The URL can be used to link to this page

97-573Council File � 9�� ordinance # ��_ Psesented i 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Re£erred To Committee: Date ,♦ RESOLVED: That application, 2D ,#18677, for a new Gambling Manaqer•s License by Gregory J. Lendway DBA Star Swi.m Club Inc. at Plums Neighborhood Bar & Grill, 480 Snellinq Avenue South, be and the same is hereby approved. � ��r� s � Requested by Department of: • - -�-- �-•- •e- ,:. � .e.�� - •� Adopted by Council: Date Adoption Certified by Council Byc Approved by Mayor: Date -��"S. }-l4 � By: �—� Green Sheet # 35329 RESOLUTION 41NT PAUL, MINNESOTA By: Tn1LU�fa.f� �• �$Wn�(/•4h Form Approved by City Attorney Approved by Mayor for Submission to Council Sy: q7 �Srl3 DEPAflTMENT/OFFiCE/COUNCiL DATEINITIATE� GREEN SHEE , N � _` �5329 CONTACT PERSON 8 PHONE O pEPAR'fMENT OIREC70RNmAVDAh � GINCOUNCII �NRIAVDATE William F. Gunther — 26b-9132 '�WN �cmnrroaNEV �CENCIEflK MUSi 8E ON CAUNCII AGENDA BY (DATE) NUMBER FOR O BUDGET DfRECfOF O FIN. 8 MGt SERVICES DIR. ROUnNG / / OADEFl O Mqypp (OR ASSISTANT) � gE1L1R : J TOTAL # OF SIGNATURE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE) ACTION fiEQUESTED: Gregory J. Lendway DBA Star Swim Club Inc. requests Council approval of his application for a new Gambling Manager's License; ID �18677, at Plums Neighborhood Bar & Grill, 480 Snelling Avenue South. RECOMMENDA7IONS: Approve (A) a Fa�act (R) PEHSONAL SERVICE CONTpACTS MUST ANSWER TME FOLLOWING QUESTIONS: _ PLANNING COMMISSION _ G�YiI SERVICE WMMISSION �� Has Mis persoNfirm ever worketl under a corrtrac[ for ihis departmen[? - _ CIB COMMIiTEE _ YES "NO _ SinFF 2. Has this person/firm ever been a ciry employee? — YES NO _ OISTRICT COUR7 � 3. Does this per5on/Firm possess a skill not nortnall y possessetl by any curten[ ciry employee? SUPPOPTSWHICXCOUNCILOBIECTIVE? YES Nd Explain all yes artswers on separate aheet and attach to gree� ahcet INITiATiNG PROBLEM, ISSUE, OPPORTUNI7Y (Who, What, Whe�. Whare, Why): ��ti��l� - INAR 28 i997 CiT �` � �T�►RNEY ADVANTAGE3 IF APPROVED: DISADVANTAGES IF APPflOVED: . � ,� �v��f4�P E� ,r, ";`.' � .y.1v97 DISADYANTPGES IF NOT APPROVED: -.- ,""' "`--" -"°' ` TOTAL AMOUNT Of TRANSACTION $ COST/REVENUE BUDGETED (CIRCLE ONE) YES NO FUNDIfdG SOURCE ACTIVITY NUMBEH GINANGIAL INFORMATION. (EXPLAIN) Greensheet # 35329 In Tracke(?___1`T"7„" ''-- L.I.E.P. REVIEW CHECKLIST �ate: A�`5�3 aPP'n Re�ived / APP'n Processed license ID # 18677 License Type: Gambling Manager Company Name: Gregory J. Lendway pgq Star Swim Club Inc. BusinessAddresss: 480 Snelling Ave. S. (Plums) BusinessPhone: �7z-�331 Contact NamejAddress: 1272 Juliet Ave. 55105 Home Phone: �72-�331 .r . Date ta Council Public Hearing Date: 'rilan l`� � i9q° Notice Sent to Applican�{� Labels Ordered: N/A District Council #: 14 Notice Sent to Public: �� Ward #: 03 Department/ Date Inspections Gomments City Attorney � �°� � �"h� �� 7 Environmentai Health �1 � Fire i+� � r1 License Site Plan Reeeived: lease Received: V �� Police �� /� �� J �� . � � Zoning ��J LG2i2 (Rev. 7!2/92) � - Minnesota I,awful Gambling Gam.bling M.anager Application FOR OFFICE BASE L�C # _ SEQ # FEE CHK DATE I"ItT .. . . .,.. . . ., . , - . . .. . , . ., �pTication , . Give date that the Rvo-day g2mbting manager seminar was completed. �! 1?! 96 Locafion oi vaining C� G� N (eiry) �� Renewal Glve date oi v2ining recerved wiL'�In three years prior Eo the date ol the applicaUOn tor rerewaL �t 1 Locatlon of traming IAST NAME FtRST NAME �,�,v4 wR �' ��E6�R 1z7Z J�ut/ET Av�. �atzon;.: <.;,::.;°::.:::<,;�:;,: MIOOI.E NAME MAIDEN �as��N State �� Date of 8irih f�.f Y � .`. Zip Code ssios MEMBERSHIP: Date gambling mana9er became a member ot the organizafion �/�/� Ot�ElTtt2Ci t24tt„�R; Name of Organization .S7"AR .Swlr✓i Address J� . Ciry/State f Soc. Secuti,y Number < <s�z> »z-1.3.�r Sex : � Male ❑ Female T � � { Llccnse 1v'umber P � Z:p Code Phone SSJoy � �y(�ZZ7� ,; , , ;... _�17Z2f.�.�4L£f3Ci#.34.TL._...___�.. _ �_. -- A$i0,040 fido�iry bor�d irs favor a# the �rganizancn mus,* t�a ob�iined for th0 gam6fing manager. !.'ar.�e nt iRSUranc2 company jdo m; use sgency name)�F.r�UE[��URFT}� f,L1', CQn+ Bond Number� Dt��2 � Acknaustedqment S dedare ihat: •� have read this application and aU informaGan sub,�nkC,ed to �he hoard, • all information is true, acc�rate and com�lete; • afI olh�er required information has peen tully disdQSed; • 3 am Ihe only gambhng manager of the organ¢ahon; • I wi+i famiiiarize myseit with Ghe 12�vs c! hiir,aeso:� 5ocemir:g la'�vfaf gambling ar,d rules oi ihe'ooard and ;gree, d licen>ed, to abide 6y ihose laws and rufes, induding amendmenis to them; • any changes +n applicatlo� inbrmation wilk 6e submitted ro the board and tocal unit of government within i� days oE the change: � An affidauit for gambting manager has heert compieted and apached, and � • 1 understand that failu�e to Orovide required informelion pr p�oviding (;}se in9ormation may rewl; in the deata� or revffcafion of the (iCenSe. of Gambiing Date Send ihe �mpleted ap�Stic�'ion and zll required at;achments to: Gambltng Control Board Suite 900 S. 17t1 W. County Road B Roseville, MN 55113 1�� LG213 Minnesota Gambling Contro/ Board oa�,s�ys Gamblinq ManagerAffidavit Q7 � S 73 Attach to the Gambiiny ManagerAppiication, Form tG212 STATE OF /1�j�,�,yESo ) AFFIDAVIT OF QUALIFlCATIpN ) ss. FOR GAMBUNG MANAGER UCENSE COUNTY OF ��s Y � AND CONSENT STATEMENT (Pursuant to Minnesota Statutes and Rules) �, �REGoQY S �ENd��Y ,underoathstatechat: (typefpri�t name) 4. I have never been convicted of a felony or a crime invoiving gambling. 2. i have not, within five years before the date of the license application, committed a violation of law or Board role that resWted in the revocation of a ficense issusd by the 8oard. 3. t have never besn convicted of a criminal violation invoiving fraud, theft, tax evasion� misrepresentation, or gambling. 4. 1 have never been convicted of (i) assault, (ii) a criminal violation invoiving the use of a fireartn, or (iii) making ferroristic threats. 5, i am not, nor ever fiave been connected with or engaged {n an ii}egal hus�ness, 6, { do not owe $5�0 or more in de}inqueRt taxss as defined in seciion 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. I have nevee, after demand, failed to fr1e tax re#urn5 required by the commissiorter of revenue. In addition,l understand, agree and hereby irrevocabty eonsent that suits and actions re�ating to the subject matter of the attached gambling manager license applicatian, or acts or omissions aristng fram s�ch applica- tion, may be cammenCed against my organization and 1 wi11 acoept the service of process for my organiza- tion in any coart of competent junsdiction in Minnesota by seroice on the Minnesota Seceetary of State of any summons, proc�ss or p{eading autharized by the iaws ofi Minrtesota. By signature 9f this document, the underslgned authorizes ihe De¢artment of Puhiic Satefy ka conduct a criminat baekgrpund check or review ar�d tc� share the results with the Gambiing Cor�traf Hoard. Failure to provide required i�fo�mation or providing false or misleading information may result in the denial or cevocation ofthe license. FURTHER AFPtANT SAY�Tfi NOT, except that this A�davit and Consent Stateme(tt are submittad in suppart of the app(ication for a gamb4i�g manager tiCense from the Gambifng Confrol Board. NOTRRYPUBLIC INFpRMATION Sea[ may not be altered. curcent and correct. SubsCriUed artd of before me this (si tu ot applicant) G `,/ ORGANIZATION /NF4RMATION ot Organization ��RY�u&ic � MiNHE50TA � ��11�4 �.3 l.. {.WCQTAS'.CYi1N�'( �.! r 4�t,/�lt�'1 LL�/�j i�C, ��"°'�'�"�� (Base License Number Council File � 9�� ordinance # ��_ Psesented i 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Re£erred To Committee: Date ,♦ RESOLVED: That application, 2D ,#18677, for a new Gambling Manaqer•s License by Gregory J. Lendway DBA Star Swi.m Club Inc. at Plums Neighborhood Bar & Grill, 480 Snellinq Avenue South, be and the same is hereby approved. � ��r� s � Requested by Department of: • - -�-- �-•- •e- ,:. � .e.�� - •� Adopted by Council: Date Adoption Certified by Council Byc Approved by Mayor: Date -��"S. }-l4 � By: �—� Green Sheet # 35329 RESOLUTION 41NT PAUL, MINNESOTA By: Tn1LU�fa.f� �• �$Wn�(/•4h Form Approved by City Attorney Approved by Mayor for Submission to Council Sy: q7 �Srl3 DEPAflTMENT/OFFiCE/COUNCiL DATEINITIATE� GREEN SHEE , N � _` �5329 CONTACT PERSON 8 PHONE O pEPAR'fMENT OIREC70RNmAVDAh � GINCOUNCII �NRIAVDATE William F. Gunther — 26b-9132 '�WN �cmnrroaNEV �CENCIEflK MUSi 8E ON CAUNCII AGENDA BY (DATE) NUMBER FOR O BUDGET DfRECfOF O FIN. 8 MGt SERVICES DIR. ROUnNG / / OADEFl O Mqypp (OR ASSISTANT) � gE1L1R : J TOTAL # OF SIGNATURE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE) ACTION fiEQUESTED: Gregory J. Lendway DBA Star Swim Club Inc. requests Council approval of his application for a new Gambling Manager's License; ID �18677, at Plums Neighborhood Bar & Grill, 480 Snelling Avenue South. RECOMMENDA7IONS: Approve (A) a Fa�act (R) PEHSONAL SERVICE CONTpACTS MUST ANSWER TME FOLLOWING QUESTIONS: _ PLANNING COMMISSION _ G�YiI SERVICE WMMISSION �� Has Mis persoNfirm ever worketl under a corrtrac[ for ihis departmen[? - _ CIB COMMIiTEE _ YES "NO _ SinFF 2. Has this person/firm ever been a ciry employee? — YES NO _ OISTRICT COUR7 � 3. Does this per5on/Firm possess a skill not nortnall y possessetl by any curten[ ciry employee? SUPPOPTSWHICXCOUNCILOBIECTIVE? YES Nd Explain all yes artswers on separate aheet and attach to gree� ahcet INITiATiNG PROBLEM, ISSUE, OPPORTUNI7Y (Who, What, Whe�. Whare, Why): ��ti��l� - INAR 28 i997 CiT �` � �T�►RNEY ADVANTAGE3 IF APPROVED: DISADVANTAGES IF APPflOVED: . � ,� �v��f4�P E� ,r, ";`.' � .y.1v97 DISADYANTPGES IF NOT APPROVED: -.- ,""' "`--" -"°' ` TOTAL AMOUNT Of TRANSACTION $ COST/REVENUE BUDGETED (CIRCLE ONE) YES NO FUNDIfdG SOURCE ACTIVITY NUMBEH GINANGIAL INFORMATION. (EXPLAIN) Greensheet # 35329 In Tracke(?___1`T"7„" ''-- L.I.E.P. REVIEW CHECKLIST �ate: A�`5�3 aPP'n Re�ived / APP'n Processed license ID # 18677 License Type: Gambling Manager Company Name: Gregory J. Lendway pgq Star Swim Club Inc. BusinessAddresss: 480 Snelling Ave. S. (Plums) BusinessPhone: �7z-�331 Contact NamejAddress: 1272 Juliet Ave. 55105 Home Phone: �72-�331 .r . Date ta Council Public Hearing Date: 'rilan l`� � i9q° Notice Sent to Applican�{� Labels Ordered: N/A District Council #: 14 Notice Sent to Public: �� Ward #: 03 Department/ Date Inspections Gomments City Attorney � �°� � �"h� �� 7 Environmentai Health �1 � Fire i+� � r1 License Site Plan Reeeived: lease Received: V �� Police �� /� �� J �� . � � Zoning ��J LG2i2 (Rev. 7!2/92) � - Minnesota I,awful Gambling Gam.bling M.anager Application FOR OFFICE BASE L�C # _ SEQ # FEE CHK DATE I"ItT .. . . .,.. . . ., . , - . . .. . , . ., �pTication , . Give date that the Rvo-day g2mbting manager seminar was completed. �! 1?! 96 Locafion oi vaining C� G� N (eiry) �� Renewal Glve date oi v2ining recerved wiL'�In three years prior Eo the date ol the applicaUOn tor rerewaL �t 1 Locatlon of traming IAST NAME FtRST NAME �,�,v4 wR �' ��E6�R 1z7Z J�ut/ET Av�. �atzon;.: <.;,::.;°::.:::<,;�:;,: MIOOI.E NAME MAIDEN �as��N State �� Date of 8irih f�.f Y � .`. Zip Code ssios MEMBERSHIP: Date gambling mana9er became a member ot the organizafion �/�/� Ot�ElTtt2Ci t24tt„�R; Name of Organization .S7"AR .Swlr✓i Address J� . Ciry/State f Soc. Secuti,y Number < <s�z> »z-1.3.�r Sex : � Male ❑ Female T � � { Llccnse 1v'umber P � Z:p Code Phone SSJoy � �y(�ZZ7� ,; , , ;... _�17Z2f.�.�4L£f3Ci#.34.TL._...___�.. _ �_. -- A$i0,040 fido�iry bor�d irs favor a# the �rganizancn mus,* t�a ob�iined for th0 gam6fing manager. !.'ar.�e nt iRSUranc2 company jdo m; use sgency name)�F.r�UE[��URFT}� f,L1', CQn+ Bond Number� Dt��2 � Acknaustedqment S dedare ihat: •� have read this application and aU informaGan sub,�nkC,ed to �he hoard, • all information is true, acc�rate and com�lete; • afI olh�er required information has peen tully disdQSed; • 3 am Ihe only gambhng manager of the organ¢ahon; • I wi+i famiiiarize myseit with Ghe 12�vs c! hiir,aeso:� 5ocemir:g la'�vfaf gambling ar,d rules oi ihe'ooard and ;gree, d licen>ed, to abide 6y ihose laws and rufes, induding amendmenis to them; • any changes +n applicatlo� inbrmation wilk 6e submitted ro the board and tocal unit of government within i� days oE the change: � An affidauit for gambting manager has heert compieted and apached, and � • 1 understand that failu�e to Orovide required informelion pr p�oviding (;}se in9ormation may rewl; in the deata� or revffcafion of the (iCenSe. of Gambiing Date Send ihe �mpleted ap�Stic�'ion and zll required at;achments to: Gambltng Control Board Suite 900 S. 17t1 W. County Road B Roseville, MN 55113 1�� LG213 Minnesota Gambling Contro/ Board oa�,s�ys Gamblinq ManagerAffidavit Q7 � S 73 Attach to the Gambiiny ManagerAppiication, Form tG212 STATE OF /1�j�,�,yESo ) AFFIDAVIT OF QUALIFlCATIpN ) ss. FOR GAMBUNG MANAGER UCENSE COUNTY OF ��s Y � AND CONSENT STATEMENT (Pursuant to Minnesota Statutes and Rules) �, �REGoQY S �ENd��Y ,underoathstatechat: (typefpri�t name) 4. I have never been convicted of a felony or a crime invoiving gambling. 2. i have not, within five years before the date of the license application, committed a violation of law or Board role that resWted in the revocation of a ficense issusd by the 8oard. 3. t have never besn convicted of a criminal violation invoiving fraud, theft, tax evasion� misrepresentation, or gambling. 4. 1 have never been convicted of (i) assault, (ii) a criminal violation invoiving the use of a fireartn, or (iii) making ferroristic threats. 5, i am not, nor ever fiave been connected with or engaged {n an ii}egal hus�ness, 6, { do not owe $5�0 or more in de}inqueRt taxss as defined in seciion 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. I have nevee, after demand, failed to fr1e tax re#urn5 required by the commissiorter of revenue. In addition,l understand, agree and hereby irrevocabty eonsent that suits and actions re�ating to the subject matter of the attached gambling manager license applicatian, or acts or omissions aristng fram s�ch applica- tion, may be cammenCed against my organization and 1 wi11 acoept the service of process for my organiza- tion in any coart of competent junsdiction in Minnesota by seroice on the Minnesota Seceetary of State of any summons, proc�ss or p{eading autharized by the iaws ofi Minrtesota. By signature 9f this document, the underslgned authorizes ihe De¢artment of Puhiic Satefy ka conduct a criminat baekgrpund check or review ar�d tc� share the results with the Gambiing Cor�traf Hoard. Failure to provide required i�fo�mation or providing false or misleading information may result in the denial or cevocation ofthe license. FURTHER AFPtANT SAY�Tfi NOT, except that this A�davit and Consent Stateme(tt are submittad in suppart of the app(ication for a gamb4i�g manager tiCense from the Gambifng Confrol Board. NOTRRYPUBLIC INFpRMATION Sea[ may not be altered. curcent and correct. SubsCriUed artd of before me this (si tu ot applicant) G `,/ ORGANIZATION /NF4RMATION ot Organization ��RY�u&ic � MiNHE50TA � ��11�4 �.3 l.. {.WCQTAS'.CYi1N�'( �.! r 4�t,/�lt�'1 LL�/�j i�C, ��"°'�'�"�� (Base License Number Council File � 9�� ordinance # ��_ Psesented i 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Re£erred To Committee: Date ,♦ RESOLVED: That application, 2D ,#18677, for a new Gambling Manaqer•s License by Gregory J. Lendway DBA Star Swi.m Club Inc. at Plums Neighborhood Bar & Grill, 480 Snellinq Avenue South, be and the same is hereby approved. � ��r� s � Requested by Department of: • - -�-- �-•- •e- ,:. � .e.�� - •� Adopted by Council: Date Adoption Certified by Council Byc Approved by Mayor: Date -��"S. }-l4 � By: �—� Green Sheet # 35329 RESOLUTION 41NT PAUL, MINNESOTA By: Tn1LU�fa.f� �• �$Wn�(/•4h Form Approved by City Attorney Approved by Mayor for Submission to Council Sy: q7 �Srl3 DEPAflTMENT/OFFiCE/COUNCiL DATEINITIATE� GREEN SHEE , N � _` �5329 CONTACT PERSON 8 PHONE O pEPAR'fMENT OIREC70RNmAVDAh � GINCOUNCII �NRIAVDATE William F. Gunther — 26b-9132 '�WN �cmnrroaNEV �CENCIEflK MUSi 8E ON CAUNCII AGENDA BY (DATE) NUMBER FOR O BUDGET DfRECfOF O FIN. 8 MGt SERVICES DIR. ROUnNG / / OADEFl O Mqypp (OR ASSISTANT) � gE1L1R : J TOTAL # OF SIGNATURE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE) ACTION fiEQUESTED: Gregory J. Lendway DBA Star Swim Club Inc. requests Council approval of his application for a new Gambling Manager's License; ID �18677, at Plums Neighborhood Bar & Grill, 480 Snelling Avenue South. RECOMMENDA7IONS: Approve (A) a Fa�act (R) PEHSONAL SERVICE CONTpACTS MUST ANSWER TME FOLLOWING QUESTIONS: _ PLANNING COMMISSION _ G�YiI SERVICE WMMISSION �� Has Mis persoNfirm ever worketl under a corrtrac[ for ihis departmen[? - _ CIB COMMIiTEE _ YES "NO _ SinFF 2. Has this person/firm ever been a ciry employee? — YES NO _ OISTRICT COUR7 � 3. Does this per5on/Firm possess a skill not nortnall y possessetl by any curten[ ciry employee? SUPPOPTSWHICXCOUNCILOBIECTIVE? YES Nd Explain all yes artswers on separate aheet and attach to gree� ahcet INITiATiNG PROBLEM, ISSUE, OPPORTUNI7Y (Who, What, Whe�. Whare, Why): ��ti��l� - INAR 28 i997 CiT �` � �T�►RNEY ADVANTAGE3 IF APPROVED: DISADVANTAGES IF APPflOVED: . � ,� �v��f4�P E� ,r, ";`.' � .y.1v97 DISADYANTPGES IF NOT APPROVED: -.- ,""' "`--" -"°' ` TOTAL AMOUNT Of TRANSACTION $ COST/REVENUE BUDGETED (CIRCLE ONE) YES NO FUNDIfdG SOURCE ACTIVITY NUMBEH GINANGIAL INFORMATION. (EXPLAIN) Greensheet # 35329 In Tracke(?___1`T"7„" ''-- L.I.E.P. REVIEW CHECKLIST �ate: A�`5�3 aPP'n Re�ived / APP'n Processed license ID # 18677 License Type: Gambling Manager Company Name: Gregory J. Lendway pgq Star Swim Club Inc. BusinessAddresss: 480 Snelling Ave. S. (Plums) BusinessPhone: �7z-�331 Contact NamejAddress: 1272 Juliet Ave. 55105 Home Phone: �72-�331 .r . Date ta Council Public Hearing Date: 'rilan l`� � i9q° Notice Sent to Applican�{� Labels Ordered: N/A District Council #: 14 Notice Sent to Public: �� Ward #: 03 Department/ Date Inspections Gomments City Attorney � �°� � �"h� �� 7 Environmentai Health �1 � Fire i+� � r1 License Site Plan Reeeived: lease Received: V �� Police �� /� �� J �� . � � Zoning ��J LG2i2 (Rev. 7!2/92) � - Minnesota I,awful Gambling Gam.bling M.anager Application FOR OFFICE BASE L�C # _ SEQ # FEE CHK DATE I"ItT .. . . .,.. . . ., . , - . . .. . , . ., �pTication , . Give date that the Rvo-day g2mbting manager seminar was completed. �! 1?! 96 Locafion oi vaining C� G� N (eiry) �� Renewal Glve date oi v2ining recerved wiL'�In three years prior Eo the date ol the applicaUOn tor rerewaL �t 1 Locatlon of traming IAST NAME FtRST NAME �,�,v4 wR �' ��E6�R 1z7Z J�ut/ET Av�. �atzon;.: <.;,::.;°::.:::<,;�:;,: MIOOI.E NAME MAIDEN �as��N State �� Date of 8irih f�.f Y � .`. Zip Code ssios MEMBERSHIP: Date gambling mana9er became a member ot the organizafion �/�/� Ot�ElTtt2Ci t24tt„�R; Name of Organization .S7"AR .Swlr✓i Address J� . Ciry/State f Soc. Secuti,y Number < <s�z> »z-1.3.�r Sex : � Male ❑ Female T � � { Llccnse 1v'umber P � Z:p Code Phone SSJoy � �y(�ZZ7� ,; , , ;... _�17Z2f.�.�4L£f3Ci#.34.TL._...___�.. _ �_. -- A$i0,040 fido�iry bor�d irs favor a# the �rganizancn mus,* t�a ob�iined for th0 gam6fing manager. !.'ar.�e nt iRSUranc2 company jdo m; use sgency name)�F.r�UE[��URFT}� f,L1', CQn+ Bond Number� Dt��2 � Acknaustedqment S dedare ihat: •� have read this application and aU informaGan sub,�nkC,ed to �he hoard, • all information is true, acc�rate and com�lete; • afI olh�er required information has peen tully disdQSed; • 3 am Ihe only gambhng manager of the organ¢ahon; • I wi+i famiiiarize myseit with Ghe 12�vs c! hiir,aeso:� 5ocemir:g la'�vfaf gambling ar,d rules oi ihe'ooard and ;gree, d licen>ed, to abide 6y ihose laws and rufes, induding amendmenis to them; • any changes +n applicatlo� inbrmation wilk 6e submitted ro the board and tocal unit of government within i� days oE the change: � An affidauit for gambting manager has heert compieted and apached, and � • 1 understand that failu�e to Orovide required informelion pr p�oviding (;}se in9ormation may rewl; in the deata� or revffcafion of the (iCenSe. of Gambiing Date Send ihe �mpleted ap�Stic�'ion and zll required at;achments to: Gambltng Control Board Suite 900 S. 17t1 W. County Road B Roseville, MN 55113 1�� LG213 Minnesota Gambling Contro/ Board oa�,s�ys Gamblinq ManagerAffidavit Q7 � S 73 Attach to the Gambiiny ManagerAppiication, Form tG212 STATE OF /1�j�,�,yESo ) AFFIDAVIT OF QUALIFlCATIpN ) ss. FOR GAMBUNG MANAGER UCENSE COUNTY OF ��s Y � AND CONSENT STATEMENT (Pursuant to Minnesota Statutes and Rules) �, �REGoQY S �ENd��Y ,underoathstatechat: (typefpri�t name) 4. I have never been convicted of a felony or a crime invoiving gambling. 2. i have not, within five years before the date of the license application, committed a violation of law or Board role that resWted in the revocation of a ficense issusd by the 8oard. 3. t have never besn convicted of a criminal violation invoiving fraud, theft, tax evasion� misrepresentation, or gambling. 4. 1 have never been convicted of (i) assault, (ii) a criminal violation invoiving the use of a fireartn, or (iii) making ferroristic threats. 5, i am not, nor ever fiave been connected with or engaged {n an ii}egal hus�ness, 6, { do not owe $5�0 or more in de}inqueRt taxss as defined in seciion 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. I have nevee, after demand, failed to fr1e tax re#urn5 required by the commissiorter of revenue. In addition,l understand, agree and hereby irrevocabty eonsent that suits and actions re�ating to the subject matter of the attached gambling manager license applicatian, or acts or omissions aristng fram s�ch applica- tion, may be cammenCed against my organization and 1 wi11 acoept the service of process for my organiza- tion in any coart of competent junsdiction in Minnesota by seroice on the Minnesota Seceetary of State of any summons, proc�ss or p{eading autharized by the iaws ofi Minrtesota. By signature 9f this document, the underslgned authorizes ihe De¢artment of Puhiic Satefy ka conduct a criminat baekgrpund check or review ar�d tc� share the results with the Gambiing Cor�traf Hoard. Failure to provide required i�fo�mation or providing false or misleading information may result in the denial or cevocation ofthe license. FURTHER AFPtANT SAY�Tfi NOT, except that this A�davit and Consent Stateme(tt are submittad in suppart of the app(ication for a gamb4i�g manager tiCense from the Gambifng Confrol Board. NOTRRYPUBLIC INFpRMATION Sea[ may not be altered. curcent and correct. SubsCriUed artd of before me this (si tu ot applicant) G `,/ ORGANIZATION /NF4RMATION ot Organization ��RY�u&ic � MiNHE50TA � ��11�4 �.3 l.. {.WCQTAS'.CYi1N�'( �.! r 4�t,/�lt�'1 LL�/�j i�C, ��"°'�'�"�� (Base License Number