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97-356Council Pile $ ` l � � S (� ��`� E�..d� �� .,�s i n `. . c v � Ordinance # Green Sheet # 35449 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 RESOLUTION OF SAINT PAUL, MINNESOTA Presented By Referred To RESOLVED: Committee: Date That application, ID $19�34, for a new Gamblinq Manaqer's License by Philip W. Swanson DBA Midway Tranaportation, Inc. at Cab's Pub & Eatery, 992 Arcade Street, be and the same is hereby approved. Requested by Department of: • - -� - � - •�- ,s� � •:�i-� • - • BY: �/ � � � ��tl� Adoption Certified by Council Secretary ss: _ � � � a- . s—� Approved by Mayor: Date �L`� t.�� By: , � l� J ff " .�--� Form Approved by City Attorney �� Approved by Mayor £or Submission to Council By: Adopted by Council: Date �y��}qq�"� t- FOR q7 -35G GREEN SHEE N 35449 INff1AVDATE MRIAVDATE — DEPARTMEN( DIRECTOR � CYfY COUNCIL GRYATTORNEY O CITYCIFflK BUDGET OIRECR]R O FIN. S MGL SERVICES OIR. MAYOR (Ofl ASSISTAMn � MTAL # OF SIGNATURE PAGES - (CLIP ALL LOCATIONS FOR SIGNATURE) Philip W. Swanson DBA Midway Transportation, Inc. requests Council approval of his application for a new Gambling Manager's License, (ID �19734), at Cab's Pub & Eatery, 992 Arcade Street. _ PIANNIN� COMMISSIDN _ CIViI SEBVICE _ C16cOMMfi7EE _ _ STAFF _ _ 04STRICT WURT _ SUPPOpTS WHfCH COUNCIL OBJECTIVE? PEHSONAL SEHYICE CONSpACTS MUST ANSWEN THE POLLOWINO QUESTIONS: 1. Has ihis personfirm ever worketl untler a coniraq for ihis deparimeM? - YES NO 2. Nas th'rs nersun�rm ever teen e ciry emp�oyee,? YES NO 3. Doea this personJfirm possess a skilt not normally possessed by any current city employee? YES P10 Explain all yes answers on saparete sheet and ettach to green sheet ECEd�� AR � v �ss7 �� A �� .�� '`�� 21 19�7 IF TOTAL AMOUNT OF TRANSACTIpN S COSTlREVENUE BUDGEiED (CIRCLE ONE) YES NO FUNDING SOURCE ACTIVITY NUMBER °INANCIAL INFOftMAT10N: (EXPI.AIN) Greensheet # 35449 In Tracker? �[ 9 License ID # 19734 L.I.E.P. REVIEW CHECKL{ST Date: f �7•.�SL App'n Receivetl / App'n Pcocessed License Type: GamblinQ Manaeer Company Name: philiv W. Swanson DBA:�Iidway Trana�nrtari n� 7n� _ BusinessAddresss: 992 Arcade St. (Cab's) BusinessPhone: h4i-o976 Contact NameJAddress: 760 Vandalia St. �/200 55114 Home Phone: 64i-o7n9 Date to Council Research: Publlc Hearing Date: � i l a i 1�9� Labels Ordered: NiA Notice Sent to Appiicarrt: �l� �R7 District Council #: OS Notice Sent to Public: NJA Ward #: O6 Department/ Date Inspections Comments City Attorney Q 1�. � �. 3 /� ? l R � EnvironmeMal Health �1� Fire �� ucense s�e� a�an �Ned:_ �� aa��ad: �� Police � � ��C6?`(,: �e� � ��- CY ° ��- 3J1� j�� Zoning ' "�� /� � i aZ -:35G Minrses�ta Lawful Gambiing Gamhlin� Manager Application incamplete, falsa, oc misleading applicat+on +nformatian may result in denial of a Organization infiormation NC CEO Name s� H K s� A�� t{ H c, c= (Cannot be gamb�ing manager) DaytimePhone( �afa ) �S`� OrganizationBase Ga►nbling Manager Information • F'astName j��+ �� Fu14MiddleName � P h c� � f 1 LastName -��+�' H So+� Maiden Name Date oi Birth! vZ J 8 1� Gfleck o�e o( ihe boxas: � fvTaie a Femafe Sociat Secunty Number. HomeStreetAddress , w >_ n .. payhme Ahone fitumber ( �! a _) /v C� 5- I became ah active rnember af this organization an: # ettended #he two•day gambt+ng manager seminar an: Disclosure af Sanial Security Number /Q Youarerequiredtaprwideyoursoaalsecu- , rity nomber on this totrrt. Your sociaf secu- ' rity numbet wiA be used to determine your r r,4mpSiartcewithtAetax4awsafNiinnesota. —�� AuthorltafiatsfQtfecynichcgyAUSSOCiaisecu- — ritynumbsr,$tovndata2U.S.C.aaS(c){i}. Band information A$10,Q00 8delity bond in fiavor of the organization has been obtained as required by Minnesota 5tatutes, seation 349.167,, subdivision -. fnsvrance Company Name: �� f��hk 6ond �fumber: ��itp Q�� l 7$� ([3O NQT USE THE AGENCY NAME� �� Gambling Manager Change �"�nenyour orgarn2am one of these sections: Emergen�y Cfiange - Rifow up to five days for , ptocessxng The ehief exeoutive o�icer, by sigr�irx� below, affirms that the emergency appiicativn is due to the faitowing reesQn (check one and F1i in dafe�; �peathafgamDlingmanageron,,, /_,,,_ ❑ Disabifity of gambling manager on! ,�„/,,,,,_,� � 3ermina#i�� a�sr�spPOymeMc�f gambiing manager on .__.__!._...._�_____ N�37E: The new gamb4ing manager may not essume duties until heishe has received the gambling manager's lieense frpm the Gambiing Controi 6oard. .S`t� ttJS"@ O� �`r�Q _,t�� ci �� Notaru.ed Sj�nature of Chiaf Execu ive Gfficer(CEO) Oate: �a� ..�.;� a� . . � �.JJ. .i.. .i`lJ.nrv _ ." . . .. ` ' �` � LG212 �.....___.__.._�.....__. ,s�ss Page 1 of 2 Board Use Only: e Lic # uence # rut Paid manager, OthC[ Gh80gC - Allow up to {en weeks for processing TMe new gambiing managePs iicense should kecome effeetive (check one}: • �`I The day aSisr the current gambi{ng managsr's license expires (forexampfe, iffhe currentgambling manager's iicense expires 7/31i96, the new gambiing manager's license becomes efifective on &lt196, provided that aii applicatipn intormation is complete). � 4Vhett tRe apptica#ion has Deen processed tip fhe Gam- bl'sng CQntra4 Bsaard—the eEfectivE daFe vtill be the �rst day of the month. NOTE: The new gambling manager may not assume duties until he/she has received e gambling manager's license from the Gamblfng Controi Board. Notary Public �nfQrmation. N�ary Pubi�e seai must be curreM and corrsst; seal may nat be akered. � Subscribed and swom ta before me this t�j-- day of t�..e.�: _:.-,-v�.--� , 19�. � �.. , - � ,; � NiyrM�"r�v�'ti0 �ar�r��nued on baek) -", S.; �„ -� t MAlBEK COtiN 2 , MY Con+� &.+�a;*� � / �.� � -.,e;3rr , ,�r.`; r Application fcontinue Affidauit and Consent Statement: I, (prt�t name) f" Yh 1{ t yJ � w 2. �n J o� under oaYh sWte that l have never: 1, been convicted of a fefony or a crime +nvofving gam- bting; 2, eommitted a violation ofiaw or 6oard ru(e that resuited in the reuocation of alicense issued by ihe Boaed within five years before the date of the license application; S. been convicted af a criminat viofation invotving fraud, th�R, taxevasion, misrepresentetion, or gambling; 4. been eonvicted of (i) assauk, {ii) a criminel viofatlon invoiving the use of a firearm, or (iii} making tetronstic threats. 5. been connected with nor engaged in an iliegai busi- aE55; 6, owad $5QQ or mqre in delinquent taxes as deflned in section 27Q.72; 7, hasi a sales and use tax permit revoked by the com- missioner of revenue within the past two years; 8, failed to file, after demand, tax retums required 6y the commissionsr of revenue. In addition, i understand, agree, artd hereby irrevacably consent that suits and actio�s relafing to the subject mat- ter offhe attached gambling managerlicense appiication, or acis or omissians arising from such application, may be commenced against me or my organization and I will actept ihe service of process in any court of aompetent jurisdiCtion in NFinnesota by service on fhe Minnesota S�cretary oi SYate o€ arty summons, process, or pkeading authorized by the laws of M+nnesota. 8y sigRature of this documenf, the undersigned aufhorizes the Departme�ts of Public Safety and Revenue to con- duct a criminat and tax background check or review and to stia�e the results with the Gambf+ng Cortrnl Board. Failure to ptovide required infatmation or providing faise or misleading informafion may resuft in ihe denia! cr revocatiorr otihe IfCensa. FURTHER AFFIANT SAYETH NOT, excepF thai this Affidavit and Conseni Statement are subm+tted in support of the appi'rcation for a gamCting manager Iicense ftom the GambGr.g Conirot Baard. Signature c�f Gambting Manager App(icant ,!� � � Notarized Sig�ature of Appticark �- r N ^ � � 7- ��Y� LG212 8196 Page 2 of 2 This pubfication will be made available in aiternarive format (i.e. large pnnt, Braiife) upon request. If you use a 7TY, you can cali �s using the Minnesota Reiay Service at 1-8�0-G27-3529 and ask them to place a call to (6t2) 639-4OOQ. The informafwn reouested on this Form wi1� be used by the Gamkiing Gantroi Board (So2rd} So defermrne yoar compfiance with Minnesota statutes and rules governi�g Iawfu! gambikng activities. AIi of the infor- mafion that yoa supply ort this form wili become public informatiort when received by the Board. 'fhe informatio� requested on this fwm (incfuding any attachments) wit! be used by fhe Board Yo determine your guailfications to �e invofved irt lawfui gambling act�vit+es in Min�esoFa, and to assist the Board in conducting a background investigation oE you. You have the right to refuse to supply the irtformation requesfed; however, if you refuse to supply this infor- mation, the Board may not be able ta determine your qualificaiians and, as a consequence, may refuse to issue you a license. If you supply the information required, the Board wili be able fo process your appii- cation. Your n2me and address wi(i be publie informaGon when received by the Board. Ali the offier information about you thaf you provide wil( be private data untit the 8oard issues your licehse. WFien the Board issues your license, a!� of tF�e in#ormetion you have providsd to the 8oard in the process af appfying for yeur license will become pubiic exaept for your sQCiai security num- ber, which remains private. If the 8oard does rrot issue you a license, all the'^for- mation you have provided in #he process of s ., ng for a ticense remains private, with the exception of your name and address, whlch wilt remain p�blic. Private data about yau is avai!abfe only to the fo}IQw- ing: Board members, staff of [he Board whose work assignment reguires that tttey have access to the informatian; the Minnesofa Department of Pubiic Safety; the Minnesota Attorney General; the Minne- sota Commissioners of Administration, Fir�ance, and Revenue; the Legistative AuditQr, natianal and inter- r�ationa! gambiing regulatory agencies; anyane pur- suant to court order; other individuals and age�cies that may be Specificalty suthorized by state or federal faw to have access to such i�formation; individuals and agencies for wfiich taw or iega( order authorizes a new use or sharing of tfie information after this notice is given; you; and anyone with your wriften consent. Notary Public tnformation. Notary Pubi�c Sea1 must be current and correct; seal may not 6e alterecl,�. , Subscribed and swom to before me tt�is � day or �;�vr�`�' . , s.�,�. � v: �sw:�� 5 � ��n� t r.ia��.�r;u ai,s�.+�r^aYC� `��. YTNUOD Y3��t �Ei ^, ro*�c�' noteafnrasa� C1A ,^�` ( Council Pile $ ` l � � S (� ��`� E�..d� �� .,�s i n `. . c v � Ordinance # Green Sheet # 35449 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 RESOLUTION OF SAINT PAUL, MINNESOTA Presented By Referred To RESOLVED: Committee: Date That application, ID $19�34, for a new Gamblinq Manaqer's License by Philip W. Swanson DBA Midway Tranaportation, Inc. at Cab's Pub & Eatery, 992 Arcade Street, be and the same is hereby approved. Requested by Department of: • - -� - � - •�- ,s� � •:�i-� • - • BY: �/ � � � ��tl� Adoption Certified by Council Secretary ss: _ � � � a- . s—� Approved by Mayor: Date �L`� t.�� By: , � l� J ff " .�--� Form Approved by City Attorney �� Approved by Mayor £or Submission to Council By: Adopted by Council: Date �yL� � }qq �"� �t FOR q7 -35G GREEN SHEE N 35449 INff1AVDATE MRIAVDATE — DEPARTMEN( DIRECTOR � CYfY COUNCIL GRYATTORNEY O CITYCIFflK BUDGET OIRECR]R O FIN. S MGL SERVICES OIR. MAYOR (Ofl ASSISTAMn � MTAL # OF SIGNATURE PAGES - (CLIP ALL LOCATIONS FOR SIGNATURE) Philip W. Swanson DBA Midway Transportation, Inc. requests Council approval of his application for a new Gambling Manager's License, (ID �19734), at Cab's Pub & Eatery, 992 Arcade Street. _ PIANNIN� COMMISSIDN _ CIViI SEBVICE _ C16cOMMfi7EE _ _ STAFF _ _ 04STRICT WURT _ SUPPOpTS WHfCH COUNCIL OBJECTIVE? PEHSONAL SEHYICE CONSpACTS MUST ANSWEN THE POLLOWINO QUESTIONS: 1. Has ihis personfirm ever worketl untler a coniraq for ihis deparimeM? - YES NO 2. Nas th'rs nersun�rm ever teen e ciry emp�oyee,? YES NO 3. Doea this personJfirm possess a skilt not normally possessed by any current city employee? YES P10 Explain all yes answers on saparete sheet and ettach to green sheet ECEd�� AR � v �ss7 �� A �� .�� '`�� 21 19�7 IF TOTAL AMOUNT OF TRANSACTIpN S COSTlREVENUE BUDGEiED (CIRCLE ONE) YES NO FUNDING SOURCE ACTIVITY NUMBER °INANCIAL INFOftMAT10N: (EXPI.AIN) Greensheet # 35449 In Tracker? �[ 9 License ID # 19734 L.I.E.P. REVIEW CHECKL{ST Date: f �7•.�SL App'n Receivetl / App'n Pcocessed License Type: GamblinQ Manaeer Company Name: philiv W. Swanson DBA:�Iidway Trana�nrtari n� 7n� _ BusinessAddresss: 992 Arcade St. (Cab's) BusinessPhone: h4i-o976 Contact NameJAddress: 760 Vandalia St. �/200 55114 Home Phone: 64i-o7n9 Date to Council Research: Publlc Hearing Date: � i l a i 1�9� Labels Ordered: NiA Notice Sent to Appiicarrt: �l� �R7 District Council #: OS Notice Sent to Public: NJA Ward #: O6 Department/ Date Inspections Comments City Attorney Q 1�. � �. 3 /� ? l R � EnvironmeMal Health �1� Fire �� ucense s�e� a�an �Ned:_ �� aa��ad: �� Police � � ��C6?`(,: �e� � ��- CY ° ��- 3J1� j�� Zoning ' "�� /� � i aZ -:35G Minrses�ta Lawful Gambiing Gamhlin� Manager Application incamplete, falsa, oc misleading applicat+on +nformatian may result in denial of a Organization infiormation NC CEO Name s� H K s� A�� t{ H c, c= (Cannot be gamb�ing manager) DaytimePhone( �afa ) �S`� OrganizationBase Ga►nbling Manager Information • F'astName j��+ �� Fu14MiddleName � P h c� � f 1 LastName -��+�' H So+� Maiden Name Date oi Birth! vZ J 8 1� Gfleck o�e o( ihe boxas: � fvTaie a Femafe Sociat Secunty Number. HomeStreetAddress , w >_ n .. payhme Ahone fitumber ( �! a _) /v C� 5- I became ah active rnember af this organization an: # ettended #he two•day gambt+ng manager seminar an: Disclosure af Sanial Security Number /Q Youarerequiredtaprwideyoursoaalsecu- , rity nomber on this totrrt. Your sociaf secu- ' rity numbet wiA be used to determine your r r,4mpSiartcewithtAetax4awsafNiinnesota. —�� AuthorltafiatsfQtfecynichcgyAUSSOCiaisecu- — ritynumbsr,$tovndata2U.S.C.aaS(c){i}. Band information A$10,Q00 8delity bond in fiavor of the organization has been obtained as required by Minnesota 5tatutes, seation 349.167,, subdivision -. fnsvrance Company Name: �� f��hk 6ond �fumber: ��itp Q�� l 7$� ([3O NQT USE THE AGENCY NAME� �� Gambling Manager Change �"�nenyour orgarn2am one of these sections: Emergen�y Cfiange - Rifow up to five days for , ptocessxng The ehief exeoutive o�icer, by sigr�irx� below, affirms that the emergency appiicativn is due to the faitowing reesQn (check one and F1i in dafe�; �peathafgamDlingmanageron,,, /_,,,_ ❑ Disabifity of gambling manager on! ,�„/,,,,,_,� � 3ermina#i�� a�sr�spPOymeMc�f gambiing manager on .__.__!._...._�_____ N�37E: The new gamb4ing manager may not essume duties until heishe has received the gambling manager's lieense frpm the Gambiing Controi 6oard. .S`t� ttJS"@ O� �`r�Q _,t�� ci �� Notaru.ed Sj�nature of Chiaf Execu ive Gfficer(CEO) Oate: �a� ..�.;� a� . . � �.JJ. .i.. .i`lJ.nrv _ ." . . .. ` ' �` � LG212 �.....___.__.._�.....__. ,s�ss Page 1 of 2 Board Use Only: e Lic # uence # rut Paid manager, OthC[ Gh80gC - Allow up to {en weeks for processing TMe new gambiing managePs iicense should kecome effeetive (check one}: • �`I The day aSisr the current gambi{ng managsr's license expires (forexampfe, iffhe currentgambling manager's iicense expires 7/31i96, the new gambiing manager's license becomes efifective on &lt196, provided that aii applicatipn intormation is complete). � 4Vhett tRe apptica#ion has Deen processed tip fhe Gam- bl'sng CQntra4 Bsaard—the eEfectivE daFe vtill be the �rst day of the month. NOTE: The new gambling manager may not assume duties until he/she has received e gambling manager's license from the Gamblfng Controi Board. Notary Public �nfQrmation. N�ary Pubi�e seai must be curreM and corrsst; seal may nat be akered. � Subscribed and swom ta before me this t�j-- day of t�..e.�: _:.-,-v�.--� , 19�. � �.. , - � ,; � NiyrM�"r�v�'ti0 �ar�r��nued on baek) -", S.; �„ -� t MAlBEK COtiN 2 , MY Con+� &.+�a;*� � / �.� � -.,e;3rr , ,�r.`; r Application fcontinue Affidauit and Consent Statement: I, (prt�t name) f" Yh 1{ t yJ � w 2. �n J o� under oaYh sWte that l have never: 1, been convicted of a fefony or a crime +nvofving gam- bting; 2, eommitted a violation ofiaw or 6oard ru(e that resuited in the reuocation of alicense issued by ihe Boaed within five years before the date of the license application; S. been convicted af a criminat viofation invotving fraud, th�R, taxevasion, misrepresentetion, or gambling; 4. been eonvicted of (i) assauk, {ii) a criminel viofatlon invoiving the use of a firearm, or (iii} making tetronstic threats. 5. been connected with nor engaged in an iliegai busi- aE55; 6, owad $5QQ or mqre in delinquent taxes as deflned in section 27Q.72; 7, hasi a sales and use tax permit revoked by the com- missioner of revenue within the past two years; 8, failed to file, after demand, tax retums required 6y the commissionsr of revenue. In addition, i understand, agree, artd hereby irrevacably consent that suits and actio�s relafing to the subject mat- ter offhe attached gambling managerlicense appiication, or acis or omissians arising from such application, may be commenced against me or my organization and I will actept ihe service of process in any court of aompetent jurisdiCtion in NFinnesota by service on fhe Minnesota S�cretary oi SYate o€ arty summons, process, or pkeading authorized by the laws of M+nnesota. 8y sigRature of this documenf, the undersigned aufhorizes the Departme�ts of Public Safety and Revenue to con- duct a criminat and tax background check or review and to stia�e the results with the Gambf+ng Cortrnl Board. Failure to ptovide required infatmation or providing faise or misleading informafion may resuft in ihe denia! cr revocatiorr otihe IfCensa. FURTHER AFFIANT SAYETH NOT, excepF thai this Affidavit and Conseni Statement are subm+tted in support of the appi'rcation for a gamCting manager Iicense ftom the GambGr.g Conirot Baard. Signature c�f Gambting Manager App(icant ,!� � � Notarized Sig�ature of Appticark �- r N ^ � � 7- ��Y� LG212 8196 Page 2 of 2 This pubfication will be made available in aiternarive format (i.e. large pnnt, Braiife) upon request. If you use a 7TY, you can cali �s using the Minnesota Reiay Service at 1-8�0-G27-3529 and ask them to place a call to (6t2) 639-4OOQ. The informafwn reouested on this Form wi1� be used by the Gamkiing Gantroi Board (So2rd} So defermrne yoar compfiance with Minnesota statutes and rules governi�g Iawfu! gambikng activities. AIi of the infor- mafion that yoa supply ort this form wili become public informatiort when received by the Board. 'fhe informatio� requested on this fwm (incfuding any attachments) wit! be used by fhe Board Yo determine your guailfications to �e invofved irt lawfui gambling act�vit+es in Min�esoFa, and to assist the Board in conducting a background investigation oE you. You have the right to refuse to supply the irtformation requesfed; however, if you refuse to supply this infor- mation, the Board may not be able ta determine your qualificaiians and, as a consequence, may refuse to issue you a license. If you supply the information required, the Board wili be able fo process your appii- cation. Your n2me and address wi(i be publie informaGon when received by the Board. Ali the offier information about you thaf you provide wil( be private data untit the 8oard issues your licehse. WFien the Board issues your license, a!� of tF�e in#ormetion you have providsd to the 8oard in the process af appfying for yeur license will become pubiic exaept for your sQCiai security num- ber, which remains private. If the 8oard does rrot issue you a license, all the'^for- mation you have provided in #he process of s ., ng for a ticense remains private, with the exception of your name and address, whlch wilt remain p�blic. Private data about yau is avai!abfe only to the fo}IQw- ing: Board members, staff of [he Board whose work assignment reguires that tttey have access to the informatian; the Minnesofa Department of Pubiic Safety; the Minnesota Attorney General; the Minne- sota Commissioners of Administration, Fir�ance, and Revenue; the Legistative AuditQr, natianal and inter- r�ationa! gambiing regulatory agencies; anyane pur- suant to court order; other individuals and age�cies that may be Specificalty suthorized by state or federal faw to have access to such i�formation; individuals and agencies for wfiich taw or iega( order authorizes a new use or sharing of tfie information after this notice is given; you; and anyone with your wriften consent. Notary Public tnformation. Notary Pubi�c Sea1 must be current and correct; seal may not 6e alterecl,�. , Subscribed and swom to before me tt�is � day or �;�vr�`�' . , s.�,�. � v: �sw:�� 5 � ��n� t r.ia��.�r;u ai,s�.+�r^aYC� `��. YTNUOD Y3��t �Ei ^, ro*�c�' noteafnrasa� C1A ,^�` ( Council Pile $ ` l � � S (� ��`� E�..d� �� .,�s i n `. . c v � Ordinance # Green Sheet # 35449 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 RESOLUTION OF SAINT PAUL, MINNESOTA Presented By Referred To RESOLVED: Committee: Date That application, ID $19�34, for a new Gamblinq Manaqer's License by Philip W. Swanson DBA Midway Tranaportation, Inc. at Cab's Pub & Eatery, 992 Arcade Street, be and the same is hereby approved. Requested by Department of: • - -� - � - •�- ,s� � •:�i-� • - • BY: �/ � � � ��tl� Adoption Certified by Council Secretary ss: _ � � � a- . s—� Approved by Mayor: Date �L`� t.�� By: , � l� J ff " .�--� Form Approved by City Attorney �� Approved by Mayor £or Submission to Council By: Adopted by Council: Date �yL� � }qq �"� �t FOR q7 -35G GREEN SHEE N 35449 INff1AVDATE MRIAVDATE — DEPARTMEN( DIRECTOR � CYfY COUNCIL GRYATTORNEY O CITYCIFflK BUDGET OIRECR]R O FIN. S MGL SERVICES OIR. MAYOR (Ofl ASSISTAMn � MTAL # OF SIGNATURE PAGES - (CLIP ALL LOCATIONS FOR SIGNATURE) Philip W. Swanson DBA Midway Transportation, Inc. requests Council approval of his application for a new Gambling Manager's License, (ID �19734), at Cab's Pub & Eatery, 992 Arcade Street. _ PIANNIN� COMMISSIDN _ CIViI SEBVICE _ C16cOMMfi7EE _ _ STAFF _ _ 04STRICT WURT _ SUPPOpTS WHfCH COUNCIL OBJECTIVE? PEHSONAL SEHYICE CONSpACTS MUST ANSWEN THE POLLOWINO QUESTIONS: 1. Has ihis personfirm ever worketl untler a coniraq for ihis deparimeM? - YES NO 2. Nas th'rs nersun�rm ever teen e ciry emp�oyee,? YES NO 3. Doea this personJfirm possess a skilt not normally possessed by any current city employee? YES P10 Explain all yes answers on saparete sheet and ettach to green sheet ECEd�� AR � v �ss7 �� A �� .�� '`�� 21 19�7 IF TOTAL AMOUNT OF TRANSACTIpN S COSTlREVENUE BUDGEiED (CIRCLE ONE) YES NO FUNDING SOURCE ACTIVITY NUMBER °INANCIAL INFOftMAT10N: (EXPI.AIN) Greensheet # 35449 In Tracker? �[ 9 License ID # 19734 L.I.E.P. REVIEW CHECKL{ST Date: f �7•.�SL App'n Receivetl / App'n Pcocessed License Type: GamblinQ Manaeer Company Name: philiv W. Swanson DBA:�Iidway Trana�nrtari n� 7n� _ BusinessAddresss: 992 Arcade St. (Cab's) BusinessPhone: h4i-o976 Contact NameJAddress: 760 Vandalia St. �/200 55114 Home Phone: 64i-o7n9 Date to Council Research: Publlc Hearing Date: � i l a i 1�9� Labels Ordered: NiA Notice Sent to Appiicarrt: �l� �R7 District Council #: OS Notice Sent to Public: NJA Ward #: O6 Department/ Date Inspections Comments City Attorney Q 1�. � �. 3 /� ? l R � EnvironmeMal Health �1� Fire �� ucense s�e� a�an �Ned:_ �� aa��ad: �� Police � � ��C6?`(,: �e� � ��- CY ° ��- 3J1� j�� Zoning ' "�� /� � i aZ -:35G Minrses�ta Lawful Gambiing Gamhlin� Manager Application incamplete, falsa, oc misleading applicat+on +nformatian may result in denial of a Organization infiormation NC CEO Name s� H K s� A�� t{ H c, c= (Cannot be gamb�ing manager) DaytimePhone( �afa ) �S`� OrganizationBase Ga►nbling Manager Information • F'astName j��+ �� Fu14MiddleName � P h c� � f 1 LastName -��+�' H So+� Maiden Name Date oi Birth! vZ J 8 1� Gfleck o�e o( ihe boxas: � fvTaie a Femafe Sociat Secunty Number. HomeStreetAddress , w >_ n .. payhme Ahone fitumber ( �! a _) /v C� 5- I became ah active rnember af this organization an: # ettended #he two•day gambt+ng manager seminar an: Disclosure af Sanial Security Number /Q Youarerequiredtaprwideyoursoaalsecu- , rity nomber on this totrrt. Your sociaf secu- ' rity numbet wiA be used to determine your r r,4mpSiartcewithtAetax4awsafNiinnesota. —�� AuthorltafiatsfQtfecynichcgyAUSSOCiaisecu- — ritynumbsr,$tovndata2U.S.C.aaS(c){i}. Band information A$10,Q00 8delity bond in fiavor of the organization has been obtained as required by Minnesota 5tatutes, seation 349.167,, subdivision -. fnsvrance Company Name: �� f��hk 6ond �fumber: ��itp Q�� l 7$� ([3O NQT USE THE AGENCY NAME� �� Gambling Manager Change �"�nenyour orgarn2am one of these sections: Emergen�y Cfiange - Rifow up to five days for , ptocessxng The ehief exeoutive o�icer, by sigr�irx� below, affirms that the emergency appiicativn is due to the faitowing reesQn (check one and F1i in dafe�; �peathafgamDlingmanageron,,, /_,,,_ ❑ Disabifity of gambling manager on! ,�„/,,,,,_,� � 3ermina#i�� a�sr�spPOymeMc�f gambiing manager on .__.__!._...._�_____ N�37E: The new gamb4ing manager may not essume duties until heishe has received the gambling manager's lieense frpm the Gambiing Controi 6oard. .S`t� ttJS"@ O� �`r�Q _,t�� ci �� Notaru.ed Sj�nature of Chiaf Execu ive Gfficer(CEO) Oate: �a� ..�.;� a� . . � �.JJ. .i.. .i`lJ.nrv _ ." . . .. ` ' �` � LG212 �.....___.__.._�.....__. ,s�ss Page 1 of 2 Board Use Only: e Lic # uence # rut Paid manager, OthC[ Gh80gC - Allow up to {en weeks for processing TMe new gambiing managePs iicense should kecome effeetive (check one}: • �`I The day aSisr the current gambi{ng managsr's license expires (forexampfe, iffhe currentgambling manager's iicense expires 7/31i96, the new gambiing manager's license becomes efifective on &lt196, provided that aii applicatipn intormation is complete). � 4Vhett tRe apptica#ion has Deen processed tip fhe Gam- bl'sng CQntra4 Bsaard—the eEfectivE daFe vtill be the �rst day of the month. NOTE: The new gambling manager may not assume duties until he/she has received e gambling manager's license from the Gamblfng Controi Board. Notary Public �nfQrmation. N�ary Pubi�e seai must be curreM and corrsst; seal may nat be akered. � Subscribed and swom ta before me this t�j-- day of t�..e.�: _:.-,-v�.--� , 19�. � �.. , - � ,; � NiyrM�"r�v�'ti0 �ar�r��nued on baek) -", S.; �„ -� t MAlBEK COtiN 2 , MY Con+� &.+�a;*� � / �.� � -.,e;3rr , ,�r.`; r Application fcontinue Affidauit and Consent Statement: I, (prt�t name) f" Yh 1{ t yJ � w 2. �n J o� under oaYh sWte that l have never: 1, been convicted of a fefony or a crime +nvofving gam- bting; 2, eommitted a violation ofiaw or 6oard ru(e that resuited in the reuocation of alicense issued by ihe Boaed within five years before the date of the license application; S. been convicted af a criminat viofation invotving fraud, th�R, taxevasion, misrepresentetion, or gambling; 4. been eonvicted of (i) assauk, {ii) a criminel viofatlon invoiving the use of a firearm, or (iii} making tetronstic threats. 5. been connected with nor engaged in an iliegai busi- aE55; 6, owad $5QQ or mqre in delinquent taxes as deflned in section 27Q.72; 7, hasi a sales and use tax permit revoked by the com- missioner of revenue within the past two years; 8, failed to file, after demand, tax retums required 6y the commissionsr of revenue. In addition, i understand, agree, artd hereby irrevacably consent that suits and actio�s relafing to the subject mat- ter offhe attached gambling managerlicense appiication, or acis or omissians arising from such application, may be commenced against me or my organization and I will actept ihe service of process in any court of aompetent jurisdiCtion in NFinnesota by service on fhe Minnesota S�cretary oi SYate o€ arty summons, process, or pkeading authorized by the laws of M+nnesota. 8y sigRature of this documenf, the undersigned aufhorizes the Departme�ts of Public Safety and Revenue to con- duct a criminat and tax background check or review and to stia�e the results with the Gambf+ng Cortrnl Board. Failure to ptovide required infatmation or providing faise or misleading informafion may resuft in ihe denia! cr revocatiorr otihe IfCensa. FURTHER AFFIANT SAYETH NOT, excepF thai this Affidavit and Conseni Statement are subm+tted in support of the appi'rcation for a gamCting manager Iicense ftom the GambGr.g Conirot Baard. Signature c�f Gambting Manager App(icant ,!� � � Notarized Sig�ature of Appticark �- r N ^ � � 7- ��Y� LG212 8196 Page 2 of 2 This pubfication will be made available in aiternarive format (i.e. large pnnt, Braiife) upon request. If you use a 7TY, you can cali �s using the Minnesota Reiay Service at 1-8�0-G27-3529 and ask them to place a call to (6t2) 639-4OOQ. The informafwn reouested on this Form wi1� be used by the Gamkiing Gantroi Board (So2rd} So defermrne yoar compfiance with Minnesota statutes and rules governi�g Iawfu! gambikng activities. AIi of the infor- mafion that yoa supply ort this form wili become public informatiort when received by the Board. 'fhe informatio� requested on this fwm (incfuding any attachments) wit! be used by fhe Board Yo determine your guailfications to �e invofved irt lawfui gambling act�vit+es in Min�esoFa, and to assist the Board in conducting a background investigation oE you. You have the right to refuse to supply the irtformation requesfed; however, if you refuse to supply this infor- mation, the Board may not be able ta determine your qualificaiians and, as a consequence, may refuse to issue you a license. If you supply the information required, the Board wili be able fo process your appii- cation. Your n2me and address wi(i be publie informaGon when received by the Board. Ali the offier information about you thaf you provide wil( be private data untit the 8oard issues your licehse. WFien the Board issues your license, a!� of tF�e in#ormetion you have providsd to the 8oard in the process af appfying for yeur license will become pubiic exaept for your sQCiai security num- ber, which remains private. If the 8oard does rrot issue you a license, all the'^for- mation you have provided in #he process of s ., ng for a ticense remains private, with the exception of your name and address, whlch wilt remain p�blic. Private data about yau is avai!abfe only to the fo}IQw- ing: Board members, staff of [he Board whose work assignment reguires that tttey have access to the informatian; the Minnesofa Department of Pubiic Safety; the Minnesota Attorney General; the Minne- sota Commissioners of Administration, Fir�ance, and Revenue; the Legistative AuditQr, natianal and inter- r�ationa! gambiing regulatory agencies; anyane pur- suant to court order; other individuals and age�cies that may be Specificalty suthorized by state or federal faw to have access to such i�formation; individuals and agencies for wfiich taw or iega( order authorizes a new use or sharing of tfie information after this notice is given; you; and anyone with your wriften consent. Notary Public tnformation. Notary Pubi�c Sea1 must be current and correct; seal may not 6e alterecl,�. , Subscribed and swom to before me tt�is � day or �;�vr�`�' . , s.�,�. � v: �sw:�� 5 � ��n� t r.ia��.�r;u ai,s�.+�r^aYC� `��. YTNUOD Y3��t �Ei ^, ro*�c�' noteafnrasa� C1A ,^�` (