97-511Council File # `�`
Ordinance #
Green Sheet # 35335
�?�`���";
�.i i 'e t `�,.1 i � '. . �. � s
Presented By
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
Referred To
COmmittee: Date
�
RESOLVED: That application, ID #19553, £or a new Gambling Manager's License by
Ernest Mutterer DBA fipilepsy Foundation of Minnesota at Herges Bar, 981
IIniversity Ave. W., be and the same is fiereby approved.
r v� u� nr,� �o„r I Requested by Department of:
Off' of L� ns Tnspections and
Environmental Protection
Adopted by Council: Date
Adoption Certified by Covncil
By:
Approved
By:
►+]
Date
RESOLUTION
CITY OF SAINT PAUL, MINNESOTA
_ : �
Form Approved by City Attorney
Approved by Mayor £or Submission to
Council
By:
A1-S11
OEPARTMENT/OFFl E/COUNCIL DA INRIATED �REEN SHEE �O 35335 �
LIEP - --
CANfAGTPERSON&PHONE ODEPqRTMENTDIRECTOR aCRYCAUNCIL �NmAVDATE
W' 11iam E. Gunther - 266-9132 "�'�" CITYATfORNEV crtrc�RK
MUST BE ON CAUNGIL AGENDA BY (DAT� ��� � BUDGET UIRECTOR � FlN. & MGT. SFAVICES DIR.
/ OROER O ypVOFt (Ofl ASSISTANn O
O
TOTAL # OF SIGNATIlRE PAG£S (CLIP ALL LOCATIONS fOR SIGNATUR�
ACiION PEWESiED:
Ernest Mutte=er DBA Epilepsy Foundation of Minnesota requests Council
approval of his application for a new Gambling Manager's License, ID �119553, at
Herges Bar, 981 University Avenue W.
pECOMMENDATIONS: Apprwe (A) a Haject (R) pERSONAL SERYICE CONTRACTS YUST ANSWER TNE FOU-0WING QUESTIONS:
_ PLANWNG COIdMISS10N _ CNlL SERVICE GOMMISSION �� Has this perwNfirtn ever worked untler a coMract tor Mis deparhnent? -
_ C�B cOAtMfiiEE YES NO
2. Has this perso�rm ever been a city employee?
_ STAFF
— VES NO
_ DISTRICT COUfiT _ 3. DOes ihis pef50nRirm
possess a skill not normaNy possessetl by any curce'rt city empbyee?
SUPPOpTS WHICH COUNCIL OBJECTIVE7 YES NO
Explain all yes answero on separate ahaet and attach to green sheet
IN[I'IATING PAOBLEM, ISSUE, OPPoRTUNIN (Wtw, What, When, Where, Why):
. . ���� f� ��
APR `� � �
�� ��, ������'���
AWANTAGES IFAPPROVED:
DISADVANTAGES IF APPROVED:
��fl?T3�`;� R,�r��i $�'
,_ �fs'>� � � ����
_.���
DISADVANTAGES IF NOT APPROVED:
TOTAL AMOUNT OF TRANSACiION S COS7/REVENUE BUDGEiED (CIRCLE ONE) YES NO
FUNDIHG SOURCE ' ACTIVI7Y NUMBER
FINANCIAL INFORMATION: (EXPLAIN)
Greensheet # 35335 L.I.E.P. REVIEW CHECKLIST Date: / q�1- S 11
In TrackeY? �ia�__�_R? APa'n Received 1 APa'n Processed
License ID # 19553 License Type: GamblinQ ManaQer
Contp2nyNatile: Ernest Mutterer DBA: Enile�sv Foundat�on of Minnesota
Business Addresss: 981 University Ave. W. (Herges) Business Phone: 646-8675
Contact PfameJAddress: 777
Date to Gouncil Research:!�
Public Hearing Date:� Z( 99 �
Notice Sent to Applicant:� �4 �
Home Phone: 646-8675
labels Ordered: 23/A
District Counci!
Nocice Sent to Pubi7c:
Ward #:
Department/ Date Inspections Comments
City Attomey �/ y�+ ��"�7P�ti/ �`I ��4�
/-f ����� / /
�� l
Environmental
Health
�° / �
C
Fire
� �`71
License �� P�� �����—
�ease aeceived:
/V/�
I
Police f/� /�� �� p7� �P._g�, ��(�?e–Cv
���! l
s
Q�
Zoning
�V��'
l
Sast STATE OF MIHNESOTA FOR BO �� gg p, Y
GAMBLING CONTROL BOARD AMT. PAID
GAMBLING XANAGER LICENSE RENEWAL AppySCATION CHECR #
LG212GMR PRINTED: 10/11/95 - DA2E
LZCENSE NUMBER: G-02928.003 EFFECTIt7E DATE: 11/O1/94 EXPIRATION DATE: 03f31/96
NAME OF ORGANIZATION: Epilepsy St Paul Minn Found
GAMBLING lSANAGER INFOFtMATZON
Ernest Eugeas Mutterer
15614 54 St NE
Rogers MN 553749053
DAYTIME PHONE NUMBER: 612-471-0033
MEMBER SINCE: O1/11/S8
DATE OF SIRTH: O1/31/45
SEX: M
SOCIAL SECURITY NUMBER: 476-48-9777
LAST DATE YOU ATTENDED A GAMBLING MANAGERS SEMINAR/CONTINUING EDUCATZON CLASS: 08J26/93
BOND II.TFORMATION
BOND COMPANY NF�ME: Continental BOND NDMBER: BND1365725
ACRNOWLEDGMENT
Z DECLARE THAT:
' I HAVE READ THIS APPLICATION AND ALL SNFORMATION SUSMZTTED TO THE GAMBLING CONTROL BOARD;
• ALL INFORMATTON TS TRUE, ACCURATE AND COMPLETE;
• ALL OTHER REQUTRED INFORMATION HAS BEEN FULLY DISCLOSED�
• I AM THE ONLY GAMBLING MANAGER OF THE ORGANIZATION;
• Z HAVE BEEN AN ACTIVE MEMBER OF THE ORGANIZATION ROR AT LEAST TWO YEAR5�
• I WILL FAMILIARIZE MYSELF WSTH THE LAWS OF MINNESOTA GOVERNING LAWFUL GAMBLING AND RULES OF
THE GAMBLING CONTROL BOARD AI3D AGREE, IF LZCEI35ED, TO ABIDE THOSE LAWS AND RULES�
INCLUDING AMENDMENTS TO TAEM�
• ANY CHANGES IN APPLICATION 2NFORMATZON WILL BE SUBMITTED TO THE GAMBLING CONTROL BOARD AND
LOCAL UNIT OF GOVERNMENT WITHIN 10 DAYS OF THE CHANGE;
• AN AFFIDAVIT FOR GAMBLING MANAGER HAS BEEN COMPLETED AND A2TACHED; AND
� I UNDERSTAND THAT FAILURE TO PROVIDE REQUIRED INFORMATION OR PROVIDING FALSE OR MISLEADING
SNFOE2MATZON MAY RESULT IN THE DENIAL OR REVOCATZON OF THE LICENSE.
SIGNATURE OF GAMBLING MANAGER
REFER TO THE CHECKI,ZST FOR REQUZRED ATTACFIMENTS
. MAZL TO: GAMBLZNG CONTROL BOARD
1711 WE5T COUNTY ROAD B, SUITE 3005
ROSEVILLE, MINNESOTA 55113
DATE
�-'/� ��1'
THIS FORM WILL BE MADE AVAILABLE IN ALTERNATIVE FORMAT (I.E. LARGE PRINT, BRAZLLE) UPON REQUEST.
/�5.�3
��z�3 Minnesota Gambling Confrol Board
oar� s�ss Gambling Nianager Affidavit �� ''S ��
Atfach fo fhe Gambling Manager Appfication, Form LG212
STA7E O� �� ; n n�CL��_ �
AFFIpAVIT OF QUAL{FICAT{ON
FOR GAMBLlNG MANAGER LiCENSE
) s.s. AND CONSENT STATEMENT
COUN�I' OF� ) (pursuant to Minnesota Statufes and Rules)
t q
�.�. t� nJ �� i � /!�j �� p ,p Under oath state that:
(typefprint name)
1. 1 have never been convicted of a fe{ony or a crime invotving gambling.
2. t have not, within five yeats before the date of the ticense application, committed a vioiation of iaw or
Boarcl rule that resuited in the revocation of a Iicense issued by the Board.
3. ! have never been convicted of a criminal violation involving fraud, theft, tax evasion, misrepresenlation,
or gambling.
4. i have never been convicted of () assauit, (ii) a criminal violation involving ihe use of a firearm, or �i)
making terroristic threats.
5. I am not, nor ever have been connecled with or engaged in an ilfegal business.
6. i do not owe $500 or more in delinquent taxes as defined in section 270.72.
7. i have not had a sales and use tax permit revoked by the commissioner of revenue within the past two
years.
8. 1 have never, after demand, failed to f+le tax retums required by the commissioner of revenue.
in addition, ! understand, agree and hereby irrevocably consent that suits and actions relating to the subject
matter of the attached gambling manager license appiication, or acts or omissions arising from such appiica-
tion, may be commenced against my on7anization and I wiA accept the service of process for my organiza-
tion in any court of competent jurisdiction in Minnesota by service on the Minnesota Secretary of State of any
summons, process or pleading authorized by the taws of Minnesota.
By signature of this document, the undersigned authorizes the Department of PUblic Safety to conduct a
criminai background check or review and to share the results with the Gamb{ing Controf Board.
Failure to provide required information or providing faise or misleading infortnation may result in the denial or
revocation of the license.
FURTH�R AFFIANT SAYETH NOT, except that this A�davit and Consent Statement are submitted in
support of the application for a gambling manager Iicense from the Gambling Contra! Board.
NOTARY PUBLIC INFORMATION
must be current
Sea! may not be altered.
Subscribed and swo to before me this
� day of � • �i 9�_
�� � �� ��-��f�
►.: �"'"..
� !,'� � ' ,
=r� �:�}. ..
��1�.�' � .
(signatu e of applicant)
ORGAN/ZATION INFORMATION
Name of Organization
� � i � � �S t,� �G t.(1��, . O
��•
Council File # `�`
Ordinance #
Green Sheet # 35335
�?�`���";
�.i i 'e t `�,.1 i � '. . �. � s
Presented By
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
Referred To
COmmittee: Date
�
RESOLVED: That application, ID #19553, £or a new Gambling Manager's License by
Ernest Mutterer DBA fipilepsy Foundation of Minnesota at Herges Bar, 981
IIniversity Ave. W., be and the same is fiereby approved.
r v� u� nr,� �o„r I Requested by Department of:
Off' of L� ns Tnspections and
Environmental Protection
Adopted by Council: Date
Adoption Certified by Covncil
By:
Approved
By:
►+]
Date
RESOLUTION
CITY OF SAINT PAUL, MINNESOTA
_ : �
Form Approved by City Attorney
Approved by Mayor £or Submission to
Council
By:
A1-S11
OEPARTMENT/OFFl E/COUNCIL DA INRIATED �REEN SHEE �O 35335 �
LIEP - --
CANfAGTPERSON&PHONE ODEPqRTMENTDIRECTOR aCRYCAUNCIL �NmAVDATE
W' 11iam E. Gunther - 266-9132 "�'�" CITYATfORNEV crtrc�RK
MUST BE ON CAUNGIL AGENDA BY (DAT� ��� � BUDGET UIRECTOR � FlN. & MGT. SFAVICES DIR.
/ OROER O ypVOFt (Ofl ASSISTANn O
O
TOTAL # OF SIGNATIlRE PAG£S (CLIP ALL LOCATIONS fOR SIGNATUR�
ACiION PEWESiED:
Ernest Mutte=er DBA Epilepsy Foundation of Minnesota requests Council
approval of his application for a new Gambling Manager's License, ID �119553, at
Herges Bar, 981 University Avenue W.
pECOMMENDATIONS: Apprwe (A) a Haject (R) pERSONAL SERYICE CONTRACTS YUST ANSWER TNE FOU-0WING QUESTIONS:
_ PLANWNG COIdMISS10N _ CNlL SERVICE GOMMISSION �� Has this perwNfirtn ever worked untler a coMract tor Mis deparhnent? -
_ C�B cOAtMfiiEE YES NO
2. Has this perso�rm ever been a city employee?
_ STAFF
— VES NO
_ DISTRICT COUfiT _ 3. DOes ihis pef50nRirm
possess a skill not normaNy possessetl by any curce'rt city empbyee?
SUPPOpTS WHICH COUNCIL OBJECTIVE7 YES NO
Explain all yes answero on separate ahaet and attach to green sheet
IN[I'IATING PAOBLEM, ISSUE, OPPoRTUNIN (Wtw, What, When, Where, Why):
. . ���� f� ��
APR `� � �
�� ��, ������'���
AWANTAGES IFAPPROVED:
DISADVANTAGES IF APPROVED:
��fl?T3�`;� R,�r��i $�'
,_ �fs'>� � � ����
_.���
DISADVANTAGES IF NOT APPROVED:
TOTAL AMOUNT OF TRANSACiION S COS7/REVENUE BUDGEiED (CIRCLE ONE) YES NO
FUNDIHG SOURCE ' ACTIVI7Y NUMBER
FINANCIAL INFORMATION: (EXPLAIN)
Greensheet # 35335 L.I.E.P. REVIEW CHECKLIST Date: / q�1- S 11
In TrackeY? �ia�__�_R? APa'n Received 1 APa'n Processed
License ID # 19553 License Type: GamblinQ ManaQer
Contp2nyNatile: Ernest Mutterer DBA: Enile�sv Foundat�on of Minnesota
Business Addresss: 981 University Ave. W. (Herges) Business Phone: 646-8675
Contact PfameJAddress: 777
Date to Gouncil Research:!�
Public Hearing Date:� Z( 99 �
Notice Sent to Applicant:� �4 �
Home Phone: 646-8675
labels Ordered: 23/A
District Counci!
Nocice Sent to Pubi7c:
Ward #:
Department/ Date Inspections Comments
City Attomey �/ y�+ ��"�7P�ti/ �`I ��4�
/-f ����� / /
�� l
Environmental
Health
�° / �
C
Fire
� �`71
License �� P�� �����—
�ease aeceived:
/V/�
I
Police f/� /�� �� p7� �P._g�, ��(�?e–Cv
���! l
s
Q�
Zoning
�V��'
l
Sast STATE OF MIHNESOTA FOR BO �� gg p, Y
GAMBLING CONTROL BOARD AMT. PAID
GAMBLING XANAGER LICENSE RENEWAL AppySCATION CHECR #
LG212GMR PRINTED: 10/11/95 - DA2E
LZCENSE NUMBER: G-02928.003 EFFECTIt7E DATE: 11/O1/94 EXPIRATION DATE: 03f31/96
NAME OF ORGANIZATION: Epilepsy St Paul Minn Found
GAMBLING lSANAGER INFOFtMATZON
Ernest Eugeas Mutterer
15614 54 St NE
Rogers MN 553749053
DAYTIME PHONE NUMBER: 612-471-0033
MEMBER SINCE: O1/11/S8
DATE OF SIRTH: O1/31/45
SEX: M
SOCIAL SECURITY NUMBER: 476-48-9777
LAST DATE YOU ATTENDED A GAMBLING MANAGERS SEMINAR/CONTINUING EDUCATZON CLASS: 08J26/93
BOND II.TFORMATION
BOND COMPANY NF�ME: Continental BOND NDMBER: BND1365725
ACRNOWLEDGMENT
Z DECLARE THAT:
' I HAVE READ THIS APPLICATION AND ALL SNFORMATION SUSMZTTED TO THE GAMBLING CONTROL BOARD;
• ALL INFORMATTON TS TRUE, ACCURATE AND COMPLETE;
• ALL OTHER REQUTRED INFORMATION HAS BEEN FULLY DISCLOSED�
• I AM THE ONLY GAMBLING MANAGER OF THE ORGANIZATION;
• Z HAVE BEEN AN ACTIVE MEMBER OF THE ORGANIZATION ROR AT LEAST TWO YEAR5�
• I WILL FAMILIARIZE MYSELF WSTH THE LAWS OF MINNESOTA GOVERNING LAWFUL GAMBLING AND RULES OF
THE GAMBLING CONTROL BOARD AI3D AGREE, IF LZCEI35ED, TO ABIDE THOSE LAWS AND RULES�
INCLUDING AMENDMENTS TO TAEM�
• ANY CHANGES IN APPLICATION 2NFORMATZON WILL BE SUBMITTED TO THE GAMBLING CONTROL BOARD AND
LOCAL UNIT OF GOVERNMENT WITHIN 10 DAYS OF THE CHANGE;
• AN AFFIDAVIT FOR GAMBLING MANAGER HAS BEEN COMPLETED AND A2TACHED; AND
� I UNDERSTAND THAT FAILURE TO PROVIDE REQUIRED INFORMATION OR PROVIDING FALSE OR MISLEADING
SNFOE2MATZON MAY RESULT IN THE DENIAL OR REVOCATZON OF THE LICENSE.
SIGNATURE OF GAMBLING MANAGER
REFER TO THE CHECKI,ZST FOR REQUZRED ATTACFIMENTS
. MAZL TO: GAMBLZNG CONTROL BOARD
1711 WE5T COUNTY ROAD B, SUITE 3005
ROSEVILLE, MINNESOTA 55113
DATE
�-'/� ��1'
THIS FORM WILL BE MADE AVAILABLE IN ALTERNATIVE FORMAT (I.E. LARGE PRINT, BRAZLLE) UPON REQUEST.
/�5.�3
��z�3 Minnesota Gambling Confrol Board
oar� s�ss Gambling Nianager Affidavit �� ''S ��
Atfach fo fhe Gambling Manager Appfication, Form LG212
STA7E O� �� ; n n�CL��_ �
AFFIpAVIT OF QUAL{FICAT{ON
FOR GAMBLlNG MANAGER LiCENSE
) s.s. AND CONSENT STATEMENT
COUN�I' OF� ) (pursuant to Minnesota Statufes and Rules)
t q
�.�. t� nJ �� i � /!�j �� p ,p Under oath state that:
(typefprint name)
1. 1 have never been convicted of a fe{ony or a crime invotving gambling.
2. t have not, within five yeats before the date of the ticense application, committed a vioiation of iaw or
Boarcl rule that resuited in the revocation of a Iicense issued by the Board.
3. ! have never been convicted of a criminal violation involving fraud, theft, tax evasion, misrepresenlation,
or gambling.
4. i have never been convicted of () assauit, (ii) a criminal violation involving ihe use of a firearm, or �i)
making terroristic threats.
5. I am not, nor ever have been connecled with or engaged in an ilfegal business.
6. i do not owe $500 or more in delinquent taxes as defined in section 270.72.
7. i have not had a sales and use tax permit revoked by the commissioner of revenue within the past two
years.
8. 1 have never, after demand, failed to f+le tax retums required by the commissioner of revenue.
in addition, ! understand, agree and hereby irrevocably consent that suits and actions relating to the subject
matter of the attached gambling manager license appiication, or acts or omissions arising from such appiica-
tion, may be commenced against my on7anization and I wiA accept the service of process for my organiza-
tion in any court of competent jurisdiction in Minnesota by service on the Minnesota Secretary of State of any
summons, process or pleading authorized by the taws of Minnesota.
By signature of this document, the undersigned authorizes the Department of PUblic Safety to conduct a
criminai background check or review and to share the results with the Gamb{ing Controf Board.
Failure to provide required information or providing faise or misleading infortnation may result in the denial or
revocation of the license.
FURTH�R AFFIANT SAYETH NOT, except that this A�davit and Consent Statement are submitted in
support of the application for a gambling manager Iicense from the Gambling Contra! Board.
NOTARY PUBLIC INFORMATION
must be current
Sea! may not be altered.
Subscribed and swo to before me this
� day of � • �i 9�_
�� � �� ��-��f�
►.: �"'"..
� !,'� � ' ,
=r� �:�}. ..
��1�.�' � .
(signatu e of applicant)
ORGAN/ZATION INFORMATION
Name of Organization
� � i � � �S t,� �G t.(1��, . O
��•
Council File # `�`
Ordinance #
Green Sheet # 35335
�?�`���";
�.i i 'e t `�,.1 i � '. . �. � s
Presented By
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
Referred To
COmmittee: Date
�
RESOLVED: That application, ID #19553, £or a new Gambling Manager's License by
Ernest Mutterer DBA fipilepsy Foundation of Minnesota at Herges Bar, 981
IIniversity Ave. W., be and the same is fiereby approved.
r v� u� nr,� �o„r I Requested by Department of:
Off' of L� ns Tnspections and
Environmental Protection
Adopted by Council: Date
Adoption Certified by Covncil
By:
Approved
By:
►+]
Date
RESOLUTION
CITY OF SAINT PAUL, MINNESOTA
_ : �
Form Approved by City Attorney
Approved by Mayor £or Submission to
Council
By:
A1-S11
OEPARTMENT/OFFl E/COUNCIL DA INRIATED �REEN SHEE �O 35335 �
LIEP - --
CANfAGTPERSON&PHONE ODEPqRTMENTDIRECTOR aCRYCAUNCIL �NmAVDATE
W' 11iam E. Gunther - 266-9132 "�'�" CITYATfORNEV crtrc�RK
MUST BE ON CAUNGIL AGENDA BY (DAT� ��� � BUDGET UIRECTOR � FlN. & MGT. SFAVICES DIR.
/ OROER O ypVOFt (Ofl ASSISTANn O
O
TOTAL # OF SIGNATIlRE PAG£S (CLIP ALL LOCATIONS fOR SIGNATUR�
ACiION PEWESiED:
Ernest Mutte=er DBA Epilepsy Foundation of Minnesota requests Council
approval of his application for a new Gambling Manager's License, ID �119553, at
Herges Bar, 981 University Avenue W.
pECOMMENDATIONS: Apprwe (A) a Haject (R) pERSONAL SERYICE CONTRACTS YUST ANSWER TNE FOU-0WING QUESTIONS:
_ PLANWNG COIdMISS10N _ CNlL SERVICE GOMMISSION �� Has this perwNfirtn ever worked untler a coMract tor Mis deparhnent? -
_ C�B cOAtMfiiEE YES NO
2. Has this perso�rm ever been a city employee?
_ STAFF
— VES NO
_ DISTRICT COUfiT _ 3. DOes ihis pef50nRirm
possess a skill not normaNy possessetl by any curce'rt city empbyee?
SUPPOpTS WHICH COUNCIL OBJECTIVE7 YES NO
Explain all yes answero on separate ahaet and attach to green sheet
IN[I'IATING PAOBLEM, ISSUE, OPPoRTUNIN (Wtw, What, When, Where, Why):
. . ���� f� ��
APR `� � �
�� ��, ������'���
AWANTAGES IFAPPROVED:
DISADVANTAGES IF APPROVED:
��fl?T3�`;� R,�r��i $�'
,_ �fs'>� � � ����
_.���
DISADVANTAGES IF NOT APPROVED:
TOTAL AMOUNT OF TRANSACiION S COS7/REVENUE BUDGEiED (CIRCLE ONE) YES NO
FUNDIHG SOURCE ' ACTIVI7Y NUMBER
FINANCIAL INFORMATION: (EXPLAIN)
Greensheet # 35335 L.I.E.P. REVIEW CHECKLIST Date: / q�1- S 11
In TrackeY? �ia�__�_R? APa'n Received 1 APa'n Processed
License ID # 19553 License Type: GamblinQ ManaQer
Contp2nyNatile: Ernest Mutterer DBA: Enile�sv Foundat�on of Minnesota
Business Addresss: 981 University Ave. W. (Herges) Business Phone: 646-8675
Contact PfameJAddress: 777
Date to Gouncil Research:!�
Public Hearing Date:� Z( 99 �
Notice Sent to Applicant:� �4 �
Home Phone: 646-8675
labels Ordered: 23/A
District Counci!
Nocice Sent to Pubi7c:
Ward #:
Department/ Date Inspections Comments
City Attomey �/ y�+ ��"�7P�ti/ �`I ��4�
/-f ����� / /
�� l
Environmental
Health
�° / �
C
Fire
� �`71
License �� P�� �����—
�ease aeceived:
/V/�
I
Police f/� /�� �� p7� �P._g�, ��(�?e–Cv
���! l
s
Q�
Zoning
�V��'
l
Sast STATE OF MIHNESOTA FOR BO �� gg p, Y
GAMBLING CONTROL BOARD AMT. PAID
GAMBLING XANAGER LICENSE RENEWAL AppySCATION CHECR #
LG212GMR PRINTED: 10/11/95 - DA2E
LZCENSE NUMBER: G-02928.003 EFFECTIt7E DATE: 11/O1/94 EXPIRATION DATE: 03f31/96
NAME OF ORGANIZATION: Epilepsy St Paul Minn Found
GAMBLING lSANAGER INFOFtMATZON
Ernest Eugeas Mutterer
15614 54 St NE
Rogers MN 553749053
DAYTIME PHONE NUMBER: 612-471-0033
MEMBER SINCE: O1/11/S8
DATE OF SIRTH: O1/31/45
SEX: M
SOCIAL SECURITY NUMBER: 476-48-9777
LAST DATE YOU ATTENDED A GAMBLING MANAGERS SEMINAR/CONTINUING EDUCATZON CLASS: 08J26/93
BOND II.TFORMATION
BOND COMPANY NF�ME: Continental BOND NDMBER: BND1365725
ACRNOWLEDGMENT
Z DECLARE THAT:
' I HAVE READ THIS APPLICATION AND ALL SNFORMATION SUSMZTTED TO THE GAMBLING CONTROL BOARD;
• ALL INFORMATTON TS TRUE, ACCURATE AND COMPLETE;
• ALL OTHER REQUTRED INFORMATION HAS BEEN FULLY DISCLOSED�
• I AM THE ONLY GAMBLING MANAGER OF THE ORGANIZATION;
• Z HAVE BEEN AN ACTIVE MEMBER OF THE ORGANIZATION ROR AT LEAST TWO YEAR5�
• I WILL FAMILIARIZE MYSELF WSTH THE LAWS OF MINNESOTA GOVERNING LAWFUL GAMBLING AND RULES OF
THE GAMBLING CONTROL BOARD AI3D AGREE, IF LZCEI35ED, TO ABIDE THOSE LAWS AND RULES�
INCLUDING AMENDMENTS TO TAEM�
• ANY CHANGES IN APPLICATION 2NFORMATZON WILL BE SUBMITTED TO THE GAMBLING CONTROL BOARD AND
LOCAL UNIT OF GOVERNMENT WITHIN 10 DAYS OF THE CHANGE;
• AN AFFIDAVIT FOR GAMBLING MANAGER HAS BEEN COMPLETED AND A2TACHED; AND
� I UNDERSTAND THAT FAILURE TO PROVIDE REQUIRED INFORMATION OR PROVIDING FALSE OR MISLEADING
SNFOE2MATZON MAY RESULT IN THE DENIAL OR REVOCATZON OF THE LICENSE.
SIGNATURE OF GAMBLING MANAGER
REFER TO THE CHECKI,ZST FOR REQUZRED ATTACFIMENTS
. MAZL TO: GAMBLZNG CONTROL BOARD
1711 WE5T COUNTY ROAD B, SUITE 3005
ROSEVILLE, MINNESOTA 55113
DATE
�-'/� ��1'
THIS FORM WILL BE MADE AVAILABLE IN ALTERNATIVE FORMAT (I.E. LARGE PRINT, BRAZLLE) UPON REQUEST.
/�5.�3
��z�3 Minnesota Gambling Confrol Board
oar� s�ss Gambling Nianager Affidavit �� ''S ��
Atfach fo fhe Gambling Manager Appfication, Form LG212
STA7E O� �� ; n n�CL��_ �
AFFIpAVIT OF QUAL{FICAT{ON
FOR GAMBLlNG MANAGER LiCENSE
) s.s. AND CONSENT STATEMENT
COUN�I' OF� ) (pursuant to Minnesota Statufes and Rules)
t q
�.�. t� nJ �� i � /!�j �� p ,p Under oath state that:
(typefprint name)
1. 1 have never been convicted of a fe{ony or a crime invotving gambling.
2. t have not, within five yeats before the date of the ticense application, committed a vioiation of iaw or
Boarcl rule that resuited in the revocation of a Iicense issued by the Board.
3. ! have never been convicted of a criminal violation involving fraud, theft, tax evasion, misrepresenlation,
or gambling.
4. i have never been convicted of () assauit, (ii) a criminal violation involving ihe use of a firearm, or �i)
making terroristic threats.
5. I am not, nor ever have been connecled with or engaged in an ilfegal business.
6. i do not owe $500 or more in delinquent taxes as defined in section 270.72.
7. i have not had a sales and use tax permit revoked by the commissioner of revenue within the past two
years.
8. 1 have never, after demand, failed to f+le tax retums required by the commissioner of revenue.
in addition, ! understand, agree and hereby irrevocably consent that suits and actions relating to the subject
matter of the attached gambling manager license appiication, or acts or omissions arising from such appiica-
tion, may be commenced against my on7anization and I wiA accept the service of process for my organiza-
tion in any court of competent jurisdiction in Minnesota by service on the Minnesota Secretary of State of any
summons, process or pleading authorized by the taws of Minnesota.
By signature of this document, the undersigned authorizes the Department of PUblic Safety to conduct a
criminai background check or review and to share the results with the Gamb{ing Controf Board.
Failure to provide required information or providing faise or misleading infortnation may result in the denial or
revocation of the license.
FURTH�R AFFIANT SAYETH NOT, except that this A�davit and Consent Statement are submitted in
support of the application for a gambling manager Iicense from the Gambling Contra! Board.
NOTARY PUBLIC INFORMATION
must be current
Sea! may not be altered.
Subscribed and swo to before me this
� day of � • �i 9�_
�� � �� ��-��f�
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� !,'� � ' ,
=r� �:�}. ..
��1�.�' � .
(signatu e of applicant)
ORGAN/ZATION INFORMATION
Name of Organization
� � i � � �S t,� �G t.(1��, . O
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