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96-1201 °� �� � � � � �'� � Council File # � � .. � �--�'' � �� '�-` i `� f .�.. Ordinance # Green Sheet # 35248 RESOLUTION OF SAINT PAUL, MINNESOTA ,s� � Presented By Referred To Committee: Date 1 RESOLVED: That application, ID #26471, for a new Gambling Manager's License by 2 Lois J. Dirksen DBA Sexual Violence Center at Billy's On Grand, 857 3 Grand Avenue, be and the same is hereby approved. 4 5 Requested by Department of: 6 __�,eaa Nav� Absent 7 B a gy ✓-_ 8 Guerin � Office of License. Inspections and 10 H Environmental Protection 11 �� 12 T une Bostrom O � By. lJ�`^, '° P,dopted by Council: Date , �.� �1�� Adoption Certified by Council Secretary Form Approved by City Attorney By: c By: Approved by Mayor: Date ?V ���v Approved by Mayor for Submission to By: ���,� _��,�,�� Council By: OE IL DA INITIA O a�"��rO, LIEP �R E E N S H E E T �- 3 5 2 4 8 a �oEw►r�Nr ox�cma N��� �cmr couNC� _.- wmnuc�►re William F. un r – – �R� ❑cirvnrnoANer �CITYCLERK IL ( ) Rp��� �BUDOET DIREC'Ibli �FIN.d MOT.S�RVICEB DIR. ar n • o2S'9-6 °R�" p�,voR�oR Assisr�m � TOTAL#E OF SIONATURE PI�GES (CLIP AL�LOCATlONS FOR 8iQNATUIRE) IlC'TION REQUESTED: Lois J. Dirksen DBA Sexual Violence Center requests Council approval of her application for a new Gambling Manager's License at Billy's On Grand, 857 Grand Avenue. (ID �26471) REOOMMENpd►TIONB:Appiow(A)a Ry�ct(R) PERSONAL SERVICE CONTRAGTS MUST AN8WEii THE FOLLOWINO�UESTIONB: _PLANNINO t�11S810N _CIV�SEflV10E COt�AM18810N. 1. Ha8 thie pefson1f11tn evlr W<Nk9d under a COnVad f0[tlNs d9pYrhnlllt? - _CIB COMMITTEE _ YES "NO 2. Has thfs psrsonMfrm ev�been a cily smployse4 —�� — YES NO _DI8TRICT COURr _ 3. Dosa this persoN�irm pos�ess a skiH not normaRY P�d bY anY ourrent dty e�4 SuPPORT8 NM�FI c�tlNCll OBJECTrvE9 YES NO Ezpldn all yp answen on Hp�nb sM�t�nd�tboh to�n sM�t u�mnTUro�.�.oProaruNm Mna,wnn,wn�,.wn.►�.wnr1: ADVANTAt�EB IF APPHOVED: DISADYIINTAOEB IF IIPPROVEO: �/�/1N 14M �� � auG 121996 D18ADNANTA3E8 IR f�T APPROYED: ' '"-" " ' TCTAL AMOtINT OF TRANSACTION S COST/RBVENUE BUDGETED(CIRCLE ONE) YES NO FUNDINO sOURCE ACTIVITY NUMBER FINMlCU1L INFORMATI�1:(EXPLAIN) Greensheet # 3���g L.I.E.P. REVIEW CHECKLIST Date: � �`',�"�� in Tracke�? �' � App�n Recetved / npp'n �rocessed Ucense ID # r��a�7� License Type: /YI / V I Q�Gl- er` Company Name: �-O S ` �SQ DBA: S � e fJ t�� h Business Addresss: /'i V(�. �h2 i'I d Business Phone: �o� 8'- '�7// Contact Name/Address: � /� � Sbu /'7� � S. S Home Phone: 4a�g� � ��� Date to Council Research: � �� g �� � Public Hearing Date: �����lb Labels Ordered: /V�� Notice Sent to Applicant: S�/��9 b District Council #: j,� Notice Sent to Public: Ward #: D�- Department/ Date Inspections Comments , City Attorney �1���6 �1�'/�-� d � Environmental Health �V�� Fire /v/� License Site Plan Reoeived: Lease Rec�ived: / V / � t Police ` � �eco r d C_h ec�. � �c�re, � al 7/3�1�6 �)r 1�,� Zoning ' "�� ,' • LG212 FOR OFFICE USE ONLY (Rev.7/2/92) BASE L1C� 1^,h` SEC1 i e� V Minnesota Lawfui Gambiing FEE Gambling Manager Application cHK DATE INIT '��`s<. ,,.; �'�'.".., ..:.�;;�:;��:�: ,,.....•.-::f,.,,::;,ya:.:�:;c;•:;:;•:�•• ::Rf::;::ss..K:45W.•;.::; .v;na:�..�. ::.•,:�':sr :E�i:o;::;%;x„•. �>:.il;,; �i;v. :.:,:,:.•y,,�'; ^^9' oJ' :i r r.. �... :..4:•:<;;�:.•��• y ,::ti:. cY �:;2:. :�.:Y: �.x: y aS'd5<.,u,.c �:"• .:r.. y. �'j9..".'"'.. /"• .!:�l•-0%�E.�n�cS'�iyrx•:.r:_;�..,.�..i�G:tt:l�:%�`•:�:�xG:;,,;::?�.}.....f.. :•.�ri'i.'�` ..��. ...{,:.:'� .�%F•t:i�.a r.�'+S�a'N:..<.. �..s..... ,3,., `/.':53'#6'i,.s.,•,.yy;T�.,.:x;.yt.;i.y,. ..';o-':?;`.+;,. •r.<?..,..::x::...�. � 6.. .� �r � .:r;.,:.,..::.:.. :..,...,-. :`.....;� I.�ru..�A,'�9x�.Yf.r �i. ..},... .F•::::.�YS'kl.�:..•....f,::bJf.'f.••r.•: �{ .r..f..sy.�••.. ....,+..>:.;•:.�:.;:.,.:,.:•�}..� �,,� ,o:., f.. e�b p��Cii�t� ` "'3'r� ���l?� e New G'n►e da�e that the Mro-day 9ambGnp manayer seminar was cornpleted.�/�/�� Locaoon of Vainin� � GE�Q/�J (p�Y) � Renewai Give date of traininp reoeived within three years prior Lo the date ot the appGcation ior renewal. / / Lccation ot training �c;"•4y/""'�9'� :s �: .: :<:. . �. .i.".'y%""`Sv:-':'•�i.'�,�'';{?r•.•��:S;Y,:',>.}: :3p� .i9':$" .;.<j.V f�"�^,"��� ,,,,.::,-;.. ;�,�, .. ,H'. . . . � }�.�Y'�"• . . . , ,y.t . , �� . . • � .5. ; •3...-: ::�s:,N,;:.,,i!...,. ;., cc::,..:,:<•:n.:::;<} �� ' .�; �:::.' . �i . '. ���:r:.". .S`..'.'": .+l_x .:.r::'..! �. :. ' ;:�CLt�3� Q�LQ . d�Q'��lY..< :4:�:.-<...: IAST NAN� FIRST NAME MIDDLE NAME MAIDEN Date cf Birth Soc•Sea��h N�^bef �Dl�se�n l0� S J�ca.�n — q�10-S� 5�'08'-336$ Address 3tatie Z�p Code Daydrt►e Phone �l o -�30�, s m� r��3 cG�� 9��r�i� MEMBERSHIP:-�aoe pambGnp manager became s member of the oryaniration �/�/� Sex: ❑Male � Female � ' � �: . ,� ,.�s.,,:= , • - �. . 3&�r,.<..�,r�''}.�-.%'�'r�:::,'a_`�.�"��.,'•.',..,.,�,''r','.�.'v..',.�'2,�'"�lf.hgryr: . . . �� �, . . � .�:•...: ' fJ�i�4�� . v . : . . • 'v..% �. : O .1 > . Q� it':•.�.�.�..:.5�;{�:.:.:x�x�:��..::�. �:,. .� ,.f,. '�. . :�:-- i. ' �.J4�n•- '. N8T@ Of Qf�8q128hOf1_ .� ' . . t, . �.�C6fli@ N1NII�f lJ' ld � �[n`k/L- ' �• �o� rp coda : Pno�e � '. - a.ioo -A�tis I�S rn s �»�J ss4o� i:: �c�t�u g'71�-SIDv - �� .,_ , . . . , . , : � ; ., _�_ .. . , . . F� � "-.� . -. . ' .. r e,, a �. .e� i,; '- � --A 510,000 fideGQl,i�orid in lavor of the or�anization must be ob�ned for 1he pamb6rq manaa0er:� '; � ,,�� �.�'��� � � _ ; � k ,� . , . '� � -. � . Z .: Gs �YiT� � '! L. ��.� � -ri t ;. .. ��.�� :s Name of�insurat�oe ��'� ;(do�not useta�ency namej � � ^*�/; � +������Jo ` o a gq�. � / "`� ��- .� y J!'��y2 �.. ' .� '��•� ' �'i•�� { � t�.. � Y.�A ,..1�= a�'T ..1 :lzj,.. ;�y,f�;ra�arT '�^,-y f .. . � � � � �- � �_ti+�py+..,._.��r , �� iN.e a�„r,. , ��a?Y�1 ;.: � =A;..� �� � >� ''� r „` r : � *,�� � �.� _ � r 1 y�• t � �t,a i :� i[i-i ,] f +.y`C�: �'+Yi :� AT+��3 . �� f J' ��8c � . � �!W478�@�18�'7 ..�rF'Sl.�a ck ,�+ -m 1 ?: �r t��. "��'.?fi"'€ }' x au,�� T�".`� �r :a't '4 +�='�( t.2 '-' • � r �s - �. .. '�: 'f,� � .� i5-_�� �''`�.. ? �". .r�' �T;�' Y � .y7� • ��, �a- � t ��C t `' t ��,� ,. �.. , .:� ..� i ,,..r yrt . . � � - ri�'k � �t18118 198d�i�'�C8bOf1���1{�111�Ofl i{JbRI�b$1B bOBId� r � - 'X9t,�^'`."� X Y, �` e s � �'"'�. ` 2 �M �M —_JMf �= Y K � r� F �' I' ''��� ��•�YM �IYV��i1R`/��W� .�', i i 4t .t qe~ �.j � �_..y �1 'tyM�� t�' .. '7.�" i� , '�' M1 � .. • iY Q�f�r �Y��YW�,��.�• ;. ,�'f �. .� �L��` i �f 4"'Th a'�./e �~ ;` � `� r ; `;• I am�e�on1yp�rt�b6nD ma�er ot the�o�anizabon:'� � ., �� �"c.�. ,� ,, r ���~� �a�'°># .? �� �ioensed�io ` � ` � `r "" • 1 vn'A tam�ar¢e myself with d�e laws:of Ninnesota goJemu�g lawtul_gambGnp and nAes`ot d�eboard and agree.��. <t� �<+ � +, - abide by;those`�ws and Nles 3ndudrp amendments b Them: . ;: . _. T ;,.°�,*'�':•; -•• '��'� '- � • any chan�es in app6ca6on lntormatioi�wiG be submitted to the board and bcal uoit of�ovetnrnent within 10 days'of t�he d�an9e; � - • M sffidavit for;�amb�inp mana9er has been o�mpleted and attad�ed.and ,. `.; , v` -� _ • 1 understand that tadure to provide req�red infom�ation or provid'ug false iniormation may result in the denial or rev�ocatian of the fioense. _ • Si�naLure of Gamb6rg Manager • � I D te . � �� -Send the oompleted application and all required attachments to: � Gambling Control Board . 5ulte 300 S. 1711 W.County Rosd B Rosevllle,MN 55113 , - aw ��� �;;2�3� Minnesota Gambling Control Board 0°"�5 Gambling Manager Afifidavit G� ` ,� a 0� Attach to the Gambling Manager Application,FoRn LG212 STATE OF m t n� sd•�-t,4 � AFFIDAVIT OF QUALIFICATION FOR GAMBLING MANAGER LICENSE )s.s. AND CONSENT STATEMENT COUNIY OF � n ��h ) (pursuant to Minnesota Statutes and Rules) �� (.Oj S ��c�,���rlCS,c.�n , Under oath state that: (type/print name) _ . 1. I have never been convicted of a felony or a crime invoiving gambling. 2. I have not,within five years before the date of the license application.committeci a violation of law o� Board nile that resufted in the revocation of a license issued by the Board. • - , ; 3. I have never been convided of a criminal violation involving fraud,theR.tax evasion, misrepreseMation.. or gambling. 4. i have�eve�been convided of(�assault.(�a criminai viotation involving the use of a firearm;,pr(ii� making temoristic threats. , , f` . "i�^ `s`� , € .i:.: .a• . :�....y� + r ''> . . ��. ��3,'�"tb�LS:ti�'�JY't�. i -.. 5. I am not. nor ever have been conneded:with orengaged in an Illegal business: �.. ,.�� S.� ��.�,�-€:_�-r �,° ^:: ; , �,_ ,..: 6. I do not owe 5500,or mor+e in deiinquent taxes as defined in section 270.72. 7.�i have not had a:saies and use tax pertnit revoked by the'commissioner of revenue within the'past.two : . - � ;;� _ . ; � {:� years. ; �� '�xY��;y,}��.t :j � '. . - ; r.. �;.� � ���� � �: � '8. I fiave never;atter,demand;failed to f le tax�retums required by the commissioner of revenue '��° }�{ `� ;� �, y .. �:' _nx '.�- ' _ r.k,., �€ ,.'t : .;: .�;. : �„_ 3•,f'�'�. , . � 7 ; Y � � '��� � �ht�SU�fB 9(Id 8CtI0tf1S� �^�1�y 0 y8 E t �� * �:in addiLon,!u e ree a Yvocab..,�cQ_ y� :� � 4 � ,�� � �,. '��� �, , x� r. C�� ��fll°�Df��YOf'�fi1�S510� � ro � .;�*, ., atter of the�`a U�1�'�na e �_ icatio � � -: n 1� ,�. �n �. ,,.. ����,: �. t �y �: on.�nay be � e ai�r�n� o _.nd�'•��` e3ennce�o �,, � �,,�. , , ,��3.; •� � � n e�lAinit� ta�5e . . j` ' t�' on�ri�any�co ,. . �iT�i i r y� �. � ::.� �mmons'�pro ea�in9,. o aws`"�'��llin es�a �, �a� � `�.�.; 3ty�{ • 4. .Y t�'' �,.+ " {�';f' -.-,��' .- �: r. � k.t: - . . rY '�;.� � ` si9nature�f e e. n . �e�; �Pattme��of�P ,;�. : .tat x.,�- �'�Qe c �e' a!� • '�,.`.`.+ �J�^�s «[r 4�}t �i �'f. � � �yT�- �. ��cnminalbackgroun . edcbr neview�n�$o re'�he tesults- �he Gambbng Co�tro � , _:. � r$ � �� r , �S �r-��' �� �. �, k�!' r .� «. , r fi . .+�,-`�"'y�, . t xr i�u '�,t•z:�t rfv �tx° .aY"tt�s ��' . 'b j��'� r✓� ��,,,�� �'�'i s+!�.1Y ' �(�''� � ���'�"''.&"+�' .. � S r� r �.�i'p�'.';..�. IIVrer��� ���0 Y�� 81�.1G ����!lj�i�r Q �t /��{. Y4 �}.'�ti � � V�VOu4�n}-O ��� �.5:: +-.�i" ��_� '.►4 f � k, .: � M�.�t . l.t�t . '3'� n �_� '�1. l' `_.aa:� y��� T...f. � � I.� j�- � r.a.. ���•�w �Fry � _,.��y,� : , � ..,-. .�. . .a����"'r. ��3 ��3� �i ,�t.� ti f � �i ` p �} is i v �d�Conserrt`StatemeM.are ,�Y F- ;� �'FUFtTHER �..i. .,k, ��� � • ��i T-T"'��+ R�.� nn r�!r� S't .".` 'h.- 'r'1 � �:SUppoR.ot�fL.��' ���1+1�Y-i 'on �or a�'gam innhg "�n�atgerlicednseyf� ro e Gambling Con�frol8�`a . xi,r�y�, � `��'� "X���a?i��`r%���Nt..�`��j.. -.��i;�'F3�Q�'��-;. ! ..ry>� z �5��� : .� Y�P?dllsf�l'f�!'F`tT� ' , vl"�''�`i�r i �1 : {T'"��i'�'?��s"��T.b����' ��}r t - 'NOTARY P�UBUC�(NFORMATION t�� ,. tE;,, � ,..• '` ° rr r r.-�::�i 4 .iF a,!..r'Ia:L•M t.� i?f .'r, � .�'., r , , . ! 'r���x:.�'1�r�C:15+. Notary Q.ublic,Seal:must.be�curre�t-and:co.�ed.,a:��lJ _.; �: ;, . ,_.; � -`{�9na ur'e"of�appiicairt)�� -r'>��;��=�=: $@8�fi18�1.�,�:��@�:';tt�C e:`j �2'J'J:f..,�� ,.»; .y1P"�' :�w•'�",: lt:� ,:4: . `', c�,;�ic !� �>J2?�YT���;�at�;�'��. �.i:.�-•� ��::° . t �� i '�3_� '° itiF} i �"." iGC j';.'�l� v�+ �:i i - 7r� .. ., :L.���ti�1+t� X.� -�A�� r -,'�.�_�. i�'> .�������. subscribed a a m to before e�his � ' '' � � - , ° _ ,1 .�.3y,'?�„3 s•rkY��'z'.�:��'�:f4 '14`..�=��.' �.� T�Z ; :r. .. . . . �9 '.,; r.� day of� ���y F ORGANIZATION 1NFORMATION - Name of Organization a s _ S� c� ✓lC1�n� �•i ■ - .. . � . . . � �� . �� � ..- �'.X : . :. . . . .. �TA � Base License Number " . M►Qi�w.�...wn.a�.�000 . ��co r� �h�c,l� �/e_�S E'✓ , `Th�-n K,��, �J��. q (�. � ZO � LICENSED GAMBLING ORGANIZATIONS S�Le���L����������i�����������L���e��e�������#��������������������:i#����������L��i ° NAMEs SEXUAL VIOLENCE CENZ'ER NUMBER OF SITE$: 1 ° ° ADDRESS: 2100 PTLLSBURY AVE S MINNEAPOLIS MN 55404 ° ° STATE LICENSE ,�:22222 PHONE ,�:871-5100 LIC CLASS: B STATUS: AC ° 0 0 �° CEO LAST NAME: DOTTY-THOMAS FIRST : BARBARA ° ° ADDRESS: 922 FAIRMOUNT AVE ST PAUL MN 55105 ° ° HOME PHONE: 224-4990 BUSINESS PHONE: DOB: 0?/26/50 ° 0 0 ° TREASURER LAST NAME: NOWLIN FIRST: MITZI ° �' O ADDRESS: 3536 ORCHARD LANE MINNETONKA MN 55305 ° ° HOME PHONE: 933-3784 BUSINESS PHONE: DOB: 10/09/48 ° 0 0 ° MANAGER LAST NAME: DIRKSEN FIRST: LOIS J ° �° ADDRESS: 410 GROVELAND ,�302 MINNEAPOLIS MN 55403 ° ° HOME PHONE: 928-4711 BUSINESS PHONE: 871-5100 170B: 09/10/55 ° 0 0 ° LAST RECORD CHECK: / / ° ������Le���eL�����������e����e��������L���������L�LL���������L�L�L�L���t#���i#�Lf Press Fi for Help Press F10 to Save i`�� , �� � ` �� � �\ \ �