97-1483council File # q�1 ly8'3
Ordinance ,�
Green Sheet # 50267
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CITY
Presented
Referred To
39
RESOLt7SD: That application, ZD #24523 & 60341 fos Gambling Manager's License for
Richard Mataon DBA St. Paul Featival & Heritage Foundation at Mr. Patom's,
995 7th Street W. and at Turf Club, 1601 IIninersity Avenue W., be and the
same are hereby approved.
RESOLUTION
�T PAUL, MINNESOTA
Committee: Date
Requested by Department of:
• - -:-- �-•.- •:_ ,e•
t ' - •e
,e . %r.
Adoption Certified by Council Secretary
By:
Approved by Mayor': Date rti(2d1��-
Form Approved by City Attorn�.�
By: C/r�L� � � ca�•-�...e�
U
Approved by Mayor for Submisaion to
By:
BY: �/" • "� `.!
Adopted by Council: Date �, o � \9qr7
�--�--�-
N° 50267
DEPYiRiMENTIOFFlCHCOUNdL � DATE INITIATED - ••�/ f V�
LIEP { GREEN SHEE
CONipCT PERSON 8 PXONE INITIAUDATE INRIAl1DATE
� DEPARTMENT DIRECTOR � pTVCOUNGIL
William -F. Gunther — 266-9132 ASSIGN � CINAttORNEY � an c�aic
MUST BE ON CAUNCIL AGENDA BY (DATE) NUNBEP i0R ❑ BUDGET DIRECTOR O FIN. 8 MGi. $EFVICE$ DIR.
POVTING
Hearing: � �� 9 ORDEF � MAYOR (OR ASSI5TANf) O
TOTAL # OF SIGNATURE PAGES (CLIP A�L LOCATIONS FOR SIGNATURE)
AGTION RE�UESTED
Richard Matson DBA St. Paul Festival and Heritage Foundation requests Council
approval of his application for Gambling Manager's Licenses, ID �124523 &/160341 at
Mr. Patoms, 995 7th St. W. and at Turf Club, 1601 University Avenue W.
RECOMMENDATIONS: npprove (A) or Rejeet (R) pERSQNAI SERVICE CONTRACTS MUST ANSWER THE fOLLOWING QUESTIONS:
_ PLANNING COMMI$$ION _ CIVII SERVICE CAMMISSION �� Has this person/firm ever worked untler a contract for this department?
_ CIB CAMMfffEE �'ES NO
— � A � F 2. Has this persontfirm ever been a ciry empioyee�
— VES NO
_ Di57RiCiCOURi _ 3. Does this person/firtn possess a skill not normaily possessed
by any current city employee�
SUPPORTS WHICH COUNCIL OBJECTNE� YES NO
Explain all yes answers on separate sheet end ettach to green aheet
INITIATING PROBLEM, ISSUE. OPPpRTUNIiY (Who. Whet. When. Whare. Why)'
ADVANTAGESIFAPPROVED:
D�SADVANTAGES IFAPPqOVE�' ,
DISADVANTAGES IF NOTAPPflOVED
lrViidl6.i �y�� y�ii�
DEC 0 3 iS97
TOTAL AMOUN70F7RANSACTION S COST/REVENUE BUDGETED (CIpCLE ONE) YES NO
FUNDIIdG SOURCE ACTIVIIV NUMBER
FINANCIAL INFORMATION: (EXPLAIN)
q�-)�l t3
0
; �; ,
:r
Lm:_
n�
`
<
�. _;._
: s,
Minnesota Lawful Gamhiing LG212
Gamblin Mana A lication $
b b rP - _ Page 1 of 2.
Incomplete, faise, or misleading appiication information may result in denial of a license. _
Organization information
cEOName Anne Ford Nelson
(Cannotbegamblingmanager) -
DaytimePhone 6( 72 � 223-4700 Organization
1 � 2
10 i 9
Gambling Manager Information
FirstName RiChard FuIlMiddleName Rnhart LastName Mat�ar
MaidenName N�A DateofBirth 3/ 10 � 39 Checkoneoftheboxes: a Male � Female
� Social Secunty Number
HomeStreetAddress 2774 Del
c�t� Roseville
� [! Y �
I DaytimePhoneNumber( 612 1 889-4453
� I became an active member of this organization on:
�� I attended the two-day gambling managerseminar on:
Disclosure of
Sociai Security Number
You are required to provide your social secu-
ritynumberontbisform.Your sociatsecu-
rity number wiil be used to determine your
compliance wkh the tax laws of Minnesota.
Authorizationfor requirin9yoursocialsecu-
rity number is found at 42 U.S.C. 405(c)(i).
Bond Information A$10,000 fidelity bond in favor of the organization has been obtained as required
by Minnesota Staiutes, section 349.167, subdivision 1.
Insurance Company Name: O1 d Reoubl i c Surety Co Bond Number: RPSO445671
(DO NOT USE THE AGENCY NAME)
Gambling Manager Change �en your organ¢ation is changing its gambling manager, complete
one of these sedions:
ER10Fg011Cy Chattg0 - AVfow up to frve days for OtfiBi Cfiatlge - Allow up to ten weeks for processing
processing
The chief executive officer, by signing below, a�rms
that the emergency application is due to the following
reason (check one and fill in date):
❑ Death of gambling manager on / /_
❑ Disability of gambling manager on /_/
❑ Termination of empioyment of gambling manager on
-�/ -_-- / �� �_- ` i : .-. _ _ . . , _ � ; �
NOTE: _ The new gambl�ng�manager may not assume
duties until he/she has received the gambiing manager's
license from the Gambling Confrol Board:��;r:,��;w;,�.,�,».__
�._ , .: ' .r-�v_ . ; bz.:�.. rF - . :....
of CEO � �.- � � ��>_ ; � __
ofChiefEzeoutiveOfficer(CEO)�� - �
�� ��� ` `� �
- .`�. -' .. ._ � __ ' '
.. . ��:` .. ..
The new gambling manager's license should become
effective (check one):
❑ The day after the currenf gambling manager's Iicense
expires (for example, if the current gambling manager's
Iicense expires 7/31/96, the new gambling manager'S
license becomes effective on 8/1/96, provided fhat all
application information is complete).
[� When the application has been processed by the Gam-
b{ing Cantrof Board-the effective date will be the first
� , day of the month. -_-�;.- � =_ � -
NOTE:s_ The new gambling manager may not assume
duties unUi he/she has received,a gambling manager's
Iicense from the Gam bling Control Board "' �`_ '--
Board Use On(y:
e Lic #
uence #
#
Nofary Public Informa�
be current and correct; seal
Subscribed and sworn to b'e
- - ot � - . ' c �c'�sE�6� G
i. Notary Public Sea(musf�
y not be altered:>�sT;;,� � 1 _'
� me this _ _ cia � ,
Y= -
- ` , 19. R-7 °. _., ."
.. ... . . ._.. _.,--_ � .. .
NOiAHYPUBLIC-MINNESOTA ( (continued on back) . _
AAMSEYCOUNTI i
�
;::
i: ;.
#� -
. �P . -
Gambling Manager Application
Affidavit and Consent Statement:
I,(printname) 2.��.�_J R•��,�C M
under oath sfate that 1 fiave never:
1. been convicted of a felony or a crime involving gam-
bling;
2. committed a violation of Iaw or Board rule that resulfed
in the revocation of a license issued by the Board within
five years before the date of the Iicanse application;
3. been convicted of a criminai violation involving fraud,
theft, tax evasion, misrepresentation, or gambling;
4. been convicted of (i) assault, (ii) a criminal violation
involving the use of a firearm, or (iii) making terroristic
threats.
5. been connected with nor engaged in an illegal busi-
ness;
6. owed $500 or more in delinquent taxes as defined in
section 270.72;
7. had a sales and use tax permit revoked by the com-
missioner of revenue within the past two years;
8. failed to file, afte� demand, tax retums required by the
commissioner of revenue.
In addition, I understand, agree, and hereby irrevocably
consent that suits and actions relating to the subject mat-
ter of the attached gambling manager license application,
or acts or omissions arising from such application, may be
commenced against me or my organization and I will
accept the service of process in any court of competent
jurisdiction in Minnesota by service on the Minnesota
Secretary of State of any summons, process, or pleading
authorized by the laws of Minnesota,
By signature of this document, the undersigned authorizes
the Departments of Public Safety and Revenue to con-
duct a criminal and tax background check or review and
to share the results with the Gambling Control Board.
Failure to provide required information or providing false
or misleading information may result in the denial or
revocation of the license.
FURTNER AFFIANT SAYETH NOT, except that this
Affidavit and Consent Statement are submitted in support
of the application for a gambling manager Iicense from
the Gamb(ing Controi Board.
9�1-1y �3
LG212
siss
Page 2 of 2
This publication will be made available in alternative
format (i.e. large print, Braille) upon request. �f you
use a T7Y, you can cail us using the Minnesota Relay
Service at 1-800-627-3529 and ask them to place a
call fo (612) 639-4000.
The information requested on this form wili be used
by the Gambling Control Board (Board) to determine
i your compliance with Minnesota statutes and rules
goveming lawful gambling activities. All of the infor-
mafion fhat you supply on this form wiil become
public information when received by the Board.
The information requested on this form (inciuding any
attachments) wili be used by the 8oard to determine
your qualifications to be involved in lawful gambling
activities in Minnesota, and to assist the Board in
conducting a background investigation of you.
You have the right to refuse to supply the information
requested; however, if you refuse to supply this infor-
mation, the Board may not be abie to determine your
qualifications and, as a consequence, may refuse to
issue you a license. If you supply the information
required, the Board will be abie to process your appli-
cation.
Your name and address will be public information when
received by the Board. A�I the other information about
you that you provide will be private data untii the Board
issues your license. When the Board issues your
license, all of the information you have provided to
the Board in the process of applying for your license
will become public exceptfor your social security num-
ber, which remains private.
Ii the Board does not issue you a ficense, all the infor-
mation you have provided in the process of applying
for a ficense remains private, with the exception of
your name and address, which will remain public.
Private data about you is available only to the follow-
ing: Board members, staff of the Board whose work
assignment requires that they have access to the
information; the Minnesota Department of Public
Safefij; the Minnesota Attorney General; the Minne-
sota Commissioners of Administration, Finance, and
Revenue; the Legislative Auditor, national and infer-
nationai gambling regufatory agencies; anyone pur-
suant to court order; other individuais and agencies
that may be specifically authorized by state or federal
faw to have access to such information; individuals
and agencies for which law or legai order authorizes a
new use or sharing of the information after thie notice
is given; you; and anyone with your written consent."
$i�itatUC@ Of G8111b{iil� Mafl1g21'`�-' -- -=. Notary Pubfic Information. Notary Pubiic Seai must
Ap ppp� �ICBIIt -- . y: be curtent and corred; seal may not be altered. � ,
,/'/ -�� Subscribed and sworn to before rrfe this .�3 day =
� L or �oc_ e� - ,`� s _�r� . -
Notanzed Sgnature ofP,pphwnt � ' - � _ ;= - .___ � � ' - '_
_ ,.. _ ` . - ...
_ - ' � —� �.` �---� - „
Date = - - - � —� � � -- _ ' Notary PubliC, w, �' - .
- . ° # ," ' . CHPoS�IEELLENSCHMIDT. - ,
. # �°�° TARY PUBLIG-MINNESOTA
� NO
� " RAMSEY COUNTY
� . , , - . , ti�'� ��ExpreflJAN31.�00 '
' — �` -- - �'y . .�.` �. .
. .,: � . . . - '.
_ . . ._,,.....,w _. _ . ..w_ . a .srs . .. Mp -- _ _ . ' ' ... _
council File # q�1 ly8'3
Ordinance ,�
Green Sheet # 50267
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25
26
27
28
29
CITY
Presented
Referred To
39
RESOLt7SD: That application, ZD #24523 & 60341 fos Gambling Manager's License for
Richard Mataon DBA St. Paul Featival & Heritage Foundation at Mr. Patom's,
995 7th Street W. and at Turf Club, 1601 IIninersity Avenue W., be and the
same are hereby approved.
RESOLUTION
�T PAUL, MINNESOTA
Committee: Date
Requested by Department of:
• - -:-- �-•.- •:_ ,e•
t ' - •e
,e . %r.
Adoption Certified by Council Secretary
By:
Approved by Mayor': Date rti(2d1��-
Form Approved by City Attorn�.�
By: C/r�L� � � ca�•-�...e�
U
Approved by Mayor for Submisaion to
By:
BY: �/" • "� `.!
Adopted by Council: Date �, o � \9qr7
�--�--�-
N° 50267
DEPYiRiMENTIOFFlCHCOUNdL � DATE INITIATED - ••�/ f V�
LIEP { GREEN SHEE
CONipCT PERSON 8 PXONE INITIAUDATE INRIAl1DATE
� DEPARTMENT DIRECTOR � pTVCOUNGIL
William -F. Gunther — 266-9132 ASSIGN � CINAttORNEY � an c�aic
MUST BE ON CAUNCIL AGENDA BY (DATE) NUNBEP i0R ❑ BUDGET DIRECTOR O FIN. 8 MGi. $EFVICE$ DIR.
POVTING
Hearing: � �� 9 ORDEF � MAYOR (OR ASSI5TANf) O
TOTAL # OF SIGNATURE PAGES (CLIP A�L LOCATIONS FOR SIGNATURE)
AGTION RE�UESTED
Richard Matson DBA St. Paul Festival and Heritage Foundation requests Council
approval of his application for Gambling Manager's Licenses, ID �124523 &/160341 at
Mr. Patoms, 995 7th St. W. and at Turf Club, 1601 University Avenue W.
RECOMMENDATIONS: npprove (A) or Rejeet (R) pERSQNAI SERVICE CONTRACTS MUST ANSWER THE fOLLOWING QUESTIONS:
_ PLANNING COMMI$$ION _ CIVII SERVICE CAMMISSION �� Has this person/firm ever worked untler a contract for this department?
_ CIB CAMMfffEE �'ES NO
— � A � F 2. Has this persontfirm ever been a ciry empioyee�
— VES NO
_ Di57RiCiCOURi _ 3. Does this person/firtn possess a skill not normaily possessed
by any current city employee�
SUPPORTS WHICH COUNCIL OBJECTNE� YES NO
Explain all yes answers on separate sheet end ettach to green aheet
INITIATING PROBLEM, ISSUE. OPPpRTUNIiY (Who. Whet. When. Whare. Why)'
ADVANTAGESIFAPPROVED:
D�SADVANTAGES IFAPPqOVE�' ,
DISADVANTAGES IF NOTAPPflOVED
lrViidl6.i �y�� y�ii�
DEC 0 3 iS97
TOTAL AMOUN70F7RANSACTION S COST/REVENUE BUDGETED (CIpCLE ONE) YES NO
FUNDIIdG SOURCE ACTIVIIV NUMBER
FINANCIAL INFORMATION: (EXPLAIN)
q�-)�l t3
0
; �; ,
:r
Lm:_
n�
`
<
�. _;._
: s,
Minnesota Lawful Gamhiing LG212
Gamblin Mana A lication $
b b rP - _ Page 1 of 2.
Incomplete, faise, or misleading appiication information may result in denial of a license. _
Organization information
cEOName Anne Ford Nelson
(Cannotbegamblingmanager) -
DaytimePhone 6( 72 � 223-4700 Organization
1 � 2
10 i 9
Gambling Manager Information
FirstName RiChard FuIlMiddleName Rnhart LastName Mat�ar
MaidenName N�A DateofBirth 3/ 10 � 39 Checkoneoftheboxes: a Male � Female
� Social Secunty Number
HomeStreetAddress 2774 Del
c�t� Roseville
� [! Y �
I DaytimePhoneNumber( 612 1 889-4453
� I became an active member of this organization on:
�� I attended the two-day gambling managerseminar on:
Disclosure of
Sociai Security Number
You are required to provide your social secu-
ritynumberontbisform.Your sociatsecu-
rity number wiil be used to determine your
compliance wkh the tax laws of Minnesota.
Authorizationfor requirin9yoursocialsecu-
rity number is found at 42 U.S.C. 405(c)(i).
Bond Information A$10,000 fidelity bond in favor of the organization has been obtained as required
by Minnesota Staiutes, section 349.167, subdivision 1.
Insurance Company Name: O1 d Reoubl i c Surety Co Bond Number: RPSO445671
(DO NOT USE THE AGENCY NAME)
Gambling Manager Change �en your organ¢ation is changing its gambling manager, complete
one of these sedions:
ER10Fg011Cy Chattg0 - AVfow up to frve days for OtfiBi Cfiatlge - Allow up to ten weeks for processing
processing
The chief executive officer, by signing below, a�rms
that the emergency application is due to the following
reason (check one and fill in date):
❑ Death of gambling manager on / /_
❑ Disability of gambling manager on /_/
❑ Termination of empioyment of gambling manager on
-�/ -_-- / �� �_- ` i : .-. _ _ . . , _ � ; �
NOTE: _ The new gambl�ng�manager may not assume
duties until he/she has received the gambiing manager's
license from the Gambling Confrol Board:��;r:,��;w;,�.,�,».__
�._ , .: ' .r-�v_ . ; bz.:�.. rF - . :....
of CEO � �.- � � ��>_ ; � __
ofChiefEzeoutiveOfficer(CEO)�� - �
�� ��� ` `� �
- .`�. -' .. ._ � __ ' '
.. . ��:` .. ..
The new gambling manager's license should become
effective (check one):
❑ The day after the currenf gambling manager's Iicense
expires (for example, if the current gambling manager's
Iicense expires 7/31/96, the new gambling manager'S
license becomes effective on 8/1/96, provided fhat all
application information is complete).
[� When the application has been processed by the Gam-
b{ing Cantrof Board-the effective date will be the first
� , day of the month. -_-�;.- � =_ � -
NOTE:s_ The new gambling manager may not assume
duties unUi he/she has received,a gambling manager's
Iicense from the Gam bling Control Board "' �`_ '--
Board Use On(y:
e Lic #
uence #
#
Nofary Public Informa�
be current and correct; seal
Subscribed and sworn to b'e
- - ot � - . ' c �c'�sE�6� G
i. Notary Public Sea(musf�
y not be altered:>�sT;;,� � 1 _'
� me this _ _ cia � ,
Y= -
- ` , 19. R-7 °. _., ."
.. ... . . ._.. _.,--_ � .. .
NOiAHYPUBLIC-MINNESOTA ( (continued on back) . _
AAMSEYCOUNTI i
�
;::
i: ;.
#� -
. �P . -
Gambling Manager Application
Affidavit and Consent Statement:
I,(printname) 2.��.�_J R•��,�C M
under oath sfate that 1 fiave never:
1. been convicted of a felony or a crime involving gam-
bling;
2. committed a violation of Iaw or Board rule that resulfed
in the revocation of a license issued by the Board within
five years before the date of the Iicanse application;
3. been convicted of a criminai violation involving fraud,
theft, tax evasion, misrepresentation, or gambling;
4. been convicted of (i) assault, (ii) a criminal violation
involving the use of a firearm, or (iii) making terroristic
threats.
5. been connected with nor engaged in an illegal busi-
ness;
6. owed $500 or more in delinquent taxes as defined in
section 270.72;
7. had a sales and use tax permit revoked by the com-
missioner of revenue within the past two years;
8. failed to file, afte� demand, tax retums required by the
commissioner of revenue.
In addition, I understand, agree, and hereby irrevocably
consent that suits and actions relating to the subject mat-
ter of the attached gambling manager license application,
or acts or omissions arising from such application, may be
commenced against me or my organization and I will
accept the service of process in any court of competent
jurisdiction in Minnesota by service on the Minnesota
Secretary of State of any summons, process, or pleading
authorized by the laws of Minnesota,
By signature of this document, the undersigned authorizes
the Departments of Public Safety and Revenue to con-
duct a criminal and tax background check or review and
to share the results with the Gambling Control Board.
Failure to provide required information or providing false
or misleading information may result in the denial or
revocation of the license.
FURTNER AFFIANT SAYETH NOT, except that this
Affidavit and Consent Statement are submitted in support
of the application for a gambling manager Iicense from
the Gamb(ing Controi Board.
9�1-1y �3
LG212
siss
Page 2 of 2
This publication will be made available in alternative
format (i.e. large print, Braille) upon request. �f you
use a T7Y, you can cail us using the Minnesota Relay
Service at 1-800-627-3529 and ask them to place a
call fo (612) 639-4000.
The information requested on this form wili be used
by the Gambling Control Board (Board) to determine
i your compliance with Minnesota statutes and rules
goveming lawful gambling activities. All of the infor-
mafion fhat you supply on this form wiil become
public information when received by the Board.
The information requested on this form (inciuding any
attachments) wili be used by the 8oard to determine
your qualifications to be involved in lawful gambling
activities in Minnesota, and to assist the Board in
conducting a background investigation of you.
You have the right to refuse to supply the information
requested; however, if you refuse to supply this infor-
mation, the Board may not be abie to determine your
qualifications and, as a consequence, may refuse to
issue you a license. If you supply the information
required, the Board will be abie to process your appli-
cation.
Your name and address will be public information when
received by the Board. A�I the other information about
you that you provide will be private data untii the Board
issues your license. When the Board issues your
license, all of the information you have provided to
the Board in the process of applying for your license
will become public exceptfor your social security num-
ber, which remains private.
Ii the Board does not issue you a ficense, all the infor-
mation you have provided in the process of applying
for a ficense remains private, with the exception of
your name and address, which will remain public.
Private data about you is available only to the follow-
ing: Board members, staff of the Board whose work
assignment requires that they have access to the
information; the Minnesota Department of Public
Safefij; the Minnesota Attorney General; the Minne-
sota Commissioners of Administration, Finance, and
Revenue; the Legislative Auditor, national and infer-
nationai gambling regufatory agencies; anyone pur-
suant to court order; other individuais and agencies
that may be specifically authorized by state or federal
faw to have access to such information; individuals
and agencies for which law or legai order authorizes a
new use or sharing of the information after thie notice
is given; you; and anyone with your written consent."
$i�itatUC@ Of G8111b{iil� Mafl1g21'`�-' -- -=. Notary Pubfic Information. Notary Pubiic Seai must
Ap ppp� �ICBIIt -- . y: be curtent and corred; seal may not be altered. � ,
,/'/ -�� Subscribed and sworn to before rrfe this .�3 day =
� L or �oc_ e� - ,`� s _�r� . -
Notanzed Sgnature ofP,pphwnt � ' - � _ ;= - .___ � � ' - '_
_ ,.. _ ` . - ...
_ - ' � —� �.` �---� - „
Date = - - - � —� � � -- _ ' Notary PubliC, w, �' - .
- . ° # ," ' . CHPoS�IEELLENSCHMIDT. - ,
. # �°�° TARY PUBLIG-MINNESOTA
� NO
� " RAMSEY COUNTY
� . , , - . , ti�'� ��ExpreflJAN31.�00 '
' — �` -- - �'y . .�.` �. .
. .,: � . . . - '.
_ . . ._,,.....,w _. _ . ..w_ . a .srs . .. Mp -- _ _ . ' ' ... _
council File # q�1 ly8'3
Ordinance ,�
Green Sheet # 50267
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
CITY
Presented
Referred To
39
RESOLt7SD: That application, ZD #24523 & 60341 fos Gambling Manager's License for
Richard Mataon DBA St. Paul Featival & Heritage Foundation at Mr. Patom's,
995 7th Street W. and at Turf Club, 1601 IIninersity Avenue W., be and the
same are hereby approved.
RESOLUTION
�T PAUL, MINNESOTA
Committee: Date
Requested by Department of:
• - -:-- �-•.- •:_ ,e•
t ' - •e
,e . %r.
Adoption Certified by Council Secretary
By:
Approved by Mayor': Date rti(2d1��-
Form Approved by City Attorn�.�
By: C/r�L� � � ca�•-�...e�
U
Approved by Mayor for Submisaion to
By:
BY: �/" • "� `.!
Adopted by Council: Date �, o � \9qr7
�--�--�-
N° 50267
DEPYiRiMENTIOFFlCHCOUNdL � DATE INITIATED - ••�/ f V�
LIEP { GREEN SHEE
CONipCT PERSON 8 PXONE INITIAUDATE INRIAl1DATE
� DEPARTMENT DIRECTOR � pTVCOUNGIL
William -F. Gunther — 266-9132 ASSIGN � CINAttORNEY � an c�aic
MUST BE ON CAUNCIL AGENDA BY (DATE) NUNBEP i0R ❑ BUDGET DIRECTOR O FIN. 8 MGi. $EFVICE$ DIR.
POVTING
Hearing: � �� 9 ORDEF � MAYOR (OR ASSI5TANf) O
TOTAL # OF SIGNATURE PAGES (CLIP A�L LOCATIONS FOR SIGNATURE)
AGTION RE�UESTED
Richard Matson DBA St. Paul Festival and Heritage Foundation requests Council
approval of his application for Gambling Manager's Licenses, ID �124523 &/160341 at
Mr. Patoms, 995 7th St. W. and at Turf Club, 1601 University Avenue W.
RECOMMENDATIONS: npprove (A) or Rejeet (R) pERSQNAI SERVICE CONTRACTS MUST ANSWER THE fOLLOWING QUESTIONS:
_ PLANNING COMMI$$ION _ CIVII SERVICE CAMMISSION �� Has this person/firm ever worked untler a contract for this department?
_ CIB CAMMfffEE �'ES NO
— � A � F 2. Has this persontfirm ever been a ciry empioyee�
— VES NO
_ Di57RiCiCOURi _ 3. Does this person/firtn possess a skill not normaily possessed
by any current city employee�
SUPPORTS WHICH COUNCIL OBJECTNE� YES NO
Explain all yes answers on separate sheet end ettach to green aheet
INITIATING PROBLEM, ISSUE. OPPpRTUNIiY (Who. Whet. When. Whare. Why)'
ADVANTAGESIFAPPROVED:
D�SADVANTAGES IFAPPqOVE�' ,
DISADVANTAGES IF NOTAPPflOVED
lrViidl6.i �y�� y�ii�
DEC 0 3 iS97
TOTAL AMOUN70F7RANSACTION S COST/REVENUE BUDGETED (CIpCLE ONE) YES NO
FUNDIIdG SOURCE ACTIVIIV NUMBER
FINANCIAL INFORMATION: (EXPLAIN)
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Minnesota Lawful Gamhiing LG212
Gamblin Mana A lication $
b b rP - _ Page 1 of 2.
Incomplete, faise, or misleading appiication information may result in denial of a license. _
Organization information
cEOName Anne Ford Nelson
(Cannotbegamblingmanager) -
DaytimePhone 6( 72 � 223-4700 Organization
1 � 2
10 i 9
Gambling Manager Information
FirstName RiChard FuIlMiddleName Rnhart LastName Mat�ar
MaidenName N�A DateofBirth 3/ 10 � 39 Checkoneoftheboxes: a Male � Female
� Social Secunty Number
HomeStreetAddress 2774 Del
c�t� Roseville
� [! Y �
I DaytimePhoneNumber( 612 1 889-4453
� I became an active member of this organization on:
�� I attended the two-day gambling managerseminar on:
Disclosure of
Sociai Security Number
You are required to provide your social secu-
ritynumberontbisform.Your sociatsecu-
rity number wiil be used to determine your
compliance wkh the tax laws of Minnesota.
Authorizationfor requirin9yoursocialsecu-
rity number is found at 42 U.S.C. 405(c)(i).
Bond Information A$10,000 fidelity bond in favor of the organization has been obtained as required
by Minnesota Staiutes, section 349.167, subdivision 1.
Insurance Company Name: O1 d Reoubl i c Surety Co Bond Number: RPSO445671
(DO NOT USE THE AGENCY NAME)
Gambling Manager Change �en your organ¢ation is changing its gambling manager, complete
one of these sedions:
ER10Fg011Cy Chattg0 - AVfow up to frve days for OtfiBi Cfiatlge - Allow up to ten weeks for processing
processing
The chief executive officer, by signing below, a�rms
that the emergency application is due to the following
reason (check one and fill in date):
❑ Death of gambling manager on / /_
❑ Disability of gambling manager on /_/
❑ Termination of empioyment of gambling manager on
-�/ -_-- / �� �_- ` i : .-. _ _ . . , _ � ; �
NOTE: _ The new gambl�ng�manager may not assume
duties until he/she has received the gambiing manager's
license from the Gambling Confrol Board:��;r:,��;w;,�.,�,».__
�._ , .: ' .r-�v_ . ; bz.:�.. rF - . :....
of CEO � �.- � � ��>_ ; � __
ofChiefEzeoutiveOfficer(CEO)�� - �
�� ��� ` `� �
- .`�. -' .. ._ � __ ' '
.. . ��:` .. ..
The new gambling manager's license should become
effective (check one):
❑ The day after the currenf gambling manager's Iicense
expires (for example, if the current gambling manager's
Iicense expires 7/31/96, the new gambling manager'S
license becomes effective on 8/1/96, provided fhat all
application information is complete).
[� When the application has been processed by the Gam-
b{ing Cantrof Board-the effective date will be the first
� , day of the month. -_-�;.- � =_ � -
NOTE:s_ The new gambling manager may not assume
duties unUi he/she has received,a gambling manager's
Iicense from the Gam bling Control Board "' �`_ '--
Board Use On(y:
e Lic #
uence #
#
Nofary Public Informa�
be current and correct; seal
Subscribed and sworn to b'e
- - ot � - . ' c �c'�sE�6� G
i. Notary Public Sea(musf�
y not be altered:>�sT;;,� � 1 _'
� me this _ _ cia � ,
Y= -
- ` , 19. R-7 °. _., ."
.. ... . . ._.. _.,--_ � .. .
NOiAHYPUBLIC-MINNESOTA ( (continued on back) . _
AAMSEYCOUNTI i
�
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Gambling Manager Application
Affidavit and Consent Statement:
I,(printname) 2.��.�_J R•��,�C M
under oath sfate that 1 fiave never:
1. been convicted of a felony or a crime involving gam-
bling;
2. committed a violation of Iaw or Board rule that resulfed
in the revocation of a license issued by the Board within
five years before the date of the Iicanse application;
3. been convicted of a criminai violation involving fraud,
theft, tax evasion, misrepresentation, or gambling;
4. been convicted of (i) assault, (ii) a criminal violation
involving the use of a firearm, or (iii) making terroristic
threats.
5. been connected with nor engaged in an illegal busi-
ness;
6. owed $500 or more in delinquent taxes as defined in
section 270.72;
7. had a sales and use tax permit revoked by the com-
missioner of revenue within the past two years;
8. failed to file, afte� demand, tax retums required by the
commissioner of revenue.
In addition, I understand, agree, and hereby irrevocably
consent that suits and actions relating to the subject mat-
ter of the attached gambling manager license application,
or acts or omissions arising from such application, may be
commenced against me or my organization and I will
accept the service of process in any court of competent
jurisdiction in Minnesota by service on the Minnesota
Secretary of State of any summons, process, or pleading
authorized by the laws of Minnesota,
By signature of this document, the undersigned authorizes
the Departments of Public Safety and Revenue to con-
duct a criminal and tax background check or review and
to share the results with the Gambling Control Board.
Failure to provide required information or providing false
or misleading information may result in the denial or
revocation of the license.
FURTNER AFFIANT SAYETH NOT, except that this
Affidavit and Consent Statement are submitted in support
of the application for a gambling manager Iicense from
the Gamb(ing Controi Board.
9�1-1y �3
LG212
siss
Page 2 of 2
This publication will be made available in alternative
format (i.e. large print, Braille) upon request. �f you
use a T7Y, you can cail us using the Minnesota Relay
Service at 1-800-627-3529 and ask them to place a
call fo (612) 639-4000.
The information requested on this form wili be used
by the Gambling Control Board (Board) to determine
i your compliance with Minnesota statutes and rules
goveming lawful gambling activities. All of the infor-
mafion fhat you supply on this form wiil become
public information when received by the Board.
The information requested on this form (inciuding any
attachments) wili be used by the 8oard to determine
your qualifications to be involved in lawful gambling
activities in Minnesota, and to assist the Board in
conducting a background investigation of you.
You have the right to refuse to supply the information
requested; however, if you refuse to supply this infor-
mation, the Board may not be abie to determine your
qualifications and, as a consequence, may refuse to
issue you a license. If you supply the information
required, the Board will be abie to process your appli-
cation.
Your name and address will be public information when
received by the Board. A�I the other information about
you that you provide will be private data untii the Board
issues your license. When the Board issues your
license, all of the information you have provided to
the Board in the process of applying for your license
will become public exceptfor your social security num-
ber, which remains private.
Ii the Board does not issue you a ficense, all the infor-
mation you have provided in the process of applying
for a ficense remains private, with the exception of
your name and address, which will remain public.
Private data about you is available only to the follow-
ing: Board members, staff of the Board whose work
assignment requires that they have access to the
information; the Minnesota Department of Public
Safefij; the Minnesota Attorney General; the Minne-
sota Commissioners of Administration, Finance, and
Revenue; the Legislative Auditor, national and infer-
nationai gambling regufatory agencies; anyone pur-
suant to court order; other individuais and agencies
that may be specifically authorized by state or federal
faw to have access to such information; individuals
and agencies for which law or legai order authorizes a
new use or sharing of the information after thie notice
is given; you; and anyone with your written consent."
$i�itatUC@ Of G8111b{iil� Mafl1g21'`�-' -- -=. Notary Pubfic Information. Notary Pubiic Seai must
Ap ppp� �ICBIIt -- . y: be curtent and corred; seal may not be altered. � ,
,/'/ -�� Subscribed and sworn to before rrfe this .�3 day =
� L or �oc_ e� - ,`� s _�r� . -
Notanzed Sgnature ofP,pphwnt � ' - � _ ;= - .___ � � ' - '_
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Date = - - - � —� � � -- _ ' Notary PubliC, w, �' - .
- . ° # ," ' . CHPoS�IEELLENSCHMIDT. - ,
. # �°�° TARY PUBLIG-MINNESOTA
� NO
� " RAMSEY COUNTY
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