97-1365Council File # g� - �.3(0�
ordinance #
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RESOLUTION
�INT PAUL, M
Presented
Referred To
Green Sheet # 50249
0
3l
Committee: Date
RESOLVSD: That application, ID ,#56890 & ID $92987, for Gambling Manager's Licenses by
Michael E. MeGinty DBA Minnesota Waterfowl Association at Beaver Lounqe, 756
Jackson Street and at Ron's Bar, 879 Rice Street, be and the same are hereby
approved.
Requested by Department of:
Adoption Certified by Council Secretary
BY � � — a- � �, .� 1
c'
Approved by Mayor: Date � ��'L,'L ��e �--
g C
• - -:_- e- - .�_ .:.
. e . �.��' � . - . e
t.t
f�
Form Approved by City Attorn
BY � �.( t�<.t.!_' `U l"�` !' i-.�li,
Approved by M�or for Submission to
Council
By:
Adopted by Council: Date '"��..,, �,s \�iq°1
� �
N° 50249
��-�.��s
DEPAflT.IENTqFFICE/COUNqL DATE INITIATED � �
LIEP GREEN SHEE
COMACf PERSON 8 PHONE INITIAVDATE INRIAUOATE
O pEPARTMENT DIRECTOR � CI7V COUNqL
William.E. Gunther - 266-9132 ASSIGN OC�n'AT70RNEY aCYiYGLEAK
MUST BE ON CqUNCIL AGEN A BY (DATE) NfINBEq i0R ❑ BUDGET D�REGTOR � FIN & MGt SERVlGES �IR.
POUTING
Hearing: �� �,1� q ORDER O MAVOft (Ofl ASSISTANTj �
TOTAL # OF SIGNATURE PAGES (CLiP ALL LOCATIONS FOR SIGNATURE)
ncTwNRwuesreo: Michael E. McGinty DBA Minnesota Waterfowl Association requests Council approval
of his applications for Gambling Manager`s Licenses at Beaver Lounge, 756 Jackson St.
(ID /186890) and at Ron's Bar, 879 Rice Street (ID �92987).
RECOMrotEOmAnONS: npprove iA) or Reject (R) pERSONAL SERVICE CONTRACTS MUST ANSWER THE FOILOWING QUESilONS:
_ PLANNINp COMMi55iON _ CNIL SERVICE COMMISSION �� Has ihis perSOnRirm ever worketl untler a contract for this tlepartmeM?
_ CIB COMMI7TEE _ YES NO "
_ STAFF 2. Has this personHirm ever been a ciry employee�
— YES NO
_ o�S7qfCr COURi _ 3. Does this DersoNfirm possess a skill not normally possessetl by any cuneM city empioyee?
SUPPORTS WHICH COUNCIL OBJECTIVE� YES NO
Explaln ell yes answers on separote aheet and attach to green sheet
INRIATING PR08LEM. ISSUE. OPPORTUNITV (W1w, Whet, When. Where. W1ryI.
ADVANTAGES IFAPPROVED: �
DISADVRNTAC�ES IF APPRWED:
DISADVANTAGES IFNOTAPPROVED�
� � `��
OCT 3 9 ��97
. �
TO7AL AMOUNT OF TRANSACTION S COST/REVENUE BUDGETED (CIRCLE ONE) YES NO
FUNDI(dG SOURCE ACTIVITY NUMBER
FINANCIAL INFORFiAT10N' (E%PLAIN)
Gambling Control Board Fax:612 Oct 21 '97 15�33 P.02iO3
�t �J t���- U ���,-� � 9�-i3�S
� �v
� ��
,1Ninnesota Lawful Gambling �^ ��zt2
G Manager Applicafion Page t 2
lncomplete, fialse, or mPsieading application informatio^ may result in denial o` a license.
prganization
6rgan¢ation
CEOlVame `
DaytimePnone( �1 � 1 �hn ���Ckganization
�
2
8oard Use
e �+c # ,
paitl ---�
$ �.
Gambling Manager Information
rwuvruaiervame �.v,,c�.�v �astname 7':��r�n I
� Maider.Name DateofBirth If} ! 7_r I{� Chr�k�nEOfth0b0%f-?� � A4a�e J � Fgm3�8
I$OCi81.52CU(I(j'NIIRlb2r ± Y4� "" �r� '� '�:f ✓ i
_ _ DI f
Nome
: r.`.'_
paytimepha�et�umbert �•1� +- 1 �' �-�-�
1 became an active member offfiis organization on:
t attended ihe two-day gambling manager seminar on:
�
m
se osure of
Soraat Security Number
You are requireCto pmvideyour social secu-
ritynumbEronthisform.Your sociafsecu-
rity numberwili be used to detertnine yvur
comptianCew�h thetax laws of Minnesota.
AtrtAOtizationTor requiringyoursocialsecu.
rhy nUmCer i5 Mune et d2 U.S.C.405(c)(i).
�O11C� �i1fOYt7'11tJOt'1 A S30,OQ0 fidelity bond in tavor of Ute org3nization has been obtained as required
by Minnesota Statutes, section 349.167, subdivision 1.
tnsuran;,e Gompar.y Name: C .I �` 17��r�:,1-��,� ._ ,�,���� C$ond Numt�er. ��S - G37
(DO NOT USE THE A�Et�ICY tJAME) [`ti �.�_
—T�--
Gambling Manager Change �en your organization is changing its gambling manager,
one of these sections:
Emcrgency Ghange -'"aiow uQ to five aays for
processing
The chief execuifve o�cer, by signing befow, affirms
ihat the emergency appiication ls due to the following
[Easort (check one and fllI in datel:
� beaft� af gambling manager on _,_,( /^
'J� / Disability of gambiing manager on 1 �
�Termina2ion of empEOyment of gambling manager on
NOTE: The new gambling manager may not assume
duties ur,t�I helshe has received the gam4ling manage�5
license from the Gambling Control Board.
of
_y�S�� l f :__.��.
< ' :' rt ac;r-� . _. -. - -
.�C r�
✓ svr.t,,,_t ;.' :: .�' . .
�.17JLiYx G? �:, 1� •'.i.i�� v`
Utlt¢r C;hatlg8 - P.1low up to ten weeks fo � ces��ig �
The nsw gambling managers Gcense shouid �?
effecfive (check one}: ��� �
❑ The day after ihe current gamb!'rng manager's Iicense
� expiees(iorexampie,iftheculren[gambiingmanageYs
ticense expires 7t31t9fi, the new gambiing manager s
iicense becomes Cffecfive on &!i/Bo', provided that al[
epplicafion information is complefe}.
[J When the applicafion has been processetl by the Gam-
bling Contro! Boarcl–the effedive date wi(I be the first
day of the month.
NDTE: The new gambling manager may not assume
duties unti! he/she has received a gambling manager's
license from the Gambling Controf Board,
Natary Public infoTmation. Notary Pubrc Seat must
be current and correct; yeal may not be altered.
Subscribed and swom Io beiore me this !r� day
� `r ,79 =a�
�z.,_;�._ = �`.,.f: :.
NOTARYPUBUC'YRO�
� �
{can ' ued on ack) ,
�%y�.u�,, v
I iI
6ambling Control Board Fax:612
Or_t 21 '97 15�33
P. 03iO3 � � - /,��
L�Z�z
s�ss
Paae 2 of 2
Gambling Manager Application (continued)
Affidavit,and Consent S
I. torint r,ame) �`�« �n-� �l ;� ru�
under oatfi sWte that 1 have never:
1. 8een tonvicted flf a felony or a crime invo;ving gam-
biing;
2. committed a violation o`taw or Board r�ie that resu!:ed
in the revocation of a Gcense issuetl by ihe 8oard withm
five years before the tlate of the license appiiration;
3, been convicted of a criminal violation involving fraud,
thefY, tax evasibn, mfsrepre5entation, Orgambiing;
4_ been convicted of (i) assavit, t��3 a crfminal violation
involving ihe use of a firearm, or (iii) making ferronsfic
thseats.
5_ beer connected with nor engaged in an i➢egal busi-
ness;
6. owetl $500 or more fn de�inqueni taxes as defined +n
section 274,72;
7. had a sales and use tax permit revoked by the com-
missioner of revenue within the past two years;
8. failed to file, after tlemand, 4ax retums required by the
commissioner of revsnue.
In addition, I undsrsTanB, agree, and hereby irravocably
conserrtfhat suits and actions relating fo the subject mat
ter of the atiached gambling manager licertse application,
or acts or omissions arising from such app3icafion, may be
�ommertcsd against me or my organization and i wifE
accept the service of p�ocess in any court of Compefenf
jurisdiction in T�/iinnesofa by service on the Minnesota
Seuefary of 5tats ofany summorts, process, ar pteading
authorized by the Eaws ofMinnesota.
By signafure of this document, the undersigned authorizes
the Department5 ofi Public Satety and Revenue to con-
duct a crfminai antl taz backgrountl check or seview and
to share She results wRh the Gambiing Control Baard.
Failure to provide required information or providing false
or mi5leading infOrmation may result in the denial or
revocation of the license.
FURTHER AFFiRNT SAYE'fH hlOT, except that this
A�davit and Consent Siatement are submitfed in suPPOrt
vt the application for a gambling manager licertse from
the Gamb(ina Corarot Soard.
Signature of Gambling Manager
A� p[icant f �, j
�� (��} �+ �� (
' 1 -�:'k✓��_ ll ;n �'- �- �j
NofatizedSignatu�80fApplitant �+ (.
{,. - 1�„ c-. = 4 ��
IlCj�4I:'..- . . _ .
1GG�a:.7.Y;D.�;.:' - ..- .
This pubficaiion wilf be made availabte in aitemaiive
format (i.e. large print, Braillej upon request If you
use a TTY. you can C3(I us using fhe Minnesofa Relay
Service ai 1-800�27-3529 and ask them to place a
call ta (6i2) 639-d000.
The information roquested on tnis br.m wii[ be us=d
by Yhs Gambling Controf Board (Board) to tlefermine
your compliance witF. Minngsota sfatutes and ruies
� goveming IawEul gambfing activi�es. At! of the infor
matian that you suppiy on this farm wit� become
public irtforma5oe when rece�ved by tfie Board.
The irtforma6on requestetl on tFris form tinclutlirtg any
attachments) will be used by ihe Board to determine
your qualifrcations to be invofued in lawful gamblina
activiiies in Minnesota, and io assist the Board in
condueting a background investigation o` you.
You have the right to refuse to suppfy the information
, eG�s�re-±: ?�o::•ev� . i� yo� r=fuse'.^ s::pp!y this i::fa.
mation, the Board may not be able to defermine your
qualificatians and, as a consequence, may refuse to
issue you a llcense. tf you supp(y the informafion
required, the Board wil! be able to process your appli-
ca5on.
Your name and address wii! be public information when
received by the Board. An the other information about
you ihat you provide wi4l be private data urrtii the Board
issues your iicense. YYhen f�e Baard issues your
license, a!1 of the information you have provided to
Yhe Soard in the process af app[ying for your license
wii! become pubiic excepf foryour sociai secur�ty num-
ber, which remains private.
{f the Soard does nof issue you a license, afl The infor-
mation you have provided in the process of applying
for a license remains private, with the exception of
your name and address, which wiR remain public.
Private data about you is available oniy to the tallaw-
ing: Board members, staft` of the Board whose work
assignment cequires that they have access to the
mformation; the MinnesoTa Departmenf of Pub(ic
Safety; ihe Minnesota Attomey Generdl; the Minne-
sota Commissioners of Administsa;ion, �inance, antl
riever�ue; ihe ieyisiativa . i�ationa! and intcr-
nationai gambling regulatory agencies; anyone pur-
suant tn court order; ather individuals a�d agencies '
thffi may be specifica!!y aufhorqed by state or federaE
!aw to have access to such inf�rmation; individuals
and agencies for which !aw or legal order authorizes a
new use or sharing of the information after this notice
+5 given; you; and anyone wSth your wriTten consent.
Notary Public lnformation. Notary Pubiic Seat must
be current and correct; seaf may npt be aitered.
Subsctibed and swOm to before me this �`D day
nf O <' <<. �.'•.� , t9 �t'
` ` i
�1�a h "r'Y.f-v.F.�a�r
s�
Council File # g� - �.3(0�
ordinance #
1
2
3
4
S
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
RESOLUTION
�INT PAUL, M
Presented
Referred To
Green Sheet # 50249
0
3l
Committee: Date
RESOLVSD: That application, ID ,#56890 & ID $92987, for Gambling Manager's Licenses by
Michael E. MeGinty DBA Minnesota Waterfowl Association at Beaver Lounqe, 756
Jackson Street and at Ron's Bar, 879 Rice Street, be and the same are hereby
approved.
Requested by Department of:
Adoption Certified by Council Secretary
BY � � — a- � �, .� 1
c'
Approved by Mayor: Date � ��'L,'L ��e �--
g C
• - -:_- e- - .�_ .:.
. e . �.��' � . - . e
t.t
f�
Form Approved by City Attorn
BY � �.( t�<.t.!_' `U l"�` !' i-.�li,
Approved by M�or for Submission to
Council
By:
Adopted by Council: Date '"��..,, �,s �
�
N° 50249
��-�.��s
DEPAflT.IENTqFFICE/COUNqL DATE INITIATED � �
LIEP GREEN SHEE
COMACf PERSON 8 PHONE INITIAVDATE INRIAUOATE
O pEPARTMENT DIRECTOR � CI7V COUNqL
William.E. Gunther - 266-9132 ASSIGN OC�n'AT70RNEY aCYiYGLEAK
MUST BE ON CqUNCIL AGEN A BY (DATE) NfINBEq i0R ❑ BUDGET D�REGTOR � FIN & MGt SERVlGES �IR.
POUTING
Hearing: �� �,1� q ORDER O MAVOft (Ofl ASSISTANTj �
TOTAL # OF SIGNATURE PAGES (CLiP ALL LOCATIONS FOR SIGNATURE)
ncTwNRwuesreo: Michael E. McGinty DBA Minnesota Waterfowl Association requests Council approval
of his applications for Gambling Manager`s Licenses at Beaver Lounge, 756 Jackson St.
(ID /186890) and at Ron's Bar, 879 Rice Street (ID �92987).
RECOMrotEOmAnONS: npprove iA) or Reject (R) pERSONAL SERVICE CONTRACTS MUST ANSWER THE FOILOWING QUESilONS:
_ PLANNINp COMMi55iON _ CNIL SERVICE COMMISSION �� Has ihis perSOnRirm ever worketl untler a contract for this tlepartmeM?
_ CIB COMMI7TEE _ YES NO "
_ STAFF 2. Has this personHirm ever been a ciry employee�
— YES NO
_ o�S7qfCr COURi _ 3. Does this DersoNfirm possess a skill not normally possessetl by any cuneM city empioyee?
SUPPORTS WHICH COUNCIL OBJECTIVE� YES NO
Explaln ell yes answers on separote aheet and attach to green sheet
INRIATING PR08LEM. ISSUE. OPPORTUNITV (W1w, Whet, When. Where. W1ryI.
ADVANTAGES IFAPPROVED: �
DISADVRNTAC�ES IF APPRWED:
DISADVANTAGES IFNOTAPPROVED�
� � `��
OCT 3 9 ��97
. �
TO7AL AMOUNT OF TRANSACTION S COST/REVENUE BUDGETED (CIRCLE ONE) YES NO
FUNDI(dG SOURCE ACTIVITY NUMBER
FINANCIAL INFORFiAT10N' (E%PLAIN)
Gambling Control Board Fax:612 Oct 21 '97 15�33 P.02iO3
�t �J t���- U ���,-� � 9�-i3�S
� �v
� ��
,1Ninnesota Lawful Gambling �^ ��zt2
G Manager Applicafion Page t 2
lncomplete, fialse, or mPsieading application informatio^ may result in denial o` a license.
prganization
6rgan¢ation
CEOlVame `
DaytimePnone( �1 � 1 �hn ���Ckganization
�
2
8oard Use
e �+c # ,
paitl ---�
$ �.
Gambling Manager Information
rwuvruaiervame �.v,,c�.�v �astname 7':��r�n I
� Maider.Name DateofBirth If} ! 7_r I{� Chr�k�nEOfth0b0%f-?� � A4a�e J � Fgm3�8
I$OCi81.52CU(I(j'NIIRlb2r ± Y4� "" �r� '� '�:f ✓ i
_ _ DI f
Nome
: r.`.'_
paytimepha�et�umbert �•1� +- 1 �' �-�-�
1 became an active member offfiis organization on:
t attended ihe two-day gambling manager seminar on:
�
m
se osure of
Soraat Security Number
You are requireCto pmvideyour social secu-
ritynumbEronthisform.Your sociafsecu-
rity numberwili be used to detertnine yvur
comptianCew�h thetax laws of Minnesota.
AtrtAOtizationTor requiringyoursocialsecu.
rhy nUmCer i5 Mune et d2 U.S.C.405(c)(i).
�O11C� �i1fOYt7'11tJOt'1 A S30,OQ0 fidelity bond in tavor of Ute org3nization has been obtained as required
by Minnesota Statutes, section 349.167, subdivision 1.
tnsuran;,e Gompar.y Name: C .I �` 17��r�:,1-��,� ._ ,�,���� C$ond Numt�er. ��S - G37
(DO NOT USE THE A�Et�ICY tJAME) [`ti �.�_
—T�--
Gambling Manager Change �en your organization is changing its gambling manager,
one of these sections:
Emcrgency Ghange -'"aiow uQ to five aays for
processing
The chief execuifve o�cer, by signing befow, affirms
ihat the emergency appiication ls due to the following
[Easort (check one and fllI in datel:
� beaft� af gambling manager on _,_,( /^
'J� / Disability of gambiing manager on 1 �
�Termina2ion of empEOyment of gambling manager on
NOTE: The new gambling manager may not assume
duties ur,t�I helshe has received the gam4ling manage�5
license from the Gambling Control Board.
of
_y�S�� l f :__.��.
< ' :' rt ac;r-� . _. -. - -
.�C r�
✓ svr.t,,,_t ;.' :: .�' . .
�.17JLiYx G? �:, 1� •'.i.i�� v`
Utlt¢r C;hatlg8 - P.1low up to ten weeks fo � ces��ig �
The nsw gambling managers Gcense shouid �?
effecfive (check one}: ��� �
❑ The day after ihe current gamb!'rng manager's Iicense
� expiees(iorexampie,iftheculren[gambiingmanageYs
ticense expires 7t31t9fi, the new gambiing manager s
iicense becomes Cffecfive on &!i/Bo', provided that al[
epplicafion information is complefe}.
[J When the applicafion has been processetl by the Gam-
bling Contro! Boarcl–the effedive date wi(I be the first
day of the month.
NDTE: The new gambling manager may not assume
duties unti! he/she has received a gambling manager's
license from the Gambling Controf Board,
Natary Public infoTmation. Notary Pubrc Seat must
be current and correct; yeal may not be altered.
Subscribed and swom Io beiore me this !r� day
� `r ,79 =a�
�z.,_;�._ = �`.,.f: :.
NOTARYPUBUC'YRO�
� �
{can ' ued on ack) ,
�%y�.u�,, v
I iI
6ambling Control Board Fax:612
Or_t 21 '97 15�33
P. 03iO3 � � - /,��
L�Z�z
s�ss
Paae 2 of 2
Gambling Manager Application (continued)
Affidavit,and Consent S
I. torint r,ame) �`�« �n-� �l ;� ru�
under oatfi sWte that 1 have never:
1. 8een tonvicted flf a felony or a crime invo;ving gam-
biing;
2. committed a violation o`taw or Board r�ie that resu!:ed
in the revocation of a Gcense issuetl by ihe 8oard withm
five years before the tlate of the license appiiration;
3, been convicted of a criminal violation involving fraud,
thefY, tax evasibn, mfsrepre5entation, Orgambiing;
4_ been convicted of (i) assavit, t��3 a crfminal violation
involving ihe use of a firearm, or (iii) making ferronsfic
thseats.
5_ beer connected with nor engaged in an i➢egal busi-
ness;
6. owetl $500 or more fn de�inqueni taxes as defined +n
section 274,72;
7. had a sales and use tax permit revoked by the com-
missioner of revenue within the past two years;
8. failed to file, after tlemand, 4ax retums required by the
commissioner of revsnue.
In addition, I undsrsTanB, agree, and hereby irravocably
conserrtfhat suits and actions relating fo the subject mat
ter of the atiached gambling manager licertse application,
or acts or omissions arising from such app3icafion, may be
�ommertcsd against me or my organization and i wifE
accept the service of p�ocess in any court of Compefenf
jurisdiction in T�/iinnesofa by service on the Minnesota
Seuefary of 5tats ofany summorts, process, ar pteading
authorized by the Eaws ofMinnesota.
By signafure of this document, the undersigned authorizes
the Department5 ofi Public Satety and Revenue to con-
duct a crfminai antl taz backgrountl check or seview and
to share She results wRh the Gambiing Control Baard.
Failure to provide required information or providing false
or mi5leading infOrmation may result in the denial or
revocation of the license.
FURTHER AFFiRNT SAYE'fH hlOT, except that this
A�davit and Consent Siatement are submitfed in suPPOrt
vt the application for a gambling manager licertse from
the Gamb(ina Corarot Soard.
Signature of Gambling Manager
A� p[icant f �, j
�� (��} �+ �� (
' 1 -�:'k✓��_ ll ;n �'- �- �j
NofatizedSignatu�80fApplitant �+ (.
{,. - 1�„ c-. = 4 ��
IlCj�4I:'..- . . _ .
1GG�a:.7.Y;D.�;.:' - ..- .
This pubficaiion wilf be made availabte in aitemaiive
format (i.e. large print, Braillej upon request If you
use a TTY. you can C3(I us using fhe Minnesofa Relay
Service ai 1-800�27-3529 and ask them to place a
call ta (6i2) 639-d000.
The information roquested on tnis br.m wii[ be us=d
by Yhs Gambling Controf Board (Board) to tlefermine
your compliance witF. Minngsota sfatutes and ruies
� goveming IawEul gambfing activi�es. At! of the infor
matian that you suppiy on this farm wit� become
public irtforma5oe when rece�ved by tfie Board.
The irtforma6on requestetl on tFris form tinclutlirtg any
attachments) will be used by ihe Board to determine
your qualifrcations to be invofued in lawful gamblina
activiiies in Minnesota, and io assist the Board in
condueting a background investigation o` you.
You have the right to refuse to suppfy the information
, eG�s�re-±: ?�o::•ev� . i� yo� r=fuse'.^ s::pp!y this i::fa.
mation, the Board may not be able to defermine your
qualificatians and, as a consequence, may refuse to
issue you a llcense. tf you supp(y the informafion
required, the Board wil! be able to process your appli-
ca5on.
Your name and address wii! be public information when
received by the Board. An the other information about
you ihat you provide wi4l be private data urrtii the Board
issues your iicense. YYhen f�e Baard issues your
license, a!1 of the information you have provided to
Yhe Soard in the process af app[ying for your license
wii! become pubiic excepf foryour sociai secur�ty num-
ber, which remains private.
{f the Soard does nof issue you a license, afl The infor-
mation you have provided in the process of applying
for a license remains private, with the exception of
your name and address, which wiR remain public.
Private data about you is available oniy to the tallaw-
ing: Board members, staft` of the Board whose work
assignment cequires that they have access to the
mformation; the MinnesoTa Departmenf of Pub(ic
Safety; ihe Minnesota Attomey Generdl; the Minne-
sota Commissioners of Administsa;ion, �inance, antl
riever�ue; ihe ieyisiativa . i�ationa! and intcr-
nationai gambling regulatory agencies; anyone pur-
suant tn court order; ather individuals a�d agencies '
thffi may be specifica!!y aufhorqed by state or federaE
!aw to have access to such inf�rmation; individuals
and agencies for which !aw or legal order authorizes a
new use or sharing of the information after this notice
+5 given; you; and anyone wSth your wriTten consent.
Notary Public lnformation. Notary Pubiic Seat must
be current and correct; seaf may npt be aitered.
Subsctibed and swOm to before me this �`D day
nf O <' <<. �.'•.� , t9 �t'
` ` i
�1�a h "r'Y.f-v.F.�a�r
s�
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RESOLUTION
�INT PAUL, M
Presented
Referred To
Green Sheet # 50249
0
3l
Committee: Date
RESOLVSD: That application, ID ,#56890 & ID $92987, for Gambling Manager's Licenses by
Michael E. MeGinty DBA Minnesota Waterfowl Association at Beaver Lounqe, 756
Jackson Street and at Ron's Bar, 879 Rice Street, be and the same are hereby
approved.
Requested by Department of:
Adoption Certified by Council Secretary
BY � � — a- � �, .� 1
c'
Approved by Mayor: Date � ��'L,'L ��e �--
g C
• - -:_- e- - .�_ .:.
. e . �.��' � . - . e
t.t
f�
Form Approved by City Attorn
BY � �.( t�<.t.!_' `U l"�` !' i-.�li,
Approved by M�or for Submission to
Council
By:
Adopted by Council: Date '"��..,, �,s �
�
N° 50249
��-�.��s
DEPAflT.IENTqFFICE/COUNqL DATE INITIATED � �
LIEP GREEN SHEE
COMACf PERSON 8 PHONE INITIAVDATE INRIAUOATE
O pEPARTMENT DIRECTOR � CI7V COUNqL
William.E. Gunther - 266-9132 ASSIGN OC�n'AT70RNEY aCYiYGLEAK
MUST BE ON CqUNCIL AGEN A BY (DATE) NfINBEq i0R ❑ BUDGET D�REGTOR � FIN & MGt SERVlGES �IR.
POUTING
Hearing: �� �,1� q ORDER O MAVOft (Ofl ASSISTANTj �
TOTAL # OF SIGNATURE PAGES (CLiP ALL LOCATIONS FOR SIGNATURE)
ncTwNRwuesreo: Michael E. McGinty DBA Minnesota Waterfowl Association requests Council approval
of his applications for Gambling Manager`s Licenses at Beaver Lounge, 756 Jackson St.
(ID /186890) and at Ron's Bar, 879 Rice Street (ID �92987).
RECOMrotEOmAnONS: npprove iA) or Reject (R) pERSONAL SERVICE CONTRACTS MUST ANSWER THE FOILOWING QUESilONS:
_ PLANNINp COMMi55iON _ CNIL SERVICE COMMISSION �� Has ihis perSOnRirm ever worketl untler a contract for this tlepartmeM?
_ CIB COMMI7TEE _ YES NO "
_ STAFF 2. Has this personHirm ever been a ciry employee�
— YES NO
_ o�S7qfCr COURi _ 3. Does this DersoNfirm possess a skill not normally possessetl by any cuneM city empioyee?
SUPPORTS WHICH COUNCIL OBJECTIVE� YES NO
Explaln ell yes answers on separote aheet and attach to green sheet
INRIATING PR08LEM. ISSUE. OPPORTUNITV (W1w, Whet, When. Where. W1ryI.
ADVANTAGES IFAPPROVED: �
DISADVRNTAC�ES IF APPRWED:
DISADVANTAGES IFNOTAPPROVED�
� � `��
OCT 3 9 ��97
. �
TO7AL AMOUNT OF TRANSACTION S COST/REVENUE BUDGETED (CIRCLE ONE) YES NO
FUNDI(dG SOURCE ACTIVITY NUMBER
FINANCIAL INFORFiAT10N' (E%PLAIN)
Gambling Control Board Fax:612 Oct 21 '97 15�33 P.02iO3
�t �J t���- U ���,-� � 9�-i3�S
� �v
� ��
,1Ninnesota Lawful Gambling �^ ��zt2
G Manager Applicafion Page t 2
lncomplete, fialse, or mPsieading application informatio^ may result in denial o` a license.
prganization
6rgan¢ation
CEOlVame `
DaytimePnone( �1 � 1 �hn ���Ckganization
�
2
8oard Use
e �+c # ,
paitl ---�
$ �.
Gambling Manager Information
rwuvruaiervame �.v,,c�.�v �astname 7':��r�n I
� Maider.Name DateofBirth If} ! 7_r I{� Chr�k�nEOfth0b0%f-?� � A4a�e J � Fgm3�8
I$OCi81.52CU(I(j'NIIRlb2r ± Y4� "" �r� '� '�:f ✓ i
_ _ DI f
Nome
: r.`.'_
paytimepha�et�umbert �•1� +- 1 �' �-�-�
1 became an active member offfiis organization on:
t attended ihe two-day gambling manager seminar on:
�
m
se osure of
Soraat Security Number
You are requireCto pmvideyour social secu-
ritynumbEronthisform.Your sociafsecu-
rity numberwili be used to detertnine yvur
comptianCew�h thetax laws of Minnesota.
AtrtAOtizationTor requiringyoursocialsecu.
rhy nUmCer i5 Mune et d2 U.S.C.405(c)(i).
�O11C� �i1fOYt7'11tJOt'1 A S30,OQ0 fidelity bond in tavor of Ute org3nization has been obtained as required
by Minnesota Statutes, section 349.167, subdivision 1.
tnsuran;,e Gompar.y Name: C .I �` 17��r�:,1-��,� ._ ,�,���� C$ond Numt�er. ��S - G37
(DO NOT USE THE A�Et�ICY tJAME) [`ti �.�_
—T�--
Gambling Manager Change �en your organization is changing its gambling manager,
one of these sections:
Emcrgency Ghange -'"aiow uQ to five aays for
processing
The chief execuifve o�cer, by signing befow, affirms
ihat the emergency appiication ls due to the following
[Easort (check one and fllI in datel:
� beaft� af gambling manager on _,_,( /^
'J� / Disability of gambiing manager on 1 �
�Termina2ion of empEOyment of gambling manager on
NOTE: The new gambling manager may not assume
duties ur,t�I helshe has received the gam4ling manage�5
license from the Gambling Control Board.
of
_y�S�� l f :__.��.
< ' :' rt ac;r-� . _. -. - -
.�C r�
✓ svr.t,,,_t ;.' :: .�' . .
�.17JLiYx G? �:, 1� •'.i.i�� v`
Utlt¢r C;hatlg8 - P.1low up to ten weeks fo � ces��ig �
The nsw gambling managers Gcense shouid �?
effecfive (check one}: ��� �
❑ The day after ihe current gamb!'rng manager's Iicense
� expiees(iorexampie,iftheculren[gambiingmanageYs
ticense expires 7t31t9fi, the new gambiing manager s
iicense becomes Cffecfive on &!i/Bo', provided that al[
epplicafion information is complefe}.
[J When the applicafion has been processetl by the Gam-
bling Contro! Boarcl–the effedive date wi(I be the first
day of the month.
NDTE: The new gambling manager may not assume
duties unti! he/she has received a gambling manager's
license from the Gambling Controf Board,
Natary Public infoTmation. Notary Pubrc Seat must
be current and correct; yeal may not be altered.
Subscribed and swom Io beiore me this !r� day
� `r ,79 =a�
�z.,_;�._ = �`.,.f: :.
NOTARYPUBUC'YRO�
� �
{can ' ued on ack) ,
�%y�.u�,, v
I iI
6ambling Control Board Fax:612
Or_t 21 '97 15�33
P. 03iO3 � � - /,��
L�Z�z
s�ss
Paae 2 of 2
Gambling Manager Application (continued)
Affidavit,and Consent S
I. torint r,ame) �`�« �n-� �l ;� ru�
under oatfi sWte that 1 have never:
1. 8een tonvicted flf a felony or a crime invo;ving gam-
biing;
2. committed a violation o`taw or Board r�ie that resu!:ed
in the revocation of a Gcense issuetl by ihe 8oard withm
five years before the tlate of the license appiiration;
3, been convicted of a criminal violation involving fraud,
thefY, tax evasibn, mfsrepre5entation, Orgambiing;
4_ been convicted of (i) assavit, t��3 a crfminal violation
involving ihe use of a firearm, or (iii) making ferronsfic
thseats.
5_ beer connected with nor engaged in an i➢egal busi-
ness;
6. owetl $500 or more fn de�inqueni taxes as defined +n
section 274,72;
7. had a sales and use tax permit revoked by the com-
missioner of revenue within the past two years;
8. failed to file, after tlemand, 4ax retums required by the
commissioner of revsnue.
In addition, I undsrsTanB, agree, and hereby irravocably
conserrtfhat suits and actions relating fo the subject mat
ter of the atiached gambling manager licertse application,
or acts or omissions arising from such app3icafion, may be
�ommertcsd against me or my organization and i wifE
accept the service of p�ocess in any court of Compefenf
jurisdiction in T�/iinnesofa by service on the Minnesota
Seuefary of 5tats ofany summorts, process, ar pteading
authorized by the Eaws ofMinnesota.
By signafure of this document, the undersigned authorizes
the Department5 ofi Public Satety and Revenue to con-
duct a crfminai antl taz backgrountl check or seview and
to share She results wRh the Gambiing Control Baard.
Failure to provide required information or providing false
or mi5leading infOrmation may result in the denial or
revocation of the license.
FURTHER AFFiRNT SAYE'fH hlOT, except that this
A�davit and Consent Siatement are submitfed in suPPOrt
vt the application for a gambling manager licertse from
the Gamb(ina Corarot Soard.
Signature of Gambling Manager
A� p[icant f �, j
�� (��} �+ �� (
' 1 -�:'k✓��_ ll ;n �'- �- �j
NofatizedSignatu�80fApplitant �+ (.
{,. - 1�„ c-. = 4 ��
IlCj�4I:'..- . . _ .
1GG�a:.7.Y;D.�;.:' - ..- .
This pubficaiion wilf be made availabte in aitemaiive
format (i.e. large print, Braillej upon request If you
use a TTY. you can C3(I us using fhe Minnesofa Relay
Service ai 1-800�27-3529 and ask them to place a
call ta (6i2) 639-d000.
The information roquested on tnis br.m wii[ be us=d
by Yhs Gambling Controf Board (Board) to tlefermine
your compliance witF. Minngsota sfatutes and ruies
� goveming IawEul gambfing activi�es. At! of the infor
matian that you suppiy on this farm wit� become
public irtforma5oe when rece�ved by tfie Board.
The irtforma6on requestetl on tFris form tinclutlirtg any
attachments) will be used by ihe Board to determine
your qualifrcations to be invofued in lawful gamblina
activiiies in Minnesota, and io assist the Board in
condueting a background investigation o` you.
You have the right to refuse to suppfy the information
, eG�s�re-±: ?�o::•ev� . i� yo� r=fuse'.^ s::pp!y this i::fa.
mation, the Board may not be able to defermine your
qualificatians and, as a consequence, may refuse to
issue you a llcense. tf you supp(y the informafion
required, the Board wil! be able to process your appli-
ca5on.
Your name and address wii! be public information when
received by the Board. An the other information about
you ihat you provide wi4l be private data urrtii the Board
issues your iicense. YYhen f�e Baard issues your
license, a!1 of the information you have provided to
Yhe Soard in the process af app[ying for your license
wii! become pubiic excepf foryour sociai secur�ty num-
ber, which remains private.
{f the Soard does nof issue you a license, afl The infor-
mation you have provided in the process of applying
for a license remains private, with the exception of
your name and address, which wiR remain public.
Private data about you is available oniy to the tallaw-
ing: Board members, staft` of the Board whose work
assignment cequires that they have access to the
mformation; the MinnesoTa Departmenf of Pub(ic
Safety; ihe Minnesota Attomey Generdl; the Minne-
sota Commissioners of Administsa;ion, �inance, antl
riever�ue; ihe ieyisiativa . i�ationa! and intcr-
nationai gambling regulatory agencies; anyone pur-
suant tn court order; ather individuals a�d agencies '
thffi may be specifica!!y aufhorqed by state or federaE
!aw to have access to such inf�rmation; individuals
and agencies for which !aw or legal order authorizes a
new use or sharing of the information after this notice
+5 given; you; and anyone wSth your wriTten consent.
Notary Public lnformation. Notary Pubiic Seat must
be current and correct; seaf may npt be aitered.
Subsctibed and swOm to before me this �`D day
nf O <' <<. �.'•.� , t9 �t'
` ` i
�1�a h "r'Y.f-v.F.�a�r
s�