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LG300 <br />(Rev. 10/3 /90) <br />Minnesota Lawful Gambling <br />Bingo Hall License Application <br />(See instructions for completion of this application) <br />Is this application for a new license, or a renewal? ❑ New X1 Renewal <br />Bttt o kcxfl: tnforntatio>� <br />1. Name of bingo hall <br />LITTLE CANADA BINGO HALL <br />FOR OFFICE USE ONLY <br />Fee <br />Date <br />Chk Initial <br />License # <br />- Part 1 <br />Bingo Hall Phone <br />(612 ) 483 -2943 <br />Street address of hall <br />2940 RICE STREET NORTH <br />County (where hall is located) <br />RAMSEY <br />City or Township where hall is located State Zip code <br />LITTLE CANADA <br />2. Mailing address of bingo hall <br />2940 RICE STREET <br />3. Is the bingo hall located within city limits? <br />Yes is 1 <br />It01$14ti#'0Yi? igt, J17 .#40Wnet <br />4. Name of legal owner of bingo hall property <br />MOVER'S WAREHOUSE, INC. <br />City <br />LITTLE CANADA <br />No <br />M4 55113 <br />State Zip code <br />MI 55113 <br />I <br />If "No,' indicate township in which bingo hall is located <br />nit 6e tfre7e�sor, of the 8lrrgahattj <br />Phone <br />(612 )483 -2943 <br />Business Mailing Address City <br />2940 RICE STREET LITTLE CANADA 144 <br />State <br />5. Names of all owners, officers, directors, partners, managers and supervisors <br />(each person named must fill out a separate Bingo Hall Personnel Information form, LG315 and Affidavit, LG316) <br />Zip Code <br />55113 <br />a. DAVID M. SLIPY <br />b. <br />f. <br />g. <br />k. <br />c. <br />d. <br />h. <br />m. <br />n. <br />Sole proprietorship <br />Partnership <br />XX <br />Corporation <br />7. Have /do any persons listed in items 4 and 5: <br />a. been convicted of a felony? <br />b. ever been convicted of a crime involving gambling? <br />c. ever held a bingo hall license previously in Minnesota? <br />RENEWAL <br />d. owe delinquent taxes in excess of $500 as defined in Minnesota Statutes section 270.72? <br />e. ever been convicted of assault, criminal violation involving the use of a firearm, or making <br />terroristic threats? <br />f. after demand, not filed tax returns required by the Minnesota Commissioner of Revenue? <br />8. Are any of the individuals listed in items 4 or 5, or a person holding a financial or managerial interest <br />in the bingo hall, or affiliate thereof -- <br />• a licensed distributor or affiliate of the distributor under section 349.161? <br />a licensed manufacturer or affiliate of the manufacturer under section 349.163? <br />Page 1 <br />• an affiliate of a wholesale distributor of alcoholic beverages? <br />Yes <br />IX 1 <br />No <br />X <br />Vl <br />V <br />V1 <br />f-1 <br />