HomeMy WebLinkAbout3F - Lion's Club Charitable Gambling Permit.
Gambling license Application
Type of Application: o Cia.. A ~Clas. B o Cia.. C o Cia.. 0
6ClV..ONo 22. Is gambling premises located within city limits]
flaY" ONo 23. Are all gambling activities conducted at the premises listed in , 18 of this application] If not. complete a separate
application for each premises (except raffles) as a separate license is required for each premise..
Dy..Ii(lNo 24. Does organization own the gambling premises? If no, .tt.ch copy of the I.... with terms of at least one year. and
attach a sketch of the premises indicating what portion is being leased. A lease and sketch are not required for
Class 0 applications.
25. Amount of Rent Per 26. Do you plan on conducting bingo with this license? If yes, give days and times of bingo occasions.
Month or Bin 0 Occasion Day Time Day Time Day Time
G(JV.. DNo 27. Has the $10,000 fidelity bond required by Minnesota Statutes 349.20 been obtained?
28. Insurance Company Name (not agency name)
United Fire & Casualtv
30. Lessor Name Lanny Adler 31. Address
d/b/a Extra Inninqs Saloon 16299 Main Ave SE
33. Gambling Manager Name 34. Address
Thomas Kedrowski 14770 Maple Trail
36. Gambling Manager Business Phone 137. Date gambling manager became
( 612 ) 447-8344 member of organization: I Month 5 'lear 851
DYes DNo 38. Has the license termination form been completed? Attach copy. N/ A
fi()Y..DNo 39. Has the compensation schedule been approved by the organization? Attach copy.
40. List the day and time of the regular meeting of the organization. Day 10
41. Bank Name 42. Bank Address
16817 Duluth Ave SE
Prior Lake, MN. 55372
GAMBLING SITE AUTHORIZATION
By my signature below, local law enforcement officers or agents of the Board are hereby authorized to enter upon the site at any
time gambling is being conducted to observe the gambling and to enforce the law for any unauthorized game or practice.
BANK RECORDS AUTHORIZATION
By my signature below, the Board is hereby authorized to inspect the bank records of the gambling bank account whenever
necessary to fulfill requirements of current gambling rules and law.
I hereby declare that: OATH
1. I have read this application and all information submitted to the Board;
2. All information submitted is true. accurate and complete;
3. All other required information has been fully disclosed;
4. I am the chief executive officer of the organization;
5. I assume full responsibility for the fair and lawful operation of all activities to be conducted;
6. I will familiarize myself with the laws of the State of Minnesota respecting gambling and rules of the Board and agree. if
licensed, to abide by those laws and rules. including amendments thereto;
7. Membershi list of the or anization will be available within seven da s after it is e uested b
44. Official, Legal Name of Organization 45. Sig e sign
Lions Club of Prior Lake x ~~
Title of Signer Date .....
President C>'
':' ACKNOWLEDGEMENT OF NOTICE BY LOCAL GOVERNING BODY
I hereby acknowledge receipt of a copy of this application. By acknowledging receipt. I admit having been served with notice that
this application will be reviewed by the Charitable Gambling Control Board and if approved by the board. will become effective
60 days from the date of receipt (noted below) unless a resolution of the local governing body is passed which specifically
disallows such activity and a copy of that resolution is received by the Charitable Gambling Control Board within 60 day. of the
below noted date.
46. Name of City or County (Local Governing Body)
55372
55372
Time 7 p.m.
43. Bank Account Number
Marquette Bank, Prior Lake
90-657-3
icer)
City of Prior Lake
If site is located within a township. item 47 must be completed. in
addition to the county signature. If township is not organized.
county must sign.
47. Name of Township
Signature of person receiving application
X
Title
Date received (60 day period
begins from this date)
Signature of person receiving application
X
48. Name of person delivering application to Local Governing Body Title
Thomas Kedrowski
CG-0001-o3 (8/88) White Copy-Board Canary-Applicent
Page 2 of 2
Pink-Local Goveming Body
Charitable Gambling Control Board
Room N-475 Griggs-Midway Building
1821 University Avenue
St. Paul, Minnesota 55104-3383
(612) 642-0555
FOR BOARD USE ONLY
I LicenM Number
PAID
AMT
CHECK#
DATE
GAMBLING LICENSE APPLICATION
INSTRUCTIONS:
A. Type or print in ink.
B. Take completed application to local governing body, obtain signature and date on all copies, and leave 1 copy. Applicant keeps 1
copy and sends original to the above address with a check.
C. Incomplete applications may be returned.
D. Enclose license fee with application.
Type of Application:
DClass A - Fee $100.00 (Bingo, Raffles, Paddlewheels, Tipboards, Pull-tabs)
~Class B - Fee $ 50.00 (Raffles, Paddlewheels, Tipboards, Pull-tabs)
DClass C - Fee $ 50.00 (Bingo only)
DClass D - Fee $ 25.00 (Raffles only)
Check one: 01 A. Organization has never been licensed.
GC 1 B. New site - Give base license number.
Meb check'lNIyeble to:
Minnesota Chertteble Gambling Control &o.rd
01 C. Renewal of existing license - Give complete license number.
01 D. Change in class of an existing license - Give complete license number.
DVe. IXINo 2. Has organization ever received a Lawful Gambling Exemption Permit from the Board? If yes, give complete
permit number I I
fXJVe.DNo 3. Have Internal Controls been submined previously on a form provided by the Board? If no, please anach copy.
4. Applicant (Official, legal name of organization) 5. Business Address of Organization
Prior Lake Lions Club 5691 Woodside Rd. Prior Lake MN. 55372
6. City, State, Zip 7. County 8. Business Phone Number
Prior Lake, MN. 55372 SCott ( 612 ) 447-4900
9. Type of organization: o Fraternal o Veterans OReligious KJOther nonprofit'
'If organization is an "other nonprofit" organization, answer Questions 10 through 12. If not. go to Question 13. "Other nonprofit" organizations
mUlt document its tax-exempt status.
~Ye. DNo 10. Is organization incorporated as a nonprofit organization? If yes, give number assigned to Articles or page and
book number: I 018 PP358 I Anach copy of certificate. Book 27 P.P.417-19 Scott County
li()Ve.DNo 11. Are articles filed with the Secretary of State?
KJV.. DNo 12. Is organization exempt from Minnesota or Federal income tax? If yes, please attach lener from IRS or Department of
Revenue declaring exemption.
DVe.li()No 13. Has license ever been denied, suspended or revoked? If yes, check all that apply:
o Denied o Suspended o Revoked Give date: I - - I
I 01558
c=J-1
c=J-1
I - I
I - I
14. Number of active members 15. Number of years in existence Note: Attach evidence of
48 three years existence.
43
16. Name of Chief Executive Officer (Cannot be 17. Name of treasurer or person who accounts for other revenues
G~bling Manager) of the organization (Cannot be Gambling Manager)
Richard Balow Dave Velishek
Title Title
President Treasurer
Business Phone Number Business Phone Number
, ( 612 ) 894-8620 ( 612 ) 447-2237
18. Name of establishment where gambling will be 19. Street address (not P.O. Box Number)
conducted
Extra InninQs Saloon 16299 Main Ave SE
20. City, State, Zip 21. County (where gambling premises is located)
Prior Lake, t-t-l. 55372 Scott
CG-OOU1-03 (8/881
White Copy-Board
Canary-Applicant
Pink-Local Governing Body
Page 1 of 2
CG 202(9189)
Lawful Gambling Lease Agreement
Premises Information
Name of legal premises owner (lessor)
Name and address of leased premises
Address . CitylZip Code Phone
P.O. Box 411 Prior Lake,MN 55372 (612)447-990
Address CitylZip Code Phone
Address CitylZlp Code
LANNY ADLER
Name of sublessor (if any)
Lions Club of Prior Lake Lions Club International of Prior Lake
,
Gambling Activity
The laYt'ful gambling activ~y which the organization will conduct are (check all that apply):
D bingo D raffles c:J paddlewheels CXXI pull-tabs c:::::J tipboards
Rent Information (See Rules 7860.0090, Subp 3)
Class A and C llcanses:
Rent for bingo and all other gambling activities conducted
during that bingo occasion may not exceed:
$200 for up to 6,000 square feet;
$300 for up to 12,000 square feet; and
$400 for more than 12,000 square feel.
I Rent to be paid per bingo occasion $ Rent to be paid per month
Rent may not b, based on a percentage of receipts or profits from lawful gambling.
Class 8 and 0 licenses:
Rent for gambling activities not including bingo
may not exceed $24 per square foot per month,
w~h a maximum of $600.
$ 200.00
Premises Description
The area leased within the premises is
5
feet by
5
feet, for a total of
25
square feet.
Attach a sketch which identifies the location of the leased premises when a portion of a building is the leased premises.
That sketch must include the dimensions of the leased premises.
Effective Dates
The lease will go into eHect at 12:01 a.m. on April 1 19 ~ and will end at 12:00 a.m. on March3i9 91
_, for a period of one year.
Times and Days of Bingo Activity (If none, indicate N/A)
[X}NlA
The bingo occasions will be held:
from (hours) (a.m.lp.m.) to
(a.m.lp.m.) on (days of week)
(am.lp.m.) on (days of week)
(am.lp.m.) on (days of week)
(a.m.lp.m.) on (days of week)
(am.lp.m.) on (days of week)
(am./p.m.) on (days of week)
from (hours) (a.m.lp.m.) to
from (hours) (a.m.lp.m.) to
from (hours) (a.m.lp.m.) to
from (hours) (a.m.lp.m.) to
from (hours) (a.m.lp.m.) to
By agreeing to the terms of this lease. It Is mutually agreed that:
· The owner of the property (lessor), and sublessor, if any, may not manage gambling at the premises.
· The lessor of the premises, his or her immediate family, and any agents or employees of the lessor may not
participate as players in the conduct of lawful gambling on the leased premises.
· The lessor/sublessor and the lessee do not have a direct or indirect financial interest in the distribution or manufac-
ture of gambling equipment.
· The lessor or sublessor of the premises will allow the Board or agents of the Board, the Commissioner of Public
Safety or agents of the commissioner, or the Commissioner of Revenue or agents of the commissioner, and law
enforcement personnel to inspect the premises at any reasonable time, and permit the organization to conduct
lawful gambling at the premises according to the terms of this lease. The lessor may not impose any conditions on
the organization regarding distributors of ~ambling equipment, services, or the use of profits.
· The organization must obtain a license from the Gambling Control Board. The organization will be responsible for
complying with the laws and rules of lawful gambling.
· The organization must have at the gambling premises a current inventory of gambling equipment, a sketch with
dimensions of the premises available for review, and a clear physical separation or divider between the lessee's
gambling equipment and the lessor's business equipment.
· The organization will be responsible for ensuring that the lessor's business activities are not conducted on the
leased premises.
· If the lease is cancelled prior to the termination date of this lease, each party agrees to notify the Gambling Control
Board explaining the reasons for the cancellation. The lease shall be terminated immediately for any gambling,
liquor, prostitution or tax evasion violations occurring on the premises.
· The lessor/sublessor of the premises shall provide the lessee access to the licensed premises during any time rea-
sonable and necessary to conduct lawful gambling on the premises and as agreed upon in this lease.
· (Write in any other conditions or restrictions that will be included as part of the lease. Attach additional sheets if
necessary )
This lease is the total and only agreement between the lessor/sublessor and the organization conducting lawful gambling
activities. There is no other agreement and no other consideration required between the parties as to the lawful gambling
and other matters related to this lease. (Any changes in this lease must be submitted to the Gambling Control Board
within 10 days of the change.)
LessorlSubleuor signalln
J.:z
DIll
/ ;;1../ 16/~ 9
CT (.)./ A:/ it /Z
A copy of this lease and sketch with dimensions must be submitted with the license application or license renewal to:d
Department of Gaming - Gambnng Control Division
Mail Station 3315
51. Paul, Minnesota 55146-3315
MINNESOTA CONSERVATION FEDERATION
"Dedicated to the wise use of our Natural Resources"
1036-8 CLEVELAND AVENUE SOUTH · ST. PAUL, MINNESOTA 55116
PHONE (612) 690-3077
r e.blLuaAY 16, 1990
Bo X 408
Red W,[ng, MH. 55066
R~C~
F." '/I/I2D
tB I
p~c!JY 6 1990
1(j~ ~
Pee B-Utch
~>.G..uYC.ee.ILk~ V66-i.ce
P~D~ L~Re, Mn. 5555372
OeM M.6. B-Utch:
It ~ O~ und~.6tan~.ng that. the ~66~ence b~een the legal coun~
nO~ YOuh C~y and the M{nn~ota Con.6~v~on red~at,[on h~ been add-
ltu-6e.d YJ~ope!l1.y by both pa..Jr.:t.iu bung -i.n c.orvta.c..t w.Uh a, .6.ta,66 pVt.6on
6Jtom .the. Ve.paJt..tment 06 Gaming.
The M. c. F wiU 6ollow the. Jtequi.Jt.e.d e.xempu.o YL.6 .tha..t Me .6 et. 60uh -trl.
M.{.nn~o.ta Sta..tu;tu 349.214 Su.dd,[v,{~ioY! ~ pa.Jtpg~aph (bJ 1-61e.). 1;(:,(,&
Itvr.eby OWl. w.(.6he.6 tha,t yowr. a.u.tholtity be. e.x~cUed b!f ~-<.gvt.<.YLg the app-
Uc.a.,Uon nolt exempuon ~o ()uJt. applic.a:ti.on can be. P~oc.e..6.6e.d -tn a :ti..mel!f
maymVt.
1 would tA.ke to thanR yo~ nine C~y 6o~ allowing the MCF and the. p~o~
La.ke Spo~men club to hold thi.6 evervt.
F~e.d Plt.tndte will pickup apptic.atioYL whe.n e.v~ It ~ .6-<'9n and a.va.,{,tabie.
~-i.nc.Vt
~_.
Je.66 C. Cole
MCF GambUng Managvr.
c.c. Glen KU.6e.t, Fax # 339-8064