09-25-2013 Additions - Laserfiche WebLink

Home Browse Search

LG214 Premises Permit Application 12/12 Page 2 of 2 Acknowledgment by Local Unit of Government: Approval by Resolution CITY APPROVAL COUNTY APPROVAL for a gambling premises located within city limits ° `at:° ;ustsab , , nt for a gambling premises located in a township City name County name Date approved by city council Date approved by county board Resolution number Resolution number Signature of city personnel Signature of county personnel Title Date signed Title Date signed TOWNSHIP NAME Complete below only if required by the county. On behalf of the township, I acknowledge that the organization is applying to conduct gambling activity within the township limits. [A township has no statutory authority to approve or deny an application, per Minnesota Statutes 349.213, Subd. 2.] Print township name Signature of township officer Title Date Acknowledgment and Oath 1. I hereby consent that local law enforcement officers, 6. I assume full responsibility for the fair and lawful the Board or its agents, and the commissioners of operation of all activities to be conducted. revenue or public safety and their agents may enter 7. I will familiarize myself with the laws of Minnesota and inspect the premises. governing lawful gambling and rules of the Board and 2. The Board and its agents, and the commissioners agree, if licensed, to abide by those laws and rules, of revenue and public safety and their agents are including amendments to them. authorized to inspect the bank records of the 8. Any changes in application information will be submitted gambling account whenever necessary to fulfill to the Board no later than 10 days after the change has requirements of current gambling rules and law. taken effect. 3. I have read this application and all information 9. I understand that failure to provide required information submitted to the Board is true, accurate, and or providing false or misleading information may result complete. in the denial or revocation of the license. 4. All required information has been fully disclosed. 10. I understand the fee is nonrefundable regardless of SCI am the hief execu 've •fficer of the organization. license approval /denial. ,:-._:N_. s, , �- CA-\LEI �> Signature of Chi f Executive Officeer (designee � ay not sign)' Date Print name /L ) / We 1/2i /57- 9 Data privacy notice: The information requested on this Board. All other information provided will be Safety; Attorney General; Commissioners form (and any attachments) will be used by the Gambling private data about your organization until of Administration, Minnesota Management Control Board (Board) to determine your organization's the Board issues the permit. When the & Budget, and Revenue; Legislative qualifications to be involved in lawful gambling activities in Board issues the permit, all information Auditor, national and international gam - Minnesota. Your organization has the right to refuse to provided will become public. If the Board bling regulatory agencies; anyone pursuant supply the information; however, if your organization does not issue a permit, all information to court order; other individuals and refuses to supply this information, the Board may not be provided remains private, with the excep- agencies specifically authorized by state able to determine your organization's qualifications and, tion of your organization's name and or federal law to have access to the as a consequence, may refuse to issue a permit. If your address which will remain public. information; individuals and agencies for organization supplies the information requested, the Board Private data about your organization are which law or legal order authorizes a new will be able to process your organization's application. available to: Board members, Board staff use or sharing of information after this Your organization's name and address will be public infor- whose work requires access to the infor- notice was given; and anyone with your oration when received by the mation; Minnesota's Department of Public written consent. This form will be made available in alternative format, i.e. largf print, Braille, upon request.