HomeMy WebLinkAbout2005-05-25 Set Agenda
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CITY COUNCIL MEETING
Wednesday, May 25, 2005
6:30 P.M.
Set Agenda Item = Red
COUNCIL MEETING
L CALL TO ORDER
1. RoD Call
II. APPROVAL OF AGENDA
IlL APPROVAL OF COUNCIL MINUTES
1. May 11, 2005 City Council Meeting Minutes
IV. CONSENT AGENDA
1. City ofCenterville May 12,2005 througb May 25, 2005 Claims
2. Centennial Fire District Claims tbrougb
3. Centennial Lakes Police Department Claims tbrougb May 12, 2005
4. Church of St. Genevieve Request for Temporary Gambling Permit (Bingo,
Rame, Paddlewbeel, Pull-Tab & Tipboards) for tbe Perisb Festival & Waive
Fee & Temporary 3.2 Malt Liquor License
5. U.S. Bank - Payoff G.O. Improvement Bond, Series 1998 (parkview)
6. Centerville Lions Club Request for Temporary Bingo Permit for Fete des
Lacs & Special Event Permit
V. AWARDSIPRESENTATIONS/APPEARANCES
1. Mr. Scott Martin - Minnesota Community Capital Fund (Review Metro
Area Economic Development Loan Program
VI. PUBLIC HEARINGS
VII. NEW BUSINESS
1. Churcb of St. Genevieve Site Plan Review - P & Z Recommendation for
Approval (Tabled from Previous Meeting)
2. Sewer Cleaning - Proposals - Award Contract
3. Res. #05-025 - Transfer of Funds in the Amount of 541,008.72 From the
General Fund to the Parkview Debt Service Fund
4. T-Mobile (Antenna Lease Amendment - New Water Tower)
5. Schedule Council Work Session - June 8. 2005 (?)
VIIL OLD BUSINESS
1. Res. #05-022 - Supporting the Efforts ofthe Regional Council of Mayors on
Transportation Priorities
2. Res. #05-023 - Authorizing Comprehensive Plan Amendments as Outlined
in Ordinance #83 & Exhibit A
3. Res. #05-024 - Authorizing Comprehensive Plan Amendments as Outlined
in Ordinance #82 & Exhibit A
4. Agreement to Conduct a Market Study by McComb Group, Inc. -
Downtown Redevelopment
IX. ANNOUNCEMENTSIUPDATES
I. City Administrator, Mr. Dallas Larson
2. 1601 LaMotte Drive - (Update)
3. Downtown Redevelopment Planning (Update)
4. CSAH14/Main Street Projeet (Update)
X. ADJOURNMENT
Kris Sweeney
'rom:
Sent:
To:
Subject:
Greg Kieselhorst [Greg.Kieselhorst@artesyn.com]
Wednesday, May 25, 2005 2:54 PM
Kris Sweeney
Re: fete des lac
~
~
~
attl.htm (1 KB) imageOO1.gif (2 KB)
The person who usually handles the Lions Insurance at TJ Adams Group, no longer does those
accounts I found out last week. The new personl Beth Kruger 630-324-2616, and I haven't
been able to link up faxes. The request is done, but I just haven't gotten the request
through. So if I ever get a return call to work things out, things may happen. Certificate
pending I guess.
"Kris Sweeney" <ksweeney@centervillemn.com> on OS/25/2005 02:34:05 PM
To: Greg Kieselhorst/NA/Artesyn@Artesyn
cc:
Subject: fete des lac
Hi Greg,
The City is looking for the Certificate of Insurance for Fete des Lacs 2005. Also, on the
agenda is the Bingo permit.
Kris
1
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" 'Esta{i{is!ird l85l
Centerville
Special Event Permit Application
L TITLE, PURPOSE, AND BRIEF DESCRIPTION OF EVENT: 2005 "Fete des Lacs"
New Application:
x
--
Renewal of or Change in Application:
CONTACT PERSON: Greg Kieselhorst
TELEPHONE: 651-653-1833
OR 612-221-9122
2. IDENTIFYING INFORMATION:
Attach a written commUDication from the organization(s) in whose name the event will be advertised which
authorizes you, the applicant, to apply for this speciaI event permit on itsitheir behalf.
Applicant's Name: _Greg Kieselhorst
Address: 7155 Brian Drive CenterviIle. MN 55038
Mailing Address: Same
Affiliation: Centerville Lions Club
Day Phone: _612-221-9122 Evening Phone:
Emergency Phone: 612~221-9141
Title: Secretmy
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 speciaI event. Include professionaI 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 organizational1y involved as principals in
the production of the proposed speciaI event. Make additional copies of the following as needed to include as of the
principals involved in the proposed special event.
Name: Centerville Lions Club
OrganizationlBusiness/ Agency! Affiliation: Lions International
Is this a non-profit organization?
_X_ Yes
No
If you are making application under non-profit status, moof of non-nrofit status must be attached to this apnlication
Mailing Address: Same
Day Phone: _Same Evening Phone: Same
Title and functional responsibility with regard to the event: Lions Secretary, as part of said
duties permit applications and insurance add-oDS etc.
Page 1 of! 0
.
4. REQUESTED EVENT COMPONENTS:
Date requested: _August 4111 to 9111, 2005 Alternate date: None
Requested hours of operation: _9am (a.m./p.m.) To: _12pm (a.m./p.m.)
Set up beginning date and time: Au~st 4111. 2004
Complete dismantle date and time: Au~st 9111. 2004
Describe the number and type of animals (ifany) to be used in this event: None
Attach a draft of the entry form for participants and/or spectators.
Anticipated number of participants: _100_ Spectators: _1,000+_
5. INSURANCE: Applied for, see attached request to T J Adams Group Ins.
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 depeud 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: Please see note after a deposit of$500.
Attach your "Plan for clean-uplMaterial Preservation". Include number, 1;ype and location of trash containers to be
provided for the event. Indicate who and how man will be responsible for emp1ying 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 dellosit of $500 will be reouired for c1ean-ulI and restoration. If
premises are left in satisfactory condition. this deoosit will be refunded in full followinl! insuection. Waste
Management is donating trash containers to be used by participants. The Lions Club will clean up any left garbage.
Please waive deposit, good standing letters provided from Mainstreet Bank in the past.
7. LOCATION: LaMotte Park in Centerville
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. _X_ Entertainment or stage locations (grandstand operators should provide you with a
"to scale" drawing.)
E. _X_Alcoholic beverage concession area.
F. _X_ Non-alcoholic concession area.
G. _X_Food concession area.
H. _X_General Merchandise concession areas.
Page 2 of 10
I '
1. _X_ Portable toilet facilities (indicate number).
1. _X_ Event participant and/or spectator parking areas.
K. _X_Event organizer's command post.
L. _X_First aid facilities.
M. _X_Fireworks or pyroteclmics site.
N. _ Vehicle fuel handling sit.
O. _X_ Cooking areas.
P. _X_Electrical sources to be used for cooking.
Q. _X_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. 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: Battle of the Teen Bands will be using
amplified sound from 7pm to Ilpm August Sth. Festival Awards will be given out using
amplified sound from 12am to Ipm August 6th. Dance Lines will be performing and using
amplified sound from 1 pm to 3pm August 6th. Karaoke will take place from Spm to 7pm August
6th. Festival Street Dance Band will be using amplified sound to provide dance music from 8pm
to I2pm. Bingo will be using amplified sound from Noon to 4pm August 7th.
Will alcoholic beverages be served? Yes _X_No
PLEASE NOTE THAT SALES OF LIOUOR/ALCOHOL IS PROHIDITED IN OTY
PARKS UNLESS THE EVENT IS A OTY CELEBRATION AND PRIOR APPROVAL
AND APPROPRIATE LICENSES ARE OBTAINED BY OTY COUNCIL ACTION.
If yes, describe what system will be used to ensure that alcoholic beverages will be consumed by
persons 21 years and older: Upon inspection ofa valid I.D.. a person will be given a wristband
at entry for identification to the servers.
If yes, describe how, where, when and by whom the alcoholic beverages will be served: At
LaMotte Park. starting August Sth at 5pm to II pm. August 6th lOam to Spm and August 7th lOam
to 5pm. up by the softball fields bv a beer trailer. Also at the Hockey Rink. starting at 5pm to
11 :30pm. with another beer trailer for Karaoke and the Street Dance August 6th. Persons will be
served by Centerville Lion Members or known volunteers only at all times.
If a casino party, a dance, or live entertaimnent is part of your event, please describe: Battle of
the Teen Bands on August Sth is made up of three live bands. Street Dance on August 6th is the
live band "Uncle Chunk".
Page 3 of! 0
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
licensinl! may be reuuired bv City. County and State al!encies. such as a LaNe Assemblv
License for l!atheriDl!S over 1.000 neoole. some tyoes of food handlinl! licensinl!. Gamhlinl!
License. Cabaret License. etc. It is your resoonsibility to check with the City Oerk or local
authorities to determine what licensinl! is reuuired prior to submittinl! this apolication.
Event Noise. Bingo. Fireworks. 3.2 Malt Liquor Event Pemit.
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.) The Centerville Lions alwavs use the health guidelines layed down by the
Anoka County Health Devartment. in handling. storing. transporting and cooking of foods and
beverages.
If Yes. YOU wiD need a Dermit from the Anoka County Deoartmeut of Environmental
Health. Please attach a coov of the oermit to this aoolicatioo. It will be forwarded once
applied for, approved and received.
9. SECURITY AND SAFETY PROCEDURES:
Describe your proposed procedures for set up, operation, internal security and crowd control: As
in the past, the Festival Committee plans on working with Centennial Lakes Police and Sergeant
Pat Aldrich to insure the whole Festival has the proper security and safety for all events.
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: Alrighty
installed LaMotte Park lighting.
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: N/ A
Attach to this application a copy of your building permit(s) if you are installing any electrical
wiring on ternporary or permanent basis and/or if you are building any temporary or permanent
structures such as bleachers, scaffolding, a grandstand, stages or platforms.
Page40flO
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: Centennial Lake Police and Fire Departments.
Name of Representative: Sergeant Pat Aldrich
Address: 200 Civic Heights Circle Circle Pines, MN 55014
Day phone: _763-784-2501 Evening phone:
Indicate medical services (if required) that will be provided for this event:
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: All concessions will be run by the Centerville Lions, to help raise
funds to pay for Festival events not covered by the City ofCenterville.
Describe how you intend to regulate, monitor and control the type, number and quality of
vendors/concessionaires whom you may pennit to operate in conjunction with the event: N/A
II. CITY SERVICES/EQUlPMENT:
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.
Street barricades. cones and all LaMotte Park facilities. ,/
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: A earlier end time for dance music
and concessions would lessen the time the Centerville Lions Club have in recouping events
Page 5 oflO
costs. The Club wants to be flexible but there'd be a point were the event sponsorship would be
in jeopardy.
13. FEE STRUCTURE I 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:
A Festival Dance Button pre-purchase fee of $7 or a $10 day-of-event fee.
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: N/A
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 NI 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:
Page 6 of 10
Signature
Title
Date:
Reason(s) for revocation:
TO BE REVIEWED/APPROVED AND SIGNED BY AFFECTED
CITY DEPARTMENT HEADS
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
Page 7 of! 0
Date:
1. Dance and! or live entertainment.
List types or pennits 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.
2.
3.
1. _ Public liability insurance naming City of Centerville and other public agencies
additionally insured is required.
Hold harmless forms executed and failed.
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:
Page 8 of 10
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:
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.
Approved by:
Title
Date: '2:; M~ 05
1. ~ Trash containers required, (# )
2, =z- 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. (#
)
)
Page 9 of 10
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. _ Pennit(s) attached.
3. Food cooked.
-
4. _ Pennit(s) attached.
5. _ List other health licensing obligations as may be require:
Page 10 oflO
MAY 20 2005 12:32 FR ARTESYN ENGINEERING 612 392 6740 TO 96514298629
02/08/02 PRI 10:32 PAX TJ ADAKS GROUP
TJ ~AM~.~~9!g~
P.03/03
IirI002
R6QUEST FOR MONS CERTIFICA TES OF INSURANCE
.....NOTE: WE REQUIRE 7 BUll_ft." DAVS TO PROCell THIS REQUEST......
Dete '7 -;Z-e> -t:;C7
Thl. form cln either b. faxed or man.d to T. J. Adam. Group, LLC
"
Addre..: 333 E. Butterfield Rd., ate. 500
Lomb.rd,'IL 80148
"ttn: Marcl Ray..
CLUB INFORMATION:
Fad: (130)3Uo2761
Attn: Marol Rey..
Name of Llonl Olub
?-rIa-I-re-i2-V11_l.--t:f"'" L--l~> ~,l3-
Addre.. -;1l?'7 6j;l..IA...l ~I\/",
City. SlIIte. Zip ./ ,",~i2-\fn_\.-U . ",,_I c.:;';;b>B
.
EVENT INFORMATION:
~ - 'I - d II
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le(l) of Event
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CERTIFICATE HOLDER/ADDITIONAL INSURED INFORMATION:
Certificate Holder:
(party requiring
certiflcate from
your club)
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\ ~ SS"/:;) lM AI.. I ~F"12"--
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Addlllonlllnlurada: (In ord.r 10 be .n eddltJonalln.Urld, the PlIrty must own the prem.... on which you
are conducting X!ur evenl ~ a PUDllc blllly l..uln; I peE!!!ll):
U None J.4 Ssm. II Certlftcele Hold.r U Different from C.rt. Holder
MAILING/FAX INFORMATION:
,/
Send To (rf maillnlil):
OR
RequlIlItedBy: h;2Eb. ILI€~H=~
Phon. . whe,. you 08n b. r..ch.d for quertlon.: bl2- - 'Z-Z-l _ <}I~~
CJ Fax Numb.r:
.... PIe... f..1 '....10 Ittach I copy of I..t y..,. certlflclt. If IVllllbl. with In)' n.c....IY oh.n".......
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Minnesota Lawful Gambling
LG220 Application for Exempt Permit
Fee $50
Page 1 of2
11/04
An exempt permit may be issued to nonprofit organizations For Board Use Only
conducting lawful gambling activity on five or fewer days, and Fee Paid
awarding less than $50,000 in prizes during a calendar year. Check No.
Organization Information
Organization legal name Previous license or exemption number, if any
t..e.l-JTIi-il.. \I \ L-l-C L\O uS t.. L-lAB
Street City State and zip code County
,65 B(2A!\.N !:::la..., \l ~ ~~4Lv\ \..-UL /VI..~ o:::;51J3'i; ~C?\..l.."'-
Name of chief executive officer (CEO)
~~ name Last name Daytime phone number
_ o\.-\..o,j TR,u..- 1_<::;'- T1'l!>. 5"17'iS
Type of nonprofit organization (check one)
o Fratemal 0 Religious
o Veteran 13 Other nonprofit organization
Type of proof of nonprofit - attach a copy (see instructions)
~ Nonprofit Articles of Incorporation or Certificate of Good Standing.. Minnesota Secretary of State's Office
o Internal Revenue Service
181 Affiliate of parent nonprofit organization (charter)
Gambling Premises Information
Name of premises where gambling activity will be conducted (for raffles, list the site where the drawing will lake place)
~l.A~\ ~ L.r>...~'\o-.'{'E.... L 1""'1 P A-;Q.. \L
Address (do not use PO box) City Zip code County
t!.J:?-~ ~R..V' u..€- 55038 Al0Ol.l..h
Date(s) of activity (for raffles, indicate the date of the drawing)
~w..-s..-r 5 , 1-ODS #-\('C\..W> I>'i- A:v..L..U.Sr- 'I "2-=S
Check the box or boxes that indicate the type of gambling activity your organization will be conducting:
~ .Bingo o Raffles 0 'Paddlewheels o 'Pull-Tabs 0 'Tipboards
'Gambling equipment for pull-tabs, tlpboards, 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.usandclickon List of Licensed Distributors. Or call 651-639-4000.
This form will be made available in altemative
fonnat (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 Board issues your permit. When the
Board issues your permit, all of the information
that you have provided to the Board in the
process of applying for your pennit 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
yourorganization'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 c;lccess to the information; the
Minnesota Department of Public Safety; the
MinnesotaAttorney 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 {'.F 1oJTe;:.tt. '\I \ \...-l.R_
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.
Pnnt name of city
Signature of city personnel receiving application
litle
Date_I---..!_
.
L\t:>!..lS CLL{.e,
Page 2 of 2
11/04
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
litle
Date_I---..!_
TOWNSHIP: On behalf ofthe township, I acknowledge that
the organization is applying for exempted gambling activity
within the township limits. [Atownship has no statutory
authonty to approve or deny an application
(Minnesota statute 349.213, subd. 2).]
Print name of township
Signature oftownship official acknowledging application
Title
Date---..!----.l_
Chief Executive Officer's Signature
The Information provided in this application 's complete and accurate to the best of my knowledge. I acknowledge that the
financial report will be completed and ret ed to the Gamb ing Control oard within 30 days of the date of our gambling
activity. ()
Chief executive officer's signature ~ '
Name (please print) :::r 0 ~/'J t-J. T \,.><\ \..l,.
Mail application and attachments
Complete an application for each
gambling activity:
one day of gambling activity
two or more consecutive days of
gambling activity
each day a raffle drawing is held
Dale~ -z.o 105
Send:
the completed application,
a copy of your proof of nonprofit status (see instructions), and
a $50 appiication fee. Make check payable to "state of Minnesota".
To: Gambling Control Board
1711 West County Road B, Suite 300 South
Roseville, MN 55113
.
LG220 Application for Exempt Permit -Instructions
11/04
Proof of nonprofit status required - attach one of the following
Minnesota Secretary of State IRS Income Tax Exemption
NonprofitArticles of Incorporation OR Under a national oraanization
or Certificate of Good Standing If your organization falls under a national organization,
obtained from: attach both of the following:
Minnesota Secretary of state 1. a copy of the I RS letter showing that your national
Business Services Division organization has been a registered nonprofit 501 (c)
180 state Office Building organization and carnes a group ruling, and
st. Paul, MN 55155 2. a copy of the charter, or letter from your national
organization, recognizing your organization as a
Phone: 651-296-2803 subordinate.
Not under a national oraanization
If your organization does not fall under a national
organization, attach a copy of the IRS income tax
exemption 501 (c) letter in the name of your organization,
showing income tax exempt status.
To obtain a copy of your federal income tax exempt letter,
send your federal 10 number and the date your
organization initially applied for tax exempt status to:
IRS
P.O. Box 2508
Room 4010
Cincinnati, OH 45201
Sales tax exempt
status or federallD
employer numbers
are not proof of
income tax exempt
status.
Financial report and record keeping required
. A financial report form and instructions will be sent with your permit. Within 30 days of your date of
activity the financial report form must be completed and retumed to the Gambling Control Board.
Questions?
Call the Licensing Section of the Gambling Control Board at 651-639-4000.
If you use a nY, call the Board by using the Minnesota Relay Service and ask to place a call to
651-639-4000. Or, check our web site at www.gcb.state.mn.us.
.
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CHURCH OF ST. GENEVIEVE
7087 Goiffon Rd.
Centerville, MN 55038
651-429-7937
May 20, 2005
Theresa Brenner
City of Centerville
1880 Main St.
Centerville, MN 55038
Dear Theresa,
On behalf of the Church of St. Genevieve, I would like to request a 3.2 beer permit for our annual picnic.
It will beheld on Sunday, August 21,2005. We would liketo serve beer from 11:00 a.m. until 5:00 p.m.
We would like to request that the permit fee be waived.
An insurance binder disclaiming the City ofCenterville from any liability will be sent from the Archdiosese.
The contact person is our secretary Donna Land.
Thank you again for your time and consideration.
Sincerely,
dtUvvJ.. a, ~
Laura A. Alberg - U
Beer Stand Coordinator
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