11-13-2002 Council Agenda - Laserfiche WebLink

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Minnesota Lawful Gambling Bingo Hall License Renewal Application - LG300 Fee Check # Bingo Hall Information License number: BH046 Name of bingo hall: DBA, if applicable: Street address: City, state or province, postal code: Phone number (with area code): Mailing address (if different than above): Effective date: 2/1/2003 Little Canada Market Place 2900 N Rice St Little Canada, MN 55113 a.ce_)S Expiration date: 1/31/2004- (a57 r) (651) 483 -1203 Fax number (with area code): Type of Business (sole proprietorship, partnership, corporation, limited liability company, film): Limited Liability Company Minnesota Tax Identification Number: Local Unit of Government Acknowledgment If the gambling premises is within city limits, the city must sign this application: On behalf of the city, I acknowledge that this application will be forwarded to the appropriate city officials, the city must pass a resolution specifically approving or denying this application, and a copy of the resolution will be forwarded to the applying organization Name of city: Little Canada n //1 1 , /L � 7 � L (Signature of city personnel receiving applicatio9)) U ✓ ) ,! (I /) f-4 <-i_ ,t.2t.% (_,- LC---L /.:' ii ii Date 7( J j-ily/i ---.- i. Title If the gambling premises is located in a township, both the county and township must sign this application: For the township: On behalf of the township, I acknowledge, by this signature, awareness of this application and that the township has no authority to deny or approve an application. Name of township: (Signature of township official acknowledging application) Title Date_J_J_— For the county: On behalf of the county, I acknowledge that this application will be forwarded to the appropriate county officials, the county must pass a resolution specifically approving or denying this application, and a copy of the resolution will be forwarded to the applying organization. Name of county: (Signature of county personnel receiving application) Title Date JJ_ Questions on this form should be directed to the Gambling Control Boad at 651-639 -4000. Headng impaired individuals using a TRY may call the Minnesota Relay Service at 1- 800 - 627-3529 and ask to plwe a call to 651-639 -4000. This publication will be made available in alternative format (i.e. large print, Braille) upon request. The information requested on this form (aid any attachments) Wll be used by the Garbling Control Board (Board) to determine your qualifications to be involved in lawful gambling activities i n 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 Boad may not be able to determine your 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. Al the other information that you provide will be about you unitl 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. If the Board does not issue you a license, all the 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 swrk 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 garbling regulatory agencies; anyone pursuant to court ceder; other individuals and agencies that are specifically authorized by state or federal law to have access to the information; individuals and agencies for whim law or leg a! order authorizes a new use or sharing of information titer this notice was given; and anyone with your written consent. - 2 -