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LG300 <br />(eev. ialogo( <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 ® Renewal <br />IMP ffri In>for m`ation <br />1. Name of bingo hall <br />LITTLE CANADA BINGO HALL <br />Street address of hall <br />2940 RICE STREET NORTH <br />2. Mailing address of bingo hall <br />2940 RICE STREET NORTH <br />run urrlut u5t ONLY <br />Fee <br />Date_ <br />Chk Initial <br />License k <br />- Part l <br />Bingo Hall Phone County (where hall is located) <br />( 612 ) 483 -2943 RAMSEY <br />City or Township where hall is located State <br />LITTLE CANADA MN <br />City <br />LITTLE CANADA <br />State <br />MN <br />Zip code <br />55113 <br />Zip code <br />55113 <br />3. Is the bingo hall located within city limits? Yes FZCI No <br />1Len(Sf IltfQnmat ,toF1(thegvnermuatbctheJsssorol <br />4. Name of legal owner of bingo hall property <br />MOVER'S WAREHOUSE, INC. <br />If 'No,' indicate township in which bingo hall is located <br />Phone <br />( 612) 483 -2943 <br />264Slne,SSl Ml ailirut,4c1dre9s NORTH <br />LITTLE CANW'&A <br />MState <br />Zip Code <br />55113 <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 />a DAVID M. SLIPY <br />b. THOMAS S. SHORT <br />0. RICHARD A. MANDERFELD <br />f. <br />9. <br />k. <br />Sole proprietorship <br />Partnership <br />XX <br />MN'. 54CE5 't- use TAX -CO <br />Corporation <br />'i4-€9678 <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 hail 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 />• an affiliate of a wholesale distributor of alcoholic beverages? <br />Page 75 <br />Yes <br />XX <br />