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97-1364Council File # g7 " �� Ordinance # Green Sheet # 50248 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 2B 23 24 25 26 27 28 Presented By RESOLUTION CITY OF SAINT PAUL, MINNESOTA 37 Committee: Date Porm Approved by City Atto� By: � Approved b ayor for Submission to Council Referred To RESOLVED: That application, ID #98324, for a Gambling Manager's License by Steven R. Leafgren DBA Arcade Business Association at Minnesota Music Club, 499 Payne Avenue, be and the same is hereby approved. Requested by Department of: • - .-�-- �-•-• •�.- .:. a� ..•e_s� , - •e i� � Adoption Certified by Council Secretary BY� � c-� 'b— � \-� e-t—k�/�—.� Appraved by Mayor: Date f �� 2�.-�� By: � By: Adopted by Council: Date � \a_\�'��"� �� N° 50248 ��-�.�iu OEFAHTMENLOFFICEICOUNCII. DATE INITIATEO � � c � LIEP GREEN SHEE CONTACT PERSON 8 PHONE INITIAUDATE fNITIAVDATE � DEPAqTMENTDIRE � CINCOUNpL William F. Gunther - 266-9132 ASSIGN OCITYATfOqNEV �CITYCLERK MUST BE ON COUNCIL AGENDA BY (DATE) NUMBER FOR O BUDGET DIRECTOR � FIN. 8 MGT SEFVICES DIR. NOUTING Hearing: j � ORDEN O MAYOR (OR ASSISfANT) ❑ TOTAL # OF SIGNATURE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE) ACTION flEQUESTED: Steven R. Leafgren DBA Payne-Arcade Business Association requesCS Council approval of his application for a Gambling Manager's License, ID 4698324, at Minnesota Music Club, 499 Payne Avenue. aECOMMENDATIONS: Approve (A) w Rejett (R) pERSONAL SERYICE COt3TRACTS MUST ANSWER THE FOILOWING �UESTIONS: , PIANNING COMMISSION _ CIVIL SERVICE COMMISSION �- Has this person/Firm ever worketl untler a conhact for this department? ._ CIB CAMMITTEE YES NO � STAFF 2. Has this personHirm ever been a city empiqree? — YES NO _ D�Sia�CiCOURT — 3. Does this personRirm possess a skill not normail ossessed b an curreM y p y y city employae? SUPPORT$ WHICH CAUNCIL OBJECTIVE? YES NO Expialn all yes answers on seperate aheet anE enach to green sheet INITIATING PROBLEM, ISSUE. OPPORTUNITV (Who. What WMn. VJhere. Why)� ADVANTAGES IF APPROVED: - ° ��- • : �: w , ;�_,.� _ ""�- - �,��_: _--__. DISADVANTAGESIFAPPROVED: � - -- �o,.�.,,., DISADVANTAGES IF N07APPROVED � � "�� UCT 3 4 i997 TOTAL AMOUNT OF TRANSACTION S - COST/REVENUE BUDGETED (CIRCLE ONE) VES NO FUNDING SOURCE ACTIVITY NUMBEH FINANpAL INFORMATION. (EXPLpIN) � � - i,�� EBat STATE OF MINNESOTA IFOR BOARD IISE ONLYI GAMBLING CONTROL BOARD ,AMT. PAID � GAMBLING MANAGER L7CENSE RENEWAL APPLICATION ICHECK # I LG212GMR PRINTED: 04/03/96 �DATE I LICENSE NUMBER: G-03785 001 EFFECTIVE DATE: 10/O1/94 EXPIRATION DATE: 09/30/96 NAME OF ORGANIZATZON: Businesa St Paul Payne Arcade Assoc Steven Robert Leafgren 6478 Beckman Ave Inver Grove Ate MN 55077 DAYTIME PHONE NUMBER: 612-776-2706 MEMBER SINCE: 12/30/86 LAST DATE YOU ATTENDED A GAMBLING MANAGERS SEMINAR/CONTINUING EDUCATION CLASS: BOND INFORbfATION BOND COMPANY NAME: Travelera Indemnity BOND NUMBER: 650J5974 law�-Q- P"��e'� Ndv . �l5 Sa-, Clo�� 11/18/94 DECLARE THAT: . I HAVE READ TAIS APPLICATION AND ALL INFORMATION SUSMITTED TO THE GAMBLING CONTROL BOARD; ALL INFORMATION IS TRUE, ACCURATE AND COMPLETE; ALL OTHER REQUIRED SNFORMATION HAS BEEN FULLY DISCLOSED; I AM THE ONLY GAMBLTNG MANAGER OF THE ORGANIZATZON; I HAVE BEEN AN ACTIVE MEMBER OF THE ORGANIZATION FOR AT LEAST TWO YEARS; I WILL FAMILIARIZE MYSELF WITA THE LAWS OF MINNESOTA GOVERNING LAWFUL GAMBLING AND RULES OF THE GAMBLING CONTROL BOARD AND AGREE, IF LICENSED, TO ABIDE THOSE LAWS AND RULES, INCLiJDING AMENDMENTS TO THEM; � ANY CHANGES IN APPLICATION INFORMATION WILL BE SUBMITTED TO THE GAMBLING CONTROL BOARD AND LOCAL UNIT OF GOVERNMENT WITHIN 10 DAYS OF THE CHANGE; AN AFFIDAVZT FOR GAMBLING MANAGER HAS BEEN COMPLETED AND ATTACfiED; AND I UNDERSTAND THAT FAILURE TO PROVIDE REQUIRED INFORMATION OR PROVIDING FALSE OR MISLEADING INFORMATION MAY RESt7LT IN THE DENIAL OR REVOCATION OF THE LICENSE. SIGy SIIRFs OF GAM a�� r--- DATE 6-t-�b REFER TO TAE CHECKLIST FOR REQUIRED ATTACHMENT3 MAIL TO: GAMBLING CONTROL BOARD 1711 WEST COUNTY ROAD S, SUITE 3005 ROSEVILLE� MINNESOTA 55113 THIS FORM WILL BE MADE AVAILABLE IN ALTERNATIVE FORMAT (I.E. LARGE PRINT, HRAILLE) UPON REQUEST GAMBLING MANAGER INFORMATION DATE OF BIRTH: 11/29/60 SEX: M SOCIAL SECURITY NUMBER: 468-88-3779 ��3Z�� p�� q�� LG213 04/18/95 STATE OF COUNTY OF Minnesofa Gamblrng Control Bcard Gambling Manager Affidavit 9 � "�3 � �/ Attach to the Gambiing Manager Application, Form LG212 ►VL i nc�¢So �G— � AFFIDAVIT OF QUALIFICATION /� ) s.s. FOR GAMBLfNG MANAGER LfCENSE Y� M �/ � AND CONSENT STATEMENT �� (Pursuant to Minnesota Statutes and Ru(es) --� �, ��GVG/1 �� LCAt� fYi1�-- , Under oath state that: . (typelprint name) ' 1. i have never been convicted of a felony or a crime involving gambiing. 2. ! have not, within five years before the date of the license apptication, committed a violation of !aw or Board rule that resulted in the revocation of a license issued by the Boarc9. 3. i have never been convicted of a criminal violation involving fraud, theft, tax evasion, misrepresentation, or gambling. 4. 1 have never been convicted of (i) assault, (ii) a criminal violation involving the use of a fireaRn, or {iii) making terroristic threats. 5. i am not, nor ever have been connected with or engaged in an iilegal business. 6. I do not owe $50� or more in delinquent taxes as defined in section 270.72. 7. i have not had a sales and use tax permit revoked by the commissioner of revenue within the past two years. 8. I have never, after demand, failed to file tax retums required by the commissioner of revenue. In addition, 1 understand, agree and hereby irrevocab{y consent that suits and actions relating to the subject matter of the attached gambling manager iicense applicatio�, or acts or omissions arising from such applica- tion, may be commenced against my organization and I will accept the service of process for my organiza- tion in any court of competent jurisdiction in Minnesota by service on the Minnesota Secretary of State of any summons, process or pleading authorized by lhe laws of Minnesota. By signature of this document, the undersigned authorizes the Department of Pubiic Safety to conduct a criminal background check or review and to share the results with the Gambli�g Controt Board. Failure to provide required information or providing false or misleading information may result in the denial of revocation of the license. FURTFiER AFFIANT SAYETH NOT, except fhat this Affidavit and Consent Statement are submitted in support of the application for a gambling manager license from the bling Control Board. NOTARY PUBLlC INFORMATION � � Notary Pubiic Seal must be current and corsect. (signature of app i nt) i Seal may not be altered. Subscribed and sworn to before me ihis of <��, ce� 19 ORGANiZAT10N INFORMAT/ON of Organization MARCEY i.. NoTr�vPUauo• (CcVrie ' �7'CSc(�L. �R9�- �6(Sir�tSS Yf'�SOL Licen Number �-o��?�� Council File # g7 " �� Ordinance # Green Sheet # 50248 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 2B 23 24 25 26 27 28 Presented By RESOLUTION CITY OF SAINT PAUL, MINNESOTA 37 Committee: Date Porm Approved by City Atto� By: � Approved b ayor for Submission to Council Referred To RESOLVED: That application, ID #98324, for a Gambling Manager's License by Steven R. Leafgren DBA Arcade Business Association at Minnesota Music Club, 499 Payne Avenue, be and the same is hereby approved. Requested by Department of: • - .-�-- �-•-• •�.- .:. a� ..•e_s� , - •e i� � Adoption Certified by Council Secretary BY� � c-� 'b— � \-� e-t—k�/�—.� Appraved by Mayor: Date f �� 2�.-�� By: � By: Adopted by Council: Date � \a_\�'��"� �� N° 50248 ��-�.�iu OEFAHTMENLOFFICEICOUNCII. DATE INITIATEO � � c � LIEP GREEN SHEE CONTACT PERSON 8 PHONE INITIAUDATE fNITIAVDATE � DEPAqTMENTDIRE � CINCOUNpL William F. Gunther - 266-9132 ASSIGN OCITYATfOqNEV �CITYCLERK MUST BE ON COUNCIL AGENDA BY (DATE) NUMBER FOR O BUDGET DIRECTOR � FIN. 8 MGT SEFVICES DIR. NOUTING Hearing: j � ORDEN O MAYOR (OR ASSISfANT) ❑ TOTAL # OF SIGNATURE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE) ACTION flEQUESTED: Steven R. Leafgren DBA Payne-Arcade Business Association requesCS Council approval of his application for a Gambling Manager's License, ID 4698324, at Minnesota Music Club, 499 Payne Avenue. aECOMMENDATIONS: Approve (A) w Rejett (R) pERSONAL SERYICE COt3TRACTS MUST ANSWER THE FOILOWING �UESTIONS: , PIANNING COMMISSION _ CIVIL SERVICE COMMISSION �- Has this person/Firm ever worketl untler a conhact for this department? ._ CIB CAMMITTEE YES NO � STAFF 2. Has this personHirm ever been a city empiqree? — YES NO _ D�Sia�CiCOURT — 3. Does this personRirm possess a skill not normail ossessed b an curreM y p y y city employae? SUPPORT$ WHICH CAUNCIL OBJECTIVE? YES NO Expialn all yes answers on seperate aheet anE enach to green sheet INITIATING PROBLEM, ISSUE. OPPORTUNITV (Who. What WMn. VJhere. Why)� ADVANTAGES IF APPROVED: - ° ��- • : �: w , ;�_,.� _ ""�- - �,��_: _--__. DISADVANTAGESIFAPPROVED: � - -- �o,.�.,,., DISADVANTAGES IF N07APPROVED � � "�� UCT 3 4 i997 TOTAL AMOUNT OF TRANSACTION S - COST/REVENUE BUDGETED (CIRCLE ONE) VES NO FUNDING SOURCE ACTIVITY NUMBEH FINANpAL INFORMATION. (EXPLpIN) � � - i,�� EBat STATE OF MINNESOTA IFOR BOARD IISE ONLYI GAMBLING CONTROL BOARD ,AMT. PAID � GAMBLING MANAGER L7CENSE RENEWAL APPLICATION ICHECK # I LG212GMR PRINTED: 04/03/96 �DATE I LICENSE NUMBER: G-03785 001 EFFECTIVE DATE: 10/O1/94 EXPIRATION DATE: 09/30/96 NAME OF ORGANIZATZON: Businesa St Paul Payne Arcade Assoc Steven Robert Leafgren 6478 Beckman Ave Inver Grove Ate MN 55077 DAYTIME PHONE NUMBER: 612-776-2706 MEMBER SINCE: 12/30/86 LAST DATE YOU ATTENDED A GAMBLING MANAGERS SEMINAR/CONTINUING EDUCATION CLASS: BOND INFORbfATION BOND COMPANY NAME: Travelera Indemnity BOND NUMBER: 650J5974 law�-Q- P"��e'� Ndv . �l5 Sa-, Clo�� 11/18/94 DECLARE THAT: . I HAVE READ TAIS APPLICATION AND ALL INFORMATION SUSMITTED TO THE GAMBLING CONTROL BOARD; ALL INFORMATION IS TRUE, ACCURATE AND COMPLETE; ALL OTHER REQUIRED SNFORMATION HAS BEEN FULLY DISCLOSED; I AM THE ONLY GAMBLTNG MANAGER OF THE ORGANIZATZON; I HAVE BEEN AN ACTIVE MEMBER OF THE ORGANIZATION FOR AT LEAST TWO YEARS; I WILL FAMILIARIZE MYSELF WITA THE LAWS OF MINNESOTA GOVERNING LAWFUL GAMBLING AND RULES OF THE GAMBLING CONTROL BOARD AND AGREE, IF LICENSED, TO ABIDE THOSE LAWS AND RULES, INCLiJDING AMENDMENTS TO THEM; � ANY CHANGES IN APPLICATION INFORMATION WILL BE SUBMITTED TO THE GAMBLING CONTROL BOARD AND LOCAL UNIT OF GOVERNMENT WITHIN 10 DAYS OF THE CHANGE; AN AFFIDAVZT FOR GAMBLING MANAGER HAS BEEN COMPLETED AND ATTACfiED; AND I UNDERSTAND THAT FAILURE TO PROVIDE REQUIRED INFORMATION OR PROVIDING FALSE OR MISLEADING INFORMATION MAY RESt7LT IN THE DENIAL OR REVOCATION OF THE LICENSE. SIGy SIIRFs OF GAM a�� r--- DATE 6-t-�b REFER TO TAE CHECKLIST FOR REQUIRED ATTACHMENT3 MAIL TO: GAMBLING CONTROL BOARD 1711 WEST COUNTY ROAD S, SUITE 3005 ROSEVILLE� MINNESOTA 55113 THIS FORM WILL BE MADE AVAILABLE IN ALTERNATIVE FORMAT (I.E. LARGE PRINT, HRAILLE) UPON REQUEST GAMBLING MANAGER INFORMATION DATE OF BIRTH: 11/29/60 SEX: M SOCIAL SECURITY NUMBER: 468-88-3779 ��3Z�� p�� q�� LG213 04/18/95 STATE OF COUNTY OF Minnesofa Gamblrng Control Bcard Gambling Manager Affidavit 9 � "�3 � �/ Attach to the Gambiing Manager Application, Form LG212 ►VL i nc�¢So �G— � AFFIDAVIT OF QUALIFICATION /� ) s.s. FOR GAMBLfNG MANAGER LfCENSE Y� M �/ � AND CONSENT STATEMENT �� (Pursuant to Minnesota Statutes and Ru(es) --� �, ��GVG/1 �� LCAt� fYi1�-- , Under oath state that: . (typelprint name) ' 1. i have never been convicted of a felony or a crime involving gambiing. 2. ! have not, within five years before the date of the license apptication, committed a violation of !aw or Board rule that resulted in the revocation of a license issued by the Boarc9. 3. i have never been convicted of a criminal violation involving fraud, theft, tax evasion, misrepresentation, or gambling. 4. 1 have never been convicted of (i) assault, (ii) a criminal violation involving the use of a fireaRn, or {iii) making terroristic threats. 5. i am not, nor ever have been connected with or engaged in an iilegal business. 6. I do not owe $50� or more in delinquent taxes as defined in section 270.72. 7. i have not had a sales and use tax permit revoked by the commissioner of revenue within the past two years. 8. I have never, after demand, failed to file tax retums required by the commissioner of revenue. In addition, 1 understand, agree and hereby irrevocab{y consent that suits and actions relating to the subject matter of the attached gambling manager iicense applicatio�, or acts or omissions arising from such applica- tion, may be commenced against my organization and I will accept the service of process for my organiza- tion in any court of competent jurisdiction in Minnesota by service on the Minnesota Secretary of State of any summons, process or pleading authorized by lhe laws of Minnesota. By signature of this document, the undersigned authorizes the Department of Pubiic Safety to conduct a criminal background check or review and to share the results with the Gambli�g Controt Board. Failure to provide required information or providing false or misleading information may result in the denial of revocation of the license. FURTFiER AFFIANT SAYETH NOT, except fhat this Affidavit and Consent Statement are submitted in support of the application for a gambling manager license from the bling Control Board. NOTARY PUBLlC INFORMATION � � Notary Pubiic Seal must be current and corsect. (signature of app i nt) i Seal may not be altered. Subscribed and sworn to before me ihis of <��, ce� 19 ORGANiZAT10N INFORMAT/ON of Organization MARCEY i.. NoTr�vPUauo• (CcVrie ' �7'CSc(�L. �R9�- �6(Sir�tSS Yf'�SOL Licen Number �-o��?�� Council File # g7 " �� Ordinance # Green Sheet # 50248 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 2B 23 24 25 26 27 28 Presented By RESOLUTION CITY OF SAINT PAUL, MINNESOTA 37 Committee: Date Porm Approved by City Atto� By: � Approved b ayor for Submission to Council Referred To RESOLVED: That application, ID #98324, for a Gambling Manager's License by Steven R. Leafgren DBA Arcade Business Association at Minnesota Music Club, 499 Payne Avenue, be and the same is hereby approved. Requested by Department of: • - .-�-- �-•-• •�.- .:. a� ..•e_s� , - •e i� � Adoption Certified by Council Secretary BY� � c-� 'b— � \-� e-t—k�/�—.� Appraved by Mayor: Date f �� 2�.-�� By: � By: Adopted by Council: Date � \a_\�'��"� �� N° 50248 ��-�.�iu OEFAHTMENLOFFICEICOUNCII. DATE INITIATEO � � c � LIEP GREEN SHEE CONTACT PERSON 8 PHONE INITIAUDATE fNITIAVDATE � DEPAqTMENTDIRE � CINCOUNpL William F. Gunther - 266-9132 ASSIGN OCITYATfOqNEV �CITYCLERK MUST BE ON COUNCIL AGENDA BY (DATE) NUMBER FOR O BUDGET DIRECTOR � FIN. 8 MGT SEFVICES DIR. NOUTING Hearing: j � ORDEN O MAYOR (OR ASSISfANT) ❑ TOTAL # OF SIGNATURE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE) ACTION flEQUESTED: Steven R. Leafgren DBA Payne-Arcade Business Association requesCS Council approval of his application for a Gambling Manager's License, ID 4698324, at Minnesota Music Club, 499 Payne Avenue. aECOMMENDATIONS: Approve (A) w Rejett (R) pERSONAL SERYICE COt3TRACTS MUST ANSWER THE FOILOWING �UESTIONS: , PIANNING COMMISSION _ CIVIL SERVICE COMMISSION �- Has this person/Firm ever worketl untler a conhact for this department? ._ CIB CAMMITTEE YES NO � STAFF 2. Has this personHirm ever been a city empiqree? — YES NO _ D�Sia�CiCOURT — 3. Does this personRirm possess a skill not normail ossessed b an curreM y p y y city employae? SUPPORT$ WHICH CAUNCIL OBJECTIVE? YES NO Expialn all yes answers on seperate aheet anE enach to green sheet INITIATING PROBLEM, ISSUE. OPPORTUNITV (Who. What WMn. VJhere. Why)� ADVANTAGES IF APPROVED: - ° ��- • : �: w , ;�_,.� _ ""�- - �,��_: _--__. DISADVANTAGESIFAPPROVED: � - -- �o,.�.,,., DISADVANTAGES IF N07APPROVED � � "�� UCT 3 4 i997 TOTAL AMOUNT OF TRANSACTION S - COST/REVENUE BUDGETED (CIRCLE ONE) VES NO FUNDING SOURCE ACTIVITY NUMBEH FINANpAL INFORMATION. (EXPLpIN) � � - i,�� EBat STATE OF MINNESOTA IFOR BOARD IISE ONLYI GAMBLING CONTROL BOARD ,AMT. PAID � GAMBLING MANAGER L7CENSE RENEWAL APPLICATION ICHECK # I LG212GMR PRINTED: 04/03/96 �DATE I LICENSE NUMBER: G-03785 001 EFFECTIVE DATE: 10/O1/94 EXPIRATION DATE: 09/30/96 NAME OF ORGANIZATZON: Businesa St Paul Payne Arcade Assoc Steven Robert Leafgren 6478 Beckman Ave Inver Grove Ate MN 55077 DAYTIME PHONE NUMBER: 612-776-2706 MEMBER SINCE: 12/30/86 LAST DATE YOU ATTENDED A GAMBLING MANAGERS SEMINAR/CONTINUING EDUCATION CLASS: BOND INFORbfATION BOND COMPANY NAME: Travelera Indemnity BOND NUMBER: 650J5974 law�-Q- P"��e'� Ndv . �l5 Sa-, Clo�� 11/18/94 DECLARE THAT: . I HAVE READ TAIS APPLICATION AND ALL INFORMATION SUSMITTED TO THE GAMBLING CONTROL BOARD; ALL INFORMATION IS TRUE, ACCURATE AND COMPLETE; ALL OTHER REQUIRED SNFORMATION HAS BEEN FULLY DISCLOSED; I AM THE ONLY GAMBLTNG MANAGER OF THE ORGANIZATZON; I HAVE BEEN AN ACTIVE MEMBER OF THE ORGANIZATION FOR AT LEAST TWO YEARS; I WILL FAMILIARIZE MYSELF WITA THE LAWS OF MINNESOTA GOVERNING LAWFUL GAMBLING AND RULES OF THE GAMBLING CONTROL BOARD AND AGREE, IF LICENSED, TO ABIDE THOSE LAWS AND RULES, INCLiJDING AMENDMENTS TO THEM; � ANY CHANGES IN APPLICATION INFORMATION WILL BE SUBMITTED TO THE GAMBLING CONTROL BOARD AND LOCAL UNIT OF GOVERNMENT WITHIN 10 DAYS OF THE CHANGE; AN AFFIDAVZT FOR GAMBLING MANAGER HAS BEEN COMPLETED AND ATTACfiED; AND I UNDERSTAND THAT FAILURE TO PROVIDE REQUIRED INFORMATION OR PROVIDING FALSE OR MISLEADING INFORMATION MAY RESt7LT IN THE DENIAL OR REVOCATION OF THE LICENSE. SIGy SIIRFs OF GAM a�� r--- DATE 6-t-�b REFER TO TAE CHECKLIST FOR REQUIRED ATTACHMENT3 MAIL TO: GAMBLING CONTROL BOARD 1711 WEST COUNTY ROAD S, SUITE 3005 ROSEVILLE� MINNESOTA 55113 THIS FORM WILL BE MADE AVAILABLE IN ALTERNATIVE FORMAT (I.E. LARGE PRINT, HRAILLE) UPON REQUEST GAMBLING MANAGER INFORMATION DATE OF BIRTH: 11/29/60 SEX: M SOCIAL SECURITY NUMBER: 468-88-3779 ��3Z�� p�� q�� LG213 04/18/95 STATE OF COUNTY OF Minnesofa Gamblrng Control Bcard Gambling Manager Affidavit 9 � "�3 � �/ Attach to the Gambiing Manager Application, Form LG212 ►VL i nc�¢So �G— � AFFIDAVIT OF QUALIFICATION /� ) s.s. FOR GAMBLfNG MANAGER LfCENSE Y� M �/ � AND CONSENT STATEMENT �� (Pursuant to Minnesota Statutes and Ru(es) --� �, ��GVG/1 �� LCAt� fYi1�-- , Under oath state that: . (typelprint name) ' 1. i have never been convicted of a felony or a crime involving gambiing. 2. ! have not, within five years before the date of the license apptication, committed a violation of !aw or Board rule that resulted in the revocation of a license issued by the Boarc9. 3. i have never been convicted of a criminal violation involving fraud, theft, tax evasion, misrepresentation, or gambling. 4. 1 have never been convicted of (i) assault, (ii) a criminal violation involving the use of a fireaRn, or {iii) making terroristic threats. 5. i am not, nor ever have been connected with or engaged in an iilegal business. 6. I do not owe $50� or more in delinquent taxes as defined in section 270.72. 7. i have not had a sales and use tax permit revoked by the commissioner of revenue within the past two years. 8. I have never, after demand, failed to file tax retums required by the commissioner of revenue. In addition, 1 understand, agree and hereby irrevocab{y consent that suits and actions relating to the subject matter of the attached gambling manager iicense applicatio�, or acts or omissions arising from such applica- tion, may be commenced against my organization and I will accept the service of process for my organiza- tion in any court of competent jurisdiction in Minnesota by service on the Minnesota Secretary of State of any summons, process or pleading authorized by lhe laws of Minnesota. By signature of this document, the undersigned authorizes the Department of Pubiic Safety to conduct a criminal background check or review and to share the results with the Gambli�g Controt Board. Failure to provide required information or providing false or misleading information may result in the denial of revocation of the license. FURTFiER AFFIANT SAYETH NOT, except fhat this Affidavit and Consent Statement are submitted in support of the application for a gambling manager license from the bling Control Board. NOTARY PUBLlC INFORMATION � � Notary Pubiic Seal must be current and corsect. (signature of app i nt) i Seal may not be altered. Subscribed and sworn to before me ihis of <��, ce� 19 ORGANiZAT10N INFORMAT/ON of Organization MARCEY i.. NoTr�vPUauo• (CcVrie ' �7'CSc(�L. �R9�- �6(Sir�tSS Yf'�SOL Licen Number �-o��?��