97-514Council File # ���sZ,_I,y
Ordinance #
Green Sheet # 35331
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������ r�
�;
� i���
Presented By�
Referred To
RESOLVED: That application, ID #22353, for a new Gambling Manager�s License by James
R. McDonough DBA St. Paul Sast Athletic Association at Moose's Locker
Room, 1177 Clarence Street, be and the same is hereby approved.
RESOLUTION
CITY OF SAINT PAUL, MINNESOTA
3�
Con¢nittee: Ddte
Requested by Department of:
O£fice of License InsDections and
Environmental Protection
Adopted by Council: Date �( q�
�
Adoption Certified by Council Secretary
By:
Approved
By:
r
►�� I
Form Approved by City Attorney
� p -� �k�-ct � ���.,
Date ��S 7
Approved by Mayor £or Submission to
Council
By:
9� -S ly
DEPARTMENT/OFFICE/COUNCIL DATE INITIATED i'd ° 3 5 3 31
LIEP GREEN SHEET _ _ � _
COMACf PEfiSON & PHONE INITIAVDATE INRIAUDAiE
O DEPAPTMENT DIRECTOR � CrtY CAUNC0.
W'lliam F. unther - 266-9132 N �"�� R ❑�T�'"'T°""�v �a'YCZ�"�
MUST BE ON COUNCIL AGEI3DA BV (DA'f� p��Np O BUDGET DIqECTOP O FI13. & MGf. SERYICES Dlfi.
ONDER O MAYOR (OR ASSISTANT) Q
earin :
TOTAL # OF SIGNANRE PAGES ' (CLIP ALL LOCATIONS FOR SIGNANR�
ACTION RC-0UESTED:
James R. McDonough DBA St. Paul East Athletic Association requests Council
approval of his application for a new Gambling Manager's License, ID �122353, at Moose`s
I,ocker Room, 1177 Clarence Street.
iiECAMMENDASIOwS: Appwe (A) m Fajea (R) PERSONAL SERVICE CONTRACTS MUST ANSWER THE FOLLOWING QUESTON3:
_ PIANNING COMMISSION _ CML SERViCE COM611SSION �� Has Nis perso�rm Bve� worked untler a Contract for Mis depar6nent? �
_C�acOMMmEE _ YES NO
���� — 2. Ha5 this perso�rm ever been a city employee?
YES NO
_ DIS7NICtCOUR7 _ 3. Does Ihis peBOn/firm possess a skili not normall
y possesud by any curtent city empiqree?
SUPPOflTS WHICH COUNCIL OBJECfIVE? YES NO
Explain all yes anawers on soperate Sheet and attaeh to graen s�eet
�.. :p.. �>
INITIATING PqOBLEM. �SSUE, OPPORNNffY(Wta, What, When, Whare. Why�: �� '
APR 14 1997
CtT`� ;�����t�fY
ADVANTAGES IFAPPFtOVED:
OISAOVANTAGES IF APPROVED:
W�Laii'vf9 a`�r''dCr��'� �'Srtk�K.�,l
t�P� � 1 1J97
� --- — — - =
DISADVANTAGES IF NOT APPROVED:
SOTAL AMOUNT OF TRANSACTION S COSTJqEVENIfE BUDGETED (CfRCLE ON£) YES NO
FUNDIHG SOURCE ACTIVITY NUMBER
FINANCIAL INf-0RMATION: (EXPLAIN)
Greensheet # 35331
In Tracker?�
License iD # _ _ _ ?2353
L.I.E.P.REVIEWCHECKLIS7 flate: /��'s�y
APP'n Received / APP'n Processed
License Type: Gambling Manager
Company P1ame: James R. McDonough DSA: Se. Paul East Athletic Association
BUSiness Addresss: 1177 Clarence St. (Moose's Locker Room) gUSin2ss Phone: 778-8751
Contact NamelAddress:_ $15 E. Montana 55106 Home Phone: 778/8751
Date to Counci!
Public Hearing Date:� 7 19�f7
Notice Sent to Appiicant: �/ f�jq
Notice Sent to Public:
labels Ordered: N/A
District Council
Ward #: 06
Oepartmentf Date inspections Comments
City Attorney .. — %a ���Y7�1 � °� �f�7 ��
��`�/�� � ✓
Environmental
Health
���/
Fire
'V ��
License S�ce a�an Rece�vea:
Leese Received:
�( �
�
Police , i' J l�� �.� �(1 l.�r i ec{C, ���-U
�� �
Zoning
jY ��
.: � r .
-� ,
, LG212
(Rev. 7/252J
Minnesota Lawfut Gambiing
Gambling Manager Application
FOR OFFICE USE ONLY
&4SE tJC i
SEQ k
FEE
CHK
DATE
INIT
�New Give date that the hvo-day garnbfing manager seminar was completed. ��I�I�S
Locafion of training �, jj�p �.��
' (Gry)
[� Renewal Give da[e of training teceivsd within three yeazs pria to the date o( the applicaflon Fw renewaL _/ /
Locatlon o( training
.(
ia�iil�Tirt� "�er`Isiforiiiafiori� ��:<.
�-�
IAST NAME FIRST NAME MIDDLE NAME
M �ba'nov�h 64me5 GZoy-���--
de�s5 '
��5 F � �h�,�� � �, � sd�, F'4 t��
MAfDEN
Date of Birth Soa SeWrity Number
�23 SS y�� -C�-3l�i
lhfv S'S/d6
MEMBERSHIP: Date gambiing manager became a member of the organizaUOn I 1 � 1�
Name of OrganizaUOn
s�,p� �c � <
Address
�.ss r
��� ��-�-h r-�-� c
h-e� �Uac�� �
City/State Zip Code
� �'a JL !r7 jy'. SSlt'�
-- A$10,000 fidelity bond In tavor of the organiza0on must be obtained for the gambling manager.
I t�'re� �����s�
Sex: (�'Male ❑ Female
[.�.;:�x;_> f's'::�.<.^x.. :. �;:;:.A..;:�p.
��rr� i � s
ticense Number
Phone (�
�G�2) /�tj`D.Sff�
Name of insuranca compeny (do not use agency �ame) _w�5� �rh SuYc�-Y C�• Bond Number
dedare that•
• i have raad this appliqtion and ali infortnauon submitted to the board;
• ail information is Ova, accurate and comp{ete;
• ail other required information has been tu4ly disdosed;
• I am the only gambling manager Dt the aganization;
• I wiil tamiiiarize myself with the laws o( bLnnesoW goveming lawtul garnbliag and rules o( the board and agree, if Iicensed, to
abide by those laws and rules, induding amendments to them;
• any changes in applicauon information will be submitted to ihe board and local unit o( govemment within 10 days of the change;
• An affidavit tor gambling manager has been completed and attached, and
•{ understand that faiNre to provide requirad inlormafion or provi�ng falsa information may result in ffie denial or revocafion o( the
ficense.
of Gambiing
� ��
I Dats
� �- 9-
Send the completed application and alf required attachments to:
Gambling Contro! Board
Sufta 300 S.
17t1 W. County Road B
RosavlUe, MN 55113
_ �� �a3s3
LG213 Minnesota Gambling Control Board
�AJ1E,'95 Gambling Manager Affidavit q 1-S � y
Attach to the Gamhfing Manager Application, Form LG212
STATE OF M��/1 -e 5 U�" n— ) AFFIDAVIT OF QUALIFICATION `
) s.s. FOR GAMBLING MANAGER LICENSE
COUNTY OF 1� 4 v�2 $�, v� } AND CONSEN7 STATEMENT
- (Pursuant to Minnesota Statutes and Ruies)
�, _�� m� S 2 a�iP. �-" (� �2c.t�J� des,oath state that:
(type/print name) ,�j � `
1. i have never been convicted of a felony or a crime invotving gambling.
2. I have not, within five years before the date of the license application, committed a violation of law or
Boarti rule that resulted in the revocation of a license issued by the Board.
3. 1 have never been convided of a criminai violation involving fraud, theft, tax evasion, misrepresentation,
or gambling.
4. I have never been convicted of (� assautt, () a criminal vioiation invotving the use of a fireartn, or (i�
making terroristic threats.
5. I am not, nor ever have been connecied with or engaged in an iHega{ business.
6. 1 do not owe $500 or more in delinquent taxes as defined in section 270.72.
7. 1 have not had a sales and use tax permit revoked by the commissioner of revenue within the past two
years.
&. I have never, after demand, failed to file tax retums required by the commissioner of revenue.
In addition, 1 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 againsi my organizaiion and I wiii 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 laws of Minnesota.
Dy signature of this document, the undersigned authorizes the Department of Pubiic Safety to conduct a
criminai background check or review and to share the resuits with the Gambltng Controi Boarcl.
Failure to provide required information or providing false or misleading infortnatio� may result in the deniai or
revocation of the Iicense.
FURTHER AFFIANT SAYETH NOT, except that this A�davit and Consent Statement are submitted in
suppart of the appiication for a gambling manager license from the Gambling Control Board.
NOTARY PUBLIC INFORMATION
�ublic Seal must be current and co
Seal may not be aitered.
Subscribed and swom to before me this
�_day of � �
/i � n
,�'4 m �,5 � 1h ��Jon n �,�L
� � �i/
(signature of applicant)
ORGANIZATION INFORMATION
of Organization
COUNTY
�s ,�. si. n
�, .7"GUl G C� f I� G
License Number
Council File # ���sZ,_I,y
Ordinance #
Green Sheet # 35331
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
������ r�
�;
� i���
Presented By�
Referred To
RESOLVED: That application, ID #22353, for a new Gambling Manager�s License by James
R. McDonough DBA St. Paul Sast Athletic Association at Moose's Locker
Room, 1177 Clarence Street, be and the same is hereby approved.
RESOLUTION
CITY OF SAINT PAUL, MINNESOTA
3�
Con¢nittee: Ddte
Requested by Department of:
O£fice of License InsDections and
Environmental Protection
Adopted by Council: Date �( q�
�
Adoption Certified by Council Secretary
By:
Approved
By:
r
►�� I
Form Approved by City Attorney
� p -� �k�-ct � ���.,
Date ��S 7
Approved by Mayor £or Submission to
Council
By:
9� -S ly
DEPARTMENT/OFFICE/COUNCIL DATE INITIATED i'd ° 3 5 3 31
LIEP GREEN SHEET _ _ � _
COMACf PEfiSON & PHONE INITIAVDATE INRIAUDAiE
O DEPAPTMENT DIRECTOR � CrtY CAUNC0.
W'lliam F. unther - 266-9132 N �"�� R ❑�T�'"'T°""�v �a'YCZ�"�
MUST BE ON COUNCIL AGEI3DA BV (DA'f� p��Np O BUDGET DIqECTOP O FI13. & MGf. SERYICES Dlfi.
ONDER O MAYOR (OR ASSISTANT) Q
earin :
TOTAL # OF SIGNANRE PAGES ' (CLIP ALL LOCATIONS FOR SIGNANR�
ACTION RC-0UESTED:
James R. McDonough DBA St. Paul East Athletic Association requests Council
approval of his application for a new Gambling Manager's License, ID �122353, at Moose`s
I,ocker Room, 1177 Clarence Street.
iiECAMMENDASIOwS: Appwe (A) m Fajea (R) PERSONAL SERVICE CONTRACTS MUST ANSWER THE FOLLOWING QUESTON3:
_ PIANNING COMMISSION _ CML SERViCE COM611SSION �� Has Nis perso�rm Bve� worked untler a Contract for Mis depar6nent? �
_C�acOMMmEE _ YES NO
���� — 2. Ha5 this perso�rm ever been a city employee?
YES NO
_ DIS7NICtCOUR7 _ 3. Does Ihis peBOn/firm possess a skili not normall
y possesud by any curtent city empiqree?
SUPPOflTS WHICH COUNCIL OBJECfIVE? YES NO
Explain all yes anawers on soperate Sheet and attaeh to graen s�eet
�.. :p.. �>
INITIATING PqOBLEM. �SSUE, OPPORNNffY(Wta, What, When, Whare. Why�: �� '
APR 14 1997
CtT`� ;�����t�fY
ADVANTAGES IFAPPFtOVED:
OISAOVANTAGES IF APPROVED:
W�Laii'vf9 a`�r''dCr��'� �'Srtk�K.�,l
t�P� � 1 1J97
� --- — — - =
DISADVANTAGES IF NOT APPROVED:
SOTAL AMOUNT OF TRANSACTION S COSTJqEVENIfE BUDGETED (CfRCLE ON£) YES NO
FUNDIHG SOURCE ACTIVITY NUMBER
FINANCIAL INf-0RMATION: (EXPLAIN)
Greensheet # 35331
In Tracker?�
License iD # _ _ _ ?2353
L.I.E.P.REVIEWCHECKLIS7 flate: /��'s�y
APP'n Received / APP'n Processed
License Type: Gambling Manager
Company P1ame: James R. McDonough DSA: Se. Paul East Athletic Association
BUSiness Addresss: 1177 Clarence St. (Moose's Locker Room) gUSin2ss Phone: 778-8751
Contact NamelAddress:_ $15 E. Montana 55106 Home Phone: 778/8751
Date to Counci!
Public Hearing Date:� 7 19�f7
Notice Sent to Appiicant: �/ f�jq
Notice Sent to Public:
labels Ordered: N/A
District Council
Ward #: 06
Oepartmentf Date inspections Comments
City Attorney .. — %a ���Y7�1 � °� �f�7 ��
��`�/�� � ✓
Environmental
Health
���/
Fire
'V ��
License S�ce a�an Rece�vea:
Leese Received:
�( �
�
Police , i' J l�� �.� �(1 l.�r i ec{C, ���-U
�� �
Zoning
jY ��
.: � r .
-� ,
, LG212
(Rev. 7/252J
Minnesota Lawfut Gambiing
Gambling Manager Application
FOR OFFICE USE ONLY
&4SE tJC i
SEQ k
FEE
CHK
DATE
INIT
�New Give date that the hvo-day garnbfing manager seminar was completed. ��I�I�S
Locafion of training �, jj�p �.��
' (Gry)
[� Renewal Give da[e of training teceivsd within three yeazs pria to the date o( the applicaflon Fw renewaL _/ /
Locatlon o( training
.(
ia�iil�Tirt� "�er`Isiforiiiafiori� ��:<.
�-�
IAST NAME FIRST NAME MIDDLE NAME
M �ba'nov�h 64me5 GZoy-���--
de�s5 '
��5 F � �h�,�� � �, � sd�, F'4 t��
MAfDEN
Date of Birth Soa SeWrity Number
�23 SS y�� -C�-3l�i
lhfv S'S/d6
MEMBERSHIP: Date gambiing manager became a member of the organizaUOn I 1 � 1�
Name of OrganizaUOn
s�,p� �c � <
Address
�.ss r
��� ��-�-h r-�-� c
h-e� �Uac�� �
City/State Zip Code
� �'a JL !r7 jy'. SSlt'�
-- A$10,000 fidelity bond In tavor of the organiza0on must be obtained for the gambling manager.
I t�'re� �����s�
Sex: (�'Male ❑ Female
[.�.;:�x;_> f's'::�.<.^x.. :. �;:;:.A..;:�p.
��rr� i � s
ticense Number
Phone (�
�G�2) /�tj`D.Sff�
Name of insuranca compeny (do not use agency �ame) _w�5� �rh SuYc�-Y C�• Bond Number
dedare that•
• i have raad this appliqtion and ali infortnauon submitted to the board;
• ail information is Ova, accurate and comp{ete;
• ail other required information has been tu4ly disdosed;
• I am the only gambling manager Dt the aganization;
• I wiil tamiiiarize myself with the laws o( bLnnesoW goveming lawtul garnbliag and rules o( the board and agree, if Iicensed, to
abide by those laws and rules, induding amendments to them;
• any changes in applicauon information will be submitted to ihe board and local unit o( govemment within 10 days of the change;
• An affidavit tor gambling manager has been completed and attached, and
•{ understand that faiNre to provide requirad inlormafion or provi�ng falsa information may result in ffie denial or revocafion o( the
ficense.
of Gambiing
� ��
I Dats
� �- 9-
Send the completed application and alf required attachments to:
Gambling Contro! Board
Sufta 300 S.
17t1 W. County Road B
RosavlUe, MN 55113
_ �� �a3s3
LG213 Minnesota Gambling Control Board
�AJ1E,'95 Gambling Manager Affidavit q 1-S � y
Attach to the Gamhfing Manager Application, Form LG212
STATE OF M��/1 -e 5 U�" n— ) AFFIDAVIT OF QUALIFICATION `
) s.s. FOR GAMBLING MANAGER LICENSE
COUNTY OF 1� 4 v�2 $�, v� } AND CONSEN7 STATEMENT
- (Pursuant to Minnesota Statutes and Ruies)
�, _�� m� S 2 a�iP. �-" (� �2c.t�J� des,oath state that:
(type/print name) ,�j � `
1. i have never been convicted of a felony or a crime invotving gambling.
2. I have not, within five years before the date of the license application, committed a violation of law or
Boarti rule that resulted in the revocation of a license issued by the Board.
3. 1 have never been convided of a criminai violation involving fraud, theft, tax evasion, misrepresentation,
or gambling.
4. I have never been convicted of (� assautt, () a criminal vioiation invotving the use of a fireartn, or (i�
making terroristic threats.
5. I am not, nor ever have been connecied with or engaged in an iHega{ business.
6. 1 do not owe $500 or more in delinquent taxes as defined in section 270.72.
7. 1 have not had a sales and use tax permit revoked by the commissioner of revenue within the past two
years.
&. I have never, after demand, failed to file tax retums required by the commissioner of revenue.
In addition, 1 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 againsi my organizaiion and I wiii 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 laws of Minnesota.
Dy signature of this document, the undersigned authorizes the Department of Pubiic Safety to conduct a
criminai background check or review and to share the resuits with the Gambltng Controi Boarcl.
Failure to provide required information or providing false or misleading infortnatio� may result in the deniai or
revocation of the Iicense.
FURTHER AFFIANT SAYETH NOT, except that this A�davit and Consent Statement are submitted in
suppart of the appiication for a gambling manager license from the Gambling Control Board.
NOTARY PUBLIC INFORMATION
�ublic Seal must be current and co
Seal may not be aitered.
Subscribed and swom to before me this
�_day of � �
/i � n
,�'4 m �,5 � 1h ��Jon n �,�L
� � �i/
(signature of applicant)
ORGANIZATION INFORMATION
of Organization
COUNTY
�s ,�. si. n
�, .7"GUl G C� f I� G
License Number
Council File # ���sZ,_I,y
Ordinance #
Green Sheet # 35331
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
������ r�
�;
� i���
Presented By�
Referred To
RESOLVED: That application, ID #22353, for a new Gambling Manager�s License by James
R. McDonough DBA St. Paul Sast Athletic Association at Moose's Locker
Room, 1177 Clarence Street, be and the same is hereby approved.
RESOLUTION
CITY OF SAINT PAUL, MINNESOTA
3�
Con¢nittee: Ddte
Requested by Department of:
O£fice of License InsDections and
Environmental Protection
Adopted by Council: Date �( q�
�
Adoption Certified by Council Secretary
By:
Approved
By:
r
►�� I
Form Approved by City Attorney
� p -� �k�-ct � ���.,
Date ��S 7
Approved by Mayor £or Submission to
Council
By:
9� -S ly
DEPARTMENT/OFFICE/COUNCIL DATE INITIATED i'd ° 3 5 3 31
LIEP GREEN SHEET _ _ � _
COMACf PEfiSON & PHONE INITIAVDATE INRIAUDAiE
O DEPAPTMENT DIRECTOR � CrtY CAUNC0.
W'lliam F. unther - 266-9132 N �"�� R ❑�T�'"'T°""�v �a'YCZ�"�
MUST BE ON COUNCIL AGEI3DA BV (DA'f� p��Np O BUDGET DIqECTOP O FI13. & MGf. SERYICES Dlfi.
ONDER O MAYOR (OR ASSISTANT) Q
earin :
TOTAL # OF SIGNANRE PAGES ' (CLIP ALL LOCATIONS FOR SIGNANR�
ACTION RC-0UESTED:
James R. McDonough DBA St. Paul East Athletic Association requests Council
approval of his application for a new Gambling Manager's License, ID �122353, at Moose`s
I,ocker Room, 1177 Clarence Street.
iiECAMMENDASIOwS: Appwe (A) m Fajea (R) PERSONAL SERVICE CONTRACTS MUST ANSWER THE FOLLOWING QUESTON3:
_ PIANNING COMMISSION _ CML SERViCE COM611SSION �� Has Nis perso�rm Bve� worked untler a Contract for Mis depar6nent? �
_C�acOMMmEE _ YES NO
���� — 2. Ha5 this perso�rm ever been a city employee?
YES NO
_ DIS7NICtCOUR7 _ 3. Does Ihis peBOn/firm possess a skili not normall
y possesud by any curtent city empiqree?
SUPPOflTS WHICH COUNCIL OBJECfIVE? YES NO
Explain all yes anawers on soperate Sheet and attaeh to graen s�eet
�.. :p.. �>
INITIATING PqOBLEM. �SSUE, OPPORNNffY(Wta, What, When, Whare. Why�: �� '
APR 14 1997
CtT`� ;�����t�fY
ADVANTAGES IFAPPFtOVED:
OISAOVANTAGES IF APPROVED:
W�Laii'vf9 a`�r''dCr��'� �'Srtk�K.�,l
t�P� � 1 1J97
� --- — — - =
DISADVANTAGES IF NOT APPROVED:
SOTAL AMOUNT OF TRANSACTION S COSTJqEVENIfE BUDGETED (CfRCLE ON£) YES NO
FUNDIHG SOURCE ACTIVITY NUMBER
FINANCIAL INf-0RMATION: (EXPLAIN)
Greensheet # 35331
In Tracker?�
License iD # _ _ _ ?2353
L.I.E.P.REVIEWCHECKLIS7 flate: /��'s�y
APP'n Received / APP'n Processed
License Type: Gambling Manager
Company P1ame: James R. McDonough DSA: Se. Paul East Athletic Association
BUSiness Addresss: 1177 Clarence St. (Moose's Locker Room) gUSin2ss Phone: 778-8751
Contact NamelAddress:_ $15 E. Montana 55106 Home Phone: 778/8751
Date to Counci!
Public Hearing Date:� 7 19�f7
Notice Sent to Appiicant: �/ f�jq
Notice Sent to Public:
labels Ordered: N/A
District Council
Ward #: 06
Oepartmentf Date inspections Comments
City Attorney .. — %a ���Y7�1 � °� �f�7 ��
��`�/�� � ✓
Environmental
Health
���/
Fire
'V ��
License S�ce a�an Rece�vea:
Leese Received:
�( �
�
Police , i' J l�� �.� �(1 l.�r i ec{C, ���-U
�� �
Zoning
jY ��
.: � r .
-� ,
, LG212
(Rev. 7/252J
Minnesota Lawfut Gambiing
Gambling Manager Application
FOR OFFICE USE ONLY
&4SE tJC i
SEQ k
FEE
CHK
DATE
INIT
�New Give date that the hvo-day garnbfing manager seminar was completed. ��I�I�S
Locafion of training �, jj�p �.��
' (Gry)
[� Renewal Give da[e of training teceivsd within three yeazs pria to the date o( the applicaflon Fw renewaL _/ /
Locatlon o( training
.(
ia�iil�Tirt� "�er`Isiforiiiafiori� ��:<.
�-�
IAST NAME FIRST NAME MIDDLE NAME
M �ba'nov�h 64me5 GZoy-���--
de�s5 '
��5 F � �h�,�� � �, � sd�, F'4 t��
MAfDEN
Date of Birth Soa SeWrity Number
�23 SS y�� -C�-3l�i
lhfv S'S/d6
MEMBERSHIP: Date gambiing manager became a member of the organizaUOn I 1 � 1�
Name of OrganizaUOn
s�,p� �c � <
Address
�.ss r
��� ��-�-h r-�-� c
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City/State Zip Code
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-- A$10,000 fidelity bond In tavor of the organiza0on must be obtained for the gambling manager.
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Sex: (�'Male ❑ Female
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ticense Number
Phone (�
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Name of insuranca compeny (do not use agency �ame) _w�5� �rh SuYc�-Y C�• Bond Number
dedare that•
• i have raad this appliqtion and ali infortnauon submitted to the board;
• ail information is Ova, accurate and comp{ete;
• ail other required information has been tu4ly disdosed;
• I am the only gambling manager Dt the aganization;
• I wiil tamiiiarize myself with the laws o( bLnnesoW goveming lawtul garnbliag and rules o( the board and agree, if Iicensed, to
abide by those laws and rules, induding amendments to them;
• any changes in applicauon information will be submitted to ihe board and local unit o( govemment within 10 days of the change;
• An affidavit tor gambling manager has been completed and attached, and
•{ understand that faiNre to provide requirad inlormafion or provi�ng falsa information may result in ffie denial or revocafion o( the
ficense.
of Gambiing
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Send the completed application and alf required attachments to:
Gambling Contro! Board
Sufta 300 S.
17t1 W. County Road B
RosavlUe, MN 55113
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LG213 Minnesota Gambling Control Board
�AJ1E,'95 Gambling Manager Affidavit q 1-S � y
Attach to the Gamhfing Manager Application, Form LG212
STATE OF M��/1 -e 5 U�" n— ) AFFIDAVIT OF QUALIFICATION `
) s.s. FOR GAMBLING MANAGER LICENSE
COUNTY OF 1� 4 v�2 $�, v� } AND CONSEN7 STATEMENT
- (Pursuant to Minnesota Statutes and Ruies)
�, _�� m� S 2 a�iP. �-" (� �2c.t�J� des,oath state that:
(type/print name) ,�j � `
1. i have never been convicted of a felony or a crime invotving gambling.
2. I have not, within five years before the date of the license application, committed a violation of law or
Boarti rule that resulted in the revocation of a license issued by the Board.
3. 1 have never been convided of a criminai violation involving fraud, theft, tax evasion, misrepresentation,
or gambling.
4. I have never been convicted of (� assautt, () a criminal vioiation invotving the use of a fireartn, or (i�
making terroristic threats.
5. I am not, nor ever have been connecied with or engaged in an iHega{ business.
6. 1 do not owe $500 or more in delinquent taxes as defined in section 270.72.
7. 1 have not had a sales and use tax permit revoked by the commissioner of revenue within the past two
years.
&. I have never, after demand, failed to file tax retums required by the commissioner of revenue.
In addition, 1 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 againsi my organizaiion and I wiii 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 laws of Minnesota.
Dy signature of this document, the undersigned authorizes the Department of Pubiic Safety to conduct a
criminai background check or review and to share the resuits with the Gambltng Controi Boarcl.
Failure to provide required information or providing false or misleading infortnatio� may result in the deniai or
revocation of the Iicense.
FURTHER AFFIANT SAYETH NOT, except that this A�davit and Consent Statement are submitted in
suppart of the appiication for a gambling manager license from the Gambling Control Board.
NOTARY PUBLIC INFORMATION
�ublic Seal must be current and co
Seal may not be aitered.
Subscribed and swom to before me this
�_day of � �
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,�'4 m �,5 � 1h ��Jon n �,�L
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(signature of applicant)
ORGANIZATION INFORMATION
of Organization
COUNTY
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License Number