HomeMy WebLinkAbout2006-063 Council ResolutionCITY OF LINO LAKES
RESOLUTION NO. 06 -63
PREMISES PERMIT APPROVAL FOR APPLICATION
FOR LAWFUL GAMBLING
FOR CENTENNIAL YOUTH HOCKEY ASSOCIATION
AT MILLER'S ON MAIN
Whereas, the Centennial Youth Hockey Association, a non - profit
organization, has applied for a premises permit for lawful gambling at Miller's on
Main located at 8001 Main Street; and
Whereas, the City of Lino Lakes conducted an investigation of the
gambling manager and chief executive officer of the Centennial Youth Hockey
Association, and
Whereas, the State of Minnesota requires local unit of government
approval of any application submitted for a premises permit;
Now, Therefore, Be It Resolved by the City Council of the City of Lino
Lakes, Minnesota:
That the City Council hereby approves the Premises Permit Application
submitted by Centennial Youth Hockey Association for charitable gambling
operations at Miller's on Main.
Adopted by the Lino Lakes City Council this 24th day of April, 2006.
ATTEST:
ne Barte , C Clerk
/I/
• n B - 'geson, Mayor
io
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8/05
Page 1 of 2
LG214 Premises Permit Application
(see Required Attachments on Page 2) Annual Fee $150
FOR BOARD USE ONLY
Check# $
Organization information
Organization name Organization license number
Gc44nn,`w / Y *L }14, c -4 7 4ssoc. 03934
Name of chief executive officer (CEO) Daytime contact phone number
1 --;sow 14c•c -L--t , + 71 ,3 •- 7cS'.1'— 7p r,
rNot the mailing address.
Do not use a P.O. box number. J
Street address where premises is located
goo i L„kt blue.
premises information
Gambling P
Name of establishment where gambling will be conducted
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City / Township
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County
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Zip code
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Does your organization own the building where the gambling wi
Yes ,�,No If no, attach LG215 Lease for Lawful Gambling
I be conducted?
Activity
Gambling bank account information
Bank name Bank account number
Bank street address City State/Zip code
Flol Mnel41 -e l c Aloe . 1111;" e7 4 A.100 i s mN 3'..s' y4?:
Address(es) in Minnesota of all temporary and permanent off -site storage space for gambling
equipment and records related to this site (may not be stored outside of Minnesota)
Address (Do not use a P.O. box number) City State /Zip code
9442 o Al. ,1.s _s4. N • e : 1 1ai., r. i v n N .5,3° ‘7"1 9
Bingo occasions (including bar bingo)
Enter day and beginning /ending hours of bingo occasions (indicate
Beginning /Ending Hours
A.M. or P.M.).
11a
An occasion may not exceed 8 hours.
Beoinningandina Hours
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LG214 Premises Permit Application
Data Privacy
The information requested on this form (and any attachments)
will be used by the Gambling Control Board (Board) to
determine your qualifications to be involved in lawful gambling
activities in 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 Board may not be able to
determine your qualifications and, as a consequence, may
refuse to issue you a premises permit If you supply the
information requested, the Board will be able to process your
application.
This form may require the disclosure of your soda) security
number. If so, your social security number will be used to
determine your compliance with the tax laws of Minnesota.
Authorization for requiring your social security number is
found at 42 U.S.C. 405 (c)(1).
Your name and address will be public information when
received by the Board. All the other information that you
provide will be private data about you until the Board issues
Acknowledgment and Oath
I hereby consent that local law enforcement officers, the Board or agents of the board, or the commissioner of
revenue or public safety or agents of the commissioners may enter the premises 1» enforce the law. The Board or
agents of the board, or the commissioner of revenue or public safety or agents of the commissioners are authorized
to inspect the bank records of the gambling account whenever necessary to fulfill requirements of current gambling
rules and law. I declare that:
1. I have read this application and all information submitted to the Board is true, accurate, and complete;
2. All required information has been fully disclosed;
3. I am the chief executive officer of the organization;
4. I assume full responsibility for the fair and lawful operation of all activities to be conducted;
5. I will familiarize myself with the laws of Minnesota goveming lawful gambling and rules of the Board and agree, if
licensed, to abide by those laws and rules, induding amendments to them;
6. Any changes in application information will be submitted to the Board and local unit of govemment within 10
days of the change; and
7. I understand that failure to provide required information or providing false or misleading information may result in
the denial or rev, • tion of the lice
Page 2 of 2
8/05
your premises permit. When the Board issues your premises
permit, all of the information that you have provided to the Board in
the process of applying for your premises permit will become public
except for your social security number, which remains private. If
the Board does not issue you a premises permit, all the information
you have provided in the process of applying for a premises permit
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, Board staff whose work 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 gambling
regulatory agencies; anyone pursuant to court order; other
individuals and agencies that are specifically authorized by state or
federal law to have access to the information; individuals and
agendes for which law or legal order authorizes a new use or
sharing of information after this notice was given; and anyone with
your consent.
Signature of Chief Executive % cer (i>/m' iggnnee? may not sign) Date
Print name tiro. - ■
Required Attachments
1. If the premises is leased, attach a copy of your lease.
Use form LG215 Lease for Lawful Gambling Activity.
2. Attach the resolution from the local unit of govemment
(city or county) which shows approval of your application.
3. For each premises permit application, a $150 annual premises
permit fee is required. Make the check payable to the "State
of Minnesota."
Mail the application with attachments to:
Gambling Control Board
1711 West County Road B, Suite 300 South
Roseville, MN 55113
NOM There is a monthly regulatory fee of 0.1%
(.001) of gross receipts from lawful gambling
conducted at the site. The fee is reported on
the G1 Lawful Gambling Monthly Summary and
Tax Return and paid with the monthly tax
report.
Questions? Call the Licensing Section of the Gambling Control
Board at 651 - 639 -4000. If you use a TTY, call the Board by using
the Minnesota Relay Service and ask to place a call to 651 -639-
4000.
This form will be made available in alternative format (Le. large
print, Braille) upon request.