Agenda - Council - 02/24/2004 - Laserfiche WebLink

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LG214 P~emises 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 qu~allflcalJons to be involved in lawful gambling activities in Minl~e.~o~ ta, al~d to assist the Board in conducting a background investigation of you. You have the right to refuse to supply the inrortnatiofl requested; however, if you refuse to supply this Info~rnation, the Board may not be able to determine your qqallfications and, as a consequence, may refuse to issue you, a premises permit. If you supply the information requeJ~ted, U~e Board will be able to process your application. This form may require the disclosure of your social security number. If so, your social security number will be used to determine your cofnpliance with the tax laws of Minnesota. Authorization for requiring your social security number is found at 42 U.S;C, 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 or,he information that you have provided to the Board ir the process of applying for your premises permit will become public except for your social security number, which remains private. If the Board does not. issue you a premises permit, all the information you have provided in the process of applying for a premises permit remains private, with the 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 Minnesota Department bf Public Safety; the Minnesota Attorney General; the Hinnesota Commissioners of Administration, Finance, and Revenue; the , Minnesota Legislative Auditor, national and international gambling regulatory agencies; anyone pursuant to court order; other individuals and agencies that are specifically authoriz ~ed bystate or federal law to have access to the information; individuals and agencies 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 consenti~that loCal law enforcement officers, the Board or agents of the board, or the commissione~' revenue or publiq:safe~', or agents of the commissioners may enter the premises to enforce the law. The ;BOard is authorized to.insl~eCt the bank records of the gambling account whenever necessary to fulfill requirements of current gambling~rules and law. ! declare that: 1. ! have read t;his application and all information submitted to the Board is true, accurate, and complete; 2. All required i~lformation has been fully disclosed;' 3. I am the chief executive officer of the organization; 4. ! assume ~ll:responsibility for the fair and lawful operation, of all activities to be conducted; 5. [ will familiarize myself with the laws of Hinnesota governing lawful gambling and rules of the Board and agree, if licensed, to qbide by those laws and rules, including amendments to them; 6. Any changesiin application information wilt be_submitted to the Board and local unit of government within days of the Change; and ........ 7. I understar~d ithat failure to:i~rd~~~on or providing false or misleadipgdnfor~na, t~ may result in _ the denial orJey._o~tio~,n:;~f~.l:he~li~'~.~...._.., ..~-~' ....... - ~._ ~.,:.'. ~" C///. .~. ..... , ,~,/'~ ~; / ,Sign~ure~of-C~]ef. Ex~utive Officer (Designee may not sign) / ~'; Date ~(/ Print name ' Required Attachments 1. !f the premisesr, is leased, attach a copy of Your lease. Use form LG21~ Lease for Lawful Gambling Activity. 2.. Attach the re~olUtion from the local unit of government (city or countY)'.which shows approval of your application. 3. For each premises permit application, a $3.50 annual premises permit fee is re~luired~ Hake the check payable to the "State of Minnesota." Mail the application, with attachments to: Gambling Control Board 171:[ West County Road B, Suite 300 South Roseville, MN $5113 There is a monthly regulatory fee of 0.1% (.OOl) 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 65:[~639-4000. If you use a TTY, call the Board by using the Hinnesota Relay Service and ask to place a call to 65~-639- 4000. This form will be made available in alternative format (i.e. large print~ Braille) upon request.