS .~ -", Apt.: -........... I tiS Race: t'l8IIP= W8IIIftI: . . . o PenIon NoIIU: .. N&me: A\I88: o Bu8Ine8B ApI.: . l~ Race: . I"l8lgIft: W8lgIE --. . , PhCIIlll - . -r. ,0: 2 Ii ffi 8 dE - ~ . i1 II: o I - ~ i Page1of2 33L ",' f~ IJf~t APPLICATION FOR MASSAGE THERAPIST CIQlTmCATIONlLlCENSE CITY OF CENTERVILLE It-lO-C)? Date MASSAGBLOCATIONlADDRESS 7Qz,c 2-D ~ Ave. 5 1.1J"f<-.I 05 OOuRsmAYSOFOPERATION MOIIJ - '?UVl q4-H/ ,fCJ 'IfM NAME OF APPLICANT W ~ (I iIJ.fA/I '"\ ~ ~ Ie r v't , ~)' ~ ~)' DATE OF BIRTH 11- UJ - If..ga ElOME TELBPHONB #: bIZ - 1<37- '10 'SS SCHOOL ATl'ENDED AND DEGREES RECBIVED: /II1lVl/ll e ~(..e.. ~ "f (()-F BJ"I1eJ's avd q/o~ ~I/~~ ./1M5~Y T/;,f~ [Xf/~MA.. UST QUALIFICATIONS RBQUIRED TO PRACflCE MASSAGE: t Yr' M~ c;~ ~ L '"'f1' ~~Y f- . 3Z ~" ' tl fJe,)J.y('ovr+ Ct.< ,'ropf77C..f,C J"C1 ~ M 1'1,;,"~SO Jl~ "'- ' .II. J IJST 1'HREE CHARACI'ERREFElU!NCES (lNa.u.oB AND BlR.THDATE):~ W14 ~~h (YAir JGl/L fg;f -770- m~ DJR 5-tj-/~6f '!)1P~,,;p f1.1';' ~t ut;.e 6fZ-ZZl-<:Ja83 l.e;I/'e cAec-M&1.K. 1.&4 plMO iGI-77b- 71'" 1):)3 ~-Z-I-/~67 008 HAS APPLICANT EVER. BEEN ~CIBD OF A CRlMB. OTHER. 'I"H'AN A TRAFFIC VIOLATION? IO-l~- ~ YES NO-A-. lFYES. PLEASE GIVE ANEXPLANATION ON A SEPARATE PIECB OF PAPER, INa.UDING TIME. PLACE AND NATURE OF SUCH CRIMB OR OFFENSE AND DISPOSlTIONTHEREOF. Ce,,",~i(1 L Nt fV 65' oJ8 TBB APPLICANT SHALL PROVIDE THE FOLLOWING INFORMATION: A. EVIDENCE OF APPLICANTS EDUCATION INCLUDING CONTINUING EDUCATION IF APPLICABLE. B. EVIDENCE OF APPLICANTS QUALIFICATIONS AND CHARACl'ER.RBFBRENCBS. C. BVlDBNCB IN TIm FORM OF A CURRENT CERTIFICATE FROM A LiCENSES PHYSICIAN PRACflCING IN ~A lNDICATING mAT SAID MASSAGE TBBRAPIST WAS BXAMINBD AND IS FREE OF ANY COMMUNICABLE DISEASE mAT WOULD DISQUALIFY THE APPLICAN'I FROM ENGAGING IN 1HE PRACflC OF MASSAGE. A RENEWAL CERTIFICATE WIlL BE REQUIRED EACH CALENDAR YEAR, 'ALONG wrm A PHYSICAl EXAMINATION CERTIFICATE,. COMP.LE'IED APPLICATION AND RENEWAL FEE OF $>>. APPLICANTS WILI. STRIcny COMPLY WITH AU. REGULATIONS PROMULGATED BY THB CITY COUNen. OF THE CITY OF CENTERWLE AND AIL ORDIANCBS OF SAID MUNICIPALITY. I hereby certify that I have read the foregoing questions and that the answers to said questions are tIUe ofmy """lmowfedse. ~ ~ ~ of Applicant Subscribed and sworn to before me ~ - j' r;2., ~ ~__ _____ U II ~~~~~~7 Notary Public Signature My Commission Expires #. LJ (Sea]\ 33~ ---' ++.t+.t MINNESOTA SCHOOL OF BUSINESS GLOBE COLLEGE SUCCESSFUL FUTURES START HERE! MASSAGE THERAPY VERIFICATION OF EDUCATION This letter serves as written confirmation that aA/lkJ/Y1 II eAY7 enrolled at the Minnesota School of Business, Richfield Campus (05296-00) in the Massage Therapy Diploma Program. This student completed the required minimum 730 hours of the program. This program is accredited by the Accrediting Council for Independent Colleges & Schools. Date of Enrollment: .tj / S /:2 6 () b , , Date of Graduation: 3/0:23/0 l / ' I Hereby certify that to the best of my knowledge and belief, the foregoing is a true statement of the record o/the individual narf above "4 School Contact: /v(}M I iLtYl4 /fh?l"i'. Y <70~h 7- Signature Print " D;Je Title: 2.?f1shdV Phone #: ( 0/ C ) 1"?t - 31-/S- Massage Therapy Diploma Reqllil ed COllrses Credits Conlan 1I0llrs r"M250 - Career Development I 20 S 150 - Kinesiolo~ 4 50 S 156 - CPRlFirst Aid! AED 1 15 S200- Biomechanics 2 30 A I 00 - Medical Tenninolo~ 4 40 MAllO - Anatomy & Physiolo~ 5 50 MS I 05 - Massa~e Techniques I 5 80 MS205 - Massage Techniques II 5 80 MS210- Business of Massage 4 40 MS261 - Massage Techniques III 7 120 MS298 - M~e Extemship I 35 BUSINESS REQUIREMENTS Students must choose one of the following four courses: CSl1I - Comouter Info. Systems 3 40 CSI3I- MS Office I 3 50 BS 11 0 - Business Communication 4 40 CM 15 5 - Interpersonal Relations 4 40 TOTAL 42 or 43 730 - (Based on Elec- tive Choice) 33;. V .,.,~'~~~ ..~'"'".,'=iI!J.' ~"'~j~~l~ ~~,&"';" .~~.~ '.~ .~...:o\,~ ,,' 1~"'t~ ~, ,~'&"'~ , .~ ~':'~"~~~ "~ "~~"'5..~ r~~ : ~'&~ ~ ~ "..,,~~~ ~~~ ~~~ =t=t~ ~ ~ ,. ~ ~ =Ft~ ~' ," ~~ '~~.",&'>>'~ ~ '~"'~ i ~ . ~~~ ~,~~~ ,~ ~. ,...,~ ~ ~'i;.:' ~$ ~~.~ ,~.~ ~ .~~"""~ ~~'&~~ ~ ~ ~'~""""""'.~ _:~ 3311 OPTION AGREEMENT TIllS OPTION AGREEMENT, made and entered into this day of June, 2007, by and between the City of Centerville, a municipal corporation under the laws of the State of Minnesota, 1880 Main Street, Centerville, MN 55038 (hereinafter "City"), and Dennis C. Shudy, 6975 20th Avenue South, Lino Lakes, Minnesota 55038-8743 (hereinafter "Shudy"). WHEREAS, Shudy owns two parcels of real property located in the City of Centerville, Minnesota, legally described as follows: Parcell: The E 410 Ft ofSWl/4 ofSWl/4 ofSEC 24 TWP 31 RGE 22, Subj to EASE of Rec (pIN # 24-31-22-33-0002) Parcel 2: the E 410 Ft of S 345 Ft of SWl/4 of SWl/4 of SEC 24 TWP 31 RGE 22, EX S 205 Ft Thereof, Ex RD, Subj. to EASE ofRec (pIN # 24-31-22-33-0016) (hereinafter the "Property"). WHEREAS, the City desires to purchase the Property from Shudy; WHEREAS, the City and Shudy recognize the necessity for allowing themselves a reasonable amount of time to prepare and negotiate a purchase agreement and the transfer of title of the Property; WHEREAS, the City and Shudy both desire to enter into an option agreement. NOW, THEREFORE, in consideration of the below described option payment and other good and valuable consideration paid by the City to Shudy, the receipt and " sufficiency of which is hereby acknowledged, IT IS HEREBY AGREED AS FOLLOWS: 1 1. Option Granted. Shudy hereby grants to the City the exclusive right and option to purchase the Property for the total purchase price of One Million. Three Hundred Thousand and No/I 00 ($1,300,000.00). 2. Option Payment. As consideration for the grant of this option, the City has contemporaneously paid to Shudy the sum of $2000.00. 3. Exercise of Option. This option, if not sooner exercised, shall expire at 5:00 p.m., Central Standard Time, on September 10, 2007. The sole method of exercising the option shall be by the City affixing its authorized signature to a purchase agreement which is satisfactory to both the City and Shudy, and delivering said Purchase Agreement to Shudy at the address listed below. The expiration time for the exercise of the option may be extended in one-month increments only in a writing executed by the City and Shudy. 4. Utilization of Option Consideration. During the above-described option period, the City may unilaterally terminate the option. In the event the City exercises its option, the option payment shall be applied to the purchase price of the Property. 5. Purchase Agreement. The City and Shudy agree to negotiate in good faith for the timely drafting and execution of the Purchase Agreement and collateral documents. Upon execution of this option, Shudy agrees to provide to the City, no later than June 22, 2007, an architectural and construction plan setting forth the manner in which the improvements to the Property will be completed in addition to the cost of constructing the improvements, and any other information the City may request in writing. . I 2 -- - -----------.- - -- - -- - --~- --- 6. Right of ~tion. During the term of this option, the City may enter upon the Property for the purpose of inspecting the Property. Entry on to the Property for other purposes must be expressly granted by Shudy. 7. Notices. Any notice required hereunder, shall be given by personal delivery at the following addresses: If to City: City of Centerville Attn: Dallas Larson 1880 Main Street Centerville, MN 55038 If to Shudy: Dennis Shudy 6975 20th Avenue South Lino Lakes, MN 55038-8743 8. Assie;nment of Option. The City's rights under this Option Agreement are not assignable. 9. Multiple Originals. It is acknowledged that. this agreement may be executed in one or more original counterparts, each of which shall be considered an original. IN WITNESS WHEREOF, this instrument has been executed by the undersigned on the day and year first above written. THE CITY OF CENTERVILLE By: Its: Mayor By: Its: City Administrator 3 --------- - ---- - -- ~ COUNTY OF ) ) ss: ) I I I I I I Dennis Shudy STATE OF MINNESOTA The foregoing instrument was acknowledged before me this day of ,W~~ ~ , the Mayor and City Administrator, respectively, of The City of Centerville, a municipal corporation, on behalf of the corporation. Notary Public STATE OF MINNESOTA ) ) ss: COUNTY OF ) The foregoing instrument was acknowledged before me this _ day of , 2007, by Dennis Shudy. Notary Public 4