Agenda - Council - 11/25/2003 - Laserfiche WebLink

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LG214 Premises Permit Application Data Privacy The information requested on this form (and any attachments) will be used by the Gambling Control Board (Board) to determine your qualifications to be involved in lawfiJI gambling activities in Minnesota, and to assist the Board in conducting a background investigation of you. You have the right to reflJse to supply the information requested; however, if you refuse to supply this information, the Board may not be able to determine your qualifications and, as a consequence, may refuse to issue you a premises permit. If you supply the information requested, the Board will be able to process your application. This form may require the dfsclosure of your social security number. If so, your social secudty number will be used to determine your compliance with the t3x Paws of Hinnesota. Authorization for recluidng your social security number is found at 42 U.$.E. 405 (c)(i). Your name and address will be public information when received by the Board. All the other information that you provide will be private data about you until the Board issues Acknowledgment and Oath Page 2 of 2 6/03 your premises permit. When the Board issues your premises permit, all of the information that you have provided Lo the Board in the process of applying for your premises permit will become public except for yoursocial security number, which remains private. I~ the Board does not issue you a premises permit, all Uae inFormai~ion you have provided in the process of applying for a premises permit remains private, with Uae exception of your name and address which will remain public. Private data about you are available only to the following: Board members, Board staff whose work assignment requires that they have access to the information; the Hinnesota Department of Public Safety; the Hinnesota Attorney General; the Ninnesota Commissioners of Administration, Finance, and Revenue; the Hinnesota Legislative Auditor, national and international gambling regulatory agencies; anyone pursuant to court order; other individuals and agencies that are specifically authorized by stale or federal raw to have access to the fnformation; individuals and agendas for which law or legal order authorizes a new use or sharing of information after this notice was given; and anyone with your consent. ! hereby consent that local law enforcement officers, the Board or agents of' the board, or the commissioner of revenue or public safety or agents of the commissioners may enter the premises to enforce the law. The Board is authorized to inspect the bank records of the gambling account whenever necessary to fulfill requirements of current gambling rules and law. I declare that: ~.. I have read this application and all informal:ion submitted to the Board is true, accurate, and complete; 2. All required information has been fully disclosed; 3, I am the chief executive officer of the organization; 4. [ assume full responsJbil?ty for the fair and lawful operation of all activities to be conducted; - 5. [ will familiarize myself with the laws of HJnnesota governing lawful gambling and rules of the Board and agree, if licensed, to abide by those laws and rules, including amendments to them; 6. Any changes in application information will be submitted to the Board and local Unit of government within days of the change; and 7. ! ~a,,t.,fa~. e to~gr~vide,,j~i~luired information or providing false or misleading information may result in ._. // / 7 Signature of Chief F. xe,,~'l~ve Officer (Designee may not sign) Date Print name _j~/-,~,,-) ~'~'/~/'~__~ ' Required Attachments If the premises is leased, attach a copy of your lease. Use form LG2~,5 Lease for Lawful Gambling Activity. 2. Attach the resolution from the local unit of government (city or county) which shows approval of your application. 3. For each premises permit application, a $:!.50 annual premises permit fee is required. Hake the check payable to the "State of Minnesota." Nail the application with attachments to: Gambling Control Board ~.71l West CounW Road B, Suite 300 South Roseville, MN 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 with the monthly tax report. questions? Call the Licensing Section of the Gambling Control Board at 551-639-4000. If you use a T/Y, call Uae Board by using the Minnesota Relay Service and ask to place a call to 65[o639- 4000. This form will be made available in alternative format ii.e, large pdnt~ Braille) u~n request,