2004_0329_Packet - Laserfiche WebLink

Home

�� : �Jg,� Current �icense E�c�� 6/30/2004 m e w e d I icense T�rm: 7/1 /2004 �� Bingo Hall: Capitol C�y Investments LLp dba Roseville Bingo Hall Phone: (612) 781�184 BusinessAddr�ess: 2525 N Snelling Ave, Roseville, MN, 55113 Fax: A separate personnel information form for each emptoyee listed below is induded witf� this aaplicadon. All i��::� +rl forms must be signed by the applicant i n the presence of a notary. Personnet forms are attachments to the bingo hall renewal application and must be ��OGdertne�, FrankMichael Gaertner r� � �� +�� Miley , Mary Jane Tanl . 'Fd�S� Description of Duties: Owner Description of Duties: Owner DesCription of Duties: Owner [7�fidb��i �f i�.14�; �vii� 1 dedare thatthis application is correct and complete to the best of my knowledge and belief. 1 will familiarize myself with the laws of the state of Mlnnesota and rules of the Board governing gambling and agree, if licensed, to abide by those laws and rules, including amendments to them. 1 declare that 1 am qualified under the terms within Minnesota R�.le, to be licensed as a bfngo hall and will abide k� the restricdons set forth in Minnesota Rule. 1 dedare that any lease agreements befinreen the bingo hall licensee and lawful gambling organizations will spedfically identify any goods or services that the organization is requlred to purchase from the lessor or a third party vendor, and that all goods and services furnished as a part ofthe lease agreementwill be valued attheirfair marketvalue. . Changes in the informatlon submitted in this application will be submitted in writing to the Board� and local unit of government within ten days atter the change occurs. Printed Name of Chlef Executive Officer �d� dA��C '�•N.�/ `'� ■ Signature of ChiefExecutivepfficer �� Date Signed ��_�� 1 �_�_ � Y�� k dxbN ar�5�a+►.t �n tY�e renewal application, a resolution of approval from U�e local unit of government (aty or county) having jurisdictlon overthe bingo hall. Complete and submit the endosed Lw3G��4 Hall qccasion Ust. Rotating Schedules must be provided in a dear legible format (i.e. calendar) forthe entire license period. The Information requested on this form w{a be used by the Gambling Corrtrol Boazd (Board) to determineyourqualKkatlons to be InvoNed in lawful gambling actfvides In Minnesota, and to assist Uie Boazd In conducting a background investlyatlon � you. You haw a tight to refuse to supplythe Infortnation requested; however, If you refi.ise to supplythk IM`omiatfon, the Board may not be b� to deiermine your quallflptions arrJ, � a oorisequenoe, may refuse to reqister ynu. I f you supplyihe ir�formatlon requested, the Board wlll be ableto registeryou. You are requlred to provide your 5oclal Secu rny number on �� forrn. Your Soaal Securtty number will be used to determine your compllance with the tax I a m of Minnesota. Authorization for requlring your Sodal Seartty number Is found at 42 U. S. G 405 f:YO. '�r fiinis and address wlll be publlc Information wfien received by the Board. All the other InformaUOr► that you provide wll be pr�vale data about you urrtil the Board approves your registration. VUien the Board approves your reylstratlon, all of the Informatlon that you have provided to the Board In the process of registering yy{I become public except fa your Sodal 5ecurfty number, whlch remains private. If the Board does mt approve your registratlon, all the informatbn you ha,�v provided In the process of regis0ering remalns prlvate, wtth the exceptlon of your riame and adrLe�,+�Fldi wlr r�n+ti publk. Prfvate data about vou are ava�lable only to the followinp: Board menWers, staR of the Board rrf�rrru'k �nmeR • requlres that they have a� to the Infnrtrwtlon; the Minr�esota Department of Publk Safety; the Mlnnesota �ta-rr� General; the Minnesota Gommissloners of Administratlon, Finar�, and Revenue; the Mlnnesota LeylslaUve Audttnr; nadonal and internatlonal gambliny regulatory agencies; ariyaie pursuantto court order, other Indalduals and agendesthat are spedfically authorized by state or federal law to ha✓v acoess to the Ir�fomiation; indivlduaLs and aflendes for whkh law or legal order authorizesa new use or sharing of Information afterthis notice v�as given; and anyone wttt� your written consent Obtaln a,rrent GC8 forms �x vlsfting us a't www.pcb.atate.mn.us _._ Licensing Contact: Ro�e Rolph Phone: (551)639�079 Fax #: (651)639-4073 E-Mall �i� Qf �IirnmYB#i Gamblin� Control Board 1711 W Co R.d B#300 SoWi Rosevtlle, MN 55113 mn.us Printed on: Monday, March 08,2004 Page � of 1