97-1114Council File � q � - \\,�
Ordinance #
Green Sheet # 37914
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Presented By
Referred To
Committee: Date
RESOLVED: That application, ID #29467, for a Gambling Manager's License by Steven P.
Tibbetts DBA Church of the Incarnation at Pickles Lounge, 1082 Arcade Street,
be and the sazne is hereby approved.
Requested by Department of:
Office of License Znspections and
Fnv+ronmental Protection
$r � ���, �• �
Certified by Council Secretary
By:
Approved by Mayor:
Date
R�so�ur�orv
CITY OF SAINT PAllL, MiNNESOTA
3.2
Form Approved by City�rney
i ,/
BY � iSo� �� �� t�t linc/L
Approved by Ma� Submission to
Council
By:
�
Adopted by Council: Date 4
°l'l -1 \ �
DEPI�Ril�ENT�OFFIGEfCOUNqL OATE INITIATED � ! J � � �
LIEP GREEN SHEE
CONTACTPERSON&PHONE a�EPAHTMENTDIRECTOR adTYCOUNCIL �NRIAL/DATE
j5T1]_IldIR F. Gunther - 266-9132 p��� O CffYATfORNEY � CITYCLERK
MUST BE ON COUNCI� AGENDA BY �DATE) pOUiING � BUDGET DIREG70R O FIN. & MGT. SEMICES OIR.
Hearing: 9 jO �J ONDER � MAYOR (OR ASS15TANT� O
TOTAL # OF SIGNATURE PAGES (CLIP ALL LOCASIONS FOR SIGNATURE)
ACCbN RE�UESTED:
Steven P. Tibbetts DBA Church of the Incarnation requests Council approval of
his application for a Gambling Manager's License, ID /129467, at Pickles Lounge,
1082 Arcade St.
RECOMMENDATIONS: Approve (A) or Re�act (R) pERSONAL SERVICE CONTFAC75 MUST ANSWER THE FOLLOWING QUESTIONS:
_ PLANNING CAMMISSION _ CIVIL SERVICE COMMISSION �- Has this person/Firm ever worked under a contrac[ for this department?
_ pB COMMITfEE YES NO
_ STAFF 2. Has this perso�rm ever been a ciry employee?
— YES NO
_ oisiR�C7 CoURT _ 3. Does this personlfirm possess a skAi not normalty possessed by any curreM ciry empioyee?
SUPPORTS WHICH COUNCIL OBJECTIVE? YES NO
Explain all yes answers on separate sheet antl attach to green sheet
INITIATING PqOBLEM, ISSUE, OPP�RTUNITV(Wha, What, When, Whero. Why)
ADVANTAGESIFAPPROVED.
� y�g : _ �� � .$�'!
kE�€� 2 81�97
DISADVANTAGES IF APPROVED
DISADVANTAGES IF NOT APPROVED:
TOTAL AMOUNT OF TAANSACTfON $ COST7REVENUE BUDGETED (CIRCLE ONE) YES NO
FUNDIWG SOURCE NCTIVITY NUMBER
FINANCIAL INFORNiATION: (EXPLAIN)
LuLIZ
(Fiev, il7192)
Miruzesata LmUfu1 Gamblirtg
Gambling Manager Application
._. _ ,. - -,-
i nn...., .�,. .. . ,. _ .
Yvn vrr+i.c wc �,�
ASE 11C 7
SEQ x
FEE ,�a
CHK
DATE
INIT
❑ New Give c'ate �:zt che :wo-Cay Su-bLng m2r.ayer semi.�r wzs comple!ed. I l�
Lo�don cf ,�ining
Q Rer.ewd Give cz;� e( ,�ining :eceived •xi^:n :hree yeus pr'n � 7:e �'E ct ie app�i�Eon `cr renewzl. 2/=�� /°0
Lxa3cn cf :2ining `^'�l� ==T `s=��escta
.
_ ...,� .. ...... ... . i� il ..
��ambtin Mdnd ei In oi ` '`� � _ ' .
US7 NAMc FiFST �AMe MIDCLE N Mc � U�AIC�N �� Date of dirth �Soe Sec'nry 4�r5er
T±bbetts Steven ?atric':c 3/17/51 4i6-62-�869
Addre=s St�ie Z�p Cede � Cayor,.e Phcne
4633 l,t'� 3.e. So. iiiaaea�ol;s 'N 5�407 (61� 32°_-=�31
NEMcEn'Sri1P: Dzte gambLr.g mu,zcer becarne a rem�er of :he orcar.iza-en Z l 1 i 1 79 Sex :� Na`e �� Fenzle
.....� ., . .............. . .. . ... ,...., ...,.:. _ . . .. ,, ,.
.�;. . , ,_ . .. ,.... . .....
I37'�Q7ILZQCIOR I7t OT7TSQh072 . . . - , - .
Name ot R'c�nia:cn Licznse 4uroer
Chv*_ch ei tie I::carnatiea __ ��E'°
it�`�
Adcress CiryiS:a:e �:? Cocz Fhore
3817 ?'easant A.ve. So. "i�ne=oolis >{V 5�409 �612 � 82?-210_
:...,.. ... . . ,., �., ;... . . _ , .,
�n„- ,r � r.. i ^r OfTTtQ tOR -� � ' . � .. •
.
" A 570,JC� ide!i,y t»ne:n !2vcr �i the c yar�z>�en rest he cca�ncc `er me ;am.rng ma.syer.
Nar.,e ot insurnce com;,�r:Y ldo nct use asenry nsr„e) � '� c z�� S �'aarant!3and \u^,Ce� "`��-'�0 =�- :0 i 0:-?2-�
i dedare �ac
� t'nzve read;his acplicsficn sd il'v:forrrarion sucri:.2d :. :`e tc�rd;
�il infomatcn is ��e, ar-�r:a and amF�a��
• zil c�er rc�uired intorr„a�cn'r.� Seen h;ily cisdosed;
� 4 am �.e onSy gzr+bGrg r„xnager c( �a x
• i will zrnibz.se nyseif wi:i 3ie laws o( Mnnesca ycverirg ;zw ��� cznbiir,g u:d vies cf 1e bc2rd snC =cree, :i :ianse:. :o
aCick by icse kvrs and cvles, inc'uding amer��ers :n ie.�;
• any d�anges in zeptia.9cn intcnaticn wiil'x sucr,�iced to �`.e bczrd and icczl unit of gcvemment within 10 cays :i �5e cr.scce:
• An a`cav+t `or Sarnciir.g -�nscer `as treen cncle�ed er•d sazr'.eC, ar:d
• I uncerra+d ;ha: `aiivre a;rcvide required iricr�dcn cr prcviding :alse inicrmadrn may rzsmt in a:e :eai�l ar :zvccaecn �i ;.e
ficar.se. . _ _
Siyramre o( Gameiing
� 7zx
?122/°�
Ser,o the dmpfeted applicsticn and ail reeuired srtac�meNS ;o:
Garnbiing Controi °oasd
Saite 3G0 S.
77'!t Y�. Ccunty Rcad 3
F.oseville, MN 55113
�'i! Z�/
r �-a�=r
t.rzu Minnesota Lm�Jul Gamb11n9
��y. d,a9z� Gambling Manager Affidavit q`�l -\ �� y
Glttach to the Gambl!ng Yianager Appllcatlon, Form LG212)
STATEOF `dinra�nra� ) AFPIDAVITOF�UALlF1CATION
) ss. FOR G:M6UNG MANAGER IICENSE
COUNiY Gr" uE��e�i� ) AND CCtJSENTSTATEMENT
(Pursua�d to M.inr,eso,a Stat��te 3t9.16 Subd. 2(e)
a�d Minnesota Rula 7861,0030,Sutip.12B(3))
i, S[evez P. Tibbetts , Undet Octh St2te that:
(typelprint name)
1, i havs never been convided cf a teleny.
2, 1 have not, wdhin five years, committed a valation of law or bo2rd ruie that resutted in the
revocafan of a license issued by the Lawfui Gzmbiing CorYrol Board.
3. 1 have never b2en conviCed of a criminzt vication invoiving traud, ihe�, tax evasion,
misrapresentstion, or garr,bling.
4. I h2ve never been conviqed of 2ss2utt, a cri,�,in21 violation imciving the use of a fire2rri,
or malcing terroristic ihreats.
S. I 2m not zn assis,arrt gzmbiing manager fcr ary other organization.
8. i am r�ct a gambling mznager!cr zny oirer crsanizaticn.
(� �dditioa, l understand, agree and hereby irs2vocsb(y consent thst suRs and actions cefatirtg to the subject
matter of the attached g2mbiing m�nager licers2, or 2cts or omissions arising irom such appiication, m2y
be comrrenced ag2inst my org2niz2tion and t wili 2ccept the service of process for my organization in any
court oI campetent jurisdicfion in Minnesota ty s=rvice on the Minnesota Secretary of St�te of any summons,
prccess cr piezding authori-<ed by the I�ws cf Mirrescta.
Sy signature of this documeM, ihe undersigned authorizes the Department of Pubiic Safety to condud a
crimin2f b�ckground check or review 2nd to sh2re the resufls wiih the L2wfui Gambiing Control Board.
Faifure to provide required inicrm2tion ar providing faise or misieading iniormation may resutt ia the denia!
or revocation of the ticense.
Subscrbed and sworn to betore me ihis
2'1 d2y of J�J v ti1 � 9 �{ '�
�� r� �� t�
County `
C�_ �Q��
Notary Pub�ic`
My commissson expires `� � � ' 4�
CLAY D. AMUNDSON
H6SARY PUSUC • fAiNNE50TA
HENNEPfN COUNTY
My w�a� v�ua a-�s�za
� � /�L�1,lf
(Signature of appiic�ant - gambiing manager)
Churci of the Incarlation`
(Name o[ orgznizationj
00639-
L;'cense numbef
Council File � q � - \\,�
Ordinance #
Green Sheet # 37914
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19
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21
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25
26
27
28
29
30
Presented By
Referred To
Committee: Date
RESOLVED: That application, ID #29467, for a Gambling Manager's License by Steven P.
Tibbetts DBA Church of the Incarnation at Pickles Lounge, 1082 Arcade Street,
be and the sazne is hereby approved.
Requested by Department of:
Office of License Znspections and
Fnv+ronmental Protection
$r � ���, �• �
Certified by Council Secretary
By:
Approved by Mayor:
Date
R�so�ur�orv
CITY OF SAINT PAllL, MiNNESOTA
3.2
Form Approved by City�rney
i ,/
BY � iSo� �� �� t�t linc/L
Approved by Ma� Submission to
Council
By:
�
Adopted by Council: Date 4
°l'l -1 \ �
DEPI�Ril�ENT�OFFIGEfCOUNqL OATE INITIATED � ! J � � �
LIEP GREEN SHEE
CONTACTPERSON&PHONE a�EPAHTMENTDIRECTOR adTYCOUNCIL �NRIAL/DATE
j5T1]_IldIR F. Gunther - 266-9132 p��� O CffYATfORNEY � CITYCLERK
MUST BE ON COUNCI� AGENDA BY �DATE) pOUiING � BUDGET DIREG70R O FIN. & MGT. SEMICES OIR.
Hearing: 9 jO �J ONDER � MAYOR (OR ASS15TANT� O
TOTAL # OF SIGNATURE PAGES (CLIP ALL LOCASIONS FOR SIGNATURE)
ACCbN RE�UESTED:
Steven P. Tibbetts DBA Church of the Incarnation requests Council approval of
his application for a Gambling Manager's License, ID /129467, at Pickles Lounge,
1082 Arcade St.
RECOMMENDATIONS: Approve (A) or Re�act (R) pERSONAL SERVICE CONTFAC75 MUST ANSWER THE FOLLOWING QUESTIONS:
_ PLANNING CAMMISSION _ CIVIL SERVICE COMMISSION �- Has this person/Firm ever worked under a contrac[ for this department?
_ pB COMMITfEE YES NO
_ STAFF 2. Has this perso�rm ever been a ciry employee?
— YES NO
_ oisiR�C7 CoURT _ 3. Does this personlfirm possess a skAi not normalty possessed by any curreM ciry empioyee?
SUPPORTS WHICH COUNCIL OBJECTIVE? YES NO
Explain all yes answers on separate sheet antl attach to green sheet
INITIATING PqOBLEM, ISSUE, OPP�RTUNITV(Wha, What, When, Whero. Why)
ADVANTAGESIFAPPROVED.
� y�g : _ �� � .$�'!
kE�€� 2 81�97
DISADVANTAGES IF APPROVED
DISADVANTAGES IF NOT APPROVED:
TOTAL AMOUNT OF TAANSACTfON $ COST7REVENUE BUDGETED (CIRCLE ONE) YES NO
FUNDIWG SOURCE NCTIVITY NUMBER
FINANCIAL INFORNiATION: (EXPLAIN)
LuLIZ
(Fiev, il7192)
Miruzesata LmUfu1 Gamblirtg
Gambling Manager Application
._. _ ,. - -,-
i nn...., .�,. .. . ,. _ .
Yvn vrr+i.c wc �,�
ASE 11C 7
SEQ x
FEE ,�a
CHK
DATE
INIT
❑ New Give c'ate �:zt che :wo-Cay Su-bLng m2r.ayer semi.�r wzs comple!ed. I l�
Lo�don cf ,�ining
Q Rer.ewd Give cz;� e( ,�ining :eceived •xi^:n :hree yeus pr'n � 7:e �'E ct ie app�i�Eon `cr renewzl. 2/=�� /°0
Lxa3cn cf :2ining `^'�l� ==T `s=��escta
.
_ ...,� .. ...... ... . i� il ..
��ambtin Mdnd ei In oi ` '`� � _ ' .
US7 NAMc FiFST �AMe MIDCLE N Mc � U�AIC�N �� Date of dirth �Soe Sec'nry 4�r5er
T±bbetts Steven ?atric':c 3/17/51 4i6-62-�869
Addre=s St�ie Z�p Cede � Cayor,.e Phcne
4633 l,t'� 3.e. So. iiiaaea�ol;s 'N 5�407 (61� 32°_-=�31
NEMcEn'Sri1P: Dzte gambLr.g mu,zcer becarne a rem�er of :he orcar.iza-en Z l 1 i 1 79 Sex :� Na`e �� Fenzle
.....� ., . .............. . .. . ... ,...., ...,.:. _ . . .. ,, ,.
.�;. . , ,_ . .. ,.... . .....
I37'�Q7ILZQCIOR I7t OT7TSQh072 . . . - , - .
Name ot R'c�nia:cn Licznse 4uroer
Chv*_ch ei tie I::carnatiea __ ��E'°
it�`�
Adcress CiryiS:a:e �:? Cocz Fhore
3817 ?'easant A.ve. So. "i�ne=oolis >{V 5�409 �612 � 82?-210_
:...,.. ... . . ,., �., ;... . . _ , .,
�n„- ,r � r.. i ^r OfTTtQ tOR -� � ' . � .. •
.
" A 570,JC� ide!i,y t»ne:n !2vcr �i the c yar�z>�en rest he cca�ncc `er me ;am.rng ma.syer.
Nar.,e ot insurnce com;,�r:Y ldo nct use asenry nsr„e) � '� c z�� S �'aarant!3and \u^,Ce� "`��-'�0 =�- :0 i 0:-?2-�
i dedare �ac
� t'nzve read;his acplicsficn sd il'v:forrrarion sucri:.2d :. :`e tc�rd;
�il infomatcn is ��e, ar-�r:a and amF�a��
• zil c�er rc�uired intorr„a�cn'r.� Seen h;ily cisdosed;
� 4 am �.e onSy gzr+bGrg r„xnager c( �a x
• i will zrnibz.se nyseif wi:i 3ie laws o( Mnnesca ycverirg ;zw ��� cznbiir,g u:d vies cf 1e bc2rd snC =cree, :i :ianse:. :o
aCick by icse kvrs and cvles, inc'uding amer��ers :n ie.�;
• any d�anges in zeptia.9cn intcnaticn wiil'x sucr,�iced to �`.e bczrd and icczl unit of gcvemment within 10 cays :i �5e cr.scce:
• An a`cav+t `or Sarnciir.g -�nscer `as treen cncle�ed er•d sazr'.eC, ar:d
• I uncerra+d ;ha: `aiivre a;rcvide required iricr�dcn cr prcviding :alse inicrmadrn may rzsmt in a:e :eai�l ar :zvccaecn �i ;.e
ficar.se. . _ _
Siyramre o( Gameiing
� 7zx
?122/°�
Ser,o the dmpfeted applicsticn and ail reeuired srtac�meNS ;o:
Garnbiing Controi °oasd
Saite 3G0 S.
77'!t Y�. Ccunty Rcad 3
F.oseville, MN 55113
�'i! Z�/
r �-a�=r
t.rzu Minnesota Lm�Jul Gamb11n9
��y. d,a9z� Gambling Manager Affidavit q`�l -\ �� y
Glttach to the Gambl!ng Yianager Appllcatlon, Form LG212)
STATEOF `dinra�nra� ) AFPIDAVITOF�UALlF1CATION
) ss. FOR G:M6UNG MANAGER IICENSE
COUNiY Gr" uE��e�i� ) AND CCtJSENTSTATEMENT
(Pursua�d to M.inr,eso,a Stat��te 3t9.16 Subd. 2(e)
a�d Minnesota Rula 7861,0030,Sutip.12B(3))
i, S[evez P. Tibbetts , Undet Octh St2te that:
(typelprint name)
1, i havs never been convided cf a teleny.
2, 1 have not, wdhin five years, committed a valation of law or bo2rd ruie that resutted in the
revocafan of a license issued by the Lawfui Gzmbiing CorYrol Board.
3. 1 have never b2en conviCed of a criminzt vication invoiving traud, ihe�, tax evasion,
misrapresentstion, or garr,bling.
4. I h2ve never been conviqed of 2ss2utt, a cri,�,in21 violation imciving the use of a fire2rri,
or malcing terroristic ihreats.
S. I 2m not zn assis,arrt gzmbiing manager fcr ary other organization.
8. i am r�ct a gambling mznager!cr zny oirer crsanizaticn.
(� �dditioa, l understand, agree and hereby irs2vocsb(y consent thst suRs and actions cefatirtg to the subject
matter of the attached g2mbiing m�nager licers2, or 2cts or omissions arising irom such appiication, m2y
be comrrenced ag2inst my org2niz2tion and t wili 2ccept the service of process for my organization in any
court oI campetent jurisdicfion in Minnesota ty s=rvice on the Minnesota Secretary of St�te of any summons,
prccess cr piezding authori-<ed by the I�ws cf Mirrescta.
Sy signature of this documeM, ihe undersigned authorizes the Department of Pubiic Safety to condud a
crimin2f b�ckground check or review 2nd to sh2re the resufls wiih the L2wfui Gambiing Control Board.
Faifure to provide required inicrm2tion ar providing faise or misieading iniormation may resutt ia the denia!
or revocation of the ticense.
Subscrbed and sworn to betore me ihis
2'1 d2y of J�J v ti1 � 9 �{ '�
�� r� �� t�
County `
C�_ �Q��
Notary Pub�ic`
My commissson expires `� � � ' 4�
CLAY D. AMUNDSON
H6SARY PUSUC • fAiNNE50TA
HENNEPfN COUNTY
My w�a� v�ua a-�s�za
� � /�L�1,lf
(Signature of appiic�ant - gambiing manager)
Churci of the Incarlation`
(Name o[ orgznizationj
00639-
L;'cense numbef
Council File � q � - \\,�
Ordinance #
Green Sheet # 37914
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
Presented By
Referred To
Committee: Date
RESOLVED: That application, ID #29467, for a Gambling Manager's License by Steven P.
Tibbetts DBA Church of the Incarnation at Pickles Lounge, 1082 Arcade Street,
be and the sazne is hereby approved.
Requested by Department of:
Office of License Znspections and
Fnv+ronmental Protection
$r � ���, �• �
Certified by Council Secretary
By:
Approved by Mayor:
Date
R�so�ur�orv
CITY OF SAINT PAllL, MiNNESOTA
3.2
Form Approved by City�rney
i ,/
BY � iSo� �� �� t�t linc/L
Approved by Ma� Submission to
Council
By:
�
Adopted by Council: Date 4
°l'l -1 \ �
DEPI�Ril�ENT�OFFIGEfCOUNqL OATE INITIATED � ! J � � �
LIEP GREEN SHEE
CONTACTPERSON&PHONE a�EPAHTMENTDIRECTOR adTYCOUNCIL �NRIAL/DATE
j5T1]_IldIR F. Gunther - 266-9132 p��� O CffYATfORNEY � CITYCLERK
MUST BE ON COUNCI� AGENDA BY �DATE) pOUiING � BUDGET DIREG70R O FIN. & MGT. SEMICES OIR.
Hearing: 9 jO �J ONDER � MAYOR (OR ASS15TANT� O
TOTAL # OF SIGNATURE PAGES (CLIP ALL LOCASIONS FOR SIGNATURE)
ACCbN RE�UESTED:
Steven P. Tibbetts DBA Church of the Incarnation requests Council approval of
his application for a Gambling Manager's License, ID /129467, at Pickles Lounge,
1082 Arcade St.
RECOMMENDATIONS: Approve (A) or Re�act (R) pERSONAL SERVICE CONTFAC75 MUST ANSWER THE FOLLOWING QUESTIONS:
_ PLANNING CAMMISSION _ CIVIL SERVICE COMMISSION �- Has this person/Firm ever worked under a contrac[ for this department?
_ pB COMMITfEE YES NO
_ STAFF 2. Has this perso�rm ever been a ciry employee?
— YES NO
_ oisiR�C7 CoURT _ 3. Does this personlfirm possess a skAi not normalty possessed by any curreM ciry empioyee?
SUPPORTS WHICH COUNCIL OBJECTIVE? YES NO
Explain all yes answers on separate sheet antl attach to green sheet
INITIATING PqOBLEM, ISSUE, OPP�RTUNITV(Wha, What, When, Whero. Why)
ADVANTAGESIFAPPROVED.
� y�g : _ �� � .$�'!
kE�€� 2 81�97
DISADVANTAGES IF APPROVED
DISADVANTAGES IF NOT APPROVED:
TOTAL AMOUNT OF TAANSACTfON $ COST7REVENUE BUDGETED (CIRCLE ONE) YES NO
FUNDIWG SOURCE NCTIVITY NUMBER
FINANCIAL INFORNiATION: (EXPLAIN)
LuLIZ
(Fiev, il7192)
Miruzesata LmUfu1 Gamblirtg
Gambling Manager Application
._. _ ,. - -,-
i nn...., .�,. .. . ,. _ .
Yvn vrr+i.c wc �,�
ASE 11C 7
SEQ x
FEE ,�a
CHK
DATE
INIT
❑ New Give c'ate �:zt che :wo-Cay Su-bLng m2r.ayer semi.�r wzs comple!ed. I l�
Lo�don cf ,�ining
Q Rer.ewd Give cz;� e( ,�ining :eceived •xi^:n :hree yeus pr'n � 7:e �'E ct ie app�i�Eon `cr renewzl. 2/=�� /°0
Lxa3cn cf :2ining `^'�l� ==T `s=��escta
.
_ ...,� .. ...... ... . i� il ..
��ambtin Mdnd ei In oi ` '`� � _ ' .
US7 NAMc FiFST �AMe MIDCLE N Mc � U�AIC�N �� Date of dirth �Soe Sec'nry 4�r5er
T±bbetts Steven ?atric':c 3/17/51 4i6-62-�869
Addre=s St�ie Z�p Cede � Cayor,.e Phcne
4633 l,t'� 3.e. So. iiiaaea�ol;s 'N 5�407 (61� 32°_-=�31
NEMcEn'Sri1P: Dzte gambLr.g mu,zcer becarne a rem�er of :he orcar.iza-en Z l 1 i 1 79 Sex :� Na`e �� Fenzle
.....� ., . .............. . .. . ... ,...., ...,.:. _ . . .. ,, ,.
.�;. . , ,_ . .. ,.... . .....
I37'�Q7ILZQCIOR I7t OT7TSQh072 . . . - , - .
Name ot R'c�nia:cn Licznse 4uroer
Chv*_ch ei tie I::carnatiea __ ��E'°
it�`�
Adcress CiryiS:a:e �:? Cocz Fhore
3817 ?'easant A.ve. So. "i�ne=oolis >{V 5�409 �612 � 82?-210_
:...,.. ... . . ,., �., ;... . . _ , .,
�n„- ,r � r.. i ^r OfTTtQ tOR -� � ' . � .. •
.
" A 570,JC� ide!i,y t»ne:n !2vcr �i the c yar�z>�en rest he cca�ncc `er me ;am.rng ma.syer.
Nar.,e ot insurnce com;,�r:Y ldo nct use asenry nsr„e) � '� c z�� S �'aarant!3and \u^,Ce� "`��-'�0 =�- :0 i 0:-?2-�
i dedare �ac
� t'nzve read;his acplicsficn sd il'v:forrrarion sucri:.2d :. :`e tc�rd;
�il infomatcn is ��e, ar-�r:a and amF�a��
• zil c�er rc�uired intorr„a�cn'r.� Seen h;ily cisdosed;
� 4 am �.e onSy gzr+bGrg r„xnager c( �a x
• i will zrnibz.se nyseif wi:i 3ie laws o( Mnnesca ycverirg ;zw ��� cznbiir,g u:d vies cf 1e bc2rd snC =cree, :i :ianse:. :o
aCick by icse kvrs and cvles, inc'uding amer��ers :n ie.�;
• any d�anges in zeptia.9cn intcnaticn wiil'x sucr,�iced to �`.e bczrd and icczl unit of gcvemment within 10 cays :i �5e cr.scce:
• An a`cav+t `or Sarnciir.g -�nscer `as treen cncle�ed er•d sazr'.eC, ar:d
• I uncerra+d ;ha: `aiivre a;rcvide required iricr�dcn cr prcviding :alse inicrmadrn may rzsmt in a:e :eai�l ar :zvccaecn �i ;.e
ficar.se. . _ _
Siyramre o( Gameiing
� 7zx
?122/°�
Ser,o the dmpfeted applicsticn and ail reeuired srtac�meNS ;o:
Garnbiing Controi °oasd
Saite 3G0 S.
77'!t Y�. Ccunty Rcad 3
F.oseville, MN 55113
�'i! Z�/
r �-a�=r
t.rzu Minnesota Lm�Jul Gamb11n9
��y. d,a9z� Gambling Manager Affidavit q`�l -\ �� y
Glttach to the Gambl!ng Yianager Appllcatlon, Form LG212)
STATEOF `dinra�nra� ) AFPIDAVITOF�UALlF1CATION
) ss. FOR G:M6UNG MANAGER IICENSE
COUNiY Gr" uE��e�i� ) AND CCtJSENTSTATEMENT
(Pursua�d to M.inr,eso,a Stat��te 3t9.16 Subd. 2(e)
a�d Minnesota Rula 7861,0030,Sutip.12B(3))
i, S[evez P. Tibbetts , Undet Octh St2te that:
(typelprint name)
1, i havs never been convided cf a teleny.
2, 1 have not, wdhin five years, committed a valation of law or bo2rd ruie that resutted in the
revocafan of a license issued by the Lawfui Gzmbiing CorYrol Board.
3. 1 have never b2en conviCed of a criminzt vication invoiving traud, ihe�, tax evasion,
misrapresentstion, or garr,bling.
4. I h2ve never been conviqed of 2ss2utt, a cri,�,in21 violation imciving the use of a fire2rri,
or malcing terroristic ihreats.
S. I 2m not zn assis,arrt gzmbiing manager fcr ary other organization.
8. i am r�ct a gambling mznager!cr zny oirer crsanizaticn.
(� �dditioa, l understand, agree and hereby irs2vocsb(y consent thst suRs and actions cefatirtg to the subject
matter of the attached g2mbiing m�nager licers2, or 2cts or omissions arising irom such appiication, m2y
be comrrenced ag2inst my org2niz2tion and t wili 2ccept the service of process for my organization in any
court oI campetent jurisdicfion in Minnesota ty s=rvice on the Minnesota Secretary of St�te of any summons,
prccess cr piezding authori-<ed by the I�ws cf Mirrescta.
Sy signature of this documeM, ihe undersigned authorizes the Department of Pubiic Safety to condud a
crimin2f b�ckground check or review 2nd to sh2re the resufls wiih the L2wfui Gambiing Control Board.
Faifure to provide required inicrm2tion ar providing faise or misieading iniormation may resutt ia the denia!
or revocation of the ticense.
Subscrbed and sworn to betore me ihis
2'1 d2y of J�J v ti1 � 9 �{ '�
�� r� �� t�
County `
C�_ �Q��
Notary Pub�ic`
My commissson expires `� � � ' 4�
CLAY D. AMUNDSON
H6SARY PUSUC • fAiNNE50TA
HENNEPfN COUNTY
My w�a� v�ua a-�s�za
� � /�L�1,lf
(Signature of appiic�ant - gambiing manager)
Churci of the Incarlation`
(Name o[ orgznizationj
00639-
L;'cense numbef