09-12-2007 Council Agenda - Laserfiche WebLink

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09/07/2007 09:03 7634247637 Minnesota Lawful Gambling QUALITY DRYWALL PAGE 07 6107 No Fee L%.7LO11 lMf,JEJlfGifarani w MY•rMa• .. +•• - - -- — -- - -- — r \kt L-41/4110.5 License number 01 c Organization name A\ e4-kV License expiration date 10 ' 1 i D7 . Gambling Premises Ay iL 7`root d s+ 1440.k ai+erzt . activity will be conducted Lou 4,1 barer u„ew, t+&Lt 1. Name of establishment or function where gambling 30107 Count-Ai (rte L +l (oho cicj nrttu SS-117 2. Street address and city / • Do not use a post office box. • if no street address, write in road designations. Example: 3 miles east of Hwy 63 on County Road 42. 3. Does your organization own the gambling premises? -Yes If yes, a lease is not required. ic' No if no, a lease agreement must be attached. Use L0224 Lease for Off -Site Gambling Activity. A lease is not required for raffles. Gambling Activity 1: Check (4) the gambling activity your organizaton will be conducting. tabs Ipboards 4 raffle paddlewheel ,_pull _hinge 2. Date of single day event -at:r , at, 30,aj4 separate days allowed per calendar year. 3. Dates of up to 12 consecutive days in connection with a county fair, state fair, Church festival, or civic celebration. Begin date End date 1 event allowed per calendar year. Acknowledgment • The parson signing this application must be the CEO of your organization and have their name on file with the Gambling Control Board. • If the CEO has,changed during the term of your license and the current CEO has not filed a LG200B Organization Officers Affidavit with the Gambling Control Board, he or she must do so at this time. 1 have read this application, and all information is true, accurate, and complete. �Ve., t — Cal Date el f 6 i 07 Chief executive officer signature ,?..Ldb.4Cen Print name- tie !3r•ecl 3S2N — CC 0 Daytime phone (2‘3)4/7-79$9 Application and Required Attachments 1. LG230 Application to Conduct Off -Site Gambling. Mali to ' Gambling Control Board There: is no application fee. Suite 300 South 2. Resolution of approval from the local unit of 1711 West County Road 3 government (city or county) Roseville, MN 55113 3. Copy of the.lease agreement Or, fax to 551- 639 -4032 No lease is required if only a raffle will be conducted or your organization owns the premises. Questions? Contact a licensing specialist at 651. 6394000. Thia publication will be made available In alternative format (.e, largo print, Braille) upon request The Information requested on bits form the (and any attachments) win be used byy determine Gambling Control Board (Board) to yourquatvAcaoonsto beinvohrann IawNlgambling 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 your qualifications and, as a consequence, may refuse to issue you a permit. If you supply the information requested, the Board will be able to process yourapplioetion. Your name and address will be public Informationwhen received byte Board. All other information you provide will be private data about you until the Board issues your perk. When the Board Issues your permit, all information you provided will become publIcexcept faryour Soda] Security number, which remains private, If the Board does not issue you a permit, all Information you provided remains private, with the exception of your name and address which will remain pubic. Private data about you are available to following: Board members end start 4 whosewofk requlresaccesstothelnformahol ; Minnesota's Department of Public Safety; Attorney General; Commissioners of Administration, Finance, and Revenue; LegWative Auditor; national and International gambling regulatory agencies; enyona pursuant to caun order, other individuals and agencies specifically euthonzed by state or federal law to have access to the Information; Individuals and agencies forwhich law or legal order authorizes a- new use or sharing of Information after this Notice wes given: and anyone with your convent.