96-533Council File # .��w � C J J�'S
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GYeen Sheet # 34956
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Requested by Department of:
Office of L�cense Inspections and
Environmental Protection
Presented By
Referred To
PAUL, MiNNESOTA
Ordinance #
RESOLVED: That application, ID 14629, for a new Gamblinq Manaqer's License by Siri A.
Fosde DBA Minnesota Youth Athletic Services at Over-The-Rainbow, 249 W. 7th
Street, be and the same is hereby approved.
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BY� ��' - �..,._.�-z...-�—,,,,�--
Approved by Mayor: Date � �'/
sy: ��< <���
Form Approved by City Attorney
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By: ` ����c� /) �. �.-„�.
Approved by Mayor for Submission to
Council
By:
I GREEN SHEET
O DEPARTMENT DIREGiOR
— 266-9132 "u'�" � cmnrrontiev
' (DAT� NUMBHR FOR ❑ BUDGEf DIRECiOA
ROUTING
n�/.i / OflDEX O MAYOR (OR ASSISTANT�
�X 7b
TOTAL # OF SIGNATURE PAGES
(CLIP ALL LOCATIONS FOR SIGNATURE�
94-533
N_ 34956
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CITY CAUNGIL
cm c�aK
FSh. & MGL SEfiViCES DIFi.
Siri A. Forde DBA Minnesota Youth Athletic Services requesCS Council approval
of her application for a new Gambling Manager's License at Over-The-Rainbow, 249 W. 7th St.
(ID �F14629)
_ PLANNING WMMISSION _ GVI�SERVICECOMMISSION
_ CIB COMMITTEE �
_ STAFF _
._o�sra�crcouar _
SUPPORTS WHICH CAUNCIL O&IECfIVE?
IFAPPqOVED'
PERSONAL SEHVICE CONTRACTS MUST AfiSWER SHE FOLLOWING QUESTIONS:
1. Has this personffirtn ever worketl under a contrect for this tlepartmentt -
YES NO
2. Has this personHirm ever been a city employee?
YES NO
3. Does Mis persoNFirtn possess a skill not normaliy possessetl by any curtent city employee?
YES NO
Ezplain al{ yes enswers on aeparete sheet antl etteeh to green aneet
'�r6`3n-`..�.�'` ...��2;+,?µr�ro� 9�0
SYire�S� �.1 r 6 �`.���
IF NOT
�
�OiAI AMOUNT OF TRANSACTION
COST/REVENUE BUDGETE� (CIRCLE ONE)
YES NO
°UNUIHG SOURCE ACTIYI7Y
'INANCIAL INFORMATION' (E%PLAIN)
Greensheet # 34956 L.I.E.P. REVIEW CNECKLIST oace: /��'S
In Trackef? �:3'R,�i a.pP'n Receivea ! a.pP'n arocessed
License iD # 14629 License Type: 6amblinQ Mana�er
Company Name: Siri A. Forde DBA: Minnesota Youth Athletic Services
Business Addresss: 249 W. 7th St. (Over-The-Rainbow) Business Phone: 781-2220
Coniact NameJAddress: Same Home Phone: 781-2220
4111 Central Ave NE Coli�mh;a urG_ 55421
Date to Council Research: '
PublicHearingDate: _� ��-� l$g�
Notice Sent to Appiicant:
Labels Ordered:
District Council
Notice Sent to
Ward #: 02
Department/ Date Inspections Comments
Ciry Attorney
Environmental
Health
Fire
License sice wan Receivea:_
Lease tiaceived:
Police �j��/�� „��� q,7T�dG!✓� /�� - � �
f`PC`a3ZY �' HEe'f' F--e' �/� C�//�°�
�/� �����'�/�
?oning
L:'.212
(fiev. 7/2192)
� NeM'
❑ a���
LAST NAME
Miiutesota Lawfui Gambiing
Gambiin,g Manager 1�pplicatian
FOq OFFtCE t1SE ONLY
aase uc a
sEC r
FEE
CHK
OATE
iNIT
Grve date tl�at the M�oday gambGng manager semirrar was �ornpleted. _Q,4,t2,],_��
Loca6onoftra;ning Roseville �
(pHl
Giva date of training raceived within thrae years prior to the date of the apPGcation tor renew.FJ. I I
Loca6on of trainin8 .
MIDDLE NAME MAIDEN � Dam of 9:M � Soc. Sea�rity Number
MEMBEASHIP: pate gambiing manager became a member oP the otganimtion 01 / 0 A� 91
of Ckganizanpn
Address
City/State Zip Coda
Sex : (] Male � Fema[�
�€ �'S' '�� N :.tn`�� , y ^+`.%
k. ;. �:A' { �fi t..).'"r >..'r.
L'�csnse Numher
APplyinq for
Phone
t612) 781-2220
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-- A 570.000 fidaGry bond in tavw of the txgaffiza6o��must bc abmined for the pamtrF.n7 m�nagse.
Name of insuranca company (do rrot use agancy namo� 2cr,� t'imter
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I dedare thaC
• i have read this application and aII infortna6on submitted ta the board;
• ali i�farmanon is cue, acwrate and compleoa;
• aU oU�ar required infortnation has baen fW1y disdosed;
• I am the only gembling manager of the organ'¢atan:
° I wiN famiGame myseif with tne faws of Mnnesota goveming lawful gambling and rules ct the board and agtee, if ticansed, to
abida by those laws and rules, induding amandments ro them;
• any changes in appGcaaon in�om�atio� witt ba submitied ro the 6card and tocat unit of gevemment within 10 days oE tha cfiarge:
• An affidaHt for gambiing manager has beeh mmplated and 9ttached, and
• I understand that (ailura m provide required infotmatlan Ct providi�g faise infotmatien may rasult in Cie de�ia! or reuceaCart of tlte
liwnsa.
SignaWre of GambGn9 �a9�' � 9ate '
�� ,'v.��...s._ 9 /! 5 /" S
Sertd the completed applicatian and ap required aaachments 4oa
GambNng Control Board
Sulte 300 S.
1711 W.County Road �
posevilie, MN 5.5113
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