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2007_0813_Packet
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2007_0813_Packet
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8/26/2009 2:57:17 PM
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Roseville City Council
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Council Agenda/Packets
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"�-=-- ,_--�.y <br />'G-:°,':' � ................. <br />� , Mir�r�esota Lawfuf Gamb�ing � : gdar��Seo�EY ; <br />Ga�nbEing ����pp�� ��wfu�� Gambling License Renewal Application <br />Control <br />Corre�i�ns st�o�Ed be made directly on this appEication ------------------ <br />- Submit orte cheek Por all renewal fees, payable to Siate of Minnesota <br />�rgani�ati�� requirern�nts. Curre�i license �erm: i Q/1/���5 �0 9/3�/���7 <br />1. An annual arganization }icense fee af $35D is requlred. R��t�tNiE1g iiC�nse t�r�'1: 10/1J20�7 tn 9/3�%2n49 <br />I�U��'1Q1"IZc��IUEY: �.% <br />Organ�zatiaat�: 1��W �ost i555 RosevilE2 <br />1�95 Waodhill Dr, Roseville, MN 5511� <br />CEU: Gien �eRay Faciden <br />Tr�asurer: J� <br />A�r�ual Gnai for Ch�aritable �onirihutions % <br />G�mbling Manager �tet�uirement5: <br />1. An ann�ai gambling manager licens� fee of �iQO is reqttired. <br />(612)483-5313 <br />County: Ramsey <br />.. _ _ __... ..._ ....� ..... .._ . <br />l�� Che[k thls bax if yaur � <br />�'I ,organlzation quaflfles for 4 <br />� the walver of the $3SD � <br />organization Ilcense Pee E <br />� defined' in MN 5tatute k <br />�. _ _ 349.1fi Subd__ 6 ,_. __ ,, <br />Gambiir�g Mae�ager A�thoriza�iort: GM-0009.i-ODf Cur�ent Licet�se Terttro: 1�/1/2045t� 9/3�/�OQ7 <br />R�tiGWi�'1t,� I{C�i1S@ �Li'It'9: 10/ 1 f 2tftli to 9 j 30/ 2p�9 <br />Michc�ei Ftal�k ThUrv �„ ihe individual listed is nat renewing their license. 4�/e have �nclosed a LC212 <br />ap�lication for the new appli�ant. <br />hEate: The gamb(ing manaqer duties may not be assumed by an <br />individual until they are licensed by Che Minnesota <br />�" Gambling Contsol Board. <br />Gamblit�g Mana�er Affic�avi� ant� Con�ent �tatetttettt <br />1. I ha�e never bee� convicted af a felony or a crime 12, i a€n �iot fnvolved directfy or ind'trec�ly as a bingo hall owner, <br />invnlvirtg garnbling. manufac�urer, or distributc�r. <br />�. I have never ca�mihhed a vialatian of law or 8nard rule 1�. T am not the chief execu�ive of�cer of this ar�anizatian. <br />that resulted in the revocation of a license issued by the 14. I am nr,t the treasu�'er of �his organization. <br />Boatd within five years befvre the da�e of the lic�nse 15. i was no� an af#icer of an �rganization at a tlme when an <br />application, o�fense occ€�rred which caused that organizatio�'s lice�se to be <br />3. I have never been convicfied af a crirninal v'salation revoked. <br />in�ol�ing fraud, theft. tax evasiar�, misreprese�ta�ion, ar �aCi���otlttd CheC�C, By signature qf this document, the <br />gambEing, undersigned a�thorizes the Departm�n�s nf Pub{ic Safeiy and <br />4. i have never been �onvicked af (i) ass�€�It, (ii) a criminai Re�en�e �o conduct a criminal and tax background eheck or review <br />viofatipn i�volving the use of a�rearm, or (iii) €r�aking and to share the res�lts wjth ihe Ga�b4is�g Cas�trol �oard. �ur�her, <br />kerrorist€c threats. I ur€derstand, agree, and here�by irre�ocabEy consent that sui�s and <br />�. I have never been, or a€� I now, con�tected with or actions r�lating io the s�bject matter a€ ��is gambling manager <br />engaged in an illegal �usiness. license appiication, or ac�s or omis5ions arising frarn such <br />6. I have never had a sales and use tax permit r�vo�Ced by �ppiicatian, may be commenced against me or my organizat[an and <br />t�e cofnmiss'soner of revenue v+rithin the pasfi two years. I will accept �he service of process in any co�rt oF eompetent <br />7. I have never, atter dernand, failed ta fie tax returns jurisdiction in Minnesota by service on th� Minnesota Secre��ry of <br />required by th� commissianer of reve€�ue. State of any summons, process, or pleading a�thorized by the laws <br />8. I do nnt �we $50q or rnore in d�Pinquent iaxes as defned �f Minnesnta. <br />in sectian �ip.i2. Failure ta prc�vicle requirec! infarmat'�on or pro�iding �'alse ar <br />9. I have be�n an active mer�ber af t€�e organization far a� mis3�ading information rr�ay result in the c#enial or re�cscatinn of the <br />least two years at the time af ac€r organizafiion's initial license lieense. <br />app�ication, or have been an ac�ive member far at faast the �hanges in the informa�ion subm€t�ed in tf�is app�icatian wilE be <br />mas� recent six months prior to the effec�ive date of aur submitted in writing no later t�an if1 days after the change has <br />arga�iza��nn`s 4ice�sse renewal. kaken e�#ect. <br />10. I am not a garnbling manager or an assis�ant gambling I have read this applitation and declare that afl informa�ion <br />rnanager for anothe� arganization. <br />1�.. I am not a Iessor, a member of the lessor's imrr�edia�e submi�ed is ��ue, ccurate, r��,gmplet <br />family or a person residing in the same household as t�e <br />I�sso�, or an employee o� a lessor of a pre€nises where �his Signature, in ink, af gamblfng manager appii ant <br />o€-ganization has a permit fssued from the Board to conduct <br />lawful gambling. Date: ��/�/ !� � ` <br />
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