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97-151Council File # �--' F ��. r-;��-.' � i�-�F[ `..r � : . ti : . a . . . .,..� Presented By, Green Sheet # 35442 � 1 Z 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 31 Referred To ordinance # Committee: Date RESOLVED: That application, ID #82486, £or a Gambling Manager's License by Thotnas R.Farrell DBA St. Paul Midway Lions Club Foundation at J. R. Mac's, 1420 W. 7th Street,(previously known at Hidway Lions Club�, be and the same is hereby approned. — r v� N(� a� Requested by Degartment of: Adopted by Council: Date Adop�ion Certified by Council Secretary 8 �` � iv-��c�. -�-_._ P+Pproved by Mayor: Date �/�S �� . By: �� ,i��1� • - -�-- ,:.- .,_ <,. _f •5.44 - •S s �.�¢¢� � �.� Form Approved by City Attorney By: �� Approved by Mayor for Submission to Gouncil By: �t�t -�s 1 DEPAq{}.�Epp�roFFICFJGOUNpL °"�'""'"TE° . GREEN SHEE �° - 3 5 4 4 2 LIEP — - CONTACT PEq$ON & PHONE INfTIAVDATE INIMIlbA7E � DEPARTMEM DIqECfOH � CRY COUNCIL William E. Gunther - 266-4132 "�'�" �cmmTOnNEV �crtrc�aK MUST BE ON ppUNCIL AGENDA BV (DAT� NUYBER FON a BUDGEi DIRECTOfl � FlN. & MGT. SFAVICES DIR. ROUTING Hearin : 02 � OHDER �MpyOfl(ORASSI5TMlf) � TQTAL # pp SIGNATUHE PAGES (CLIP ALL LOCATIONS FOR SIGNASIfRE) PAT�ON qEWEg7ED: Application for a new Gambling Manager`s License, ID 4182486, for Thomas R. Farrell DBA St. Pau1 Midway Lions C1uli Eoundation at .T. R. Mac's, 1420 W. 7th Street (previously Midway Lions Club) RECOMMENOA710N5: Approue (A) or Fajec[ (R) PERSONAI SERVICE CONTRACTS NUST ANSWER TNE FOLLOWING �UESTIONS: — PLANNMG COMMiS510N _ CML SERVICE COMMISS�ON �� Has ihis persoNfirm ever wo�ked under a contrect tor this dep�rtrneM? - _ CIB COMM�7-tEE YES �NO � _� 2. Has this person/firm ever been a city employee? — YES NO _ oISiAIC7 COUFr _ 3. Does this PersoNBrm possess a skiu fwt normalty possessed by any cuneM city employee? ' SUPPOR'Byy�{ICHCOUNpLOBJECTIVE7 YES NO Explaln ali yes anawers on separete aheet antl attaeh W graen sheet INRIq71NG PROBLEM, ISSUE OPPOF7UNITY (WM, Wha4'ti'hen, Where, Why�: _ ��' ��s� 28 ?Q97 _�.��^��.. _Y_ � _�_ . E.,..._ ; �� ADVANTAGESIFqpPqpVED: �ISADyqNTAGES IF APPROVED' ' (4 _.N.PP �i?Fs�'k,!LIC �Lffi4 e� �Fii� �u� 6� r� DISADVANTAGES IF NOTAPPROVED: � - 707AL AMOUNT OF TflANSACTION $ COST/REVENUE BUDGETED (CIRCLE ONE) YES NO FUNDI(dG SOURCE NCTIVITY NUMBER FINqNC1AL INFpRMATION: (EXPLAIN) Greensneet # 35442 L.I.E.P. REVIEW CNECKLlST �ate: /`�� ' � S� In TraCke�'? i O 2� ApP'n Received j App'n Processed License ID # 82486 ucense Type: Gamblin¢ Manager Company Name: Thomas R. Farrell DBA:St. Paul Midway Lions Club Foundation BusinessAddresss: 1420 W. 7th St. (JR Mac`s) BusinessPhone: 454-7674 Contact Name/Address:__ 1111 Elwav St. IE403 55116 Home Pfione: 646-6134 Date to Councii �.abe�s ordered: N�i�' District Council #: 09 Pubiic Hearing Date: ��Z � I�f 97 Nrnice Sent to Appiicarn: Notice Sent to Public: Ward #: � Department/ Date Inspections Comments CiryAttomey � �� +� �/,� 6 / Errvironmental Heaith /V / � 6 Fire lv�� License si�e wen Rece�ved: Lease Received: �`�/fl f Police t9�.f,rwPj p� Q�Q/��E'1t f�/R?31C. (�z L/ „_,,.� J �/�" J Zoning �1� q"1 -\S\ Mirznesotct LawfuT Gambiing ��Z�L fiteo Gambling Manager Application Pa 1 of 2 Incompiete, false, or misleading application information may result in denial of 2 license. Organization information Organization (Cannot be gambiing manager) oaytimePhone(iflt2- l4Sy- OrganizationBaseLicense Board Use On!y: _ �ic �r # Gambling Manager 4nformation FirstName ir+on,r+S Fu➢MiddleName 1'�tcr+,arao LastName �AR2E�-L- Maiden Name — Date of Birth `� / q/� Check one ofthe boxes: � Male � Female Social Security Home StreetA� r_za�� Daytime Phone Number Disclosure of Social Security tdumber You are required to provide your soc�at secu- ritynumberonthisform.Your socialsecu- rity number wtll be used to determine your compliance with the tax iaws of Minnesota Authorization for requiring your social secu- riry number is found at 42 U-S.C: 405(c)(i). � became an active memberofthis orgae�zahon on� ( O / 19 /°1 i attended the two-day gambling manage� seminar on: 3! /_ Bond Information A$1o.000 fidelity bond in favor of the osganization has been obtained as required by M�nnesota Statufes, section 349.167, subdivision 1. Insurance Gompany Name: Bond Number: (DO NOT USE THE AGENCY NAME) GambiingMana�erChange '�'enyourorganizati< one of these sections: � EtriergenCy Ch8ftg2 - Allow up to five days for processing The chief executive officer, by signing below, affirms that the emergency application is due to the following reason (check one and fiN in date): _; Death of gambling manager on ^/ 1, Disability of gambling manager o� _' Terminafion of employment of gambiing manager on NOTE: The new gambiing manager may not assume duties untii he/she has received the gambling manager's license from the Gambling Control Board. manager, - AAow up to ten weal:s io� processing The new gambfing manager's license shouio �ecome ; effective (check one): ;❑ The day after the current gambling m�;i ��=ger's license expires (for example, if the current gamb;ing manager's license expires 7/3�/96, the new gaml7li;iy manager's Iicense becomes effective on 8/�'�U, provicled that all application information is compleYe;. � When the application has been processed by the Gam- biing Control Board--the effective da4e w�iii be. the first ; day of the month. � NOTE: The new gambling manag�r may ;;%t assume duties untii he/she has received a gamblir, n��anager's licensefrom the Gambling Control Board. S�gnature of CEO � ,i r9i�/' m Nota rized Sgnature of Chief Execuhve Officer (CEO) �ate: l Zf L3/°fto Notary Public Information. Notary Public � eal must be curreni and correct; seal may not be ;fte� �d. Subscribad and swom to before me this _._ `?--��> ? �'day oi_1� c.Gtm�P>t2 ____ , i�', E�,s�z__ Cl;i;lgl �e cLLeiJ SC-. � - �'J . . c .-:, .. _ .,_.,. CtiRiS71EE ','�„„�.,�u r-�'�il:�r2ck)_;.�.:� NOTARY PU9lIC—p,1�tvNE50TA � �� ,� Gambling Manager Application (cotttinued) Affidavit and Consent Statement: under oath state that i have never: 1. been convicted of a felony or a crime involving gam- bling; 2. committed a violation of Iaw pr Board rule that resulted in fhe revocation of a license issued by the Board within five years before the date of the license application; - 3, been convicted of a criminal violation invoiving fraud, theft, tax evasion, misrepresentation; or gamb4ing; 4, been convicted of (i) assault, (ii) a criminal vio(atlon involving the use of a ferearm, or (iii) making terzorist+c threats. $- 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. faifed to file, after demand, tax returns required by the commissioner of revenue. ln addition, 1 understand, agree, and hereby irrevocably consent that suits and actions relating to the subject mat- ter of the attached gambfing manager license application, or acts or omissions arising from such application, may be commenced against me or my organization and I will accept the serv+ce of process in any court of competent }urisdiction in �viinnesota by service on the Minnesota Secretary of State of any summons, process. or pieading authorized by the laws of Minnesota. 3y signature of this documeni, ihe 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 Contro! Boacd. Failure to provide required information or providing faise o� misieading information may result in the denial or revocation of the ficense. F�F'.THER AFFIANT SAYETH NOT, except that this A�dav'st and Consent Statement are submitted in support oF the appiication for a gambiing manager license from the Gambfing Cortrol Board. Signature of Gambling Manager APP�icant ./! � f`= G"SY-P/V t NotarizetlSignatu2ofAppl�ca t - laLa3/�l� '_P�G � � ' �.S � 3786 ?ao= 2 oz 2 This publication will be made available in alternative format (i.e. iarge print, Braille) upon request. If you use a TTY, you can caii us using the Minnesota Relay Service at (612) 297-5353 or 1-800-627-3529 and ask them to place a call to (612) 639-4�00. 7he information requested on this form will be used by the Gambling Controi Board (Board) to determine your compiiance with Minnesota statutes and rules goveming lawful gambling activities. Aii of the infor- mation that you suppfy on this form wiil hecome pubiic information when received by the Board. The information requested on this form (including any attachments) wili be used by the Board to determine your qualifications to be invoived in lawful gambling activities iri Minnesota, and to assist the Board in conducting a background investigation of you. You have the right to refuse to supply the infiormation 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. tf you supply the information required, the Board will be abie to process your appli- cation. Your name end address will be public information when received by the Board. Ali the other information about you that you provide wiii be private data unti! the Board +ssues your license. When the Board issues your {icense, all of the information you have provided to the Board in the process of applying for your ficense wiii become putilic exceptforyour sociai security num- ber, which remains private. If the Board does not issue you a Iicense, all 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 wiN remain pubfic. Private data about you is available only to the fol(ow- ing: Board members, staff of the Board whose work assignment requires that they have access to the information; the Minnesota Department of Public Safety; the Minnesota Attorney General; the Minne- sota Commissioners of Administration, Finance, and Revenue; the Legisiative Auditor; naiional and inter- national gambling regulatory agencies; anyone pur- suant to court order; other individuals and agencies that may be specifically authorized by state or federal iaw to have access to such information; individuals and agencies for which law or legal order authorizes a new use or sharing of the information after this notice is given; you; and anyone with your wsitten consent. Notary Public information. Notary Pubiic Seai must be current and correct; seai may not be aitered. Subscribed and sworn to before me this 23� day of �ecE�,-.Bea� , 19�1(0 . r+aMS�v Cou, � �/p Ca; m sw rsc:�a5 j:4 37..'�^,,,M Council File # �--' F ��. r-;��-.' � i�-�F[ `..r � : . ti : . a . . . .,..� Presented By, Green Sheet # 35442 � 1 Z 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 31 Referred To ordinance # Committee: Date RESOLVED: That application, ID #82486, £or a Gambling Manager's License by Thotnas R.Farrell DBA St. Paul Midway Lions Club Foundation at J. R. Mac's, 1420 W. 7th Street,(previously known at Hidway Lions Club�, be and the same is hereby approned. — r v� N(� a� Requested by Degartment of: Adopted by Council: Date Adop�ion Certified by Council Secretary 8 �` � iv-��c�. -�-_._ P+Pproved by Mayor: Date �/�S �� . By: �� ,i��1� • - -�-- ,:.- .,_ <,. _f •5.44 - •S s �.�¢¢� � �.� Form Approved by City Attorney By: �� Approved by Mayor for Submission to Gouncil By: �t�t -�s 1 DEPAq{}.�Epp�roFFICFJGOUNpL °"�'""'"TE° . GREEN SHEE �° - 3 5 4 4 2 LIEP — - CONTACT PEq$ON & PHONE INfTIAVDATE INIMIlbA7E � DEPARTMEM DIqECfOH � CRY COUNCIL William E. Gunther - 266-4132 "�'�" �cmmTOnNEV �crtrc�aK MUST BE ON ppUNCIL AGENDA BV (DAT� NUYBER FON a BUDGEi DIRECTOfl � FlN. & MGT. SFAVICES DIR. ROUTING Hearin : 02 � OHDER �MpyOfl(ORASSI5TMlf) � TQTAL # pp SIGNATUHE PAGES (CLIP ALL LOCATIONS FOR SIGNASIfRE) PAT�ON qEWEg7ED: Application for a new Gambling Manager`s License, ID 4182486, for Thomas R. Farrell DBA St. Pau1 Midway Lions C1uli Eoundation at .T. R. Mac's, 1420 W. 7th Street (previously Midway Lions Club) RECOMMENOA710N5: Approue (A) or Fajec[ (R) PERSONAI SERVICE CONTRACTS NUST ANSWER TNE FOLLOWING �UESTIONS: — PLANNMG COMMiS510N _ CML SERVICE COMMISS�ON �� Has ihis persoNfirm ever wo�ked under a contrect tor this dep�rtrneM? - _ CIB COMM�7-tEE YES �NO � _� 2. Has this person/firm ever been a city employee? — YES NO _ oISiAIC7 COUFr _ 3. Does this PersoNBrm possess a skiu fwt normalty possessed by any cuneM city employee? ' SUPPOR'Byy�{ICHCOUNpLOBJECTIVE7 YES NO Explaln ali yes anawers on separete aheet antl attaeh W graen sheet INRIq71NG PROBLEM, ISSUE OPPOF7UNITY (WM, Wha4'ti'hen, Where, Why�: _ ��' ��s� 28 ?Q97 _�.��^��.. _Y_ � _�_ . E.,..._ ; �� ADVANTAGESIFqpPqpVED: �ISADyqNTAGES IF APPROVED' ' (4 _.N.PP �i?Fs�'k,!LIC �Lffi4 e� �Fii� �u� 6� r� DISADVANTAGES IF NOTAPPROVED: � - 707AL AMOUNT OF TflANSACTION $ COST/REVENUE BUDGETED (CIRCLE ONE) YES NO FUNDI(dG SOURCE NCTIVITY NUMBER FINqNC1AL INFpRMATION: (EXPLAIN) Greensneet # 35442 L.I.E.P. REVIEW CNECKLlST �ate: /`�� ' � S� In TraCke�'? i O 2� ApP'n Received j App'n Processed License ID # 82486 ucense Type: Gamblin¢ Manager Company Name: Thomas R. Farrell DBA:St. Paul Midway Lions Club Foundation BusinessAddresss: 1420 W. 7th St. (JR Mac`s) BusinessPhone: 454-7674 Contact Name/Address:__ 1111 Elwav St. IE403 55116 Home Pfione: 646-6134 Date to Councii �.abe�s ordered: N�i�' District Council #: 09 Pubiic Hearing Date: ��Z � I�f 97 Nrnice Sent to Appiicarn: Notice Sent to Public: Ward #: � Department/ Date Inspections Comments CiryAttomey � �� +� �/,� 6 / Errvironmental Heaith /V / � 6 Fire lv�� License si�e wen Rece�ved: Lease Received: �`�/fl f Police t9�.f,rwPj p� Q�Q/��E'1t f�/R?31C. (�z L/ „_,,.� J �/�" J Zoning �1� q"1 -\S\ Mirznesotct LawfuT Gambiing ��Z�L fiteo Gambling Manager Application Pa 1 of 2 Incompiete, false, or misleading application information may result in denial of 2 license. Organization information Organization (Cannot be gambiing manager) oaytimePhone(iflt2- l4Sy- OrganizationBaseLicense Board Use On!y: _ �ic �r # Gambling Manager 4nformation FirstName ir+on,r+S Fu➢MiddleName 1'�tcr+,arao LastName �AR2E�-L- Maiden Name — Date of Birth `� / q/� Check one ofthe boxes: � Male � Female Social Security Home StreetA� r_za�� Daytime Phone Number Disclosure of Social Security tdumber You are required to provide your soc�at secu- ritynumberonthisform.Your socialsecu- rity number wtll be used to determine your compliance with the tax iaws of Minnesota Authorization for requiring your social secu- riry number is found at 42 U-S.C: 405(c)(i). � became an active memberofthis orgae�zahon on� ( O / 19 /°1 i attended the two-day gambling manage� seminar on: 3! /_ Bond Information A$1o.000 fidelity bond in favor of the osganization has been obtained as required by M�nnesota Statufes, section 349.167, subdivision 1. Insurance Gompany Name: Bond Number: (DO NOT USE THE AGENCY NAME) GambiingMana�erChange '�'enyourorganizati< one of these sections: � EtriergenCy Ch8ftg2 - Allow up to five days for processing The chief executive officer, by signing below, affirms that the emergency application is due to the following reason (check one and fiN in date): _; Death of gambling manager on ^/ 1, Disability of gambling manager o� _' Terminafion of employment of gambiing manager on NOTE: The new gambiing manager may not assume duties untii he/she has received the gambling manager's license from the Gambling Control Board. manager, - AAow up to ten weal:s io� processing The new gambfing manager's license shouio �ecome ; effective (check one): ;❑ The day after the current gambling m�;i ��=ger's license expires (for example, if the current gamb;ing manager's license expires 7/3�/96, the new gaml7li;iy manager's Iicense becomes effective on 8/�'�U, provicled that all application information is compleYe;. � When the application has been processed by the Gam- biing Control Board--the effective da4e w�iii be. the first ; day of the month. � NOTE: The new gambling manag�r may ;;%t assume duties untii he/she has received a gamblir, n��anager's licensefrom the Gambling Control Board. S�gnature of CEO � ,i r9i�/' m Nota rized Sgnature of Chief Execuhve Officer (CEO) �ate: l Zf L3/°fto Notary Public Information. Notary Public � eal must be curreni and correct; seal may not be ;fte� �d. Subscribad and swom to before me this _._ `?--��> ? �'day oi_1� c.Gtm�P>t2 ____ , i�', E�,s�z__ Cl;i;lgl �e cLLeiJ SC-. � - �'J . . c .-:, .. _ .,_.,. CtiRiS71EE ','�„„�.,�u r-�'�il:�r2ck)_;.�.:� NOTARY PU9lIC—p,1�tvNE50TA � �� ,� Gambling Manager Application (cotttinued) Affidavit and Consent Statement: under oath state that i have never: 1. been convicted of a felony or a crime involving gam- bling; 2. committed a violation of Iaw pr Board rule that resulted in fhe revocation of a license issued by the Board within five years before the date of the license application; - 3, been convicted of a criminal violation invoiving fraud, theft, tax evasion, misrepresentation; or gamb4ing; 4, been convicted of (i) assault, (ii) a criminal vio(atlon involving the use of a ferearm, or (iii) making terzorist+c threats. $- 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. faifed to file, after demand, tax returns required by the commissioner of revenue. ln addition, 1 understand, agree, and hereby irrevocably consent that suits and actions relating to the subject mat- ter of the attached gambfing manager license application, or acts or omissions arising from such application, may be commenced against me or my organization and I will accept the serv+ce of process in any court of competent }urisdiction in �viinnesota by service on the Minnesota Secretary of State of any summons, process. or pieading authorized by the laws of Minnesota. 3y signature of this documeni, ihe 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 Contro! Boacd. Failure to provide required information or providing faise o� misieading information may result in the denial or revocation of the ficense. F�F'.THER AFFIANT SAYETH NOT, except that this A�dav'st and Consent Statement are submitted in support oF the appiication for a gambiing manager license from the Gambfing Cortrol Board. Signature of Gambling Manager APP�icant ./! � f`= G"SY-P/V t NotarizetlSignatu2ofAppl�ca t - laLa3/�l� '_P�G � � ' �.S � 3786 ?ao= 2 oz 2 This publication will be made available in alternative format (i.e. iarge print, Braille) upon request. If you use a TTY, you can caii us using the Minnesota Relay Service at (612) 297-5353 or 1-800-627-3529 and ask them to place a call to (612) 639-4�00. 7he information requested on this form will be used by the Gambling Controi Board (Board) to determine your compiiance with Minnesota statutes and rules goveming lawful gambling activities. Aii of the infor- mation that you suppfy on this form wiil hecome pubiic information when received by the Board. The information requested on this form (including any attachments) wili be used by the Board to determine your qualifications to be invoived in lawful gambling activities iri Minnesota, and to assist the Board in conducting a background investigation of you. You have the right to refuse to supply the infiormation 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. tf you supply the information required, the Board will be abie to process your appli- cation. Your name end address will be public information when received by the Board. Ali the other information about you that you provide wiii be private data unti! the Board +ssues your license. When the Board issues your {icense, all of the information you have provided to the Board in the process of applying for your ficense wiii become putilic exceptforyour sociai security num- ber, which remains private. If the Board does not issue you a Iicense, all 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 wiN remain pubfic. Private data about you is available only to the fol(ow- ing: Board members, staff of the Board whose work assignment requires that they have access to the information; the Minnesota Department of Public Safety; the Minnesota Attorney General; the Minne- sota Commissioners of Administration, Finance, and Revenue; the Legisiative Auditor; naiional and inter- national gambling regulatory agencies; anyone pur- suant to court order; other individuals and agencies that may be specifically authorized by state or federal iaw to have access to such information; individuals and agencies for which law or legal order authorizes a new use or sharing of the information after this notice is given; you; and anyone with your wsitten consent. Notary Public information. Notary Pubiic Seai must be current and correct; seai may not be aitered. Subscribed and sworn to before me this 23� day of �ecE�,-.Bea� , 19�1(0 . r+aMS�v Cou, � �/p Ca; m sw rsc:�a5 j:4 37..'�^,,,M Council File # �--' F ��. r-;��-.' � i�-�F[ `..r � : . ti : . a . . . .,..� Presented By, Green Sheet # 35442 � 1 Z 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 31 Referred To ordinance # Committee: Date RESOLVED: That application, ID #82486, £or a Gambling Manager's License by Thotnas R.Farrell DBA St. Paul Midway Lions Club Foundation at J. R. Mac's, 1420 W. 7th Street,(previously known at Hidway Lions Club�, be and the same is hereby approned. — r v� N(� a� Requested by Degartment of: Adopted by Council: Date Adop�ion Certified by Council Secretary 8 �` � iv-��c�. -�-_._ P+Pproved by Mayor: Date �/�S �� . By: �� ,i��1� • - -�-- ,:.- .,_ <,. _f •5.44 - •S s �.�¢¢� � �.� Form Approved by City Attorney By: �� Approved by Mayor for Submission to Gouncil By: �t�t -�s 1 DEPAq{}.�Epp�roFFICFJGOUNpL °"�'""'"TE° . GREEN SHEE �° - 3 5 4 4 2 LIEP — - CONTACT PEq$ON & PHONE INfTIAVDATE INIMIlbA7E � DEPARTMEM DIqECfOH � CRY COUNCIL William E. Gunther - 266-4132 "�'�" �cmmTOnNEV �crtrc�aK MUST BE ON ppUNCIL AGENDA BV (DAT� NUYBER FON a BUDGEi DIRECTOfl � FlN. & MGT. SFAVICES DIR. ROUTING Hearin : 02 � OHDER �MpyOfl(ORASSI5TMlf) � TQTAL # pp SIGNATUHE PAGES (CLIP ALL LOCATIONS FOR SIGNASIfRE) PAT�ON qEWEg7ED: Application for a new Gambling Manager`s License, ID 4182486, for Thomas R. Farrell DBA St. Pau1 Midway Lions C1uli Eoundation at .T. R. Mac's, 1420 W. 7th Street (previously Midway Lions Club) RECOMMENOA710N5: Approue (A) or Fajec[ (R) PERSONAI SERVICE CONTRACTS NUST ANSWER TNE FOLLOWING �UESTIONS: — PLANNMG COMMiS510N _ CML SERVICE COMMISS�ON �� Has ihis persoNfirm ever wo�ked under a contrect tor this dep�rtrneM? - _ CIB COMM�7-tEE YES �NO � _� 2. Has this person/firm ever been a city employee? — YES NO _ oISiAIC7 COUFr _ 3. Does this PersoNBrm possess a skiu fwt normalty possessed by any cuneM city employee? ' SUPPOR'Byy�{ICHCOUNpLOBJECTIVE7 YES NO Explaln ali yes anawers on separete aheet antl attaeh W graen sheet INRIq71NG PROBLEM, ISSUE OPPOF7UNITY (WM, Wha4'ti'hen, Where, Why�: _ ��' ��s� 28 ?Q97 _�.��^��.. _Y_ � _�_ . E.,..._ ; �� ADVANTAGESIFqpPqpVED: �ISADyqNTAGES IF APPROVED' ' (4 _.N.PP �i?Fs�'k,!LIC �Lffi4 e� �Fii� �u� 6� r� DISADVANTAGES IF NOTAPPROVED: � - 707AL AMOUNT OF TflANSACTION $ COST/REVENUE BUDGETED (CIRCLE ONE) YES NO FUNDI(dG SOURCE NCTIVITY NUMBER FINqNC1AL INFpRMATION: (EXPLAIN) Greensneet # 35442 L.I.E.P. REVIEW CNECKLlST �ate: /`�� ' � S� In TraCke�'? i O 2� ApP'n Received j App'n Processed License ID # 82486 ucense Type: Gamblin¢ Manager Company Name: Thomas R. Farrell DBA:St. Paul Midway Lions Club Foundation BusinessAddresss: 1420 W. 7th St. (JR Mac`s) BusinessPhone: 454-7674 Contact Name/Address:__ 1111 Elwav St. IE403 55116 Home Pfione: 646-6134 Date to Councii �.abe�s ordered: N�i�' District Council #: 09 Pubiic Hearing Date: ��Z � I�f 97 Nrnice Sent to Appiicarn: Notice Sent to Public: Ward #: � Department/ Date Inspections Comments CiryAttomey � �� +� �/,� 6 / Errvironmental Heaith /V / � 6 Fire lv�� License si�e wen Rece�ved: Lease Received: �`�/fl f Police t9�.f,rwPj p� Q�Q/��E'1t f�/R?31C. (�z L/ „_,,.� J �/�" J Zoning �1� q"1 -\S\ Mirznesotct LawfuT Gambiing ��Z�L fiteo Gambling Manager Application Pa 1 of 2 Incompiete, false, or misleading application information may result in denial of 2 license. Organization information Organization (Cannot be gambiing manager) oaytimePhone(iflt2- l4Sy- OrganizationBaseLicense Board Use On!y: _ �ic �r # Gambling Manager 4nformation FirstName ir+on,r+S Fu➢MiddleName 1'�tcr+,arao LastName �AR2E�-L- Maiden Name — Date of Birth `� / q/� Check one ofthe boxes: � Male � Female Social Security Home StreetA� r_za�� Daytime Phone Number Disclosure of Social Security tdumber You are required to provide your soc�at secu- ritynumberonthisform.Your socialsecu- rity number wtll be used to determine your compliance with the tax iaws of Minnesota Authorization for requiring your social secu- riry number is found at 42 U-S.C: 405(c)(i). � became an active memberofthis orgae�zahon on� ( O / 19 /°1 i attended the two-day gambling manage� seminar on: 3! /_ Bond Information A$1o.000 fidelity bond in favor of the osganization has been obtained as required by M�nnesota Statufes, section 349.167, subdivision 1. Insurance Gompany Name: Bond Number: (DO NOT USE THE AGENCY NAME) GambiingMana�erChange '�'enyourorganizati< one of these sections: � EtriergenCy Ch8ftg2 - Allow up to five days for processing The chief executive officer, by signing below, affirms that the emergency application is due to the following reason (check one and fiN in date): _; Death of gambling manager on ^/ 1, Disability of gambling manager o� _' Terminafion of employment of gambiing manager on NOTE: The new gambiing manager may not assume duties untii he/she has received the gambling manager's license from the Gambling Control Board. manager, - AAow up to ten weal:s io� processing The new gambfing manager's license shouio �ecome ; effective (check one): ;❑ The day after the current gambling m�;i ��=ger's license expires (for example, if the current gamb;ing manager's license expires 7/3�/96, the new gaml7li;iy manager's Iicense becomes effective on 8/�'�U, provicled that all application information is compleYe;. � When the application has been processed by the Gam- biing Control Board--the effective da4e w�iii be. the first ; day of the month. � NOTE: The new gambling manag�r may ;;%t assume duties untii he/she has received a gamblir, n��anager's licensefrom the Gambling Control Board. S�gnature of CEO � ,i r9i�/' m Nota rized Sgnature of Chief Execuhve Officer (CEO) �ate: l Zf L3/°fto Notary Public Information. Notary Public � eal must be curreni and correct; seal may not be ;fte� �d. Subscribad and swom to before me this _._ `?--��> ? �'day oi_1� c.Gtm�P>t2 ____ , i�', E�,s�z__ Cl;i;lgl �e cLLeiJ SC-. � - �'J . . c .-:, .. _ .,_.,. CtiRiS71EE ','�„„�.,�u r-�'�il:�r2ck)_;.�.:� NOTARY PU9lIC—p,1�tvNE50TA � �� ,� Gambling Manager Application (cotttinued) Affidavit and Consent Statement: under oath state that i have never: 1. been convicted of a felony or a crime involving gam- bling; 2. committed a violation of Iaw pr Board rule that resulted in fhe revocation of a license issued by the Board within five years before the date of the license application; - 3, been convicted of a criminal violation invoiving fraud, theft, tax evasion, misrepresentation; or gamb4ing; 4, been convicted of (i) assault, (ii) a criminal vio(atlon involving the use of a ferearm, or (iii) making terzorist+c threats. $- 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. faifed to file, after demand, tax returns required by the commissioner of revenue. ln addition, 1 understand, agree, and hereby irrevocably consent that suits and actions relating to the subject mat- ter of the attached gambfing manager license application, or acts or omissions arising from such application, may be commenced against me or my organization and I will accept the serv+ce of process in any court of competent }urisdiction in �viinnesota by service on the Minnesota Secretary of State of any summons, process. or pieading authorized by the laws of Minnesota. 3y signature of this documeni, ihe 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 Contro! Boacd. Failure to provide required information or providing faise o� misieading information may result in the denial or revocation of the ficense. F�F'.THER AFFIANT SAYETH NOT, except that this A�dav'st and Consent Statement are submitted in support oF the appiication for a gambiing manager license from the Gambfing Cortrol Board. Signature of Gambling Manager APP�icant ./! � f`= G"SY-P/V t NotarizetlSignatu2ofAppl�ca t - laLa3/�l� '_P�G � � ' �.S � 3786 ?ao= 2 oz 2 This publication will be made available in alternative format (i.e. iarge print, Braille) upon request. If you use a TTY, you can caii us using the Minnesota Relay Service at (612) 297-5353 or 1-800-627-3529 and ask them to place a call to (612) 639-4�00. 7he information requested on this form will be used by the Gambling Controi Board (Board) to determine your compiiance with Minnesota statutes and rules goveming lawful gambling activities. Aii of the infor- mation that you suppfy on this form wiil hecome pubiic information when received by the Board. The information requested on this form (including any attachments) wili be used by the Board to determine your qualifications to be invoived in lawful gambling activities iri Minnesota, and to assist the Board in conducting a background investigation of you. You have the right to refuse to supply the infiormation 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. tf you supply the information required, the Board will be abie to process your appli- cation. Your name end address will be public information when received by the Board. Ali the other information about you that you provide wiii be private data unti! the Board +ssues your license. When the Board issues your {icense, all of the information you have provided to the Board in the process of applying for your ficense wiii become putilic exceptforyour sociai security num- ber, which remains private. If the Board does not issue you a Iicense, all 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 wiN remain pubfic. Private data about you is available only to the fol(ow- ing: Board members, staff of the Board whose work assignment requires that they have access to the information; the Minnesota Department of Public Safety; the Minnesota Attorney General; the Minne- sota Commissioners of Administration, Finance, and Revenue; the Legisiative Auditor; naiional and inter- national gambling regulatory agencies; anyone pur- suant to court order; other individuals and agencies that may be specifically authorized by state or federal iaw to have access to such information; individuals and agencies for which law or legal order authorizes a new use or sharing of the information after this notice is given; you; and anyone with your wsitten consent. Notary Public information. Notary Pubiic Seai must be current and correct; seai may not be aitered. Subscribed and sworn to before me this 23� day of �ecE�,-.Bea� , 19�1(0 . r+aMS�v Cou, � �/p Ca; m sw rsc:�a5 j:4 37..'�^,,,M