96-1517 Council File # l � ` ` S � l
Ordinance #
Green Sheet#` 35406
SOLUTION
CI OF AI PAUL, MINNESOTA �
.
Presented By
a
Referred To Coa�r►ittee: Date
1 RESOLVED: That application, ID #63382, for a new Gambling Manager's License by
2 Michael J. Michlitsch DBA Midway Training Services, Inc. at Amelia's,
3 175 E. 5th Street, Suite 312, be and the same is hereby approved.
4
5 Requested by Department of:
6 �.� Nays Absent
7 B a gy �_
8 Guerin Office of License, Ina�pctions and
10 ✓ ✓ Environmental Protection
11 e tm ✓
12 T une ✓
Bostrom �
Adopted by Council: Date 3�LQ"�,
BY� �r.Llla� ��S257G�
Adoption rtified by C un i �ecretary
Form Approved by City Attorney
� ` �By� _�J
/� BY=
Approved by Mayo : Date � �v� `Z
� Approved by Mayor for Submission to
By:
��C Council
By:
.�lG- �s ��1
LIEP � ���� �REEN SHEET _N_ 35406
� �oew►�eHr a�cTOR Nmnva�� �cm courica �rruua��
William F. Gunther - 266-9132 �� �CITYATTORNEY �cmc�K
NCIL BY Dl1 pp�Np �BUDQET OIREC1�OFi �FIN.d MOT.BftiVICE3 DIR.
� �p �MAYOR(OR AS$�STAPIn �
Hearin :
TOTAI.#t OF SKiNATURE PAQES ` (CLIP ALL LOCATIONS FOR 81tiNA'fURE)
ACTION REQUE8TED:
Michael J. Michlitsch DBA Midway Training Services, Inc. requests Council
approval of a new Gambling Manager's License, ID ��63382, at Amelia's, 175 E. �th Street,
Suite 312.
RECOMMENDATIONS:Approw(A)a Ryect(R) PER80NAL SERVICE CONTRACTS MU8T ANSWER TNE FOlL01AflNQ WlESTIONS:
_PLANNMIO COMMISS�N �CIVIL 8ERV�E Cq�N+118810N 1. Hes this perooNfirm ever worksd under a Cond�act for this dsperhn�M4 .
_CIB c:OMMITTEE _ YES NO
—�� _ 2. Has this persaVfirm ever been s c�ty empbyee?
YES NO
_D18THICT COURT _ 3. Does this psrsoMfirm possess e skill not normaNY Poseeased bY a�Y cu�rsM�hY s�toyes?
BUPPORT8 WNK�1 COUNCIL OBJECTIYE7 YES NO
Ezplaln�II ya answsn on ap�nU�M�t�nd�ttach to�n�n thNt
INRURINO PR08LEM�ISSUE.OPPARTUNITY Mlho.WMt.iNMn.WF�rs.WhYY �..,, �,
. `;� � .. �Y`;y�l,•-�r
�ti� � ��
��i��
NOV 02 �
CI�'Y A�dR
NEY
����:
DISADVANTAOE8 IF APPROVED:
DIBADVANTIKIKiE8 IF NOR APPROVED:
TOTAL AMOUNT OF TRANSACTION = COST/REVENUE BUD(iETED{CIRCLH ONE) YES NO
FUNDIfid 80URCE ACTIVITY NUMBER
FlNANGIIL INRORMAI'ION:(EXPLAIN)
Greensheet # 35406 L.I.E.P. REVIEW CHECKLIST �ate: / �G� -�S l�
In TraCker? .� S� 9.6 App'n Received / App'n Processed
Llcense ID # 63382 License Type: Gamblin� Mana�er
Company Name: Michael J. Michlitsch DBA: Midwa�Training ServirPC, Tnr_
Business Addresss: 175 E. Sth St. (Amelia's? Suite 312 Business Phone: 64t-0709
Contact Name/Address: 720 Vandalia St. 55114 Home Phone: 641-0709
Date to Council Research: /a��/9�
Public Hearing Date: D.�,�, I 1 i 1 19b Labels Ordered: N/A
Notice Sent to Applicant: District Council #: 17
Notice Sent to Public: N/A Ward #: 02
Department/ Date Inspections Comments
,
City Attorney � � f� S'�_� � �," j�/I �o`�e2-1�,(�
� / �
Q�
Environmental
Health
,✓/Iq
Fire
/�/A
License ���������
Lease Received:
/v / �
Police �eCEJ^C� �illec IC �'��AC��-C!.
o,� �,��,�9�
Zoning
N �
�'�� �a��=�
" . LG212 ' �S I�
(Rev. 7l?J92) FOR OFFICE USE ONLY
BASE UC�
. SEQ �
Mirtriesota Lawfui Gambling FEE
Gambling Manager Application cHK
DATE
INIT
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� New Give date that ihe two-day gambling manager seminar was comp{eted.�/��/��
L.ocaGon of training -S h O�'�-V� �w
(Gry)
� Renewal Give date of training received within three years prior to the date of the application for renewal._/ /_
Loca6on of training
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LAST NAME FIRST NAME MIDDLE NAME MAIDEN Date of Birth Soc.Security Number
I� I .sc, c.ha�-I Jol� r l�-�4-s6 y71-7o-87 �a
Address State Zp Code Daytime Phone
7D � +�v� ss S , s"S l� (��a).y��-�3 ��
MIEMBERSHIP: Date gambling manager became a member of the organiza6on �/�� /$ g Sex : �$Male ❑ Female
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Name of Organization License Number
IQwA�/ Y� iNG� S uICC /N Ov� `7�� �-
Address Ciry/State Zip Code Phone
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Bond l formatYOn><::::>:::!<:::>:;<'
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--A $10,000 fidolity bond in(avor of the organizaoon must be obtained for tlie gambling manager.
Name of insurance company (do not use agency name)�-=O^f'^°o"��`� ��u"''�� Bond Number Cg� 6/�G �{��..
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I dedare that:
• I have read this applica6on and all informabon submitted to the board;
• all information is trve, accurate and complete;
• aC:��2r;�;:ired i�(crrrsticr.hzs bear, F�!!y dis�'osed;
• I am the only gambling manager of the organization;
• I will familiarize myself with the laws oi Minnesota goveming lawful gambling and rules ot the board and agree, if licensed, to
abide by those laws and rules, induding amendments to them;
• any changes in applicapon information will be submitted to the board and local unit of government within 10 days of the change;
• An aKdavit(or gambling manager has been completed and attached, and
• I understand that failure to provide required information or providing (alse information �;�ay result in the denial or revocation of tt�e
license.
Signature of Gamblin Manager I Date
�c.�" �� '- � � �/ / y ��
� Send the completed application and all required attachments to: �
Gambling Control Board
Suite 3Q0 S.
1711 W. CouRty Road B
Rosevllle, MN 55113
�.�3��
�:�2,3, ehinnesora c�an�fli�r�� c;onrror r�oa�o
;� `��'�'`J5 Gambling 1Vlanager A�davit
� Attach to the Gambiin9 Mana9er Application, Form LG212 fA J `i S ,�
STATE 0 F j1')/N N CSO %� ) "I �� �
AFFIDAVIT OF QUALIFICATION
) s.s. FOR GAMBLING MANAGER LICENSE
COUNTY OF R-A Y�')S E � � AND CONSENT STATEMENT
(Purs�ant to Minnesota Statutes and Rules)
i, %'►'1 i��z�� J� V►�i c-��� fi S c.� , Under oath state that:
(type/print name)
1. I have never been convided of a felony or a crime involving gambiing. '
2. I have not, within five years before the date of the license application, committed a violation of taw or
Board rule that resufted in the revocation of a license issued by the Boarci.
3. I have never been convided of a criminal violation involving fraud, theft, tax evasion, misrepresentation,
or gambling.
4. t have never been convicted of(� assault, (i� a criminal vioiation invoiving the use of a firearm, or(ii�
making terroristic threats.
5. ! am not, nor ever have been connected with or engaged in an illegal business.
6. I do not owe $500 or more in delinquent taxes as defined in section 270.72.
7. I have not had a sales and use tax permit revoked by the commissioner of revenue within the past two
years. -�--
8. I have never, after demand, failed to file tax retums required by the commissioner of revenue.
In addition, I understand, agree and hereby irrevocabty consent that suits and actions relating to the subjed
matter�f the attached gambling manager license application, or acts or omissions arising from such applica-
tion, may be commenced against my organization and I will accept the service of process for my organiza-
tion in any court of competent jurisdidion in Minnesota by service on the Minnesota Secretary of State of any
summons, process or pieading authorized by the laws of Minnesota.
By signature of this document, the undersigned authorizes the Department of Public Safety to conduct a
cnminal background check or review and to share the results with the Gambling Control Board. -
Failure to provide required information or providing false or misleading information may result in the denial or
revocation of the license.
�URTHER AFFIANT SAYETH NOT, except that this Affidavit and Corsert Staternent are submiYed �n
support of the application for a gambling manager license from the Gambling Control Board.
NOTARY PUBUC IIVFORMATION
Notary Public Seal must be current and correct. ( nature of applicant)
Seal may not be attered.
Subscribed and swom to before me this
.� �day of 19 9� .
ORGANIZAT/ON lNFORMATION
, � Name of Organization
Ptil P W. 8WANSON m � �� � lR�l NI�F' S��viCCS� //1/ °L
ppTqqY p(J8110 - FAiNNE80TA
RAht8EY COUNTY
- .' t�t�r�Com��+� - Base License Numb�� / /a�
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