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97-1063Council File � `� �'�GJ Ordinance # Green Sheet # 37907 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 �-,� • �.fi,� Presented By Referred To RESOLVED: That application, ID �`49864, for a new Gambling Manager'e License by Paulette D. %linger DBA Catholic Parents Club at Sherwood Lounge, 1418 White Bear Avenue N., be and the same is hereby approved. RESOLUTION CITY OF SAINT PAUL, MINNESOTA 3� Committee: Date Requested by Department of: • - -�-- �- - ..- -�. � i- - t �I . tf_, Form Approved by City Attor By: VVL�Ti�vc.-c�, ✓ ��-v.�.__ Approved by Mayor for Submission to By: Approved by Mayor: Date U��s��/� By: S� L' ` / _" By: Adopted by Council: Date a Adoption Certified by Council Secretary �t�-toG3 DEPAR7MEN7AFFICE/COUNdL DATE INITIATED �� J V� LIEP GREEN SHEE CONTACT PERSON & PHONE INITIAVDATE fNiT1ALIDATE �DEPARTMENTDIRECTOR �CITYCOUNCIL William F. Gunther - 266-9132 ^� O pTYATfORNEY O CffYCLERK Nuua�tFOR MUST BE ON CAUNCIL AGENDA BY (DATE) pOUTING � BUDGET DIRECTO � FIN, & MGT. SERVICES Dlfl. Hearin : �I e2 .� ORDEA O MAYOR (OR ASSISTAN� O TOTAL # OF SIGNATURE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE) ACTION REQUESTED: Paulette D. Klinger DBA Catholic Parents Club requests Council approval of her application for a new Gambling Manager's License, ID 1149864, at Sherwood I.ounge, 1418 White Sear Avenue N. RECOMMENDAT�ONS: Approva (A) rn Rejacl(q) pERSONAL SERVICE CONiRACTS MUST ANSWER TME FOLLOWING �UESTIONS: _ PLANNING COMMISSION _ CIVIL SERVIGE COMMISSION �� Nas tAis personffvm ever worketl untler a conirac[ for ihis department? _ CIB CAMMI7TEE _ �'ES NO _ S7AFF 2. Has this person/firm ever been a city employee? — YES NO _ DISiRIC7 CoURT _ 3. Does this personttirm possess a skill not normally possessed by any curtent city employee? SUPPOR75 WHICH COUNqL OBJECTNE? YES NO Explain all yes answe[s on seperate sheet antl attech to 9�een sheet INITIATING PR08LEM, ISSUE, OPPORTUNITY (Who. What, Whan, Where, Why): ADVANTA�ESIFAPPpOVED: DISADVANTAGES IF APPROVED: LtinastYS� � �� uv.r � ��tl�G `a 1�9T � DISADVANTAGES IF NOT APPflOVED. � 70iAL AMOUNT OF TRANSAC710N $ COST/REVENUE BUDGETED (CIRCLE ONE1 YES NO FUNDIfdG SOURCE ACTIVITY NUMBER FINANCIAL INFORN"iATION� (EXPLAIN) Greensheet # ��' �d L.I.E.P. REVIEW CHECKLlST oate: f In Trackef? 37907 app'n Received J npp'n Processea �? - l0�3 LicenselD # 49864 License Type: GamblinQ Manazer Cotnp3ny N2m2: Paulette D, Rlin¢er DBA: Catholic Parents Club SUSiness Addresss: 1418 White Bear Ave. (Sherwood) Business Phone: 771-8757 Contact Name/. Date to Council Public Hearing Date: � ��7� i�R'7 Notice Ser�t to Appiicant u�9� Notice Sent to Public: N/A Home Phone: 771-8757 Labels Ordered: N1A District Council #:. Ward 02 Department/ Date Inspections Comments City AttorneY Q� °'� l:-� � /TlTdr�� g/6I97 �/�/9� Environmental Health 1 �� Fire / "�� license Site Plan Received:� tease ReCeived: !"/ � C Po�,� ��j�� /�� . o�� Zoning �� 9�- �0�3 gy,$t STATE OF XINNESOTA FoR BOARD USE ONLY GAMBLING CONTROL BOARD AMT. PA2D GAHBLING XANAGER LZCEN58 REN6'WAL APPLZCATZON CHECK # LG212GMA PRINTED: 16/30j95 DATE LICENSE NllMBER: 0-00812 003 EFFECTIVE DATE: 07/O1/95 EXPIRATTON DATE: 06i30/46 NAME OF ORGANIZATION: Catholic Parents St Paul Club GAMSLIN6 MANAGER INFORMATZOH Paulette Delmar Rlinget �efi-�a '7 d b`E ;� 5 t.`J Y l� 14apbewee3-#8i--5�5�2-4 p GY.d a1 �, 1'n lV J S l a S DAYTIME PHONE NUMBER: 612-T36-4211 MEMBER SSNCE: O6J01/89 DATE OF BIRTH: 10/O1/59 SEX: F SOCIAL SECURITY NUMBER: 670-84-1169 LAST DATE YOU ATTENDED A GAMBLING MANAGERS SEMINARJCONTiNUING EDUCATION CLASS: 04/20/95 BOND TNFORMATION BaND COMPANY NAME: Old Republic BOND NUMBER: RP5405150 ACRN047LEDGME23T Y DECLARE THATs • I HAVE READ THIS APPLICATION AND ALL INFORMATION SUBMITTED TO THE GAMBLING CONTROL BOARD; • ALL YNFORMATION IS TRUE� ACCURATE AND COMPLETE� • ALL OTHER REQUIRED SNFORMATION HAS BEEN FULLY DISCLOSED; • I AM THE ONLY GAMBLING MANAGER OF THE ORGANlZRTION; • I HAVE BEEN AN ACTIVE MEMBER OF THE ORGANIZATTON FOR AT LEAST TWO YEARS; • I WILL FAMILIARIZE MY5ELF WITH THE LAWS OF MINNESOTA GOVERNING LAWFUL GAMBLYNG AND RULES OF THE GAMBLING CONTROL BOARp ANO AGREE� IF LICENSED, TO ABIOE THOSE LAWS AND RULES INCLUDING AMENDMENTS TO THEM; • ANY CHANGES IN A?PLICATTON INFORMATSON WILL BE SUBMZTTED TO THE GAMSLSNG CONTROL BOAftII AND LOCRL UNIT OF GOVERNMENT WITHFN 10 DAY5 OF THE CHANGE� � AN AFFIDAVIT FOR GAMBLING MANAGER HAS BEEN COMPLETED AND ATTACHED; AND • i UNDERSTAND THAT FAILURE TO PROVIDE REQUIRED INFORMATION OR PROVIDING FALSE OR MISLEADING INFORMATION MAY RESULT IN THE DENSAL OR REVOCATION OF THE LICENSE. SIGNATIJRE OF CAMSLSN� MANAGER �Cl.l.�'.11��. �"'�.4��.C DATE � " � `� " `� 4� REFER TO THE CHECRLYST FOR REQUIRED ATTACFiMENT3 MASL TOt GAMBLIN(i C6NTROL BOARD 1711 WEST COUISTY ROAD B, SUSTE 3003 ROSEVIIS,E, MSNNESOTA 55113 THIS FORM HILL BE MADE AVAILABLE IN ALTERNATIVE FORMAT (I.E. LARGE PRINT� BRAILLE) UPON REQUEST. e 7/QY1� LG213 Minnesota Gambiing Contro! Soard oai,arss Gambling Manaqer Atfidavit 0�'1- Attach to the Gamb{ing Manager Apptication, Fomt LG212 SYATE OF y�\ <<� � 2 � �=} c� ) AFFIDAVIT OF QUAUFiCATION ) s.s. FOF2 GAMBLING MANAGER LICENSE COUNTY OF � EZ cL �� 5 z�� AND CONSENT STATEMENT (Pursuant to Minnesota Stalutes and Ru{es} I, � Cc �.� � e }��z � � � +�� e < , Under oath state that: (type/print name) 1. I have never been convicted of a felony or a crime involving gambling. 2. 1 have not, within five years be(ore the date o( ihe license application, committed a violation o( law or Board rule that resulted in the revocation of a license issued by the Board. 3. I have never been convicied of a criminal violation involving fraud, theft, tax evasion, misrepresentation, or gamb4ing. 4. I have never been convicted of (i) assault, (ii) a criminai violation invofvir.g the use of a firearm, or (iii) making terroristic threats. 5. I am not, nor ever have been connected with or engaged in an illegal business. 6. i do not owe $S�� or more in deli�que�t taxes as defined in sectioa 2T0.72. 7. I have not had a safes and use tax permit revoked by the commissioner of revenue within the past two years. 8. I have never, afterdemand, failed to file tax retums required by the commissioner of revenue. In addition, I understand, agree and hereby irrevocatrly consent that suits and actions relating to the subjed matter of the attached gambiing manager license application, or acts or omissions arising from such app4ica- tion, may be commenced against my organization and I will accept the service of process for my organiza- tion i� any couA of competent jurfsdiction in Minnesota by service on th� Minnesota Secretary of State of any summons, process or pieading authorized by the iaws of tviinnesota. By signature of this dacument, fhe undersigned authorizes the Department of Public Safety tn conduct a criminai background check or review and to share the results with the Gambling Controi Board. Failure to provide required infortnation or providing false or misleading information may result in the denial or revocation of the license. FllR7HER AFFiANT SAYETH NOT, except that this Affidavit and Consent Statement are submitted in support of fhe appiication for a gambiing manager license from the Gambling Controi Board. NOTARY PUSUC /NFORMATION Notary Public Seai must Seal may not be altered. Subscribed and swom to befare me ihis ��day of � {�- t ` ,�Cl.�,�.Q..Z.�L. i�Xl,��r � (signature of applicant) ORGAN/ZAT/ON /NfORMATION of Organization ��,IXI�N�IlG.4{h4E80�A � � -' � 'NASHtY�TCNCOUNTY �� G� C �G; � � t�k 5 �`uU 117C:.nc,tss4.o£t�;as.an 2t.2000 tivw 9ase license Number .�, .-, n i � �oG3 Council File � `� �'�GJ Ordinance # Green Sheet # 37907 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 �-,� • �.fi,� Presented By Referred To RESOLVED: That application, ID �`49864, for a new Gambling Manager'e License by Paulette D. %linger DBA Catholic Parents Club at Sherwood Lounge, 1418 White Bear Avenue N., be and the same is hereby approved. RESOLUTION CITY OF SAINT PAUL, MINNESOTA 3� Committee: Date Requested by Department of: • - -�-- �- - ..- -�. � i- - t �I . tf_, Form Approved by City Attor By: VVL�Ti�vc.-c�, ✓ ��-v.�.__ Approved by Mayor for Submission to By: Approved by Mayor: Date U��s��/� By: S� L' ` / _" By: Adopted by Council: Date a Adoption Certified by Council Secretary �t�-toG3 DEPAR7MEN7AFFICE/COUNdL DATE INITIATED �� J V� LIEP GREEN SHEE CONTACT PERSON & PHONE INITIAVDATE fNiT1ALIDATE �DEPARTMENTDIRECTOR �CITYCOUNCIL William F. Gunther - 266-9132 ^� O pTYATfORNEY O CffYCLERK Nuua�tFOR MUST BE ON CAUNCIL AGENDA BY (DATE) pOUTING � BUDGET DIRECTO � FIN, & MGT. SERVICES Dlfl. Hearin : �I e2 .� ORDEA O MAYOR (OR ASSISTAN� O TOTAL # OF SIGNATURE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE) ACTION REQUESTED: Paulette D. Klinger DBA Catholic Parents Club requests Council approval of her application for a new Gambling Manager's License, ID 1149864, at Sherwood I.ounge, 1418 White Sear Avenue N. RECOMMENDAT�ONS: Approva (A) rn Rejacl(q) pERSONAL SERVICE CONiRACTS MUST ANSWER TME FOLLOWING �UESTIONS: _ PLANNING COMMISSION _ CIVIL SERVIGE COMMISSION �� Nas tAis personffvm ever worketl untler a conirac[ for ihis department? _ CIB CAMMI7TEE _ �'ES NO _ S7AFF 2. Has this person/firm ever been a city employee? — YES NO _ DISiRIC7 CoURT _ 3. Does this personttirm possess a skill not normally possessed by any curtent city employee? SUPPOR75 WHICH COUNqL OBJECTNE? YES NO Explain all yes answe[s on seperate sheet antl attech to 9�een sheet INITIATING PR08LEM, ISSUE, OPPORTUNITY (Who. What, Whan, Where, Why): ADVANTA�ESIFAPPpOVED: DISADVANTAGES IF APPROVED: LtinastYS� � �� uv.r � ��tl�G `a 1�9T � DISADVANTAGES IF NOT APPflOVED. � 70iAL AMOUNT OF TRANSAC710N $ COST/REVENUE BUDGETED (CIRCLE ONE1 YES NO FUNDIfdG SOURCE ACTIVITY NUMBER FINANCIAL INFORN"iATION� (EXPLAIN) Greensheet # ��' �d L.I.E.P. REVIEW CHECKLlST oate: f In Trackef? 37907 app'n Received J npp'n Processea �? - l0�3 LicenselD # 49864 License Type: GamblinQ Manazer Cotnp3ny N2m2: Paulette D, Rlin¢er DBA: Catholic Parents Club SUSiness Addresss: 1418 White Bear Ave. (Sherwood) Business Phone: 771-8757 Contact Name/. Date to Council Public Hearing Date: � ��7� i�R'7 Notice Ser�t to Appiicant u�9� Notice Sent to Public: N/A Home Phone: 771-8757 Labels Ordered: N1A District Council #:. Ward 02 Department/ Date Inspections Comments City AttorneY Q� °'� l:-� � /TlTdr�� g/6I97 �/�/9� Environmental Health 1 �� Fire / "�� license Site Plan Received:� tease ReCeived: !"/ � C Po�,� ��j�� /�� . o�� Zoning �� 9�- �0�3 gy,$t STATE OF XINNESOTA FoR BOARD USE ONLY GAMBLING CONTROL BOARD AMT. PA2D GAHBLING XANAGER LZCEN58 REN6'WAL APPLZCATZON CHECK # LG212GMA PRINTED: 16/30j95 DATE LICENSE NllMBER: 0-00812 003 EFFECTIVE DATE: 07/O1/95 EXPIRATTON DATE: 06i30/46 NAME OF ORGANIZATION: Catholic Parents St Paul Club GAMSLIN6 MANAGER INFORMATZOH Paulette Delmar Rlinget �efi-�a '7 d b`E ;� 5 t.`J Y l� 14apbewee3-#8i--5�5�2-4 p GY.d a1 �, 1'n lV J S l a S DAYTIME PHONE NUMBER: 612-T36-4211 MEMBER SSNCE: O6J01/89 DATE OF BIRTH: 10/O1/59 SEX: F SOCIAL SECURITY NUMBER: 670-84-1169 LAST DATE YOU ATTENDED A GAMBLING MANAGERS SEMINARJCONTiNUING EDUCATION CLASS: 04/20/95 BOND TNFORMATION BaND COMPANY NAME: Old Republic BOND NUMBER: RP5405150 ACRN047LEDGME23T Y DECLARE THATs • I HAVE READ THIS APPLICATION AND ALL INFORMATION SUBMITTED TO THE GAMBLING CONTROL BOARD; • ALL YNFORMATION IS TRUE� ACCURATE AND COMPLETE� • ALL OTHER REQUIRED SNFORMATION HAS BEEN FULLY DISCLOSED; • I AM THE ONLY GAMBLING MANAGER OF THE ORGANlZRTION; • I HAVE BEEN AN ACTIVE MEMBER OF THE ORGANIZATTON FOR AT LEAST TWO YEARS; • I WILL FAMILIARIZE MY5ELF WITH THE LAWS OF MINNESOTA GOVERNING LAWFUL GAMBLYNG AND RULES OF THE GAMBLING CONTROL BOARp ANO AGREE� IF LICENSED, TO ABIOE THOSE LAWS AND RULES INCLUDING AMENDMENTS TO THEM; • ANY CHANGES IN A?PLICATTON INFORMATSON WILL BE SUBMZTTED TO THE GAMSLSNG CONTROL BOAftII AND LOCRL UNIT OF GOVERNMENT WITHFN 10 DAY5 OF THE CHANGE� � AN AFFIDAVIT FOR GAMBLING MANAGER HAS BEEN COMPLETED AND ATTACHED; AND • i UNDERSTAND THAT FAILURE TO PROVIDE REQUIRED INFORMATION OR PROVIDING FALSE OR MISLEADING INFORMATION MAY RESULT IN THE DENSAL OR REVOCATION OF THE LICENSE. SIGNATIJRE OF CAMSLSN� MANAGER �Cl.l.�'.11��. �"'�.4��.C DATE � " � `� " `� 4� REFER TO THE CHECRLYST FOR REQUIRED ATTACFiMENT3 MASL TOt GAMBLIN(i C6NTROL BOARD 1711 WEST COUISTY ROAD B, SUSTE 3003 ROSEVIIS,E, MSNNESOTA 55113 THIS FORM HILL BE MADE AVAILABLE IN ALTERNATIVE FORMAT (I.E. LARGE PRINT� BRAILLE) UPON REQUEST. e 7/QY1� LG213 Minnesota Gambiing Contro! Soard oai,arss Gambling Manaqer Atfidavit 0�'1- Attach to the Gamb{ing Manager Apptication, Fomt LG212 SYATE OF y�\ <<� � 2 � �=} c� ) AFFIDAVIT OF QUAUFiCATION ) s.s. FOF2 GAMBLING MANAGER LICENSE COUNTY OF � EZ cL �� 5 z�� AND CONSENT STATEMENT (Pursuant to Minnesota Stalutes and Ru{es} I, � Cc �.� � e }��z � � � +�� e < , Under oath state that: (type/print name) 1. I have never been convicted of a felony or a crime involving gambling. 2. 1 have not, within five years be(ore the date o( ihe license application, committed a violation o( law or Board rule that resulted in the revocation of a license issued by the Board. 3. I have never been convicied of a criminal violation involving fraud, theft, tax evasion, misrepresentation, or gamb4ing. 4. I have never been convicted of (i) assault, (ii) a criminai violation invofvir.g the use of a firearm, or (iii) making terroristic threats. 5. I am not, nor ever have been connected with or engaged in an illegal business. 6. i do not owe $S�� or more in deli�que�t taxes as defined in sectioa 2T0.72. 7. I have not had a safes and use tax permit revoked by the commissioner of revenue within the past two years. 8. I have never, afterdemand, failed to file tax retums required by the commissioner of revenue. In addition, I understand, agree and hereby irrevocatrly consent that suits and actions relating to the subjed matter of the attached gambiing manager license application, or acts or omissions arising from such app4ica- tion, may be commenced against my organization and I will accept the service of process for my organiza- tion i� any couA of competent jurfsdiction in Minnesota by service on th� Minnesota Secretary of State of any summons, process or pieading authorized by the iaws of tviinnesota. By signature of this dacument, fhe undersigned authorizes the Department of Public Safety tn conduct a criminai background check or review and to share the results with the Gambling Controi Board. Failure to provide required infortnation or providing false or misleading information may result in the denial or revocation of the license. FllR7HER AFFiANT SAYETH NOT, except that this Affidavit and Consent Statement are submitted in support of fhe appiication for a gambiing manager license from the Gambling Controi Board. NOTARY PUSUC /NFORMATION Notary Public Seai must Seal may not be altered. Subscribed and swom to befare me ihis ��day of � {�- t ` ,�Cl.�,�.Q..Z.�L. i�Xl,��r � (signature of applicant) ORGAN/ZAT/ON /NfORMATION of Organization ��,IXI�N�IlG.4{h4E80�A � � -' � 'NASHtY�TCNCOUNTY �� G� C �G; � � t�k 5 �`uU 117C:.nc,tss4.o£t�;as.an 2t.2000 tivw 9ase license Number .�, .-, n i � �oG3 Council File � `� �'�GJ Ordinance # Green Sheet # 37907 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 �-,� • �.fi,� Presented By Referred To RESOLVED: That application, ID �`49864, for a new Gambling Manager'e License by Paulette D. %linger DBA Catholic Parents Club at Sherwood Lounge, 1418 White Bear Avenue N., be and the same is hereby approved. RESOLUTION CITY OF SAINT PAUL, MINNESOTA 3� Committee: Date Requested by Department of: • - -�-- �- - ..- -�. � i- - t �I . tf_, Form Approved by City Attor By: VVL�Ti�vc.-c�, ✓ ��-v.�.__ Approved by Mayor for Submission to By: Approved by Mayor: Date U��s��/� By: S� L' ` / _" By: Adopted by Council: Date a Adoption Certified by Council Secretary �t�-toG3 DEPAR7MEN7AFFICE/COUNdL DATE INITIATED �� J V� LIEP GREEN SHEE CONTACT PERSON & PHONE INITIAVDATE fNiT1ALIDATE �DEPARTMENTDIRECTOR �CITYCOUNCIL William F. Gunther - 266-9132 ^� O pTYATfORNEY O CffYCLERK Nuua�tFOR MUST BE ON CAUNCIL AGENDA BY (DATE) pOUTING � BUDGET DIRECTO � FIN, & MGT. SERVICES Dlfl. Hearin : �I e2 .� ORDEA O MAYOR (OR ASSISTAN� O TOTAL # OF SIGNATURE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE) ACTION REQUESTED: Paulette D. Klinger DBA Catholic Parents Club requests Council approval of her application for a new Gambling Manager's License, ID 1149864, at Sherwood I.ounge, 1418 White Sear Avenue N. RECOMMENDAT�ONS: Approva (A) rn Rejacl(q) pERSONAL SERVICE CONiRACTS MUST ANSWER TME FOLLOWING �UESTIONS: _ PLANNING COMMISSION _ CIVIL SERVIGE COMMISSION �� Nas tAis personffvm ever worketl untler a conirac[ for ihis department? _ CIB CAMMI7TEE _ �'ES NO _ S7AFF 2. Has this person/firm ever been a city employee? — YES NO _ DISiRIC7 CoURT _ 3. Does this personttirm possess a skill not normally possessed by any curtent city employee? SUPPOR75 WHICH COUNqL OBJECTNE? YES NO Explain all yes answe[s on seperate sheet antl attech to 9�een sheet INITIATING PR08LEM, ISSUE, OPPORTUNITY (Who. What, Whan, Where, Why): ADVANTA�ESIFAPPpOVED: DISADVANTAGES IF APPROVED: LtinastYS� � �� uv.r � ��tl�G `a 1�9T � DISADVANTAGES IF NOT APPflOVED. � 70iAL AMOUNT OF TRANSAC710N $ COST/REVENUE BUDGETED (CIRCLE ONE1 YES NO FUNDIfdG SOURCE ACTIVITY NUMBER FINANCIAL INFORN"iATION� (EXPLAIN) Greensheet # ��' �d L.I.E.P. REVIEW CHECKLlST oate: f In Trackef? 37907 app'n Received J npp'n Processea �? - l0�3 LicenselD # 49864 License Type: GamblinQ Manazer Cotnp3ny N2m2: Paulette D, Rlin¢er DBA: Catholic Parents Club SUSiness Addresss: 1418 White Bear Ave. (Sherwood) Business Phone: 771-8757 Contact Name/. Date to Council Public Hearing Date: � ��7� i�R'7 Notice Ser�t to Appiicant u�9� Notice Sent to Public: N/A Home Phone: 771-8757 Labels Ordered: N1A District Council #:. Ward 02 Department/ Date Inspections Comments City AttorneY Q� °'� l:-� � /TlTdr�� g/6I97 �/�/9� Environmental Health 1 �� Fire / "�� license Site Plan Received:� tease ReCeived: !"/ � C Po�,� ��j�� /�� . o�� Zoning �� 9�- �0�3 gy,$t STATE OF XINNESOTA FoR BOARD USE ONLY GAMBLING CONTROL BOARD AMT. PA2D GAHBLING XANAGER LZCEN58 REN6'WAL APPLZCATZON CHECK # LG212GMA PRINTED: 16/30j95 DATE LICENSE NllMBER: 0-00812 003 EFFECTIVE DATE: 07/O1/95 EXPIRATTON DATE: 06i30/46 NAME OF ORGANIZATION: Catholic Parents St Paul Club GAMSLIN6 MANAGER INFORMATZOH Paulette Delmar Rlinget �efi-�a '7 d b`E ;� 5 t.`J Y l� 14apbewee3-#8i--5�5�2-4 p GY.d a1 �, 1'n lV J S l a S DAYTIME PHONE NUMBER: 612-T36-4211 MEMBER SSNCE: O6J01/89 DATE OF BIRTH: 10/O1/59 SEX: F SOCIAL SECURITY NUMBER: 670-84-1169 LAST DATE YOU ATTENDED A GAMBLING MANAGERS SEMINARJCONTiNUING EDUCATION CLASS: 04/20/95 BOND TNFORMATION BaND COMPANY NAME: Old Republic BOND NUMBER: RP5405150 ACRN047LEDGME23T Y DECLARE THATs • I HAVE READ THIS APPLICATION AND ALL INFORMATION SUBMITTED TO THE GAMBLING CONTROL BOARD; • ALL YNFORMATION IS TRUE� ACCURATE AND COMPLETE� • ALL OTHER REQUIRED SNFORMATION HAS BEEN FULLY DISCLOSED; • I AM THE ONLY GAMBLING MANAGER OF THE ORGANlZRTION; • I HAVE BEEN AN ACTIVE MEMBER OF THE ORGANIZATTON FOR AT LEAST TWO YEARS; • I WILL FAMILIARIZE MY5ELF WITH THE LAWS OF MINNESOTA GOVERNING LAWFUL GAMBLYNG AND RULES OF THE GAMBLING CONTROL BOARp ANO AGREE� IF LICENSED, TO ABIOE THOSE LAWS AND RULES INCLUDING AMENDMENTS TO THEM; • ANY CHANGES IN A?PLICATTON INFORMATSON WILL BE SUBMZTTED TO THE GAMSLSNG CONTROL BOAftII AND LOCRL UNIT OF GOVERNMENT WITHFN 10 DAY5 OF THE CHANGE� � AN AFFIDAVIT FOR GAMBLING MANAGER HAS BEEN COMPLETED AND ATTACHED; AND • i UNDERSTAND THAT FAILURE TO PROVIDE REQUIRED INFORMATION OR PROVIDING FALSE OR MISLEADING INFORMATION MAY RESULT IN THE DENSAL OR REVOCATION OF THE LICENSE. SIGNATIJRE OF CAMSLSN� MANAGER �Cl.l.�'.11��. �"'�.4��.C DATE � " � `� " `� 4� REFER TO THE CHECRLYST FOR REQUIRED ATTACFiMENT3 MASL TOt GAMBLIN(i C6NTROL BOARD 1711 WEST COUISTY ROAD B, SUSTE 3003 ROSEVIIS,E, MSNNESOTA 55113 THIS FORM HILL BE MADE AVAILABLE IN ALTERNATIVE FORMAT (I.E. LARGE PRINT� BRAILLE) UPON REQUEST. e 7/QY1� LG213 Minnesota Gambiing Contro! Soard oai,arss Gambling Manaqer Atfidavit 0�'1- Attach to the Gamb{ing Manager Apptication, Fomt LG212 SYATE OF y�\ <<� � 2 � �=} c� ) AFFIDAVIT OF QUAUFiCATION ) s.s. FOF2 GAMBLING MANAGER LICENSE COUNTY OF � EZ cL �� 5 z�� AND CONSENT STATEMENT (Pursuant to Minnesota Stalutes and Ru{es} I, � Cc �.� � e }��z � � � +�� e < , Under oath state that: (type/print name) 1. I have never been convicted of a felony or a crime involving gambling. 2. 1 have not, within five years be(ore the date o( ihe license application, committed a violation o( law or Board rule that resulted in the revocation of a license issued by the Board. 3. I have never been convicied of a criminal violation involving fraud, theft, tax evasion, misrepresentation, or gamb4ing. 4. I have never been convicted of (i) assault, (ii) a criminai violation invofvir.g the use of a firearm, or (iii) making terroristic threats. 5. I am not, nor ever have been connected with or engaged in an illegal business. 6. i do not owe $S�� or more in deli�que�t taxes as defined in sectioa 2T0.72. 7. I have not had a safes and use tax permit revoked by the commissioner of revenue within the past two years. 8. I have never, afterdemand, failed to file tax retums required by the commissioner of revenue. In addition, I understand, agree and hereby irrevocatrly consent that suits and actions relating to the subjed matter of the attached gambiing manager license application, or acts or omissions arising from such app4ica- tion, may be commenced against my organization and I will accept the service of process for my organiza- tion i� any couA of competent jurfsdiction in Minnesota by service on th� Minnesota Secretary of State of any summons, process or pieading authorized by the iaws of tviinnesota. By signature of this dacument, fhe undersigned authorizes the Department of Public Safety tn conduct a criminai background check or review and to share the results with the Gambling Controi Board. Failure to provide required infortnation or providing false or misleading information may result in the denial or revocation of the license. FllR7HER AFFiANT SAYETH NOT, except that this Affidavit and Consent Statement are submitted in support of fhe appiication for a gambiing manager license from the Gambling Controi Board. NOTARY PUSUC /NFORMATION Notary Public Seai must Seal may not be altered. Subscribed and swom to befare me ihis ��day of � {�- t ` ,�Cl.�,�.Q..Z.�L. i�Xl,��r � (signature of applicant) ORGAN/ZAT/ON /NfORMATION of Organization ��,IXI�N�IlG.4{h4E80�A � � -' � 'NASHtY�TCNCOUNTY �� G� C �G; � � t�k 5 �`uU 117C:.nc,tss4.o£t�;as.an 2t.2000 tivw 9ase license Number .�, .-, n i � �oG3