HomeMy WebLinkAbout03-005
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CITY OF ARDEN HILLS
COUNTY OF RAMSEY
STATE OF MINNESOTA
RESOLUTION NO. 03-05
RESOLUTION APPROVING BINGO HALL LICENSE RENEWAL APPLICATION
NOW THEREFORE, BE IT RESOL YED by the City Council of the City of Arden
Hills, Minnesota, that the City agrees to approve the Bingo Hall License Renewal for the
Arden Hills Bingo Hall (Pot 0' Gold) from Goldie K. Siedow, 3776 Connelly Avenue,
Arden Hills, Minnesota.
ADOPTED BY THE CITY COUNCIL OF THE CITY OF ARDEN HILLS THIS
13th DAY OF JANUARY, 2003.
.?J;'~J1 ~//AI/-U~h'
/ B verly Aplikowski, MAYOR
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Minnesota Gambling Control Board
Bingo Hall License Renewal Application
Pot O'Gold
3776 Connelly
Arden Hills, MN 55112
License number: BH013
License expiration date: 5/31/2003
DBA, if applicable:
Return by: 3/2/2003
Enclosed are your preprinted license application renewal forms.
lG300 - Bingo Hall license Renewal Application
_ Draw a line through inaccurate information and write in the correct information.
_ Write in any missing infonnation.
_ Obtain and submit a resolution of approval from the local unit of government.
_ The Chief Executive Officer must sign the renewal application.
lG302 - Bingo Hall list Occasion
_ Complete and submit tl1e endosed LG302 - Bingo Hall Occasion Ust
_ If you have a rotating schedule, submit a calendar for tl1e license period.
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lG315 - Bingo Hall Personnel Information
_ Draw a line through inaccurate infonnation and write in the correct information.
_ Write in any missing information.
_ Each legal owner must complete a LG315 Bingo Hall Personnel Information form.
If tl1e legal owner of tl1e bingo hall is an organization, corporation, finn, limited liability company, sole
proprietorship, or partnership, tl1e following individuals must complete a LG315 fonn: partners, member
of tl1e board of directors, members of tl1e board of governors; each officer (induding but not limited In
president, vice-president, secretary, treasurer, controller, or general counsel); manager or supervisor of
personnel or security, and each person or entity with a direct or indirect interest of 5% or more in tl1e
applicant
_ If any person listed will not be renewing, write tl1e termination date on his or her renewal form and return it
with your renewal application.
If you need additional forms, visit our Web site at www.gcb.state.mn.usandclickon Bingo Ha//under
Genera/Information and FOITTlS.
For Your Information
All personnel forms will be sent In tl1e Department of Public Safety for a Bureau of Criminal Apprehension
dea rance a nd In tl1e Department of Revenue for a tax clearance.
Minnesota Rules, part 7862.0010, subpart lOa, provide: "Before issuing or renewing a bingo hall license,
tl1e board shall conduct or request tl1e director of alcohol and gambling enforcement In conduct a
background investigation, which may indude a review of tl1e applicant's sources of finandng, ownership,
and organizational structure. Actual costs in addition to the initial and renewal application fees shall be
borne by tl1e applicant."
Upon receipt and clearance, your application for renewal will be presented to the Gambling Control Board
for consideration at a monthly meeting.
If you have questions, please contact tl1e Gambling Control Board at 651-639-4000.
Minnesota Lawful Gambling
Bingo Hall License Renewal Application - lG300
Fee
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Check #
Bingo Hall Information
License number: 8H013
Name of bingo hall:
DBA, if applicable:
Street address:
Oty, state or province, postal rode:
Phone number (with area code):
Mailing address
(if different than above):
Type of Business
(sole proprietorship, partnership, corporation, limited liability company, firm): Sole Proprietorship
Minnesota Tax Identification Number: 1123411
Pot O'Gold
Efferovedate: 6/1/2003
Expiration date:
~665
5/31/'J:004
3776 Connelly
Arden Hills, MN 55112
(651) 631-1724 Fax number (with area rode):
Local Unit of Government Acknowledgment
If the gamb6ng premises is within city limits, the city
must sign this application:
On behalf of the dty, I ackrowledge that lIlis application wil be
forwarded to the appropriate city offdais, the dty must pass a
resolution specifically approving or denying this application, and a
copy of the resolution wil be fOrwarded to lIle applying organization.
N/~d~HiW
(Signature ot at)' personnel receiving application)
Hie Gt( -rJ1L~
Date\h.i\ Ie, ,61-
If the gamb6ng premises is located in a township, both
the a>unty and township must sign this application:
For the townshiD: On behalf of the township, I acknowledge, by
this sgoature, awareness of lIlis application and that the township
has no authority to deny or app""" an application.
NiJ'lle ot township:
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(Signature of township official acknowledging application)
Title
Date---1---1_
For the county: On behalf of the county, I acknowledge that
this appncation wiR be forwarded to the appropriate county
offiaals, the county must pass a resolution spedfically approving
or denying lIlis application, a1d a copy of the resolution wil be
forwarded to the applying organization.
NiJ'lle of county:
(SignabJre of county personnel receiving application)
Title
Date---1---1_
Questions on this form should be directed to the Gambling Control Boad at
651-639-4000. Hearing impaired in::lividuals USing a TTY may caU the
MInnesota Relay SErVice at 1-800-627-3529 and ask to pla:e a call to
651-639-4000. This publiCation will be made available In altErnative tonnat
(i.e. large print, 8r.ai1le) upon request-The information rEquESted on this form
(m any atta:hrrents) wit be used by the GaTlbling Cbntrol Board (Board) to
determine your qualifications to be in\rdved in la.vful gambling activities!n
Minnesota, and to assist the Board in COnducting a bac:kgmUld investigation of
'ttlu. You have Ule right to refuse to supply the infonnation requested;
however, if ~u refuse to supply this information, the Bocrd mer; oot be able
to detennine your qualifiC<tions ir"Id, as a consequence, may rEfuse to issue
you a license. If you supp tv the infOlTflation requested, the Board will be cb Ie
to process your application. Your name ..,d crldress IMII be public information
when received by the Board. All the other information that 'rOU provide win be
about you unit! the Board issues your license. W1len the Boa-d issues 'yOur license, aU of the
information that you have provided to the Board in the process of applying tor yotK license will
berome public. If the Board does not issue you a license, an the infQrrretion you hale provided
in the process of applying for a license remains private, with the elCl:epti on r:J your name and
address which will remain pubfic.. Private data abou: you are available only to the following;
Board members, slitf of the Board whose work assignment reqUire; that they h<we a:cess to
the infonnation; the Minnesota Department of Public Salety; the Minnesota Momey Ge/"lEfal;
the Minnesota CommssloOffS of Administration, Finance, and Re~mJe; the Minnesota
I..egislitive htditor, national and intern(tion<j ganbling regulatory agencies; anyone pursuant to
murt a-der; other indi\.1duas: and agencies that are spedfJCa11y authortzed by state or federal
law to halle accESS to the infOlTflation; individuals: and agencies for which law or legal order
authorizes a new use or sharing of Irlform<tion <Iter this odice was given; ald anyone wth your
written consent.
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Minnesota Lawful Gambling
.ingo Hall License Renewal Application - LG300
License number:
Effective date:
8H013
6/1/2003
Name of applicant:
Expiration date:
Pot O'~~
5/31/1004-
Personnel:
The owner of the premises must be the lessor of the bingo hall. Subleases are not allowed.
. Verify that the personnel list below is complete and accurate, and contains all owners, officers, managers,
directors, supervisors, and persons or entities with a direct or indirect finandal interest of five percent or more,
as prescribed by board rule.
. Add new personnel not listed and submit an LG315.
Name
Goldie Katherine Siedow
Role
Owner
Duties
None
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Oath
1 declare that any lease agreements between the
~d=~:~~: ::::: ~~:~=.and complete bingo hall licensee and lawful gambling organizations
I will familiarize myself with the laws of the state of will specifically identify any goods or services that the
organization is required to purchase from the lessor or
Minnesota and rules of the Board governing gambling
and agree, if licensed, to abide by those laws and a third party vendor, and that all goods and services
furnished as a part of the lease agreement will be
rules, induding amendments to them. valued at their fair market value.
I declare that I am qualified under the terms of
Olanges in the information submitted in this
Minnesota Rules, part 7862.0010, subpart 3, to be pl' t' '11 b bm'lted' .t. to th Be d
I. sed b' hall d '11 b'de b th ap lca IOn WI e su I In wn Ing e ar
lcen as a Ingo an WI a lye , . .
est. ti t f rth. M' ta R I rt and local Unit of government Within ten days after the
r nc ons se 0 In Inneso u es, pa ch
ange occurs.
7862.0010, subpart 4. <U f)..' .r f) ,
7L~~,I".d~ Date: fg-IS-(J~
Signature ot chief executive officer
r,...D I J. I ~ K....s; p ,t 0 uJ
Name (please print)
Mail Renewal Application to Gambling Control Board, with attachments.
LG300 - Bingo Hall License Renewal Application Mail to:
LG302 - Bingo Hall Occasion Ust
LG315 - Bingo Hall Personnel Information
. Resolution - Local unit of government approval
resolution (dty or CDUnty); and
Check for , payable to "State of
Minnesota" (fees are cons' ed earned and are not _
prorated or transferrable) ,$S, <JOt> 00 dOJ.J.J LhGSl(j Q... - \ Ul0 'IeOS-
Gambling Control Board
Suite 300 South
1711 West County Road B
Roseville, MN 55113
Minnesota Lawful Gambling
LG302 Bingo Hall Occasion List
Bingo Hall Information
Bingo Hall Namepot 1
Rotating Schedule: Yes 0
No
1/98
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old. Address -3 II 4> en \'\" ~..H 'f Itde..
(It yes, submit a calendar with the name of the organization(s) conducting bingo on each day.)
A I"a. e.. - . ..55\\
Schedule1
Name ot Organization
Conducting Bingo Occa~ons
Sunday .st. 0.. H-. e.. r-i
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Monday ;- 0
n "
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Tuesday Sr. .....r-
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Organization's Premises Permit or
Exemption Pennit Number or
Excluded Authotization Bingo Oale2
Hours of
Bingo
Occasions3
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I'
"
H
Wednesday
....00
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Thursday
..
"
Friday
ell.
Saturday
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"
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1 No more than 21 bingo occasions
are permitted at each hall per week.
2 If the organization does not yet have
a permit number, write "permit (or
exemption) applied for"
3 Enter the starting and ending times
for each occasion (for example,
7-9 p,m" 3:30-6 p.m.), A bingo
occasion must be at least 90
minutes and no more than four
hours long.
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Questions on this torm should be
directed to the Gambling Control Board
aI651-639-4oo0. It you use a TTY. you
can call us by using the Minnesota
Relay Service and ask 10 place a call to
651-639-4000. This fonn will be made
available in alternative format (Le. large
print, Braille) upon request.
The infonnation requested on Ihis tonn
will become public information when
received by the Board, and will be used
to determine your compliance with
Minnesota statutes and rules governing
lawful gambling activities.
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Changes in the above information
must be submitted in writing to the
Board within ten days if :
I. an organization conducts bingo
on a day and time other than that
reflected on the Bingo Hall Occasion
Lisl, or
2. an organization is added or
deleted on the schedule.
Mail this form to:
Gambling Control Board
Suite 300 South
1711 W. County Road B
Roseville, MN 55113
....Ii..ngo Hall Personnel Information - LG315
W:ense number: BH013 Name of person:
Oath and Consent Statement
1. I ha~ never been convicted of a
fElony.
2. I ha'loe never been convictEd of a crime
involving gambfing.
3. I have never been convictEd of assault,
a criminal violatbn involving the use of
a firmrm, or maJdng lErroristic threats.
4. I am not rurrently or have neve- been
engaged in or conneclEd with an i1<>;Jal
business.
S. 1 do not owe $500 or more in
delinquent taxes to the state of
Minnesota.
6, 1 have not had a sales and U5e tax
pennit revoked by the commissioner of
revenue within the last two years.
7. 1 have filed, 1fter demand, tax
returns rB:Iuired by the rommissioner of
revEJlue.
8. 1 am not a ficensed distlibutor or
affifiale of a distributor under Minn.
stat. sec. 349.161.
9. 1 am not a ficensed manufacturer or
affifiat:e of a manufacture- under Minn.
stat. see. 349.163,
1....1 not be an officer, d'wector, paid
~Ioyee, orvolunteer of a licensed,
exempt, or exdJded organization in its
conduct of lawful gambling, or
represent a &censed, exempt, or
exckxled organization In the purchase
of or inft uence the purchase ot lawful
gambfing equipment.
11. 1 am not a wholesale distributor or an
amOale or an employee of a wholesale
disbibutor of alcohoHc beverages.
12. 1 wil not provi:le any staff to conduct or
assist in ttle conduct ot bing:> or any
other form of lawful gambing on the
premises.
13. 1 wiD not acquire gambling equipment
or provi:le inventory control for any
organization that conducts lawful
gambing on the premises.
14. I wi! not prepare or assist in the
preparation of any reports required by
Minn. Rules, part 7861.0120, subp. 3,
for an organization conducting lawful
gambting on the premises.
is. I wiD not provide ao:ounting services to
any organization conducting lawful
gambling on the premises.
16. I win not sofidt, suggest, encourage, or
make any expenditures of an
.aniZationt 5 gross receipts from lawful
mbling.
17. 1 wift not charge any fee to a person
without which ttle person could not play
bingo or par1idpale in another!Onn of
Icwful gambling on the premises.
18. I wiR not provi::le assistance or
participate in the conduct of lawful
gambing on the premises.
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Goldie Katherine Siedow
19. I wiD not permit more than 11 bingo
occasions to be conducted on the
premises in any week.
20. I wi. not recruit a person to become a
gambling mancger or assistant gambling
manager or iclentify to an organization a
person as a candidate to become a
gambling man;:ger or assistant gambling
manager.
21. I wi. not be involved in the procurement
of, or influencing the prOClD'"ement of,
I....fill gambling equipment !Or an
organization which corK:Iu:t.s lawful
gambling on the li:ensee's premises.
22. I wiB not provide or permit an afiliate or
person acting on behalf of the bing:> haft
Ucensee to provide any compensation,
gift, gratuity, premium, contribution, or
thing of value to a Gambling Control
Board empio"", or manber of the
G<mbling Control Board.
23. 1 wil not diroctly or indirectly give gifts,
trips, prizes, loans of money, premiums,
or other gratuities to gambling
organizations, or their employees.. other
than nominal gifts not to exceed a value
of $25 per oryaniz2tion in a calendar year.
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(Signature of bingo aD nnel apphc1<11)
1Ut.M)~
Cou nty of
be!Ore me this~ day of
Notary Pubic: )J.oJ ,q ,
My commission eXPires:..lJ---2L~
In addition, 1 understand, <gree, and herEDY
irreJocably consent that suits and actions
relating to ttle subject matter of the bingo haft
license appli:::ation, or acts or omissions
arising from such appHcation, may be
commenced against me in any court of
competEnt jurisdiction in Minnesota by service
on the Minnesota secretary of State of any
summons, process, or pleading authorized by
ttle laws of Minnesota.
Bysignature of this doaJrnent, the undersigned
autholizes ttle Department of Publi: Safety to
conduct a background investigation pursu1<1t to
Minnesota Rules, part 7862.0010, subpart lOa,
By signature of this doannent, the undersigned
attests that information pro\lided in this
application is true and correct. Failure to
provKle required information, or provKling false
or misleading infurmation, may result in the
denial or relocation of the ticense.
Changes in application infonnatbn will be
submitted within tEn days.
FURlliER AFFIANT SAYElH NOT, except that
this Oath and Consent St<tement is submitted
in support of ttle application for a bingo hall
Ii:ense from the Gambing Control Board.
./dJ .Mi1ll...
Dale signed
SUbscrlbed and sworn to
20 O;A .
The infonnation requested on this form (and any iIj:<K:h~nts) v.M1 be used by the Ganbling Control Board
(Board) rodetermine your qualifICations to be invclved in lawful ganbling acti\tities In MInnesota, m to assist
the Board in conducting a background investigation of l<lu. You have a right to refuse to supply the
jnformation requested; however, jf you refuse to supply this intonnatioo, the Board may not be iDle tD
determine }Qur qualifICations ald.. as a consequence, may rduse to register you. If ~u supply the information
requested. the Board will be able to register 'rOu. You are required to prtl\'ide your sodaf seaJrit)t number on
this fonn. Yoursociat seaJrity number will be used todEterrrine youroompliance with thet~ law; of
Minnesota. Authorizction fi:lr requiling your social seaJrtty nurrber is found at 42 U.S.C. 4)5 (cXi). Your name
and address will be public information when received by the Board. AJI the other information that you pro'lide
will be privcte data about ',QU until the Board approves your registration. When the Board approvesyour
registration, all of the infonnation that you ha~ provided to the Board in the process ri rfl'.Jlsterlng wfU berome
public E!l(cept for your social security number, which rermins private, lfthe Board does not ~proW! your
~istration, aU the information you haole prcMded in the process of registering remains private, with the
'e)lJ:eption of your name and address, which will remain public. Privite data about you are avaOable omy to the
follOWing: Board m:-mbefS, stiif of the Board whose mrk assignment require; that they hale aa:ESS to the
information; the Minnesota Department of Public SafEty; the Minnesota Attorney General; the Minnesota
Cnmmissioners of Mministrition, FJnance, and RevEnJe; the Minnesota legislative Auditor; national and
intemctiQnal gambling regulatory agencies; anyone pursuant to court order; other individuals and agencie5~t
are spedflCally authCJ"ized by state or federal law to ha~ access to the information; individuals and c.;jenciesfor
which law or legal CJ"der authorizes a new use or sharing of informction after thi snctice was givm; lIld anyone
with your vvritten consent.