Agenda - Council - 03/10/2009 - Laserfiche WebLink

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LG214 Premises Permit Application 11/08 Page 2 oft Data Privacy When the Board issues your premises permit, all permit The information requested on this form (and any attachments) will information provided will become public. If the Board does not be used by the Gambling Control Board (Board) to determine your issue you a premises permit, all the information.provided remains qualifications to be involved in lawful gambling activities in private, with the exception of your name and address that will Minnesota, and to assist the Board in conducting a background remain public. investigation of you. You have the right to refuse to supply the information requested; however, if you refuse to supply this Private data about you are available to: Board members; Board information, the Board may not be able to determine your staff whose work requires access to the information; Minnesota's qualifications and, as a consequence, may refuse to issue you a Department of Public Safety; Attorney General; Commissioners of premises permit. If you supply the information requested, the Administration, Finance, and Revenue; Legislative Auditor; Board will be able to process your application. national and international gambling regulatory agencies; anyone pursuant to court order; other individuals and agencies that are Your name and address will be public information when received specifically authorized by state or federal law to have access to by the Board. All other information you provide will be private the information; individuals and agencies for which law or legal data until the Board issues your premises permit. order authorizes a new use or sharing of information after this notice was given; and anyone with your consent. Acknowledgment and Oath 1. I hereby consent that local law enforcement officers, the Board or its agents, and the commissioners of revenue or public safety and their agents may enter the premises to inspect it and enforce the law. 2. The Board and its agents, and the commissioners of revenue and public safety and their agents are authorized to inspect the bank records of the gambling account whenever necessary to fulfill requirements of current gambling rules and law. 3. 1 have read this application and all information submitted to the Board is true, accurate, and complete: 4. All required information has been fully disclosed.. 5. 1 am the chief executive officer ofthe organization. 6. 1 assume full responsibility for the fair and lawful operation of all activities.to be conducted. 7. 1 will familiarize myself with the laws of Minnesota governing lawful gambling and rules of the Board and agree, if licensed, to abide by those laws and rules, including amendments to them. 8. Any changes in application information will be submitted to the Board no later than 10 days after the change has taken effect. 9. 1 understand that failure to provide required information or providing false or misleading information may result in the denial or r vocati of a li se. , � /z3 Signature of Chief Executive Officer (designee may not sign) Date Print name App and Required Attachments. 1. LG214 Premises Permit Application 2. If the premises is leased, attach a copy of your lease. Use LG215 Lease for Lawful Gambling Activity. 3. Attach a resolution from the local unit'of government that shows approval of your application: • if the premises is within a city, attach city approval, or • if the premises is within a township, attach county approval. 4. $150 annual premises permit fee, for each permit. Make check payable to "State of Minnesota." Mail to: _Gambling Control Board 1711 West County Road B, Suite 300 South Roseville, MN 55113 Monthly Regulatory Fee If you receive a premises permit for this site, there is a monthly regulatory fee of 0.1 % (.001) of gross receipts from lawful gambling conducted at the site. The fee is reported on the G1 Lawful Gambling Monthly Summary and Tax Return and paid withethe monthly tax report. Questions? Call the Licensing Section of the Gambling Control Board at 651- 639 -4000. This form will be made available in alternative format (i.e. large print, Braille) upon request. k FK� tenet IFom —53— .