Agenda - Council - 10/25/2005 - Laserfiche WebLink

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Minnesota Lawful Gambling License Renewal Application Continued Premises permit requirements: 1. An annual premises permit fFee of $150, 2. A separate resolution of approval including the site ~ddress from the local unit of government, (The local unit of government does not sign this renewal application) and 3. A LG215 lease agreement for each site your organization does not own is required. Board Use Only Auth ID 02002-072 Site Current license term 3Rs Outpost 6141 Hwy 10, Ramsey, MN 55303 L---This site is located in the Organization owns this site ts bingo conducted by organization? 3/1/2004 - 2/28/2006 JCheck this box if this site has been discontinued or will not be renewed. township within the county of i ...... ~n'o'l~a" 'i Y/(N) .... if yes, the attached list of the days and beginning/ending "--~' hours of your bingo occasions must be updated and returned. Gambling account # 6551312495 , 14125 St Francis Blvd, Ramsey, MN 55303 Chief Executive Officer's Acknowledgement and Oath I have read this application and all information submitted to I understand that failure to provide required information the Board. All information is true, accurate and complete, or providing false or misleading information may result in All other required information has been fully disclosed. I am denial or revocation of the license ..... the chief executive officer of the organization. I assume full responsibility for the fa r and awful operat on of .----" _----~--~~ ...... all gambling activities to' be conducted. I will familiarize myself~. I with the laws of Hinnesota governing lawful gambling and /~../~:-~.*''¢; ~-.'". , ..~. ,' ....... -- blgna , In InK, or crier executive orrlcer rules of the Board and agree, if licensed, to abide by those ~._.~_--- I..~u~, ~ ....... ..... /-'[ laws and'rul~, inc,uding ~m~ndmenb to them. '- Date:~/ 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 lawful gambling activities in Minnesota, and to assist the Board in conducting a background investigation of you. You have the right to refuse to supply the information requested; however, if you refuse to supply this information, the Board may not be able to determine you~ qualifications and, as a consequence, may refuse to issue you a license, if you supply the information requested, the Board will be able to process your application. 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 your license. When the Board issues your license, alt of the information that you have provided to the Board in the process of applying for your license will become public except for your Social Security number, which remains private. If the Board does not issue you a license, all information you have provided in the process of applying for a license 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, staff of the Board whose work assignment requires that they have access to the information; the Minnesota Department of Public Safety; the Minnesota Attorney General; the Minnesota Commissioners of Administration, Finance, and Revenue; the Minnesota Legislative Auditor, national and international gambling regulatory agencies; anyone pursuant to court order; othe~ individuals and agencies that are specifically authorized by state 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 written consent. Climb J_jc~nse renewal due by t2/30/200S //0-