09-22-2004 Council Agenda - Laserfiche WebLink

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AUG. 31.2004 8:58AM GROOTWASSINK REAL ESTATE NO. 779 P. 10 Return Complete Renewal Application Or 11/2/2004 Submit a check made payable to the State of Minnesota for the $4,000 license fee. Bingo Hall: Lithe Canada Market Place Business Address' 2900 N Rice St, Little Canada, MN, 55113 Phone: (651) 483 -1203 Fax: license #. BHO46 Type: Limited Liability Company Business ID #: Current License Expires: 1/31/21305 Renewed License Term; 2/2/2004 to 1/310096 rd; rm. .1.b4d1rv71�:!'r: ^CIi�Ni; "1.v i.ynp. A separate personnel information form for each employee listed below is included with this application. All personnel forms must be signed by the applicant in the presence of a notary. Personnel forms am attachments to the bingo hall renewal application and must be r h- in hall ren- .I a..li� Grootwassink, Robert Edward Hot2ler, Mark Allen Duties: Duties; ire limwl Il biro a I declare that this application is correct and complete to the best of my knowledge and belief, I will familiarize myself with the laws of the state of Minnesota and rules of the Board goveming gambling and agree, if licensed, to abide by those laws and rules, including amendments to them. I declare that I am qualified under the terms within Minnesota Rule, to be licensed as a bingo hall and will abide by fie restrictions set forth in Minnesota Rule. I declare that any lease agreements between the bingo hall licensee and lawful gambling organizations will specifically identify any goods or services that the organization Is required to purchase From the lessor or a third party vendor, and that all goods and services furnished as a part of the lease agreement will be valued at their fair market value. Changes in the information submitted in this application will be submitted In writing to the Board and local unit of government within ten days after the c nge occurs. Printed Name of Chief Executive Officer Signature of Chief Executive Officer Date Signed /S2? You must obtain and submit with the renewal application, a resolution of approval from the local unit of govemment (city or county) having jurisdlctlon over the bingo hall. Complete and submit the enclosed LG302-Bingo Hall Occasion List Rotating Schedules must be provided in a clear legible format (Le. calendar) for the entire license period, The Information requested on this form will be used by the Gambling Control Board (Board) to determine your qualincadbns to be Involved In lawful gambdng activities In Minnesota, and to asslstthe Board In conducting a background Investigation of you. You have a right to refuse to supply the Information requested; however, If you refuse to supply [MIS Information, the Board may not be able to determine your quelldcation$ and, as a consequence, may refuse to register you. If you supply the Information requested, the Board will be able to register you. You are required to provide your Social Security number on this form. Your Social Security number will be used to determine your compliance with the tax laws Of Minnesota. Authorization for requiring your Soda! Security number Is found at 42 U.S.C. 405 (c)(p. 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 approves your registration, When the Board approves your registration, all of the Information that you have provided to the Board in the process of registering will become public except for your Social Security number, which remains private. If the Board does not approve your registration, all the Information you have Private data the oprocess are available onlyt i thefolloowing: Board exception of the Board address, which public. requires that they have acceeS 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; other Indviduals and agencies that are specifically authodted by state or federal law to have artess to the nfomlatlon; individuals and agendes for which law or eg I order authorizes a new use or sharing of Information after this notice was given; and anyone with your written consent. Obtain current GCB forms by visiting us at www.gebstate.mn.us Licensing Contact: Roxie Rolph Phone: (651)6394079 Fax #: (651)639-4073 E -Mail: State of Minnesota Gambling Control Board 1711 W Co Rd B #300 South Roseville, MN 55118 roxierolph@gcb.state.mn.us Printed on: -3 Friday, July 30, 2004 Page 1of1