Fillable Application for a Permit to Conduct a Class (Town of Somers)

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Application for a Permit to Conduct a Class (Town of Somers)

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Application for a Permit to Conduct a Class 3 Bazaar
Instructions:
1. The completed form shall be submitted to:
at le
ast fifteen (15) days prior to the start of the bazaar.
2. Applyin
g organization must be a qualifying non-profit functioning for a minimum of six (6) months.
3. Your application must be completed, signed, and accompanied by a check or money order made payable to
“ ” Fee will be $ .00 per day for up to ten (10) consecutive days.
Name of Sponsoring Organization
If this organization previously held a raffle permit, list permit number:
FEIN
IRS Exempt Status Code
Street Address
City
State
Zip Code
Mailing Address (if different than above)
City
State
Zip Code
Telephone Number (with area code)
Contact Person for this Application
Contact Telephone Number
Contact Email Address
Organization Category (check only one):
An educational or charitable organization
An officially recognized organization or association of veterans
of any war in which the U. S. was engaged
A civic, service, or social club An officially recognized volunteer fire company
A fraternal or fraternal benefit society
A political party or town committee of the municipality in
which the raffle is to be held
A church or religious organization
Give the names of the three (3) Designated Active Members of the sponsoring organization under whom the bazaar
is to be conducted. These individuals will affix their signature to form CGR-1A. The three (3) Designated Active
Members must be residents of the state of Connecticut.
First Name
Last Name
Telephone Number (with area code)
Date of Birth
First Name
Last Name
Telephone Number (with area code)
Date of Birth
First Name
Last Name
Telephone Number (with area code)
Date of Birth
Ranking Officer Name
Title
Date of Birth
Residence Street Address
City
State
Zip Code
For Official Use Only
St. John's Church - Men's Club
BAZR.9999
06-1122334
501 (c) 3
263 Cedar Mountain Road
Anytown
CT
06000
PO Box 1
Anytown
CT
06000
(860) 555-7562
Stjohns@gmail.com
William Couto
(860) 555-5309
wcouto@gmail.com
Brian
Markow
(860) 555-9540
06/17/1959
William
Couto
(860) 555-5309
07/16/1963
Leonard
Rogers
(860) 555-8650
04/07/1947
Trevor Smith
Vice-President
01/04/1952
13 Holly Hill
Anytown
CT
06000
SAMPLE
Bazaar Description:
Provide the date(s) and time(s) for each day the bazaar will be conducted:
Place Where Bazaar is to be Held:
Name of Place
Street Address
City
State
Zip Code
Types of Games and Total Number to be Operated:
Blower Ball/Cage Ball Total: _______________________ Teacup Raffle Total: _______________________
50/50
(up to 3 drawings per day)
Total: _______________________ Other: ___________________ Total: _______________________
If applicable, from whom are the games of chance equipment to be obtained:
Registered Dealer Name
Dealer Registration Number
Equipment Rental Fee Paid
List the items o
f expense intended to be incurred or paid in connection with the holding, operating, and conducting of
such bazaar and the names and addresses of the persons to whom, and the purposes for which, they are to be paid.
*Attach additional sheets as necessary.
Expense ($)
Name
Street Address
City
State
Purpose
Separately list in detail all items offered as prizes in connection with such bazaar, indicate whether or not the
items were donated, list the price to be paid by the organization or the retail value of any prize donated, and the
names and addresses of persons from whom the items were purchased or by whom donated.
*
Attach additional sheets as necessary.
Merchandise
Donated
Yes/No
Retail
Value
Amt. Paid
by Org.
Name
Street Address
City
State
State the specific purpose to which the entire net proceeds of such bazaar are to be devoted.
I certify, under penalty of law (Sec. 53a-157b, Class A Misdemeanor), that the information provided on this
application is the truth to the best of my knowledge.
Signature of Ranking Officer
Date
May 23, 2014 - 6:00 pm to 10:00 pm May 24, 2014 - 6:00 pm to 10:30 pm May 25 2012 5:00 pm to 11:00 pm
St. John's Church grounds
263 Cedar Mountain Rd
Anytown
CT
06000
✔
1
✔
1
✔
1
✔
finish line game
1
Dealer Equipment Company
7537245
$450.00
$30.00
Town of Anytown
Cedar St
Anytown
CT
permit fee
$450.00
Dealer Equipment Company
7 Hope Street
Anytown
CT
Equipment Rental fee
$49.99
Anytown Department Store
963 Berlin St
Next-town
CT
drill bit set
$29.99
Anytown Department Store
963 Berlin St
Next-town
CT
discman
$27.89
Anytown Department Store
963 Berlin St
Next-town
CT
dust-buster
$45.00
Fran's part shop
37 Sunset Blvd
Anywhere
CT
50/50 and teacup tkts
Baked Goods
yes
$200.00
$0.00
Eva Smith
10 Jolly Dr
Anytown
CT
Lamp
yes
$75.00
$0.00
Charles Cicone
102 Kettle St
Anytown
CT
Hand made afghan
yes
$55.00
$0.00
Lillian Turgeon
71 Maple St
Anytown
CT
Drill bit set
no
$49.99
$49.99
Anytown Dept. Store
963 Berlin St
Anytown
CT
Discman
no
$29.99
$29.99
Anytown Dept. Store
963 Berlin St
Next-town
CT
Dust-buster
no
$30.00
$27.89
Anytown Dept. Store
963 Berlin St
Next-town
CT
The net proceeds will be used to help balance St. John's Catholic School's budget.
10/15/2014
Trevor Smith
STATEMENT OF ACTIVE MEMBERS DESIGNATED BY SPONSORING
ORGANIZATION UNDER WHOM THE BAZAAR IS TO BE HELD, OPERATED OR
CONDUCTED
We, the undersigned, do hereby EACH make the following statement under the penalty of False Statement with
respect to the foregoing application:
1. I am a resident of the state of Connecticut.
2. I am a bona fide active member of the sponsoring organization making this application to conduct a bazaar
and all statements contained in this application are true to the best of my knowledge and belief.
3. I will be responsible for the holding, operation and conduct of such bazaar in accordance with the terms of the
permit, the provisions of the Act, and regulations.
4. I have never been convicted of a felony.
5. I am familiar with the provisions of the Act which PROHIBIT:
a. The giving of alcoholic beverages as prizes.
b. The paying of commission, salary, compensation, reward or recompense, directly or indirectly, to any
person holding, operating, conducting or assisting therein in the operation of a bazaar.
c. The promotion or operation of a bazaar by other than duly qualified members of the sponsoring
organization.
d. The giving of pay to any member for his time or effort in connection with a bazaar.
e. The promotion, conduct or operation of a bazaar by a person under the age of 18 or the permitting of same
by the sponsoring organization.
f. The use of funds derived from the bazaar for purposes other than as stated in this application.
g. The paying of any monies except in reasonable amounts for goods, wares and merchandise furnished or
services rendered which are necessary for the operation of a bazaar.
6. I am familiar with the provisions of the Act which:
a. Make mandatory the immediate revocation of a permit to conduct a bazaar for a violation of the provisions
of the Bazaar or Raffle Act, and which provide that an organization whose permit has been revoked for a
violation shall not be granted another permit for a period of three years.
b. Provide a fine of not more than one thousand dollars or imprisonment for not more than one year or both
for a violation of the Act.
PRINTED NAMES AND SIGNATURES OF DESIGNATED ACTIVE MEMBERS:
NAME (Please print)
1.
NAME (Please print)
2.
NAME (Please print)
3.
SIGNATURE AND DATE
SIGNATURE AND DATE
SIGNATURE AND DATE
For Official Use Only
SAMPLE
Brian Markow
William Couto
Leonard Rogers
Brian Markow
10/15/2014
William Couto
10/15/2014
Leonard Rogers
10/15/2014
INSTRUCTIONS TO COMPLETE A BAZAAR APPLICATION
Please complete each section on the Application for a Permit to Conduct a Bazaar form, and the Statement
of Active Members form. Please keep in mind that a bazaar event only encompasses games of chance and
not games of skill.
APPLICATION FOR A PERMIT TO CONDUCT A BAZAAR (CGR-1)
1. If the organization has a determination letter from the IRS confirming the organization’s exempt
status, please include a copy.
2. Provide a complete name and address (number, street, city/town, state, zip) of the sponsoring
organization.
3. Provide a complete mailing address (number, street, city/town, state, zip) of the sponsoring organization.
4. Provide a telephone number and email address.
5. Provide the name, telephone number, and email address of the contact person for this application.
6. Choose one of the seven (7) categories that applies to your organization.
7. Give the complete name, date of birth (month, day, year) and telephone number for each of the three
Designated Active Members
Note: The three Designated Active Members MUST be residents of the State of
Connecticut and at least eighteen years of age.
8. Provide the title, complete name (first, middle, last), complete home address (number, street,
city/town, state, zip) and a complete date of birth (month, day, year) for the officer of the sponsoring
organization.
9. Provide the date(s) (month, day, year), along with the commencing time and terminating time
(including a.m. or p.m.), for each day the bazaar is to be conducted.
10. Provide a complete address of the place where the bazaar is to be held (name of place, number, street,
city/town, state, zip).
11. Please check the types and number of games to be operated.
12. Provide the registered dealer information if applicable.
13. Provide all of the expenses directly incurred for the bazaar activity including permit fees and coupon
ticket purchases etc. and the names and addresses to whom they were paid.
14. Provide all the merchandise information that will be awarded for the bazaar activity including the
names and addresses of the persons/organizations from whom the items were purchased or donated.
Note: If an item is donated then the “Retail Value” must be completed.
If the item is purchased then the “Amt. Paid by Org.” must be completed.
If an item is purchased at a reduced price, complete the “Amt. Paid by Org.”
15. Provide the specific purpose of the entire net proceeds.
16. The ranking officer of the sponsoring organization must sign his/her name, provide his/her title,
and date the form.
Note: Only the individual listed on the front of this application is recognized as an
officer and may sign as the ranking officer.
Page 2
Sample Bazaar Application Instructions
STATEMENT OF ACTIVE MEMBERS
1. The three Designated Active Members listed on the bazaar application must read the information provided
on the Statement of Active Members application, print their names in the designated areas and affix their
signatures to the form.
ALLOWABLE BAZAAR PRIZES
All prizes given at a bazaar shall be *merchandise. There is an exception, however, which provides for cash
awards for only two specific types of bazaar games, which are the “fifty-fifty” coupon game and the blower ball
cash game. Any organization conducting a bazaar may operate three “fifty-fifty” coupon drawings each day of
a permitted bazaar event and must award cash prizes of fifty percent of “fifty-fifty” coupon game sales for each
coupon drawing conducted. Blower ball games were already approved for use with merchandise prize awards;
however, the law now allows for cash prizes up to $50.00 each to be awarded, as well. These are the only
exceptions that have been made with respect to the type of prizes that may be awarded at a bazaar. Therefore,
any qualifying organization that has obtained a bazaar permit may only award merchandise prizes for every
other permissible bazaar game.
*Merchandise includes gift certificates. Gift certificates must be a value redeemed at a business ie: $50.00 gift
certificate redeemable at Kohl’s. It cannot be a certificate for a specific service or item such as a haircut or ice-
cream cone.
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Application for a Permit to Conduct a Class (Town of Somers)

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Completed 16 July 2020

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