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
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e�b p��Cii�t� `
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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
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;:�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 �
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'- � --A 510,000 fideGQl,i�orid in lavor of the or�anization must be ob�ned for 1he pamb6rq manaa0er:� '; � ,,�� �.�'��� � � _ ; �
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��.�� :s Name of�insurat�oe ��'� ;(do�not useta�ency namej � � ^*�/; � +������Jo ` o a gq�.
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`� 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
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�:in addiLon,!u e ree a Yvocab..,�cQ_ y� :� � 4 � ,�� � �,. '���
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., 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 .
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on�ri�any�co ,. . �iT�i i r y� �. � ::.�
�mmons'�pro ea�in9,. o aws`"�'��llin es�a �, �a� � `�.�.;
3ty�{ • 4. .Y t�'' �,.+ "
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� ` 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
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'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'>��;��=�=:
$@8�fi18�1.�,�:��@�:';tt�C e:`j �2'J'J:f..,�� ,.»; .y1P"�' :�w•'�",: lt:� ,:4: . `', c�,;�ic !� �>J2?�YT���;�at�;�'��. �.i:.�-•� ��::°
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�� i '�3_� '° itiF} i �"." iGC j';.'�l� v�+ �:i i - 7r� .. ., :L.���ti�1+t� X.� -�A�� r -,'�.�_�. i�'> .�������.
subscribed a a m to before e�his � ' '' � � - , °
_ ,1 .�.3y,'?�„3 s•rkY��'z'.�:��'�:f4 '14`..�=��.'
�.� T�Z ; :r. .. . . . �9 '.,; r.�
day of� ���y F
ORGANIZATION 1NFORMATION
- Name of Organization
a s _ S� c� ✓lC1�n�
�•i ■ - .. . � . . . � �� . �� � ..-
�'.X : . :. . . . ..
�TA � Base License Number "
.
M►Qi�w.�...wn.a�.�000 .
��co r� �h�c,l� �/e_�S E'✓ ,
`Th�-n K,��, �J��. q (�. � ZO �
LICENSED GAMBLING ORGANIZATIONS
S�Le���L����������i�����������L���e��e�������#��������������������:i#����������L��i
° NAMEs SEXUAL VIOLENCE CENZ'ER NUMBER OF SITE$: 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: / / °
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