The URL can be used to link to this page

Home My WebLink About2I - Lions Club Charitable Gambling Permit GAMBLING CONTROL DIVISION Mail Stalion 3315 51. Paul, MN 65146.3316 612/297.6300 ,... .......-.., ,.",1 '-'~.Ylll"'"" I Licon so Numbor PAID AMT CHECK 1/ DATE J GAMBLING LICENSE APPLICATION INSTRUCTIONS A Type or prllll in ink. o Take compleled ApplicAtion 10 local governing body, obtain signature and dale on all copies, and leave 1 copy. Applicant keeps 1 copy And sends original to Iho auove address with a chock. C IncOlllplulO appllcAlions may bo relurned. o Enclose license fee wilh Application. Type of Applicalion o Class A - Feo $20000 (011100, naH/es. Paddlowheels, Tipbonrds. Pull-Tabs) tJ Class D -- Fee $12500 (Rallies, Paddlewheels, Tipboards, Pull-labs) r - Class C - Fee 6100.00 (Dinoo only) o Class D _. Feo $7500 (Rallies only) Mlko checks plya"ll 10: Canunlulalle, 01 Revenue Chod ono. 0 1^ O,Ui1l1lzallon has never been licensed ~ 1 [] Nuw slle - Give base license number I 01558 l [] 1 C Renewal of eXlslll1Y license - Give complnle license nllmber r=J - I DID Change in class 01 an eXlsllng license - Give complele license number c:==J - ~ . -. - -...--------------- I-~J I- ! I - --------- .-------------- DYes lXNo 2 H.1S Ol\JilllililllOn evCl received a Lawful Gilmbling Exel11pllOn Permil frol11lhe Ooard' II yes. give cOl11plele Pl.!f11111 nllllllJllr [==-=----=--- ~ ... '---'-----' ..------.----------- XXYes 0 No 3 Ililvc Inlernal Conlrols been SUllfllllled previously on il lorm provided by lhe BOilrd] rr no. pleilse attach copy. -,--,-- ---- .-------------------==J----- " ,APPllcantlOrlie,lill. leg.1lnal1lc o',org illllliHIO, n) 5 Ousll1ess Address 01 Organizallon Prior Lake Lions Club 5691 Woodside Rd., Prior Lake, MN, 55372 6__~i~f'~~,~, _ 55372 ~==------- 7 ~tt'Y I~ 6~2''''~'4~~~49~Ombe' 9 Type 01 OIO.1nllilllofl OFralcrnill OVelerans Oflcllgious ~Iher nonprofit XkYes 0 No 10 Is orgilnlzalion incor ora led as a non Holll orgilnizalion? rr yes. give number assigned to Articles or page and book number [Q18 PP358 Attach copy of corlificato. Book 27 P.P. 417-19 'Scott County XkYes 0 No 11 Arc Mlleles fried wlthlhe Secretary 01 Slale? ------ XkYes 0 No 12. Is organization exempt from Mlnnesola or Federal Income lax? rr yes. please attach lotler from IRS or Oer>arlmenl 01 Revenue declaring exemption. DYes XkNo 13 HilS license ever ucen denied. suspended or revoked? /I yes, check alllhal apply: o Denied 0 Suspended 0 Revoked Give date: ~ - I 14 Number of active members 15. Number of years in existence 48 43 NOle: Attach evidence -of three years existence. 16. Name of Chief Executive Officer (Cannot be Gambling Manager) Richard Balow Title 17_ Name of treasurer or person who accounts for other revenues of the organization (Cannot be Gambling Manager) Dave Velishek Title President Treasurer Business Phone Number Business Phone Number 18. Name of eSlablishment where gambling will be conducted ( 19. Street address (not P.O. Box Number) McWillies 20. Cily, Slate, Zip 3950 Green Hei hts Trail SW 21. County (where gambling premises is localed) Prior Lake, MN, 55372 CG-0001-03 (7/89) White Copy-Board Scott Canary-Applicant Pink-Local Governing Body Page 1 of 2 ElXVOI 0 No 22. Is gambling premises located within city limits? Jax.VOI 0 No 23. Aro nil gambling activitios conduClod 811ho promisos IISlod in "18 ot Ihis opplicalion? II nOl, complelo 8 separale npplicnlion tor ooch promisos (oxcepl rallies) ns a soparale Iicenso is required tor each premises. o Yel til No,..24. 0005 orgllnilolion own Iho Ollmbling premises? It no, nttllch copy of tho 101lle with lerms ot 811easl one year, ond Ilttoch n .ketch ot Iho premises indlco.ling whot ponion is be(ng loosed. A leoso and sketch 8re not required tor Class 0 a l llicolions. 25 Amollnt 01 nont Por 20. Do you plan on conducting bingo with this license? II yes. give days And limes of bingo occasions. ManU or 0 Occas Day T,"le Day " Tlmo Day Timo I. ~OO ~~:o ;0'1' l8IXVos 0 No 27. HilS the $10,000 tldelil bond ra 20 Insurance Company Name (not agency nomo) United Fire & Casualty 30 Minnesota Statules 349.20 been oblained? 29. Ilond Number 51-72657 31. Address 32 Clly. Stille. Zip Prinr Take ~ 55372 35 City. StiltO. IIp . Dalu galllhllllU l1lanager beCilme memher of orUilnilalion I Month 5 Year 8S n Vns (] No 30 HilS 11ll! license termination form hoell completed? AliRe" copy. N/A ~ Vns 0 No 39, HilS tho componSillion scllOdule hoon opproved by Iho organllillion? Allach copy. 40 Llsl Iho d.1 find timo or the re! IIlar moolll1 of Ihe or i1ninllion Da 10 Timo....lIl--- 41 flank N.1I1H! 112 n.1nk Addross 113 !3i1nk Account NumllCr Marquette Bank, Prior Lake GAMIlLlNG SITE AUTHORIZATION Oy my siunillllre helow. local law onforcement offlcors or agent~ of the OOilrd Me hereby authorized to enter upon the sile at any tllllO gilmhllng is being conducted to observe the gillnbllflg find tu enrorco the law for any unauthorized gLlme or practice. BANK RECORDS AUTHORIZATION (Jy illY signi'HurO below. the 130ard IS hereby authoriled 10 inspect tho bank records of the galllbllflg bank account whenever nocessary 10 fulfIll requiremenls of currenl gambling rules and law I hereby declare thaI: 1 I have read this application and all information submilled to Ihe Board. 2. All informillion submitted is true. accurate and complete; 3. All other required information has boen fully disclosed; 4. I alll the chief executive officer of tile orgilnization; 5 I assume tull responsibility for tho fair ilnd lilwtul operation of all activities to be conducted; G I will familiarize myself with tho laws of the Stale of Minnesota respecting gambling and rulos of the l30ard and agree. if licensed. to abide by those laws and rules. including amendments Il1ereto; 7. Membershi l list of the or anilation will be available within seven da s afte tis re 44. Official. Legal Name of Organization 45. Sign ure (m Lions Chili of Prior Lake X OATH Title of Signer President Date ACKNOWLEDGEMENT OF NOTICE BY lOCAL GOVERNING BODY I hereby acknowledge receipl ot a copy ot this application_ By acknowledging receipt. I admit having been served with notice that this applicalion will be reviewed by the Charitable Gambling Control Board and if approved by the board. will become effective 60 days fromlhe date of receipt (noted below) unless a resolution ot Ihe local governing body is passed which specifically disallows such aClivitv and a CODV of that resolution is received bv the Charitable Gamblina Contror Board within 60 days of Ihe below noled date. 4G. Name ot City or County (Local Governing Body) It site is located wilhin a township, item 47 must be compleled. in addition 10 the county signature. It township is not organized. county must sign. 47. Name of Township Citv of Prior Lake Signature ot person receiving application X Tille Dale received (60 day period begins from Ihis date) Signature ot person receiving application x 48. Name of person delivering application to Local Governing Body Title 'Ihanas Kedrowski CG-0001-03 (3/89) White Copy-Board Canary-Applicant ~ Pink-local Governing Body Page 2 of 2 co 202(iJli) Lawful' Gambling Lease Agreement Premise. information Nam. of legal premlM. own.r (Ieuor) Addr... CltyIZlp Cod. MN 55372 (612) Clty~ Code Phon. 447-3524 PhoM JANIS K. BAlLARD Name of lul*teor (I any) 15171 West Ave. Prior Lake, Add,.... Name MCIIddr... or leaHd premiHs Add,.... McWillies 3950 Green Heights Trail SW, Name 01 Of'gMlZauon Ieutng the prem.... {......) Prior Lake Lions Club CftyfZlp COde Prior Lake, MN (612) 447-9603 LICense Numoer, I KnOWn GulbliDl Activity Th. lawful gambling -aivlty which the organization win conduct are (check aU that apply): CJblngo CJ raff... c::Jpaddlewheell IiiiI pull-tabl c::Jtlpboardl Rent information (See Rules 7860.0090, Subp 3) Clu. A and C 11cenaea: R.nt for bingo and all oth.r gambling activities conducted during that bingo occasion may not exceed: $200 for up to 8,000 square fMt; $300 tor up to 12,000 square feet; and $400 for more than 12,000 squ.... feet. I Ront to be pald '* bingo llCOOtlon $ I Rent ID be paid par month Rent may not be baNd on a percentJlge of recelpta or profit. from lawful gambling. CIa.. Band D 11cen...: Rent for gambling actIvitI.. not Including bingo may not exceed $2" per square foot per month, with a maximum of $600. $ 200.00 I PremJael Delcriptlon The are. leased within the premises is 5 fMtby 5 fe., for a total of ?s square feet. Attach . sketch which Identifies the Jocatlon of the leased premises when a portion of a building is the leased premises. That akltch must include the dimensions of the leased premises. Effective Dates The .... will go Into effect at 12:01 Lm. on ---.J for a period of on. year. Mav 1 19.2!L-.. and will end at 12:00 Lm. on ApT; 1 101991 Time. and Da7S of Bm,o Activit,' (If none, indicate NlA) The bingo occasions wiN be held: from (hours) (Lm./p.m.) to from (howl) (LmJp.m.) to from (hours) (Lm./p.m.) to from (hours) (Lm./p.m.) to from (hours) (Lm./p.m.) to from (hours) (Lm./p.m.) to CJ NlA (LmJp.m.) on (days of week) (Lm./p.m.) on (days of week) (am./p.m.) on (days of week) (am./p.m.) on (days of week) (am./p.m.) on (days of week) (am./p.m.) on (days of week) By atreelq to the terms of thla leue. It Is mutually aereed that: · The owner of the property (Inaor). and .ublenor. . any. may not mAMge gambling at the prem.... · The IHIOr of the prem.... hla or her Immedl8le family. and any llQenta or employ... of theleaor may not participate as play.,. In the conduct of lIIwful gambling on the Ieued prem.... · The leaorllubleuor and the IeuH do not have a dlNct or indirect f1nanciallnterat In the distribution or manute,- tur. of gambling equipment. · The Ieaor or IUbletIOr of the premiln will allow the Board or llQ.ntI of the BoIIrd. th. Commluloner of PubIlc Safety or llQentI of the commllllon.r. or th. Commlllioner of Revenue or llg.ntI of th. commluloMr. Met law enforcement peI'IOnMI to Inspect the prem... at wry reuonabIe tlm., and penn. the organization to conduct lawful gamblng at the premia. a::cordlng 110 the terms of thllleue. The IHIOr may not ImpoM any cond.1onI on th. organlz.1on regarding diltrbullO" of gambling equ~nt, MrYIceI. or the UN of profltl. · The organization mUll obtain a Ilcenn from the Gambling Control &.rd. The organization wfI be rMpOnlble for complying with the laws and rules of lawful gambling. · The organization mutt have . the gambling pr.m..s a curr.nt Inv.ntory of gambling equlpm.nt, . Iketch with dim.nsions of the prem.., available for r.vlew, and a clear physical separ8lion or divkf.r between the Ie.....s gambling equipment and th. lessor's bus In... equlpm.nt. · Th. organization wi. be r'lpOnsible for ensuring that th.l_sor's business activities are not conducted on the Ieued preml.... · If the lease Ia cancelled prior to the t.rminatlon date of this I..... .ach party Igr... to notify the GamblIng Control Board .xplainlng the r.ason, for the cancellation. Th. leu. shall be t.rmlnated Immediat.1y for any gambllng, liquor, prostitution or tax evasion violations occurring on the premises. · Th. lessor/sublessor of the pr.mia.s shall provide the lessee access to the licensed premises during any tim. r.a- sonable and necessary to conduct lawful gambling on the premises and as agreed upon In this leas.. · (Writ. in any other conditions or restridions that will be Included as part 01 the leas.. Attach additionalsh..ts if necessary) This I.... Is the total and only agrelmlnt between thl lessor/sublessor and thl organization conducting lawful gambling activities. The,. Is no other IlQr..m.nt and no other consid.ration required between the ~.. as to the lawful gambllng and other mattl,. related to thlsleasl. (Any chang.. In this Ilasl must be submitted to the GamblIng Control Board within 10 days of the change.) lMIorlSublMlor Iig,... :~.20 ~?!&,~~j 3-$ ~9~ fl~ I" A copy of this lease and sketch with dimensions must be submitted with the license application or license renewal to: ~ K ~d/~ ~~/- Department of Gaming - Gambling Control Division Mail Station 3315 51. Paul, Minnesota 55146-3315