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

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l'iinnesota l_awful Gambling License Renewal Application Continued Premises permit requirements: !. An annual premises permit fFee of $150, 2. A separate resolution of approval including the site address 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. Beard Use Only Al~th ID 02002-048 %itc Current license term Diamonds Sports Bar & Grill 7550 Hwy 10 NW, Ramsey, MN 55303 ~ This site is located in the city 3/1/2004 - 2/28/2006 Check this box if this site has been discontinued or will not be renewed. township within the county of Organization owns this site ! N : . Is bingo conducted by organi~;~iC~'?. Y/i/~') .... zr 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 J t have read this application and all information submitted to l:lqe Board. All information is true, accurate and complete. Alt other required information has been fully disclosed. ! am the chief executive officer of the organization. all gambling activities to be conducted. I will familiarize myself /_.~.-~' . with the laws of Minnesota governing lawful gambling and /'"Si '~atat~-'f~. ~~, I" , of chief executive officer fL,les of the Board and agree, if licensed, to abide by those I .'~/..~ ~~ laws and rules, including amendments to them. ~Dar 7C//~ ~6 //.l, · :[ understand that failure to provide required information or providing false or misleading information may result in denial or revocation of the license. i he information requested on this form (and any attachments) will be used by ~:he Gambling Control Board (Board) to determine your qualifications i:o be involved in lawful gambling activities in Minnesota, and to assist the Board in conduclJng 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 your qualifications and, as a consequence, may refuse to issue you a license. [f you supply the information requested, the Board will be able to process yohr application. ¥o~r name and address will be public information when received by the Board. All the other information that you provide will be private data about ,/ou until the Board issues your license. When the Board issues your license, all 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 ./ou d license, all information you have provided in the process of applying for a license remains private, with the exception of your name and :~dflress which will remain public. Pr{rate 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 Safetyi the Minnesota Attorney General; the Minnesota Commissioners of Administration, Finance, and Revenue; the Minnesota Legislative Auditor, national and international gambling regulatory agencies; anyone pu~ suant to cour~ order; other 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. (]lirnb Jnc ~mens_~ renewal due by 12/30/2005 -1 19-