5G, Resolution 2012-043 Approving a Premise Permit Application for Spring Lake Park Lions for Charitable Gambling License at Welsch's Big Ten Tavern

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LG214 Premises Permit Application 7/12 Page 2 of 2 Acknowledgment by Local Unit of Government: Approval by Resolution CITY APPROVAL Local unitq uernment COUNTY APPROVAL for a gambling premises musts�gn for a gambling premises located within city limits 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, 5. I am the chief executive officer of the organization. the Board or its agents, and the commissioners of 6. I assume full responsibility for the fair and lawful revenue or public safety and their agents may enter operation of all activities to be conducted. and inspect the premises. 7. I will familiarize myself with the laws of Minnesota 2. The Board and its agents, and the commissioners governing lawful gambling and rules of the Board and of revenue and public safety and their agents are agree, if licensed, to abide by those laws and rules, authorized to inspect the bank records of the including amendments to them. gambling account whenever necessary to fulfill 8. Any changes in application information will be submitted requirements of current gambling rules and law. to the Board no later than 10 days after the change has 3. I have read this application and all information taken effect. submitted to the Board is true, accurate, and 9. I understand that failure to provide required information complete. or providing false or misleading information may result 4. All r Ire infor do h be fully disclosed. in the denial or revocation of the license. �1- 13 -12. Signat a of Ch' Execu a fficer(designee may not sign) Date Print name �i� - ye-ilz_ 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 mation when received by the mation; Minnesota's Department of Public written consent. This form will be made available in alternative format, i.e. large print, Braille, upon request.