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<br />Minnesota Lawful Gambling <br />(LG200R) Lawful Gambling License Renewal Application <br />Corrections should be made directly on this application <br />Submit one check for all renewal fees, payable to State of Minnesota <br /> <br />Organization requirements: <br />1. An annual organization license fee of $350 is required. <br /> <br />Authorization: 3162 <br />Organization: American Business WOOlens Chapt Lady Slipper <br />c/o G Bailey 5607 Sheldon St N, Shoreview, MN <br />r <br />Darlene Adair Tollefson <br />329 Geneva Ave #304, Oakdale, MN 55128 <br />Treasurer: Kenneth S Damman <br />346 S McCarrons Blvd. Roseville, MN <br /> <br />Annual Goal for Charitable Contributions <br /> <br />Gambling Manager Requirements: <br />1. An annual gambling manager license fee of $100 is required. <br /> <br />U. ::Zb';ng <br />( Control <br />, <br />'\ <br /> <br />CEO: <br /> <br />Board Use Only <br /> <br />Current license term: 8/1/2005 to 7/31/2007 <br />Renewing iicense term: 8/1/2007 to 7/31/2009 <br /> <br />(612)481-0672 <br />5512 County: Ramsey <br /> <br />i. Check thj~ box if your <br />! organization qualifies for <br />, the waiver of the $350 <br />! organization license fee <br />I defined In MN Statute <br />349,16 Sl!l:)d--,_6 <br /> <br />(651)739-8686 <br /> <br />55113 <br />70 <br /> <br />(651)481-0672 <br /> <br />0/0 <br /> <br />Gambling Manager Authorization: GM-03162-002 Curren~ Lic!,nse Term: 8/1/2005 to 7/31/2007 <br />RenewIng license term: 8/1/200700 7/31/2009 <br />Marlyn Julianne Damman The individual listed is not renewing their license. We have enclosed a LG212 <br />346 S McCarrons Blvd Roseville MN 55113 applicabon for the new applicant. <br />(651)481-0672 ' . ' Note: The gambling manager duties may not be assumed by an <br />Bond. # 51082790 . individuai until they are licensed by the Minnesota <br />Company: Umted Fire & Casualty Gambling Control Board. <br /> <br />Gambling Manager Affidavit and Consent Statement <br /> <br />1. I have never been convicted of a felony or a crime <br />involving gambling. <br />2. I have never committed a violation of law or Board rule <br />that resulted in the revocation of a license issued by the <br />Board within five years before the date of the license <br />application. <br />3. I have never been convicted of a criminal violation <br />involving fraud, theft, tax evasion, misrepresentation, or <br />gambling. <br />4. I have never been convicted of (i) assault, (ii) a criminal <br />violation involving the use of a firearm, or (Iii) making <br />terroristic threats. <br />5. I have never been, or am I now, connected with or <br />engaged in an illegal business. <br />6. I have never had a sales and use tax permit revoked by <br />the commissioner of revenue within the past two years. <br />7. I have never, after demand. failed to file tax returns <br />required by the commissioner of revenue. <br />8. I do not owe $500 or more in delinquent taxes as defined <br />in section 270.72. <br />9. I have been an active member of the organization for at <br />least two years at the time of our organization's initial license <br />application, or have been an active member for at least the <br />most recent six months prior to the effective date of our <br />organization's license renewal. <br />10. I am not a gambling manager or an assistant gambling <br />manager for another organization. <br />11. I am not a lessor, a member of the lessor's immediate <br />family or a person residing in the same household as the <br />lessor, or an employee of a lessor of a premises where this <br />organization has a permit issued from the Board to conduct <br />lawful gambling. <br /> <br />12. I am not involved directly or indirectly as a bingo hall owner, <br />manufacturer, or distributor. <br />13. I am not the chief executive officer of this organization. <br />14. I am not the treasurer of this organization. <br />15. I was not an officer of an organization at a time when an <br />offense occurred which caused that organization's license to be <br />revoked. <br />Background Check. By signature of this document, the <br />undersigned authorizes the Departments of Public Safety and <br />Revenue to conduct a criminal and tax background check or review <br />and to share the resuits with the Gambling Control Board. Further, <br />I understand, agree, and hereby irrevocably consent that suits and <br />actions relating to the subject matter of this gambiing manager <br />license application, or acts or omissions arising from such <br />application, may be commenced against me or my organization and <br />I will accept the service of process in any court of competent <br />jurisdiction in Minnesota by service on the Minnesota Secretary of <br />State of any summons, process, or pleading authorized by the laws <br />of Minnesota. <br />Failure to proVide required information or providing false or <br />misleading information may result in the denial or revocation of the <br />license. <br />Changes in the information submitted in this application will be <br />submitted in writing no later than 10 days after the change has <br />taken effect. <br /> <br /> <br />Date: ~~~ <br />