Fillable GamblingPremisePermit2019Fillable City of Farmington

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GamblingPremisePermit2019Fillable City of Farmington

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CITY OF FARMINGTON
LICENSE PROCESS
Gambling Premise Permit
A gambling premise permit is required to regulate gambling activities at businesses such as pull tabs. Please
review Title 3 Chapter 19 of the city code for complete details. All permits are effective until the gambling
activity ceases to exist. Following is the process to obtain a gambling premise permit:
1. Application forms and fees should be submitted to the city of Farmington at least two weeks prior to
a City Council meeting.
2. A background check will be performed by the Farmington Police Department.
3. Approval is required by the City Council. Council meetings are held the first and third Mondays of
every month.
4. Upon City Council approval, a permit is issued. The entire application process takes approximately
two weeks. Upon City Council approval, the applicant should submit the proper forms and fee to the
state if required.
5. Investigation Fee: $50
If you have questions, please contact:
Cynthia Muller, Administrative Assistant
City of Farmington
430 Third Street
Farmington, MN 55024
Tel: 651-280-6803
E-mail: CMuller@FarmingtonMN.gov
Checklist for Gambling Premises Permit
Business Name: _________________________________________
Please return this list with your application materials. Incomplete applications cannot be
processed until all of the items listed are received and complete.
Required Applicant City Staff
Documents Initials Initials
1. Gambling Premises Permit Application (Form GP2009) ____________ ____________
2. All applicable Fees (See fee schedule below) ____________ ____________
3. Copy of Lease, or Evidence of Ownership of Premises __________ __________
4. Copy of organization’s gambling license and premises permit __________ __________
issued by the Gambling Control Board.
5. Copy of the Gambling Manager’s fidelity bond. __________ __________
6. Copy of the Gambling Manager’s license. __________ __________
7. Sketch of the premises, showing the location of all gambling __________ __________
activities and storage of equipment on site.
8. Copy of applicant’s driver’s license. __________ __________
9. State application (for signature). __________ __________
License Fees
Investigation Fee $50
Application for Gambling Premises Permit
(Form GP2009)
APPLICANT INFORMATION
Applicant Name: ________________________________________Title: ___________________________
(First) (Middle) (Last)
Applicant Address: _____________________________________________________________________
(Street) (City, State, ZIP)
Applicant Home Phone: _______________________________ Date of Birth: _______________________
BUSINESS INFORMATION
Business Name/Organization:_____________________________________________________________
Address:______________________________________________________________________________
(Street) (City, State, ZIP)
Business Phone: __________________ FAX:___________________ Email: _______________________
Gambling Manager: _____________________________________Phone Number: __________________
Address: _____________________________________________________________________________
(Street) (City, State, ZIP)
PROPOSED GAMBLING PREMISES LOCATION INFORMATION
Address: _____________________________________________________________________________
Telephone Number: ________________________ FAX: _________________________
Property Owner/Lessor: _________________________________________________________________
Property Owner/Lessor Address: __________________________________________________________
(Street) (City, State, ZIP)
Property Owner/Lessor Telephone Number: _________________________________________________
Rents and other charges for use of premises: ________________________________________________
Description of gambling activities to be conducted on premises by organization; including days & hours:
_____________________________________________________________________________________
_____________________________________________________________________________________
I hereby certify that all statements made in this application are true and complete to the
best of my knowledge. I understand that any misstatements or omissions of material facts
may result in the disqualification or denial of the license. I authorize the City of Farmington
to investigate the information and contact persons/organizations named on this
application. The undersigned agrees that the use of the Premises for gambling will
conform to all applicable state laws, Gambling Control Board regulations, and ordinances
of the City of Farmington.
Name of Applicant (please print) ___________________________________________________
Signature _________________________________________________Date _______________
APPROVALS
Department Signature Date Comments
Police ______________________ __________ _____________________________
City Clerk/Deputy Clerk_____________________ __________ _____________________________
Applicant will need copy of permit and signed resolution to send to the State of Minnesota.
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CITY OF FARMINGTON
GENERAL AUTHORIZATION AND RELEASE OF DATA
In order to comply with State and Federal Data Privacy Act Laws, the City of Farmington is requesting your
authorization and consent to permit the City to conduct a background investigation. Please provide the
following personal data, read the paragraphs below and sign where indicated.
Full Name: ____________________________________________________________________
(First, Middle, Last)
Address: ______________________________________________________________________
Number Street City County State Zip Code
Date of Birth: _________________ Driver’s License Number: __________________________
Month/Date/Year
Have you ever been convicted of any crime, either felony or misdemeanor? ________ If yes, please state
place and nature of offense: _____________________________________________
______________________________________________________________________________
I, the undersigned, hereby authorize and grant my informed consent to permit the Bureau of Criminal
Apprehension (hereafter “BCA”) and the Farmington Police Department (hereafter “FPD”) to release to and
make available to the City of Farmington, Minnesota (hereafter “City”) and/or its representatives all data
classified as private which concerns me and which may be in your possession. The data, classified as
private under M.S. 13.02, Subd. 12, includes all data which has been collected, created, received, retained or
disseminated in whatever form which in any way relates to my dealings with the BCA and/or the FPD. I
understand the purpose of permitting the City to have access to this information is to determine my
suitability for licensure.
By signing this authorization, I hereby release the BCA and the FPD from any and all liability which
otherwise may or does accrue as a result of the release of any and all data, regardless of its accuracy. I also
release the City from any and all liability for its receipt and use of data received pursuant to this consent. I
understand that if I am rejected on the basis of a criminal conviction, I will be notified in writing and be
given rights of redress subject to applicable laws. I also understand that I am not legally required to sign
this form, but if I do not, the City will not be able to determine whether my conviction record is a license-
related consideration.
This authorization shall be valid for a period of one year, but I reserve the right, at any time prior to that
expiration, to cancel the written authorization by providing written notice to the City of that intent.
_______________________________________________ ________________________
(Signature) (Date)
_______________________________________________
(Full Name Printed)
Please return to:
City of Farmington
Attn: Administration
430 Third Street
Farmington, MN 55024
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CITY OF FARMINGTON – DATA PRACTICES ACT NOTICE
Minnesota law requires that you be informed of your rights as they pertain to private information (“private
data”) collected from you by the City of Farmington (“the City”). Private data is that information held by
the City which is available to you, but not to the public.
You have the right to refuse to provide the information requested on this application form, however, without
certain information, the City may be unable to approve the license applied for. If you feel that certain
information requested is an unwarranted invasion of privacy, please contact the Human Resources Director.
The dissemination and the use of private data we collect is limited to that necessary for the administration
and management of the City’s licensing program. Persons or agencies with whom this information may be
shared include:
City personnel, including law enforcement personnel, administering the license program;
The Bureau of Criminal Apprehension;
The City Attorney and support staff of the City Attorney’s office;
Federal, state, local, and contracted private auditors;
Federal and State agencies with oversight or responsibility related to the licensed business;
Those individuals or agencies as to whom you give your express written permission for release of
the information.
Unless otherwise authorized by state statute or federal law, other governmental agencies utilizing the
reported private data must also treat the information as private.
You may wish to exercise your rights as contained in the Minnesota Government Data Practices Act. These
rights include:
The right to see and obtain copies of data maintained about you;
The right to be told the contents and meaning of the data; and
The right to contest the accuracy and completeness of the data.
To exercise these rights, contact the Farmington Human Resources Director at 430 Third Street,
Farmington, MN 55024 (651) 280-6800. I have read and I understand the above information regarding my
rights as a subject of government data.
___________________________________________ _______________________
Applicant Date
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Completed 12 July 2020

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