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LG300 <br />taw. icaosef <br />Minnesota Lawful Gambling <br />Bingo Hall License Application - Part 1 <br />(See instructions for completion of this application) <br />Is this application for a new license, or a renewal? ❑ New ❑ Renewal <br />FOR OFFICE USE ONLY <br />Fee <br />Date <br />Chk Initial <br />License * <br />Burg i Haft In `ormaixoi <br />1. Name of bingo hall <br />Little Canada Market Place Bingo <br />Street address of hall <br />2900 N. Rice Street <br />2. Mailing ddress of bingo hall <br />c/o Grootwassink Real Estate <br />6440 Flying Cloud Dr. Suite 203 <br />County (where hall is located) <br />(612 )483 -1203 Ramsey <br />City or Township where hall is located State Zip code <br />MN 55113 <br />State Zp code <br />Little Canada <br />City <br />Eden Prairie <br />MN <br />55344 <br />3. Is the bingo hall located within city limits? Yes ® No <br />If -No; indicate township in which bingo hall is located <br />ill#C7(S)311 i) YTXittti!! IL:{ theawnrrtfwatbsttinre3sotaftfte -k(H4 . <br />4. Name of legal owner of bingo hall property Phone <br />Market Place Center Limited Liability Co. (612) 944 -1665 <br />Business Mailing Address City State Zip Code <br />6440 Flying Cloud Dr., Suite 203 Eden Prairie MN 55344 <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' Robert E. Grootwassink <br />f. <br />b. Mark A. Hotzler <br />9. <br />k. <br />a <br />h. <br />m. <br />d. <br />n. <br />e. <br />;'ri:. <xzTe:g <br />0. <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 />d. owe delinquent taxes in excess of 5500 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 r� <br />terroristic threats? (j l n i <br />f. after demand, not filed tax returns required by the Minnesota Commissioner of Revenue? P1 <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? n <br />Yes <br />n <br />No <br />0 <br />n <br />Ell <br />n <br />