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97-75Council File # l�"= � S Ordinance # Green Sheet# 35416 CITY Presented By Referred To Committee: Date s 6 7 8 9 1� 11 12 13 1 2 3 4 RESOLVED: That application, ID #77002, for a new 6ambling Manager's License by Richatd M. Henricks DBA Camden Neighborhood Gym at B B Dixon's Tavern fi Grill, 1834 St. Clair Avenue, be and the same is hereby approved. v�o�� N� ��,� ar heer+ � Requested by Department of: • - -r.- e-•� •+_ ,+• � .��-� - •� Adopted by Council: Date Adoption Certified by Council Secretary t'� $Y —R��-�� t� �M-.�O/LJ3�-��-� c- Approved by Mayore Date By: /"�l�i-2t�(.v-C'�JS RESOLUTION 41NT PAUL, MINNESOTA By: ��*/�t.Ut�ir �J�� Form Approved by City Attorney BY� ' � Approved by Mayor for Submiasian to Council By' `{ DEPARTMENTlOFPICFJCOUNCIL DATEINITtATED �REEN SHEE �O 33416 LIEP -- -- CONTACf PEASON & PHONE INRIAVOATE INRIAV�ATE � DEPAHTMENTDIRECTOR O CT'COUNCIL ASSM+X CRVATTORNEY CflYCLERK William F. Gunther - 266-9132 NUYBERiOR 0 MUST BE ON dJUNCIL AGENDA BY (DATE) pp�nN� O BUDGET DIRECIOR O FIPI. & MGL SERV(CES DIR. Hearin : / �a- �J OROER OMAYOH(ORASSISTANT� � TOTAL # OF SIGNATURE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE) AC710N RE�UESiED: Richaxd M. Henxicks DBA Camden Neighborhood Gym requests Council approval of his application for a new Gambling Manager's License at B B Dixon's, 1834 St. Clair Avenue. (ID I677002) RECOMMENDATIONS: Approve (A) or Reject (R) pEHSONAL SERVICE CONTHACTS MUST ANSWEq TNE POLLOWING �UESTIONS: _ PLANNMG CqMMIS510N _ CNIL SERVICE COMMISSION t Has Nis persoMirm ever worked untle� a coMract for Mis departmeM? - _ CIB COMMITTEE YES NO — �� F 2. Has this personlfirm ever been a city empbyee? — YES NO _ DISTRtC7 COUR7 _ 3. Does this person/firm possess a skill not normally possessed by any curteM city employee? SUPPOfiTS WNICH COUNCIL O&IECTIVE? YES NO Explain sll yes a�swers on separete sheet and ettaeh to green sheot INITIATING PROBLEM, ISSUE, OPPORTUNITY (Wtp, Whet, Whan, WHere, Why): �� fl�C 05 1996 C��°Y' ATT�RN�� ADVANTAGESIFAPPROVED: , DISADVANTAGESIFAPPROVED: ��_` �� d � �� . ��J� DISADVANTAGES IF NOT APPROVED: TOTAL AMOUNT OF TRANSACTION $ CAST7REYENUE BUDGETED (CIRCLE ONE) YES NO FUNDIHG SOURCE NCTIVITY NUMBER FINqNCIAL INFORMATION. (EXPLAIN) Greensneet # 35416 L.I.E.P. REVIEW CHECKLIST oate: /��—`� 5 In Tracker? a� /0 9 App'n Received ( App n Processed LicenselD# 77002 LicenseType: Gamb�; Mana�r Company Name: Richard M Henricks �B/�: Camden NPjghhnrhnnd C,�m, BusinessAddresss: 1834 St Clair Ave lBB D�xon'al BusinessPhone: s�q-��t�q Contact Name/Address: 7762 Yo.-k Lane Home Phone: s�o_ti7�q Date to Councif Research: Brooklyn Park, MN 55443 Public Hearing Date: c .�.� �2� f�i� Labels Ordered: N/A Notice Sent to Applicant: District Council #: 14 Notice Sent to Pubtic: NJA Ward #: 03 Department/ Date Inspections Comments City Attorney f C? �l�� &TU�`� � �� L�;� o,� �� l� Environmental Heaith NfR Fire �f � License Site Plan Heceived: � Lease Reeeived: JV � � Poiice ��0� l�1LP�� /'7 yT�-�-1��-C3 � � �/��9.(� Zoning �1� .� ��-�S Central STATE pF HINNESOTA FOR BOARD USE OHLY fi'AMBZ.TX6 CONTROL BORRD AMT. PAID GAMBLING MANAGER LZCENSE REXEWAL AppLICATION CAECIC # LG212GHR PRINTED: 09/40/95 DATE LSCENSE NUHBER: (i-03067 002 EFFECTIVE DATE: O1/O1J95 EXPIRATION DATE: 1Z/31/95 NAME OF ORGANZZATION: Neighborhood Minaeapolis Oy� Camden CiAMBLSDi6 lSANA6ER I2LA'ORMATIOH Richard Marvin Hearicks '�� s-�� -- -'� `rork �s�G : "' �tvoklyn Park� tVltv 55�I�}3 DATE OF BIRTH: O1/1T/40 SEX: N SOCZAL SECt3RITY NUMBER: 470-38-2962 DAYTIME PHONE NUMBER: �'^ ^^° ^"^° MEMBER SZNCE: 09/15/88 1i - YY LAS2 DATE YOU ATTENDED A GAMBLING MANAGERS SEMINAR/CONTINUING EDUCATZON CLASS: -B{f$9i-03 BOND ZNFORMATION BOND COMPANY NAME: 67estern Surety BOND NUMBER: 58451510 ACRNOWLEDGMENT Z DECS,RRE THATt' . � � . .. . . � . '_I fI�Vfi READ THIS F�pPLICATION AND ALL INFORMATZON SUBMITTED TO THE GAMBLING @ONTROL BOARD;: • ALL INFORMATION IS TRUE, ACCURATE AND COMPLETE; , _ °�I.L OTHER REQUIRED INFQRMATZON HAS BEEN FULLY DSSCLO5EDy �� • I AM THE ONLY GAMBLING HANAGER OF THE ORGANIZATION; • I HAVfi BfiEN AN ACTIVE MEMBER OF THE ORGANIZATION FOR AT LEAST TWO YEARS� ° I WILL FAMTLIARZZB MYSELF WITH THE LAWS OF MINNESOTA GOVfiRNZNG LAWFUL GAHBLING AND RULES OF THE GAMBLING CONTROL BOARD ANO AGREE, ZF LZCENSED, TO ABIDE THOSE LAWS AND RULES, INCLUDING AMENDMENTS TO TAEM; ° ANY CHANGES IN APPLICATION ZNFORMATION WILL BE SUBHITTED TO THE GAMBLING CONTROL BOARD AND LOCAL UNIT OF GOVERNMENT WITHIN 10 DAYS OF THE CHANGE; • AN AEFIDAVIT FOR GAMBLZNG MANAGER HAS BEEN COMPLETED AND ATTACHED; A13D � I UNDERSTAND THAT FAILURE TO PROVIDE REQUIRED INFORMATION OR PROVIDING FALSE OR MISLEADSNG ZNFORMRTION MAY RESULT IN THE DENIAL OR REVOCATION OF THE LICENSE. S7.(3N�TURE OF 6A!ffiLINGF W1NA6ER DpTg � �� n , , � REFER TO THE CHECKLI5T�FOR REQUIRED ATTACffi4ENT8 MAIL TOS 6AMBLZN6 CONTROL BOARD 1711 WEST COtJH17 ROAD B, SUZTE 3008 ROSEVILLE, HI2IltESOTA 55113 �s THIS FORM WILL BE MADE AVAILABLE YN ALTERNATIVE FORMAT (I.E. LARGE PRINT� BRAILLE) UPO,N REQUES2. �. . � � � 7��' . LG21� '- . 04/18J95 Minnesota Gambling Control Board `��I, -`l 5 AFFIDAVIT OF QUALIFICATION FOR GAMBLING MANAGER LICENSE ) s.s_ AND CONSENT STATEMENT COUNTY OF �,� �, � s ) (Pursuant to Minnesota Statutes and Rules) Gambling Manager Affidavit Attach to the Gambling Manager Appiication, Fortn LG212 STATE OF M Y� ) ' �,�`i �-�t 1 �- � n.� r �'t � NVt�� th state that: (type/print name) 1. i have never been convicted of a felony or a c�me involving gambiing. 2. I have not, within five years before the date of the license application, committed a violation of law or Board ruie that �esufied in ihe revocation of a ticense issued by the Board. 3. 1 have never been convicted of a criminaf violation involving fraud, theft, tax evasion, misrepresentation, or gambling. 4. 1 have never been convicted o( (i) assault, (ii) a criminal viofation invoiving the use of a fireartn, or (iii) making terroristic threats. 5. I am not, nor ever have been connected with or enqaged in an illegai business. 6. I do not owe $Stl0 or more in delinquent taxes as defined in section 270.72. 7. t have not had a sales and use tax permit revoked by the commissioner of revenue within the past two years. 8. I have never, after demand, failezi to file tax retums required by the commissioner of revenue. in addition, i understand, agree and hereby irr�yoc2bly consent thet suits and actions relating to the subject matter of the attached gatnbling enanager ticense application, or acts or omissions arising from such appfica- tion, may be commenced against my organization and 1 wiil accept Yhe service of process for my or�aniza- tion in any couri of competent jurisdictian in Minnesota by service on the Minnesota Secretary of State of any summons, process or pleading autharized by the lavrs of Minnesota. Sy signature of this document, the undersigned authorizes the pepactment of Public Safety to conduct a criminal background check or review and to share the resuits with the Gamb4ing Controi Boasd. Failure to provide required information or providing faise or misleading information may result in the denia( or revocation of the license. FURTHER AFFlANT SAYETH NOT, except that this A�davit and Consent Statement are submitted in support of the appiication for a gambiing manager license from the Gambling Control Boaid. NOTARY PUBLIC lNFORMATlON Notary Public Seal must be current and correct. S may not be aitered. Subscribed and swom to 6efore me this o S day of O 4� �, h z � 19 �iS C/ `,"� — � � Notary Public ` µ�y�,r�rnvu � EfLEEN G: SCNWARZ p{q7pAy pUgtSC - MINYESOTA � A4 C.Oinir. E�..Jen. �9 � 2000 c �.,_,�.� � —2 (o( 5�4 (signature of appiicant) ORGANlZATIOIV INFORMATlON of Orgarrization License �� Council File # l�"= � S Ordinance # Green Sheet# 35416 CITY Presented By Referred To Committee: Date s 6 7 8 9 1� 11 12 13 1 2 3 4 RESOLVED: That application, ID #77002, for a new 6ambling Manager's License by Richatd M. Henricks DBA Camden Neighborhood Gym at B B Dixon's Tavern fi Grill, 1834 St. Clair Avenue, be and the same is hereby approved. v�o�� N� ��,� ar heer+ � Requested by Department of: • - -r.- e-•� •+_ ,+• � .��-� - •� Adopted by Council: Date Adoption Certified by Council Secretary t'� $Y —R��-�� t� �M-.�O/LJ3�-��-� c- Approved by Mayore Date By: /"�l�i-2t�(.v-C'�JS RESOLUTION 41NT PAUL, MINNESOTA By: ��*/�t.Ut�ir �J�� Form Approved by City Attorney BY� ' � Approved by Mayor for Submiasian to Council By' `{ DEPARTMENTlOFPICFJCOUNCIL DATEINITtATED �REEN SHEE �O 33416 LIEP -- -- CONTACf PEASON & PHONE INRIAVOATE INRIAV�ATE � DEPAHTMENTDIRECTOR O CT'COUNCIL ASSM+X CRVATTORNEY CflYCLERK William F. Gunther - 266-9132 NUYBERiOR 0 MUST BE ON dJUNCIL AGENDA BY (DATE) pp�nN� O BUDGET DIRECIOR O FIPI. & MGL SERV(CES DIR. Hearin : / �a- �J OROER OMAYOH(ORASSISTANT� � TOTAL # OF SIGNATURE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE) AC710N RE�UESiED: Richaxd M. Henxicks DBA Camden Neighborhood Gym requests Council approval of his application for a new Gambling Manager's License at B B Dixon's, 1834 St. Clair Avenue. (ID I677002) RECOMMENDATIONS: Approve (A) or Reject (R) pEHSONAL SERVICE CONTHACTS MUST ANSWEq TNE POLLOWING �UESTIONS: _ PLANNMG CqMMIS510N _ CNIL SERVICE COMMISSION t Has Nis persoMirm ever worked untle� a coMract for Mis departmeM? - _ CIB COMMITTEE YES NO — �� F 2. Has this personlfirm ever been a city empbyee? — YES NO _ DISTRtC7 COUR7 _ 3. Does this person/firm possess a skill not normally possessed by any curteM city employee? SUPPOfiTS WNICH COUNCIL O&IECTIVE? YES NO Explain sll yes a�swers on separete sheet and ettaeh to green sheot INITIATING PROBLEM, ISSUE, OPPORTUNITY (Wtp, Whet, Whan, WHere, Why): �� fl�C 05 1996 C��°Y' ATT�RN�� ADVANTAGESIFAPPROVED: , DISADVANTAGESIFAPPROVED: ��_` �� d � �� . ��J� DISADVANTAGES IF NOT APPROVED: TOTAL AMOUNT OF TRANSACTION $ CAST7REYENUE BUDGETED (CIRCLE ONE) YES NO FUNDIHG SOURCE NCTIVITY NUMBER FINqNCIAL INFORMATION. (EXPLAIN) Greensneet # 35416 L.I.E.P. REVIEW CHECKLIST oate: /��—`� 5 In Tracker? a� /0 9 App'n Received ( App n Processed LicenselD# 77002 LicenseType: Gamb�; Mana�r Company Name: Richard M Henricks �B/�: Camden NPjghhnrhnnd C,�m, BusinessAddresss: 1834 St Clair Ave lBB D�xon'al BusinessPhone: s�q-��t�q Contact Name/Address: 7762 Yo.-k Lane Home Phone: s�o_ti7�q Date to Councif Research: Brooklyn Park, MN 55443 Public Hearing Date: c .�.� �2� f�i� Labels Ordered: N/A Notice Sent to Applicant: District Council #: 14 Notice Sent to Pubtic: NJA Ward #: 03 Department/ Date Inspections Comments City Attorney f C? �l�� &TU�`� � �� L�;� o,� �� l� Environmental Heaith NfR Fire �f � License Site Plan Heceived: � Lease Reeeived: JV � � Poiice ��0� l�1LP�� /'7 yT�-�-1��-C3 � � �/��9.(� Zoning �1� .� ��-�S Central STATE pF HINNESOTA FOR BOARD USE OHLY fi'AMBZ.TX6 CONTROL BORRD AMT. PAID GAMBLING MANAGER LZCENSE REXEWAL AppLICATION CAECIC # LG212GHR PRINTED: 09/40/95 DATE LSCENSE NUHBER: (i-03067 002 EFFECTIVE DATE: O1/O1J95 EXPIRATION DATE: 1Z/31/95 NAME OF ORGANZZATION: Neighborhood Minaeapolis Oy� Camden CiAMBLSDi6 lSANA6ER I2LA'ORMATIOH Richard Marvin Hearicks '�� s-�� -- -'� `rork �s�G : "' �tvoklyn Park� tVltv 55�I�}3 DATE OF BIRTH: O1/1T/40 SEX: N SOCZAL SECt3RITY NUMBER: 470-38-2962 DAYTIME PHONE NUMBER: �'^ ^^° ^"^° MEMBER SZNCE: 09/15/88 1i - YY LAS2 DATE YOU ATTENDED A GAMBLING MANAGERS SEMINAR/CONTINUING EDUCATZON CLASS: -B{f$9i-03 BOND ZNFORMATION BOND COMPANY NAME: 67estern Surety BOND NUMBER: 58451510 ACRNOWLEDGMENT Z DECS,RRE THATt' . � � . .. . . � . '_I fI�Vfi READ THIS F�pPLICATION AND ALL INFORMATZON SUBMITTED TO THE GAMBLING @ONTROL BOARD;: • ALL INFORMATION IS TRUE, ACCURATE AND COMPLETE; , _ °�I.L OTHER REQUIRED INFQRMATZON HAS BEEN FULLY DSSCLO5EDy �� • I AM THE ONLY GAMBLING HANAGER OF THE ORGANIZATION; • I HAVfi BfiEN AN ACTIVE MEMBER OF THE ORGANIZATION FOR AT LEAST TWO YEARS� ° I WILL FAMTLIARZZB MYSELF WITH THE LAWS OF MINNESOTA GOVfiRNZNG LAWFUL GAHBLING AND RULES OF THE GAMBLING CONTROL BOARD ANO AGREE, ZF LZCENSED, TO ABIDE THOSE LAWS AND RULES, INCLUDING AMENDMENTS TO TAEM; ° ANY CHANGES IN APPLICATION ZNFORMATION WILL BE SUBHITTED TO THE GAMBLING CONTROL BOARD AND LOCAL UNIT OF GOVERNMENT WITHIN 10 DAYS OF THE CHANGE; • AN AEFIDAVIT FOR GAMBLZNG MANAGER HAS BEEN COMPLETED AND ATTACHED; A13D � I UNDERSTAND THAT FAILURE TO PROVIDE REQUIRED INFORMATION OR PROVIDING FALSE OR MISLEADSNG ZNFORMRTION MAY RESULT IN THE DENIAL OR REVOCATION OF THE LICENSE. S7.(3N�TURE OF 6A!ffiLINGF W1NA6ER DpTg � �� n , , � REFER TO THE CHECKLI5T�FOR REQUIRED ATTACffi4ENT8 MAIL TOS 6AMBLZN6 CONTROL BOARD 1711 WEST COtJH17 ROAD B, SUZTE 3008 ROSEVILLE, HI2IltESOTA 55113 �s THIS FORM WILL BE MADE AVAILABLE YN ALTERNATIVE FORMAT (I.E. LARGE PRINT� BRAILLE) UPO,N REQUES2. �. . � � � 7��' . LG21� '- . 04/18J95 Minnesota Gambling Control Board `��I, -`l 5 AFFIDAVIT OF QUALIFICATION FOR GAMBLING MANAGER LICENSE ) s.s_ AND CONSENT STATEMENT COUNTY OF �,� �, � s ) (Pursuant to Minnesota Statutes and Rules) Gambling Manager Affidavit Attach to the Gambling Manager Appiication, Fortn LG212 STATE OF M Y� ) ' �,�`i �-�t 1 �- � n.� r �'t � NVt�� th state that: (type/print name) 1. i have never been convicted of a felony or a c�me involving gambiing. 2. I have not, within five years before the date of the license application, committed a violation of law or Board ruie that �esufied in ihe revocation of a ticense issued by the Board. 3. 1 have never been convicted of a criminaf violation involving fraud, theft, tax evasion, misrepresentation, or gambling. 4. 1 have never been convicted o( (i) assault, (ii) a criminal viofation invoiving the use of a fireartn, or (iii) making terroristic threats. 5. I am not, nor ever have been connected with or enqaged in an illegai business. 6. I do not owe $Stl0 or more in delinquent taxes as defined in section 270.72. 7. t have not had a sales and use tax permit revoked by the commissioner of revenue within the past two years. 8. I have never, after demand, failezi to file tax retums required by the commissioner of revenue. in addition, i understand, agree and hereby irr�yoc2bly consent thet suits and actions relating to the subject matter of the attached gatnbling enanager ticense application, or acts or omissions arising from such appfica- tion, may be commenced against my organization and 1 wiil accept Yhe service of process for my or�aniza- tion in any couri of competent jurisdictian in Minnesota by service on the Minnesota Secretary of State of any summons, process or pleading autharized by the lavrs of Minnesota. Sy signature of this document, the undersigned authorizes the pepactment of Public Safety to conduct a criminal background check or review and to share the resuits with the Gamb4ing Controi Boasd. Failure to provide required information or providing faise or misleading information may result in the denia( or revocation of the license. FURTHER AFFlANT SAYETH NOT, except that this A�davit and Consent Statement are submitted in support of the appiication for a gambiing manager license from the Gambling Control Boaid. NOTARY PUBLIC lNFORMATlON Notary Public Seal must be current and correct. S may not be aitered. Subscribed and swom to 6efore me this o S day of O 4� �, h z � 19 �iS C/ `,"� — � � Notary Public ` µ�y�,r�rnvu � EfLEEN G: SCNWARZ p{q7pAy pUgtSC - MINYESOTA � A4 C.Oinir. E�..Jen. �9 � 2000 c �.,_,�.� � —2 (o( 5�4 (signature of appiicant) ORGANlZATIOIV INFORMATlON of Orgarrization License �� Council File # l�"= � S Ordinance # Green Sheet# 35416 CITY Presented By Referred To Committee: Date s 6 7 8 9 1� 11 12 13 1 2 3 4 RESOLVED: That application, ID #77002, for a new 6ambling Manager's License by Richatd M. Henricks DBA Camden Neighborhood Gym at B B Dixon's Tavern fi Grill, 1834 St. Clair Avenue, be and the same is hereby approved. v�o�� N� ��,� ar heer+ � Requested by Department of: • - -r.- e-•� •+_ ,+• � .��-� - •� Adopted by Council: Date Adoption Certified by Council Secretary t'� $Y —R��-�� t� �M-.�O/LJ3�-��-� c- Approved by Mayore Date By: /"�l�i-2t�(.v-C'�JS RESOLUTION 41NT PAUL, MINNESOTA By: ��*/�t.Ut�ir �J�� Form Approved by City Attorney BY� ' � Approved by Mayor for Submiasian to Council By' `{ DEPARTMENTlOFPICFJCOUNCIL DATEINITtATED �REEN SHEE �O 33416 LIEP -- -- CONTACf PEASON & PHONE INRIAVOATE INRIAV�ATE � DEPAHTMENTDIRECTOR O CT'COUNCIL ASSM+X CRVATTORNEY CflYCLERK William F. Gunther - 266-9132 NUYBERiOR 0 MUST BE ON dJUNCIL AGENDA BY (DATE) pp�nN� O BUDGET DIRECIOR O FIPI. & MGL SERV(CES DIR. Hearin : / �a- �J OROER OMAYOH(ORASSISTANT� � TOTAL # OF SIGNATURE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE) AC710N RE�UESiED: Richaxd M. Henxicks DBA Camden Neighborhood Gym requests Council approval of his application for a new Gambling Manager's License at B B Dixon's, 1834 St. Clair Avenue. (ID I677002) RECOMMENDATIONS: Approve (A) or Reject (R) pEHSONAL SERVICE CONTHACTS MUST ANSWEq TNE POLLOWING �UESTIONS: _ PLANNMG CqMMIS510N _ CNIL SERVICE COMMISSION t Has Nis persoMirm ever worked untle� a coMract for Mis departmeM? - _ CIB COMMITTEE YES NO — �� F 2. Has this personlfirm ever been a city empbyee? — YES NO _ DISTRtC7 COUR7 _ 3. Does this person/firm possess a skill not normally possessed by any curteM city employee? SUPPOfiTS WNICH COUNCIL O&IECTIVE? YES NO Explain sll yes a�swers on separete sheet and ettaeh to green sheot INITIATING PROBLEM, ISSUE, OPPORTUNITY (Wtp, Whet, Whan, WHere, Why): �� fl�C 05 1996 C��°Y' ATT�RN�� ADVANTAGESIFAPPROVED: , DISADVANTAGESIFAPPROVED: ��_` �� d � �� . ��J� DISADVANTAGES IF NOT APPROVED: TOTAL AMOUNT OF TRANSACTION $ CAST7REYENUE BUDGETED (CIRCLE ONE) YES NO FUNDIHG SOURCE NCTIVITY NUMBER FINqNCIAL INFORMATION. (EXPLAIN) Greensneet # 35416 L.I.E.P. REVIEW CHECKLIST oate: /��—`� 5 In Tracker? a� /0 9 App'n Received ( App n Processed LicenselD# 77002 LicenseType: Gamb�; Mana�r Company Name: Richard M Henricks �B/�: Camden NPjghhnrhnnd C,�m, BusinessAddresss: 1834 St Clair Ave lBB D�xon'al BusinessPhone: s�q-��t�q Contact Name/Address: 7762 Yo.-k Lane Home Phone: s�o_ti7�q Date to Councif Research: Brooklyn Park, MN 55443 Public Hearing Date: c .�.� �2� f�i� Labels Ordered: N/A Notice Sent to Applicant: District Council #: 14 Notice Sent to Pubtic: NJA Ward #: 03 Department/ Date Inspections Comments City Attorney f C? �l�� &TU�`� � �� L�;� o,� �� l� Environmental Heaith NfR Fire �f � License Site Plan Heceived: � Lease Reeeived: JV � � Poiice ��0� l�1LP�� /'7 yT�-�-1��-C3 � � �/��9.(� Zoning �1� .� ��-�S Central STATE pF HINNESOTA FOR BOARD USE OHLY fi'AMBZ.TX6 CONTROL BORRD AMT. PAID GAMBLING MANAGER LZCENSE REXEWAL AppLICATION CAECIC # LG212GHR PRINTED: 09/40/95 DATE LSCENSE NUHBER: (i-03067 002 EFFECTIVE DATE: O1/O1J95 EXPIRATION DATE: 1Z/31/95 NAME OF ORGANZZATION: Neighborhood Minaeapolis Oy� Camden CiAMBLSDi6 lSANA6ER I2LA'ORMATIOH Richard Marvin Hearicks '�� s-�� -- -'� `rork �s�G : "' �tvoklyn Park� tVltv 55�I�}3 DATE OF BIRTH: O1/1T/40 SEX: N SOCZAL SECt3RITY NUMBER: 470-38-2962 DAYTIME PHONE NUMBER: �'^ ^^° ^"^° MEMBER SZNCE: 09/15/88 1i - YY LAS2 DATE YOU ATTENDED A GAMBLING MANAGERS SEMINAR/CONTINUING EDUCATZON CLASS: -B{f$9i-03 BOND ZNFORMATION BOND COMPANY NAME: 67estern Surety BOND NUMBER: 58451510 ACRNOWLEDGMENT Z DECS,RRE THATt' . � � . .. . . � . '_I fI�Vfi READ THIS F�pPLICATION AND ALL INFORMATZON SUBMITTED TO THE GAMBLING @ONTROL BOARD;: • ALL INFORMATION IS TRUE, ACCURATE AND COMPLETE; , _ °�I.L OTHER REQUIRED INFQRMATZON HAS BEEN FULLY DSSCLO5EDy �� • I AM THE ONLY GAMBLING HANAGER OF THE ORGANIZATION; • I HAVfi BfiEN AN ACTIVE MEMBER OF THE ORGANIZATION FOR AT LEAST TWO YEARS� ° I WILL FAMTLIARZZB MYSELF WITH THE LAWS OF MINNESOTA GOVfiRNZNG LAWFUL GAHBLING AND RULES OF THE GAMBLING CONTROL BOARD ANO AGREE, ZF LZCENSED, TO ABIDE THOSE LAWS AND RULES, INCLUDING AMENDMENTS TO TAEM; ° ANY CHANGES IN APPLICATION ZNFORMATION WILL BE SUBHITTED TO THE GAMBLING CONTROL BOARD AND LOCAL UNIT OF GOVERNMENT WITHIN 10 DAYS OF THE CHANGE; • AN AEFIDAVIT FOR GAMBLZNG MANAGER HAS BEEN COMPLETED AND ATTACHED; A13D � I UNDERSTAND THAT FAILURE TO PROVIDE REQUIRED INFORMATION OR PROVIDING FALSE OR MISLEADSNG ZNFORMRTION MAY RESULT IN THE DENIAL OR REVOCATION OF THE LICENSE. S7.(3N�TURE OF 6A!ffiLINGF W1NA6ER DpTg � �� n , , � REFER TO THE CHECKLI5T�FOR REQUIRED ATTACffi4ENT8 MAIL TOS 6AMBLZN6 CONTROL BOARD 1711 WEST COtJH17 ROAD B, SUZTE 3008 ROSEVILLE, HI2IltESOTA 55113 �s THIS FORM WILL BE MADE AVAILABLE YN ALTERNATIVE FORMAT (I.E. LARGE PRINT� BRAILLE) UPO,N REQUES2. �. . � � � 7��' . LG21� '- . 04/18J95 Minnesota Gambling Control Board `��I, -`l 5 AFFIDAVIT OF QUALIFICATION FOR GAMBLING MANAGER LICENSE ) s.s_ AND CONSENT STATEMENT COUNTY OF �,� �, � s ) (Pursuant to Minnesota Statutes and Rules) Gambling Manager Affidavit Attach to the Gambling Manager Appiication, Fortn LG212 STATE OF M Y� ) ' �,�`i �-�t 1 �- � n.� r �'t � NVt�� th state that: (type/print name) 1. i have never been convicted of a felony or a c�me involving gambiing. 2. I have not, within five years before the date of the license application, committed a violation of law or Board ruie that �esufied in ihe revocation of a ticense issued by the Board. 3. 1 have never been convicted of a criminaf violation involving fraud, theft, tax evasion, misrepresentation, or gambling. 4. 1 have never been convicted o( (i) assault, (ii) a criminal viofation invoiving the use of a fireartn, or (iii) making terroristic threats. 5. I am not, nor ever have been connected with or enqaged in an illegai business. 6. I do not owe $Stl0 or more in delinquent taxes as defined in section 270.72. 7. t have not had a sales and use tax permit revoked by the commissioner of revenue within the past two years. 8. I have never, after demand, failezi to file tax retums required by the commissioner of revenue. in addition, i understand, agree and hereby irr�yoc2bly consent thet suits and actions relating to the subject matter of the attached gatnbling enanager ticense application, or acts or omissions arising from such appfica- tion, may be commenced against my organization and 1 wiil accept Yhe service of process for my or�aniza- tion in any couri of competent jurisdictian in Minnesota by service on the Minnesota Secretary of State of any summons, process or pleading autharized by the lavrs of Minnesota. Sy signature of this document, the undersigned authorizes the pepactment of Public Safety to conduct a criminal background check or review and to share the resuits with the Gamb4ing Controi Boasd. Failure to provide required information or providing faise or misleading information may result in the denia( or revocation of the license. FURTHER AFFlANT SAYETH NOT, except that this A�davit and Consent Statement are submitted in support of the appiication for a gambiing manager license from the Gambling Control Boaid. NOTARY PUBLIC lNFORMATlON Notary Public Seal must be current and correct. S may not be aitered. Subscribed and swom to 6efore me this o S day of O 4� �, h z � 19 �iS C/ `,"� — � � Notary Public ` µ�y�,r�rnvu � EfLEEN G: SCNWARZ p{q7pAy pUgtSC - MINYESOTA � A4 C.Oinir. E�..Jen. �9 � 2000 c �.,_,�.� � —2 (o( 5�4 (signature of appiicant) ORGANlZATIOIV INFORMATlON of Orgarrization License ��