Item 4B, Flaherty's Charitable Gambling License

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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. Your name and address will be public information when received by the Board. All other information you provide will be private data until the Board issues your premises permit. 6107 Page 2 of 2 When the Board issues your premises permit, all permit infonnation provided will become public. If the Board does not issue you a premises permit, all the information provided remains private, with the exception of your name and address that will remain public. Private data about you are available to: Board members; Board staff whose work requires access to the information; Minnesota's Department of Public Safety; Attorney General; Commissioners of Administration, Finance, and Revenue; LegislativeAtJditor; 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 agencies for which law or legal order authorizes a new use or sharing of Information after this notice was given; and anyone with your consent. 1. I hereby consent that local law enforcement officers, the Board or its agents, and the commissioners of revenue or public safety and their agents may enter the premises to inspect it and enforce the law. 2. The Board and its agents, and the commissioners of revenue and public safety and their agents are authorized to inspect the bank records of the gambling account whenever necessary to 'fulfill requirements of current gambling rules and law. 3. I have read this application and all information submitted to the Board is true, accurate, and complete. 4. All required information has been fully disclosed. 5. I am the chief executive officer of the organization. 6. I assume full responsibility for the fair and lawful operation of all activities to be conducted. 7. I will familiarize myself with the laws of Minnesota governing lawful gambling and rules of the Board and agree, if licensed, to abide by those laws and rules, including amendments to them. 8. Any changes in application information will be submitted to the Board no later than 10 days after the change has taken effect. 9. I understand that failure to provide required information or providing false or misleading information may result in the denial or revocation of the license. __~ 'rnc~ Signature of Chief Executive Officer (designee may not sign) Pri nt name __<2.~_~_~_'-<i___~:-_~_~':'~":_'i__________________________ ~3o) Date DE Monthly Reguhitory Fee If you receive a premises permit for this site, 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. 1. LG214 Premises Permit Application 2. If the premises is leased, attach a copy of your lease. Use LG215 Lease for Lawful Gambling Activity. 3. Attach a resolution from the local unit of government that shows approval of your application: if the premises is within a city, attach city approval, or if the premises is within a township, attach county approval. 4. $150 annual premises permit fee, for each permit. Make check payable to "State of Minnesota." Mail to: Gambling Control Board 1711 West County Road B, Suite 300 South Roseville, MN 55113 Questions? Call the Licensing Section of the Gambling Control Board at 651-639-4000. This form will be made available in alternative format (Le. large print, Braille) upon request.