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

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=G214 Premises permit Application 11 ,08 Page 2 of 2 Data Privacy Th a information re up ested When, the Board issues your premises permit, all permit I q on this form (and any attachments) will information provided will become public. If the Board does not 1 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 i information requested; however, if you refuse to supply this Private data about you are available to: Board members; Board I 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 Your name and address will be public information when received pursuant to court order; other individuals and agencies that are 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. � ��nree�eetrc Cast 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. i 5. 1 am the chief executive officer of the 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 ial ozrevoca 'on of the license. Signature of Chief Execut e Officer (designee y not sin te O� 9) Crate -Print name IA,7�1\ LRppiicatton and r�ea�uornd , attachments Monthly Regulatory Fee 1. LG214 Premises Permit Application If you receive a premises permit for this site, there is a monthly regulatory fee of 0.1 % (.001) 2, If the premises is leased, attach a copy of your lease. of gross receipts from lawful gambling conducted Use LG215 Lease for Lawful Gambling Activity. at the site. The fee is reported on the 3. Attach a resolution from the local unit of government that G1 Lawful Gambling Monthly Summary and Tar, shows approval of your application: I Return and paid with the monthly tax report. • if the premises is within a city, attach city approval, or • if the premises is within a township, attach county Questions? approval. Call the Licensing Section of the Gambling 4. $150 annual premises permit fee, for each permit. Control Board at 651 - 039 - 4000. Make check payable to "State of ,Minnesota." This form will be made available in alternative (tJlail to: format (i.e. large print, Braille) upon request. Gambling Control Board 1711 West County Road B, Suite 300 South Roseville, MN 55113 - J ResetF;orm Prmt Forrn -63-