97-790Council File # � � ��
Ordinance #
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�' y—t j�. E�; i; 1
t f ; � ;
`�.,a i 4 t`�.�r 4 t S ; ,_
Presented By
Referred To
Green Sheet # 35348
RESOLUTION
OF SAfNT PAUL, MINNESOTA
�
Committeee Date
RESOLVED: That application, ID 544121, for a new Gambling Manager's License by Sheri J.
2igan DBA I3eighboxhood Aouse Association at Reenan's 620 Club, 620 W. 7th
Street, be and the same is hereby approved.
Requested by Department of:
• -- •-: - . .- • -
�af••.. •�_n-� , - .�
_:.:�. ���� w �'
Adopted by Council: Date � Q�
Adoption Certified by council secretary
By:
Form Approved by City Attor
sy: 1� �c�.-..L�
Approved by yor for Submission to
Council
Approved by Mayor: Date � ��� �-
By: � G� i '7`__
9� -�9D
OE DATE INR7ATED GREEN SHEE N � � J� 4 H
CAtlTACTPEFiSON&PHONE �DEPARIMENTDIFECTOR OCITYCAUNCIL �NR�aUDATE
William F. Gunther - 266-9132 A���x �CRYATTORNEV OCRYCLERK
MUST BE ON COUNCILAGENDA BY (DATE) pU �FOR � BUOGEf DIPECCOq O FIN. fi MGT. SERVICES 010.
HEdTYIIg: OROER �MpyOR(ORASSISTANn �
TOTAL # OF SIGNATORE PAGES (CLIP ALL LOCATIONS FOR SIGNATUR�
ACf10N qEQUESTED:
Sheri S. Zigan DBA Neighborhood House Association requests Council approval of
her application for a new Gambling Manager's License at Reenan`s 620 Club, 620 W. 7th Street
(ID �44121)
RECOMMENDATIONS: Approva (A) or Rejecl (F) pERSONAL SEHVICE CONTHACTS MUST ANSWER TXE FOLLOWING �UESTIONS:
_ PLANNING CAMMISSION _ CIVIL SERVICE CAMMISSION �� H25 tF115 pefSOMlfin eVBf WOrked undef a CAntfaGt fof Mi5 dBPartrtleM? �
_ CIB COMMITTEE _ YES NO
— STAFF 2. Has this person/firm ever been a city employee?
— VES NO
_ DISTNICi CAUR7 _ 3. Does this person/firm pOSSess a sltill not normally possessed by any curtent city employee?
SUPPORTS WHICl1 CAUNCII O&IECTIVE? YES NO
Explaln all yes answere on seperate shee[ antl attaeh to graen sheet
INITIATING PROBLEM, ISSUE, OPPoRTUNITV (Who. Whaq When, Where, Why): �-w �... ��
��` ���. .�.��,��!
. Fs4��..�fi:k `% I:a°
��� �� 2��3�
���� ���' ��
r�� � °�
ADVANTAGES IFAPPROVED:
DISADVAMAGESIFAPPROVED: '
�1+,� �€t�i
��� � � ���
DISADVANTAGES IF NOT APPROVED: �
e
TOTAL AMOUNT OF TRANSACTION $ COST/FiEVENUE BUDGE7ED (CIRCLE ONE) YES NO
FUNDING SOURCE ACTIVITV NUMBER
FINANCIAI iNFORMATION. (EXPLIIN)
Greensheet #
tn Trackef? [ a
License ID # 44121
L.I.E.P. REVIEW CHECKLIST �ate: / q� '�9�
APP'n Recerved ( APP'n Processed
Ucense Type: Gambline Manager
Company Name: Sheri J. ZiQan DBA: Neighhnrhnod Arnica Accnri�tipyy
Business Addresss: 620 W. 7th St. (Keenan's 620 Club) Business Phone: 227-9291
Contact Name/Address: 179 E. Robie St. 55107 Home Phone: 227-9291
Date to Council
Public Hearing
Notice Sent to
Labeis Ordered: NiA
District Council #: 09
Notice Sent to Public: N/A Ward #: 09
Departmentj Date Inspections Comments
City Attorney /0 �: T�J 7T�/��'n� b l� /q`J
t /f��q7 �
Environmental
Health
� ��
Fire
/Nf ��
License Site Plan Received:_
Lease Received:
� ��
Police �� ��'c���i ���'��
� �� ���m�'c��
Zoning
/���
�C�-�qo
East STATE OF MINNESOTA FOR BOARD USE ONLY
. GAHBLING CONTROL BOARD AMT. PAZD ^
GAMBLING MANAGER LICENSE RENEWAL AppLICATION CHECK #
LG212GMR PRINTED: O1/02/46 �, DATE
:.ICENSE NUMBER: (3-02537 003 EFFECTIVE DATE: OS/O1/95 EXPIRATION DATS: 06/30/96
:+A2{& OF ORGANIZATZON: Neighborhood St Paul House Assoc
GAMBLING MANAGER INFORMATZON
Shori Jean Zigan
1638 Evans
South St Paul 147 55075
DATE OF SIRTH: 10�14/59
SEX: F
SOCIAL SECURITY NUMBER: 476-84-4511
DAYTIME PHONE NUMBER: 612-4�.X��'�.�.'22]-j291
N�'MBER SINCE: 1OJ21/85
�ST ➢ATE YOU ATTENDED A GAMBLING MANAGERS SEMINAR/CONTINUING EDUCATION CLASS: 03/14/95
SOND INFORMATZON
BOND COMPANY NAME: Allied Group Insuran BOND NUMBER: BD7900552001
ACRNOWLEDGMENT
Z DECLARE THAT:
' Z HAVE READ THIS APPLICATION AND ALL INFORMATION SUBMITTED TO THE GAMBLING CONTROL BOARD�
• ALL INFORMATION SS TRUE� ACCURATE AND COMPLETE;
• ALL OTHER REQUIRED INFORMATION HAS BEEN FULLY DISCLOSED;
• I AM THE ONLY GAMBLZNG MANAGER OF THE ORGANIZATION;
• I HAVE BEEN AN ACTIVE MEMBER OF THE ORGANIZATION FOR AT LEAST TWO YEARS;
• I WILL FAMILIARIZE MYSELF WI�TH TAE LAWS OF�MINNESOTA GOVERNING LAWFUL GAMBLING AND RULES OF
THE GAMBLZNG CONTR�L BOARD AND AGREE� IF LICENSED� TO ABIDE THOSE LAWS AND RULES� .
INCLUDING AMENDMENTS TO THEM� �
• ANY CfiANGES IN APPLICATION INFOf2MATZON WILL BE SUBMITTED TO THE GAMBLING CONTROL BOARD AND
LOCAL UNIT OF GOVERNMENT WITHIN 10 DAYS OF THE CFIANGE;
• AN AFFIDAVIT FOR GAMBLING MANAGER HAS BEEN COMPLETED AND ATTACAED; AND
• I IINDERSTAND THAT FAILURE TO PROVIDE REQUIRED INFORMFiTION OR PROVZDZNG FALSE OR MZSLEADING
INFORMATION MAY RESULT IN THE DENIAL OR REVOCATION OF THE LZCENSE. . -
GAMBI�IN(i
DATE
�`/9-9
REFER TO THE CHECP.I,IST FOR REQUIRED ATTACHb�NTS
MAIL TO: GAMBLING CONTROL BOARD
1711 WEST COUNTY ROAD B� SUITE 3005
ROSEVILLE� MZNNESOTA 55113
THIS FORM WZLL SE MI�DE AVAILABLE IN ALTERNATIVE FORMAT�(I.E. LARGE PRZNT� HRAZLLE) UPON REQUEST.
�S77o �l/��-6/�/�� �s�/�./
LG213 Minnesofa Gambling Control Board �
oa�, a�ss Gambling Manager Affidavit ��"��
Attach to 2he GamblSng Manager Application, Form LG212
STATE OF MINNESOTA )
AFFlDf�VIT OF QUALIFICATION
) s.s. FOR GA1u1BL1NG MANAGER LICENSE
COUNTY OF Ramsey � AND CONSENT STATEMEM
(Pursuant fo Minnesofa Statvtes and Ruies)
1, Sheri Ziqan ,Underoathstatethat:
(type/print name)
1. i have never been convicied of a felony or a crime invoiving gambiing.
2. i have not, within five years before the date of the license application, committed a violation of law or
Board rufe that resufted in the revocation ofi a license issued by fhe Board.
3. I have never been convided of a criminai violation involving fraud, theft, tax evasion, misrepresentation,
or gambling.
4. i have never been convicied af n assauft, () a criminai violation involving the use of a firearm, or (i)
making terroristic fhreats.
5. i am not, nor ever have been connected with or engaged in an iilegai business.
6. I do not owe $500 ormore in delinquent taxes as defined in sedion 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 haye never, after demand, failed to file tax retums required by the commissioner of revenue.
in addition, 1 understar,d, agree and hereby irrevocably consent that suits and actions relating to the subjed
matter of the attached gambling manager license application, or acts or omissions arising from such applica-
tion, may be commenced against my organization 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 pieading authorized by the laws of Minnesota.
By signature of this document, the undersigned authorizes the Department of Public Safety to conducf a
criminal background check or review and to share the resutts with the Gambling Control Boarzi.
Failure to provide required information or providing false or misteading information may resuft in the deniai or
revocation of fhe license. .
FURTHER AFFIANT SAYETH NOT, except that this A�davit and Consent Statement are submitted in
support of the application for a gambling manager license from the trol Board.
r-_
NOTARY PUBLIC INFORMA770N �
Notary Pubiic Seai must be current and corred.
Seal may not be aftered. - ... . (signature f cant)
Subscribed and swom to before me this
�D day of =�i��cc'��_ is / �o
ORGANIZA770N INFORMATION
�- " ��1 Name of Orpanization
�bliry�,i,N„�,nM� NEIGhIBORH00D HOUSE ASSOCIATIOi�
REBEbCA J_ CURTIS
X07ARY PUBLIC-NiNHE50TA
wasrt�ncrorv counn
MyCOmm.EsplresJan.31,2000 Base License Number
Council File # � � ��
Ordinance #
1
2
3
4
5
6
7
S
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
�' y—t j�. E�; i; 1
t f ; � ;
`�.,a i 4 t`�.�r 4 t S ; ,_
Presented By
Referred To
Green Sheet # 35348
RESOLUTION
OF SAfNT PAUL, MINNESOTA
�
Committeee Date
RESOLVED: That application, ID 544121, for a new Gambling Manager's License by Sheri J.
2igan DBA I3eighboxhood Aouse Association at Reenan's 620 Club, 620 W. 7th
Street, be and the same is hereby approved.
Requested by Department of:
• -- •-: - . .- • -
�af••.. •�_n-� , - .�
_:.:�. ���� w �'
Adopted by Council: Date � Q�
Adoption Certified by council secretary
By:
Form Approved by City Attor
sy: 1� �c�.-..L�
Approved by yor for Submission to
Council
Approved by Mayor: Date � ��� �-
By: � G� i '7`__
9� -�9D
OE DATE INR7ATED GREEN SHEE N � � J� 4 H
CAtlTACTPEFiSON&PHONE �DEPARIMENTDIFECTOR OCITYCAUNCIL �NR�aUDATE
William F. Gunther - 266-9132 A���x �CRYATTORNEV OCRYCLERK
MUST BE ON COUNCILAGENDA BY (DATE) pU �FOR � BUOGEf DIPECCOq O FIN. fi MGT. SERVICES 010.
HEdTYIIg: OROER �MpyOR(ORASSISTANn �
TOTAL # OF SIGNATORE PAGES (CLIP ALL LOCATIONS FOR SIGNATUR�
ACf10N qEQUESTED:
Sheri S. Zigan DBA Neighborhood House Association requests Council approval of
her application for a new Gambling Manager's License at Reenan`s 620 Club, 620 W. 7th Street
(ID �44121)
RECOMMENDATIONS: Approva (A) or Rejecl (F) pERSONAL SEHVICE CONTHACTS MUST ANSWER TXE FOLLOWING �UESTIONS:
_ PLANNING CAMMISSION _ CIVIL SERVICE CAMMISSION �� H25 tF115 pefSOMlfin eVBf WOrked undef a CAntfaGt fof Mi5 dBPartrtleM? �
_ CIB COMMITTEE _ YES NO
— STAFF 2. Has this person/firm ever been a city employee?
— VES NO
_ DISTNICi CAUR7 _ 3. Does this person/firm pOSSess a sltill not normally possessed by any curtent city employee?
SUPPORTS WHICl1 CAUNCII O&IECTIVE? YES NO
Explaln all yes answere on seperate shee[ antl attaeh to graen sheet
INITIATING PROBLEM, ISSUE, OPPoRTUNITV (Who. Whaq When, Where, Why): �-w �... ��
��` ���. .�.��,��!
. Fs4��..�fi:k `% I:a°
��� �� 2��3�
���� ���' ��
r�� � °�
ADVANTAGES IFAPPROVED:
DISADVAMAGESIFAPPROVED: '
�1+,� �€t�i
��� � � ���
DISADVANTAGES IF NOT APPROVED: �
e
TOTAL AMOUNT OF TRANSACTION $ COST/FiEVENUE BUDGE7ED (CIRCLE ONE) YES NO
FUNDING SOURCE ACTIVITV NUMBER
FINANCIAI iNFORMATION. (EXPLIIN)
Greensheet #
tn Trackef? [ a
License ID # 44121
L.I.E.P. REVIEW CHECKLIST �ate: / q� '�9�
APP'n Recerved ( APP'n Processed
Ucense Type: Gambline Manager
Company Name: Sheri J. ZiQan DBA: Neighhnrhnod Arnica Accnri�tipyy
Business Addresss: 620 W. 7th St. (Keenan's 620 Club) Business Phone: 227-9291
Contact Name/Address: 179 E. Robie St. 55107 Home Phone: 227-9291
Date to Council
Public Hearing
Notice Sent to
Labeis Ordered: NiA
District Council #: 09
Notice Sent to Public: N/A Ward #: 09
Departmentj Date Inspections Comments
City Attorney /0 �: T�J 7T�/��'n� b l� /q`J
t /f��q7 �
Environmental
Health
� ��
Fire
/Nf ��
License Site Plan Received:_
Lease Received:
� ��
Police �� ��'c���i ���'��
� �� ���m�'c��
Zoning
/���
�C�-�qo
East STATE OF MINNESOTA FOR BOARD USE ONLY
. GAHBLING CONTROL BOARD AMT. PAZD ^
GAMBLING MANAGER LICENSE RENEWAL AppLICATION CHECK #
LG212GMR PRINTED: O1/02/46 �, DATE
:.ICENSE NUMBER: (3-02537 003 EFFECTIVE DATE: OS/O1/95 EXPIRATION DATS: 06/30/96
:+A2{& OF ORGANIZATZON: Neighborhood St Paul House Assoc
GAMBLING MANAGER INFORMATZON
Shori Jean Zigan
1638 Evans
South St Paul 147 55075
DATE OF SIRTH: 10�14/59
SEX: F
SOCIAL SECURITY NUMBER: 476-84-4511
DAYTIME PHONE NUMBER: 612-4�.X��'�.�.'22]-j291
N�'MBER SINCE: 1OJ21/85
�ST ➢ATE YOU ATTENDED A GAMBLING MANAGERS SEMINAR/CONTINUING EDUCATION CLASS: 03/14/95
SOND INFORMATZON
BOND COMPANY NAME: Allied Group Insuran BOND NUMBER: BD7900552001
ACRNOWLEDGMENT
Z DECLARE THAT:
' Z HAVE READ THIS APPLICATION AND ALL INFORMATION SUBMITTED TO THE GAMBLING CONTROL BOARD�
• ALL INFORMATION SS TRUE� ACCURATE AND COMPLETE;
• ALL OTHER REQUIRED INFORMATION HAS BEEN FULLY DISCLOSED;
• I AM THE ONLY GAMBLZNG MANAGER OF THE ORGANIZATION;
• I HAVE BEEN AN ACTIVE MEMBER OF THE ORGANIZATION FOR AT LEAST TWO YEARS;
• I WILL FAMILIARIZE MYSELF WI�TH TAE LAWS OF�MINNESOTA GOVERNING LAWFUL GAMBLING AND RULES OF
THE GAMBLZNG CONTR�L BOARD AND AGREE� IF LICENSED� TO ABIDE THOSE LAWS AND RULES� .
INCLUDING AMENDMENTS TO THEM� �
• ANY CfiANGES IN APPLICATION INFOf2MATZON WILL BE SUBMITTED TO THE GAMBLING CONTROL BOARD AND
LOCAL UNIT OF GOVERNMENT WITHIN 10 DAYS OF THE CFIANGE;
• AN AFFIDAVIT FOR GAMBLING MANAGER HAS BEEN COMPLETED AND ATTACAED; AND
• I IINDERSTAND THAT FAILURE TO PROVIDE REQUIRED INFORMFiTION OR PROVZDZNG FALSE OR MZSLEADING
INFORMATION MAY RESULT IN THE DENIAL OR REVOCATION OF THE LZCENSE. . -
GAMBI�IN(i
DATE
�`/9-9
REFER TO THE CHECP.I,IST FOR REQUIRED ATTACHb�NTS
MAIL TO: GAMBLING CONTROL BOARD
1711 WEST COUNTY ROAD B� SUITE 3005
ROSEVILLE� MZNNESOTA 55113
THIS FORM WZLL SE MI�DE AVAILABLE IN ALTERNATIVE FORMAT�(I.E. LARGE PRZNT� HRAZLLE) UPON REQUEST.
�S77o �l/��-6/�/�� �s�/�./
LG213 Minnesofa Gambling Control Board �
oa�, a�ss Gambling Manager Affidavit ��"��
Attach to 2he GamblSng Manager Application, Form LG212
STATE OF MINNESOTA )
AFFlDf�VIT OF QUALIFICATION
) s.s. FOR GA1u1BL1NG MANAGER LICENSE
COUNTY OF Ramsey � AND CONSENT STATEMEM
(Pursuant fo Minnesofa Statvtes and Ruies)
1, Sheri Ziqan ,Underoathstatethat:
(type/print name)
1. i have never been convicied of a felony or a crime invoiving gambiing.
2. i have not, within five years before the date of the license application, committed a violation of law or
Board rufe that resufted in the revocation ofi a license issued by fhe Board.
3. I have never been convided of a criminai violation involving fraud, theft, tax evasion, misrepresentation,
or gambling.
4. i have never been convicied af n assauft, () a criminai violation involving the use of a firearm, or (i)
making terroristic fhreats.
5. i am not, nor ever have been connected with or engaged in an iilegai business.
6. I do not owe $500 ormore in delinquent taxes as defined in sedion 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 haye never, after demand, failed to file tax retums required by the commissioner of revenue.
in addition, 1 understar,d, agree and hereby irrevocably consent that suits and actions relating to the subjed
matter of the attached gambling manager license application, or acts or omissions arising from such applica-
tion, may be commenced against my organization 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 pieading authorized by the laws of Minnesota.
By signature of this document, the undersigned authorizes the Department of Public Safety to conducf a
criminal background check or review and to share the resutts with the Gambling Control Boarzi.
Failure to provide required information or providing false or misteading information may resuft in the deniai or
revocation of fhe license. .
FURTHER AFFIANT SAYETH NOT, except that this A�davit and Consent Statement are submitted in
support of the application for a gambling manager license from the trol Board.
r-_
NOTARY PUBLIC INFORMA770N �
Notary Pubiic Seai must be current and corred.
Seal may not be aftered. - ... . (signature f cant)
Subscribed and swom to before me this
�D day of =�i��cc'��_ is / �o
ORGANIZA770N INFORMATION
�- " ��1 Name of Orpanization
�bliry�,i,N„�,nM� NEIGhIBORH00D HOUSE ASSOCIATIOi�
REBEbCA J_ CURTIS
X07ARY PUBLIC-NiNHE50TA
wasrt�ncrorv counn
MyCOmm.EsplresJan.31,2000 Base License Number
Council File # � � ��
Ordinance #
1
2
3
4
5
6
7
S
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
�' y—t j�. E�; i; 1
t f ; � ;
`�.,a i 4 t`�.�r 4 t S ; ,_
Presented By
Referred To
Green Sheet # 35348
RESOLUTION
OF SAfNT PAUL, MINNESOTA
�
Committeee Date
RESOLVED: That application, ID 544121, for a new Gambling Manager's License by Sheri J.
2igan DBA I3eighboxhood Aouse Association at Reenan's 620 Club, 620 W. 7th
Street, be and the same is hereby approved.
Requested by Department of:
• -- •-: - . .- • -
�af••.. •�_n-� , - .�
_:.:�. ���� w �'
Adopted by Council: Date � Q�
Adoption Certified by council secretary
By:
Form Approved by City Attor
sy: 1� �c�.-..L�
Approved by yor for Submission to
Council
Approved by Mayor: Date � ��� �-
By: � G� i '7`__
9� -�9D
OE DATE INR7ATED GREEN SHEE N � � J� 4 H
CAtlTACTPEFiSON&PHONE �DEPARIMENTDIFECTOR OCITYCAUNCIL �NR�aUDATE
William F. Gunther - 266-9132 A���x �CRYATTORNEV OCRYCLERK
MUST BE ON COUNCILAGENDA BY (DATE) pU �FOR � BUOGEf DIPECCOq O FIN. fi MGT. SERVICES 010.
HEdTYIIg: OROER �MpyOR(ORASSISTANn �
TOTAL # OF SIGNATORE PAGES (CLIP ALL LOCATIONS FOR SIGNATUR�
ACf10N qEQUESTED:
Sheri S. Zigan DBA Neighborhood House Association requests Council approval of
her application for a new Gambling Manager's License at Reenan`s 620 Club, 620 W. 7th Street
(ID �44121)
RECOMMENDATIONS: Approva (A) or Rejecl (F) pERSONAL SEHVICE CONTHACTS MUST ANSWER TXE FOLLOWING �UESTIONS:
_ PLANNING CAMMISSION _ CIVIL SERVICE CAMMISSION �� H25 tF115 pefSOMlfin eVBf WOrked undef a CAntfaGt fof Mi5 dBPartrtleM? �
_ CIB COMMITTEE _ YES NO
— STAFF 2. Has this person/firm ever been a city employee?
— VES NO
_ DISTNICi CAUR7 _ 3. Does this person/firm pOSSess a sltill not normally possessed by any curtent city employee?
SUPPORTS WHICl1 CAUNCII O&IECTIVE? YES NO
Explaln all yes answere on seperate shee[ antl attaeh to graen sheet
INITIATING PROBLEM, ISSUE, OPPoRTUNITV (Who. Whaq When, Where, Why): �-w �... ��
��` ���. .�.��,��!
. Fs4��..�fi:k `% I:a°
��� �� 2��3�
���� ���' ��
r�� � °�
ADVANTAGES IFAPPROVED:
DISADVAMAGESIFAPPROVED: '
�1+,� �€t�i
��� � � ���
DISADVANTAGES IF NOT APPROVED: �
e
TOTAL AMOUNT OF TRANSACTION $ COST/FiEVENUE BUDGE7ED (CIRCLE ONE) YES NO
FUNDING SOURCE ACTIVITV NUMBER
FINANCIAI iNFORMATION. (EXPLIIN)
Greensheet #
tn Trackef? [ a
License ID # 44121
L.I.E.P. REVIEW CHECKLIST �ate: / q� '�9�
APP'n Recerved ( APP'n Processed
Ucense Type: Gambline Manager
Company Name: Sheri J. ZiQan DBA: Neighhnrhnod Arnica Accnri�tipyy
Business Addresss: 620 W. 7th St. (Keenan's 620 Club) Business Phone: 227-9291
Contact Name/Address: 179 E. Robie St. 55107 Home Phone: 227-9291
Date to Council
Public Hearing
Notice Sent to
Labeis Ordered: NiA
District Council #: 09
Notice Sent to Public: N/A Ward #: 09
Departmentj Date Inspections Comments
City Attorney /0 �: T�J 7T�/��'n� b l� /q`J
t /f��q7 �
Environmental
Health
� ��
Fire
/Nf ��
License Site Plan Received:_
Lease Received:
� ��
Police �� ��'c���i ���'��
� �� ���m�'c��
Zoning
/���
�C�-�qo
East STATE OF MINNESOTA FOR BOARD USE ONLY
. GAHBLING CONTROL BOARD AMT. PAZD ^
GAMBLING MANAGER LICENSE RENEWAL AppLICATION CHECK #
LG212GMR PRINTED: O1/02/46 �, DATE
:.ICENSE NUMBER: (3-02537 003 EFFECTIVE DATE: OS/O1/95 EXPIRATION DATS: 06/30/96
:+A2{& OF ORGANIZATZON: Neighborhood St Paul House Assoc
GAMBLING MANAGER INFORMATZON
Shori Jean Zigan
1638 Evans
South St Paul 147 55075
DATE OF SIRTH: 10�14/59
SEX: F
SOCIAL SECURITY NUMBER: 476-84-4511
DAYTIME PHONE NUMBER: 612-4�.X��'�.�.'22]-j291
N�'MBER SINCE: 1OJ21/85
�ST ➢ATE YOU ATTENDED A GAMBLING MANAGERS SEMINAR/CONTINUING EDUCATION CLASS: 03/14/95
SOND INFORMATZON
BOND COMPANY NAME: Allied Group Insuran BOND NUMBER: BD7900552001
ACRNOWLEDGMENT
Z DECLARE THAT:
' Z HAVE READ THIS APPLICATION AND ALL INFORMATION SUBMITTED TO THE GAMBLING CONTROL BOARD�
• ALL INFORMATION SS TRUE� ACCURATE AND COMPLETE;
• ALL OTHER REQUIRED INFORMATION HAS BEEN FULLY DISCLOSED;
• I AM THE ONLY GAMBLZNG MANAGER OF THE ORGANIZATION;
• I HAVE BEEN AN ACTIVE MEMBER OF THE ORGANIZATION FOR AT LEAST TWO YEARS;
• I WILL FAMILIARIZE MYSELF WI�TH TAE LAWS OF�MINNESOTA GOVERNING LAWFUL GAMBLING AND RULES OF
THE GAMBLZNG CONTR�L BOARD AND AGREE� IF LICENSED� TO ABIDE THOSE LAWS AND RULES� .
INCLUDING AMENDMENTS TO THEM� �
• ANY CfiANGES IN APPLICATION INFOf2MATZON WILL BE SUBMITTED TO THE GAMBLING CONTROL BOARD AND
LOCAL UNIT OF GOVERNMENT WITHIN 10 DAYS OF THE CFIANGE;
• AN AFFIDAVIT FOR GAMBLING MANAGER HAS BEEN COMPLETED AND ATTACAED; AND
• I IINDERSTAND THAT FAILURE TO PROVIDE REQUIRED INFORMFiTION OR PROVZDZNG FALSE OR MZSLEADING
INFORMATION MAY RESULT IN THE DENIAL OR REVOCATION OF THE LZCENSE. . -
GAMBI�IN(i
DATE
�`/9-9
REFER TO THE CHECP.I,IST FOR REQUIRED ATTACHb�NTS
MAIL TO: GAMBLING CONTROL BOARD
1711 WEST COUNTY ROAD B� SUITE 3005
ROSEVILLE� MZNNESOTA 55113
THIS FORM WZLL SE MI�DE AVAILABLE IN ALTERNATIVE FORMAT�(I.E. LARGE PRZNT� HRAZLLE) UPON REQUEST.
�S77o �l/��-6/�/�� �s�/�./
LG213 Minnesofa Gambling Control Board �
oa�, a�ss Gambling Manager Affidavit ��"��
Attach to 2he GamblSng Manager Application, Form LG212
STATE OF MINNESOTA )
AFFlDf�VIT OF QUALIFICATION
) s.s. FOR GA1u1BL1NG MANAGER LICENSE
COUNTY OF Ramsey � AND CONSENT STATEMEM
(Pursuant fo Minnesofa Statvtes and Ruies)
1, Sheri Ziqan ,Underoathstatethat:
(type/print name)
1. i have never been convicied of a felony or a crime invoiving gambiing.
2. i have not, within five years before the date of the license application, committed a violation of law or
Board rufe that resufted in the revocation ofi a license issued by fhe Board.
3. I have never been convided of a criminai violation involving fraud, theft, tax evasion, misrepresentation,
or gambling.
4. i have never been convicied af n assauft, () a criminai violation involving the use of a firearm, or (i)
making terroristic fhreats.
5. i am not, nor ever have been connected with or engaged in an iilegai business.
6. I do not owe $500 ormore in delinquent taxes as defined in sedion 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 haye never, after demand, failed to file tax retums required by the commissioner of revenue.
in addition, 1 understar,d, agree and hereby irrevocably consent that suits and actions relating to the subjed
matter of the attached gambling manager license application, or acts or omissions arising from such applica-
tion, may be commenced against my organization 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 pieading authorized by the laws of Minnesota.
By signature of this document, the undersigned authorizes the Department of Public Safety to conducf a
criminal background check or review and to share the resutts with the Gambling Control Boarzi.
Failure to provide required information or providing false or misteading information may resuft in the deniai or
revocation of fhe license. .
FURTHER AFFIANT SAYETH NOT, except that this A�davit and Consent Statement are submitted in
support of the application for a gambling manager license from the trol Board.
r-_
NOTARY PUBLIC INFORMA770N �
Notary Pubiic Seai must be current and corred.
Seal may not be aftered. - ... . (signature f cant)
Subscribed and swom to before me this
�D day of =�i��cc'��_ is / �o
ORGANIZA770N INFORMATION
�- " ��1 Name of Orpanization
�bliry�,i,N„�,nM� NEIGhIBORH00D HOUSE ASSOCIATIOi�
REBEbCA J_ CURTIS
X07ARY PUBLIC-NiNHE50TA
wasrt�ncrorv counn
MyCOmm.EsplresJan.31,2000 Base License Number