97-872ORlGI�lAL
Council File #� L v� d`
Ordinance #
�3'��D
Green Sheet # ��
RESOLUTION
SAINT PAUL, MINNESOTA
Presented
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
26
27
28
29
30
Referred To
Committee: Date
y5
RESOLVED: That application, (ID $32979), for a new Gambling Manager's License by ICaren
L. Wirkus DBA Climb, Inc. at Top Hat Lounge, 134 E. Sth Street, be and the
same is hereby approved.
Requested by nepartment of:
Adopted by Council: Date �
Adoption Certified by Council Secretary
By: � ,- r-a
Approved by M � R pL ?!3 9..2_,
By: P! d��� �/[�
. .-. - � .- �.._ ,�•
a � - � - �3"�7
� � ��
.A iF
Form Approved by City Atto�
By: � �2./�ti..�v�
Approved by Mayor for Submission to
Council
sy:
°�� - �� a.
DEPApTME� DA7EINITIATED GREEN SHEE N_ 35350
CONTACT PERSON & PHONE �NITIAVDATE INRIAVDAiE
O DEPAHTMENT D1AfCTOi1 � CRY CAUNCiI
William F. Gunther - 266-9132 ASSIGN OCINATfORNEY �CRYCLEflK
MUST BE ON CAUNCIL AGENDA BY (DATE) NUYBER FOR ❑ BUDGET DIRECTOR � FIN. & MGT. SERVICES DIR.
FOUTING
Hearing: cl OflDER �Mpypp�ORAS515fANn �
TOTAL # OF SIGNATURE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE�
ACTION FiE�UESTED:
Karen L. Wirkus DBA Climb, Inc. requests Council approval of her application
for a Gambling Manager's License at Top Hat, 134 E. Sth Street. (ID /132979)
RECOMMENDA7ION5: Approve (A) or Reject (Ii) pEHSONAI SERVICE CONTRACTS MUST ANSWER TXE FOLLOWING QUFSTIONS:
_ PLqNNING CAMMISSION _ CIVIL SEfiVICE CAMMISSION 1. Has this perso�rtn ever worked untler a coM2ct for this departrneM? �
, CIBCOMMITTEE __ VES NO
_ SiqFF 2. Has this person�rm ever been a city employee?
— VES NO
^ DISTRICT COUH7 _ 3. Does this personRi�m possess a skill not normall
y possessed by any curtent ciry amployee?
SUPPORT$ WHICN COUNCIL O&IECfIVE7 YES NO
Explein all yes answers on separate sheat and ettach to grean sheet
INITIATMG PROBLEM, ISSUE.OPPORTUNRV (Who, What, When, VJhere, Why): ' � ,
�� ������
� � Jura rt7 �9st
��T� b���� ��
ADVANTAGES IFAPPROVED:
DISADVAMAGES IFAPPROVED�
D4S0.DVANTAGES IF NOT APPROYEO:
�
���. � 1 �997
TOTAL AMOUNT OF THANSACTION $ COS7/REVENUE BUDGETED (CIRCLE ONE) YES NO
FUNDIIdG SOURCE ACTiVYfY NUMBEB
FINANCIAL INFORMATION: (EXPLAIN)
Greensheet # 35349
In Tracker? 7%/_ /R�/
L.I.E.P. REVIEW CHECKLIST Date: /`� — a ��
App'n Received / App'n Processed
LiCense ID # 32979 LiCense Type: Gamb� ing Manaeer
Company Name: Karen L. Wirkus DBA: Climb, Inc.
Business Addresss: 13G E. Sth St. (Tou Hat Lounge) Business Phone: 227-9660
Contact
Date to Cotsncil
Pubiic Hearing Date: , `i�', /59]
Notice Sent to Applicant:_� !�9 7
Home Phone: 227-9660
Labels Ordered: N/A
District Council
Notice Sent to Public: N/A Ward #: �a
Department/ Date Inspections Comments
City Attorney
��- ��/��9'7
Environmental
Health
�lA
Fire
N �X�
License si�e Pian aeceived:_
j Lease Received:
�!7/
/
Police S2Q Cbt�-CI1L'U L�COY"' �'et.� �""' "
D � .�/a�/9�
Zoning
���
�East �. . - 1 f -O / �^
STATE OF MINNESOTA �FOR BoARD USE OxLY
- GAM6LING CONTROL BOARD �AMT. PAID
GAMBLING MANAGER LICENSE RENEWAL APPLZCATZON ICHECK #`
LG212GMR PRINTED: 09/OS/95 DATE
s
LICENSE NUMBER: 6-0200� 002 E-FFECTIVE DATE: 03/O1/96 EXPIRATZON DATEt 02/29/96
NAME OF ORGANIZATIONs Climb St Paul
GABSBLINa MANAGER INFORMATION
%arep Lea Wirkus
55:.: crosby Ave E
Inver Grpve 8eighta MN 55076
DAYTIME PHONE NUMBER: 612-227-9660
MEMBER SINCE: 11/07/89
Y
DATE OF BIRTH: 10/26/43
SEX: F
SOCIAL SECURITY NUMBER: 471-48-')872
LAST DATE YOU ATTENDED A GAMBLING MANAGERS SEMINAR/CONTSNUING EDUCATION CLASSs
BOND INFORMATION
SOND COMFANY NAME: North River Zns Co BOND NOMBER: 626011202
ACKNOWLEDGMENT
/l/ / P/9S
11.�3-2%B$
I DECLARE THAT: v
• I HAVE READ TiiIS APPLICATION AND ALL INFORMATION SUBMITTE� TO THE GAMBLING CONTEZOL 80ARD)
� ALL INFORMATSON YS TRUE� ACCURATE AND COMPLETE;
• ALL OTHER REQUZRED INFORMATION HAS BEEN FULLY DISCLOSEDj
• I AM THE ONLY GAMBLING MANAGER OF THE ORCANSZATIONj
• I HAVE BEEN AN ACTIVE MEMBER OF THE ORGANI2ATION FOR AT LEAST TWO YEARSj
• I WILL PAMZLIARIZE MYSELF WITH THE LAWS OF MINNESQTA GOV£RNING LAWFUL GAMBLTNG AND RULES OF
THE GAMBLINC CONTROL BOARD ANA AGREE, IF LICENSED� TO ABXDE THOSE LAWS AND RULES�
INCLUDING AMENDMENTS 1'O THEM)
• ANY CHANGES IN APPLICATION SNFORMATION WILL BE SUBMZTTED TO THE GAMBLSNG CONTROL BOARD AND
LOCAL UNIT OF GOVERNMENT WSTHIN 10 AAYS OF THE CHANGEp
• AN AFFIDAVIT FOR GAMBLING MANAGER HRS BEEN COMPLETED AND ATTACHEDj AND
• S UNDERSTANA TNAT FAILURE TO PROVIDE REQUIRED INFORMATION OR PROVIDING FALSE OR MISLEADING
INFORMATION MAY RESULT IN THE DENIAL OR R$VOCATION OF THE LICENSE.
SIGNATURE OF� CAbfBLIN6 HANAGER
REFER TO THE CBECKLIST FOR REQUZRED ATTACHMENTS
MASL TO� GAILBLIN6 CONTROL SOARD
Y711 WEST COtTNTY ROAD B� SUITE 3003
ROSEVILLE, MIN2tESOTA 55113
8
THZS FORM WILL SE MADE AVAILABLE IN ALTERNATIVE FOF2MAT (I.E. LARGE PRINT� BRAILLE) UPON REQUEST.
DATE
�
�
�
� --r�
LG213 lNinnesota Gambling Confrol Board
oar�a�ss Gambling Manager Affidavif
Attach 4o the Gambling Manager App4icacion, Fo[m LG212
�f `l - �� �-
STATE OF � � � AFFIDAVIT OF QUALIFICATION
L ) 5.5. �OR GAMBIfNG MANAGER LiCENSE
COUNTY Oh��K�,�,.�, � a �„ � AND CO`NSENT STATEMENT
�__�..a�� (Pursuant to Minnesota Statutes and Rules)
�� 'tlAhe A� �• �; �.h�u , Under oath state that:
(type/print name)
1. ( have never been convicted of a felony or a crime involving gambling.
2. i have not, within five yea�s before the date of the ficense application, committed a violation oi law or
Board rule that resulted in the revocation oi a license issued by the Board,
3. I have never been convicted of a criminal violation invoiving fraud, theft, tax evasion, misrepresentation,
or gambling.
4. 1 have never been convicted of (i) assauit, (ii) a criminai violation involving the use of a firearm, or (iii)
making terzoristic threats.
5, i am not, nor ever have been connecied with or engaged in an iliegal business.
6, i do not owe 5500 or more in delinquent taxes as defined in section 270.72.
7. I have nol had a sales and use tax permit revoked by the commissioner of revenue within the past hvo
years.
8, I have never, after demand, failed to flfe tax retums required by ihe commissioner of ravenue.
In addition, I understand, agree and hereby irrevocabiy consent that suits and actions relating to fhe subject
matter of the attached gambiing manager license appfication, or acis or omissions arising from such applica-
tion, may be commenced against my organizatio� and f will accept the service of process for my organiza-
tion in any caurt of competent jurisdiction in Minnesota by service on the Minnesota Seceetary of State of any
summons, process or pleadi�g authorized by the laws of Minnesota.
By signature of this document, the undersigned authorizes the Department of Pubiic Safety to conduct a
criminal background check or review and to share the results with the Gambli�g Gontro4 Board.
Failure to provide required information or providing false or misleading informafion may result in the deniai or
revocation o( the Iicense.
FURTHER AFFIANT SAYETH NOT, except that this Affidavit and Consent Statement are submltted In
support of the appiication for a gambling manager license from the Gambiing Control Board.
NOTARYPUBLIC INFORMATlON ��,. ^ n' _ ) / � / / ,
IJ��Uf/�� ��t � /t/J�.A1. A
j Notary Pubfic Seal musi be current and correct. (signature of applica�t)
Seal may not be altered.
Subscribed and swom to betore me t
�`� day of ��'U�Pn'%�C�/
�il�,�,:�v-�
9,��"
ORGANIZA7ION 1NFORMATION
of Organization
t�rnt�sroH exP�aes
IANUAI;'P31, 2000
C�h�B'�(hcaTre J NL
Base l.icense Number
O��C� _-�
ORlGI�lAL
Council File #� L v� d`
Ordinance #
�3'��D
Green Sheet # ��
RESOLUTION
SAINT PAUL, MINNESOTA
Presented
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
26
27
28
29
30
Referred To
Committee: Date
y5
RESOLVED: That application, (ID $32979), for a new Gambling Manager's License by ICaren
L. Wirkus DBA Climb, Inc. at Top Hat Lounge, 134 E. Sth Street, be and the
same is hereby approved.
Requested by nepartment of:
Adopted by Council: Date �
Adoption Certified by Council Secretary
By: � ,- r-a
Approved by M � R pL ?!3 9..2_,
By: P! d��� �/[�
. .-. - � .- �.._ ,�•
a � - � - �3"�7
� � ��
.A iF
Form Approved by City Atto�
By: � �2./�ti..�v�
Approved by Mayor for Submission to
Council
sy:
°�� - �� a.
DEPApTME� DA7EINITIATED GREEN SHEE N_ 35350
CONTACT PERSON & PHONE �NITIAVDATE INRIAVDAiE
O DEPAHTMENT D1AfCTOi1 � CRY CAUNCiI
William F. Gunther - 266-9132 ASSIGN OCINATfORNEY �CRYCLEflK
MUST BE ON CAUNCIL AGENDA BY (DATE) NUYBER FOR ❑ BUDGET DIRECTOR � FIN. & MGT. SERVICES DIR.
FOUTING
Hearing: cl OflDER �Mpypp�ORAS515fANn �
TOTAL # OF SIGNATURE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE�
ACTION FiE�UESTED:
Karen L. Wirkus DBA Climb, Inc. requests Council approval of her application
for a Gambling Manager's License at Top Hat, 134 E. Sth Street. (ID /132979)
RECOMMENDA7ION5: Approve (A) or Reject (Ii) pEHSONAI SERVICE CONTRACTS MUST ANSWER TXE FOLLOWING QUFSTIONS:
_ PLqNNING CAMMISSION _ CIVIL SEfiVICE CAMMISSION 1. Has this perso�rtn ever worked untler a coM2ct for this departrneM? �
, CIBCOMMITTEE __ VES NO
_ SiqFF 2. Has this person�rm ever been a city employee?
— VES NO
^ DISTRICT COUH7 _ 3. Does this personRi�m possess a skill not normall
y possessed by any curtent ciry amployee?
SUPPORT$ WHICN COUNCIL O&IECfIVE7 YES NO
Explein all yes answers on separate sheat and ettach to grean sheet
INITIATMG PROBLEM, ISSUE.OPPORTUNRV (Who, What, When, VJhere, Why): ' � ,
�� ������
� � Jura rt7 �9st
��T� b���� ��
ADVANTAGES IFAPPROVED:
DISADVAMAGES IFAPPROVED�
D4S0.DVANTAGES IF NOT APPROYEO:
�
���. � 1 �997
TOTAL AMOUNT OF THANSACTION $ COS7/REVENUE BUDGETED (CIRCLE ONE) YES NO
FUNDIIdG SOURCE ACTiVYfY NUMBEB
FINANCIAL INFORMATION: (EXPLAIN)
Greensheet # 35349
In Tracker? 7%/_ /R�/
L.I.E.P. REVIEW CHECKLIST Date: /`� — a ��
App'n Received / App'n Processed
LiCense ID # 32979 LiCense Type: Gamb� ing Manaeer
Company Name: Karen L. Wirkus DBA: Climb, Inc.
Business Addresss: 13G E. Sth St. (Tou Hat Lounge) Business Phone: 227-9660
Contact
Date to Cotsncil
Pubiic Hearing Date: , `i�', /59]
Notice Sent to Applicant:_� !�9 7
Home Phone: 227-9660
Labels Ordered: N/A
District Council
Notice Sent to Public: N/A Ward #: �a
Department/ Date Inspections Comments
City Attorney
��- ��/��9'7
Environmental
Health
�lA
Fire
N �X�
License si�e Pian aeceived:_
j Lease Received:
�!7/
/
Police S2Q Cbt�-CI1L'U L�COY"' �'et.� �""' "
D � .�/a�/9�
Zoning
���
�East �. . - 1 f -O / �^
STATE OF MINNESOTA �FOR BoARD USE OxLY
- GAM6LING CONTROL BOARD �AMT. PAID
GAMBLING MANAGER LICENSE RENEWAL APPLZCATZON ICHECK #`
LG212GMR PRINTED: 09/OS/95 DATE
s
LICENSE NUMBER: 6-0200� 002 E-FFECTIVE DATE: 03/O1/96 EXPIRATZON DATEt 02/29/96
NAME OF ORGANIZATIONs Climb St Paul
GABSBLINa MANAGER INFORMATION
%arep Lea Wirkus
55:.: crosby Ave E
Inver Grpve 8eighta MN 55076
DAYTIME PHONE NUMBER: 612-227-9660
MEMBER SINCE: 11/07/89
Y
DATE OF BIRTH: 10/26/43
SEX: F
SOCIAL SECURITY NUMBER: 471-48-')872
LAST DATE YOU ATTENDED A GAMBLING MANAGERS SEMINAR/CONTSNUING EDUCATION CLASSs
BOND INFORMATION
SOND COMFANY NAME: North River Zns Co BOND NOMBER: 626011202
ACKNOWLEDGMENT
/l/ / P/9S
11.�3-2%B$
I DECLARE THAT: v
• I HAVE READ TiiIS APPLICATION AND ALL INFORMATION SUBMITTE� TO THE GAMBLING CONTEZOL 80ARD)
� ALL INFORMATSON YS TRUE� ACCURATE AND COMPLETE;
• ALL OTHER REQUZRED INFORMATION HAS BEEN FULLY DISCLOSEDj
• I AM THE ONLY GAMBLING MANAGER OF THE ORCANSZATIONj
• I HAVE BEEN AN ACTIVE MEMBER OF THE ORGANI2ATION FOR AT LEAST TWO YEARSj
• I WILL PAMZLIARIZE MYSELF WITH THE LAWS OF MINNESQTA GOV£RNING LAWFUL GAMBLTNG AND RULES OF
THE GAMBLINC CONTROL BOARD ANA AGREE, IF LICENSED� TO ABXDE THOSE LAWS AND RULES�
INCLUDING AMENDMENTS 1'O THEM)
• ANY CHANGES IN APPLICATION SNFORMATION WILL BE SUBMZTTED TO THE GAMBLSNG CONTROL BOARD AND
LOCAL UNIT OF GOVERNMENT WSTHIN 10 AAYS OF THE CHANGEp
• AN AFFIDAVIT FOR GAMBLING MANAGER HRS BEEN COMPLETED AND ATTACHEDj AND
• S UNDERSTANA TNAT FAILURE TO PROVIDE REQUIRED INFORMATION OR PROVIDING FALSE OR MISLEADING
INFORMATION MAY RESULT IN THE DENIAL OR R$VOCATION OF THE LICENSE.
SIGNATURE OF� CAbfBLIN6 HANAGER
REFER TO THE CBECKLIST FOR REQUZRED ATTACHMENTS
MASL TO� GAILBLIN6 CONTROL SOARD
Y711 WEST COtTNTY ROAD B� SUITE 3003
ROSEVILLE, MIN2tESOTA 55113
8
THZS FORM WILL SE MADE AVAILABLE IN ALTERNATIVE FOF2MAT (I.E. LARGE PRINT� BRAILLE) UPON REQUEST.
DATE
�
�
�
� --r�
LG213 lNinnesota Gambling Confrol Board
oar�a�ss Gambling Manager Affidavif
Attach 4o the Gambling Manager App4icacion, Fo[m LG212
�f `l - �� �-
STATE OF � � � AFFIDAVIT OF QUALIFICATION
L ) 5.5. �OR GAMBIfNG MANAGER LiCENSE
COUNTY Oh��K�,�,.�, � a �„ � AND CO`NSENT STATEMENT
�__�..a�� (Pursuant to Minnesota Statutes and Rules)
�� 'tlAhe A� �• �; �.h�u , Under oath state that:
(type/print name)
1. ( have never been convicted of a felony or a crime involving gambling.
2. i have not, within five yea�s before the date of the ficense application, committed a violation oi law or
Board rule that resulted in the revocation oi a license issued by the Board,
3. I have never been convicted of a criminal violation invoiving fraud, theft, tax evasion, misrepresentation,
or gambling.
4. 1 have never been convicted of (i) assauit, (ii) a criminai violation involving the use of a firearm, or (iii)
making terzoristic threats.
5, i am not, nor ever have been connecied with or engaged in an iliegal business.
6, i do not owe 5500 or more in delinquent taxes as defined in section 270.72.
7. I have nol had a sales and use tax permit revoked by the commissioner of revenue within the past hvo
years.
8, I have never, after demand, failed to flfe tax retums required by ihe commissioner of ravenue.
In addition, I understand, agree and hereby irrevocabiy consent that suits and actions relating to fhe subject
matter of the attached gambiing manager license appfication, or acis or omissions arising from such applica-
tion, may be commenced against my organizatio� and f will accept the service of process for my organiza-
tion in any caurt of competent jurisdiction in Minnesota by service on the Minnesota Seceetary of State of any
summons, process or pleadi�g authorized by the laws of Minnesota.
By signature of this document, the undersigned authorizes the Department of Pubiic Safety to conduct a
criminal background check or review and to share the results with the Gambli�g Gontro4 Board.
Failure to provide required information or providing false or misleading informafion may result in the deniai or
revocation o( the Iicense.
FURTHER AFFIANT SAYETH NOT, except that this Affidavit and Consent Statement are submltted In
support of the appiication for a gambling manager license from the Gambiing Control Board.
NOTARYPUBLIC INFORMATlON ��,. ^ n' _ ) / � / / ,
IJ��Uf/�� ��t � /t/J�.A1. A
j Notary Pubfic Seal musi be current and correct. (signature of applica�t)
Seal may not be altered.
Subscribed and swom to betore me t
�`� day of ��'U�Pn'%�C�/
�il�,�,:�v-�
9,��"
ORGANIZA7ION 1NFORMATION
of Organization
t�rnt�sroH exP�aes
IANUAI;'P31, 2000
C�h�B'�(hcaTre J NL
Base l.icense Number
O��C� _-�
ORlGI�lAL
Council File #� L v� d`
Ordinance #
�3'��D
Green Sheet # ��
RESOLUTION
SAINT PAUL, MINNESOTA
Presented
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
26
27
28
29
30
Referred To
Committee: Date
y5
RESOLVED: That application, (ID $32979), for a new Gambling Manager's License by ICaren
L. Wirkus DBA Climb, Inc. at Top Hat Lounge, 134 E. Sth Street, be and the
same is hereby approved.
Requested by nepartment of:
Adopted by Council: Date �
Adoption Certified by Council Secretary
By: � ,- r-a
Approved by M � R pL ?!3 9..2_,
By: P! d��� �/[�
. .-. - � .- �.._ ,�•
a � - � - �3"�7
� � ��
.A iF
Form Approved by City Atto�
By: � �2./�ti..�v�
Approved by Mayor for Submission to
Council
sy:
°�� - �� a.
DEPApTME� DA7EINITIATED GREEN SHEE N_ 35350
CONTACT PERSON & PHONE �NITIAVDATE INRIAVDAiE
O DEPAHTMENT D1AfCTOi1 � CRY CAUNCiI
William F. Gunther - 266-9132 ASSIGN OCINATfORNEY �CRYCLEflK
MUST BE ON CAUNCIL AGENDA BY (DATE) NUYBER FOR ❑ BUDGET DIRECTOR � FIN. & MGT. SERVICES DIR.
FOUTING
Hearing: cl OflDER �Mpypp�ORAS515fANn �
TOTAL # OF SIGNATURE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE�
ACTION FiE�UESTED:
Karen L. Wirkus DBA Climb, Inc. requests Council approval of her application
for a Gambling Manager's License at Top Hat, 134 E. Sth Street. (ID /132979)
RECOMMENDA7ION5: Approve (A) or Reject (Ii) pEHSONAI SERVICE CONTRACTS MUST ANSWER TXE FOLLOWING QUFSTIONS:
_ PLqNNING CAMMISSION _ CIVIL SEfiVICE CAMMISSION 1. Has this perso�rtn ever worked untler a coM2ct for this departrneM? �
, CIBCOMMITTEE __ VES NO
_ SiqFF 2. Has this person�rm ever been a city employee?
— VES NO
^ DISTRICT COUH7 _ 3. Does this personRi�m possess a skill not normall
y possessed by any curtent ciry amployee?
SUPPORT$ WHICN COUNCIL O&IECfIVE7 YES NO
Explein all yes answers on separate sheat and ettach to grean sheet
INITIATMG PROBLEM, ISSUE.OPPORTUNRV (Who, What, When, VJhere, Why): ' � ,
�� ������
� � Jura rt7 �9st
��T� b���� ��
ADVANTAGES IFAPPROVED:
DISADVAMAGES IFAPPROVED�
D4S0.DVANTAGES IF NOT APPROYEO:
�
���. � 1 �997
TOTAL AMOUNT OF THANSACTION $ COS7/REVENUE BUDGETED (CIRCLE ONE) YES NO
FUNDIIdG SOURCE ACTiVYfY NUMBEB
FINANCIAL INFORMATION: (EXPLAIN)
Greensheet # 35349
In Tracker? 7%/_ /R�/
L.I.E.P. REVIEW CHECKLIST Date: /`� — a ��
App'n Received / App'n Processed
LiCense ID # 32979 LiCense Type: Gamb� ing Manaeer
Company Name: Karen L. Wirkus DBA: Climb, Inc.
Business Addresss: 13G E. Sth St. (Tou Hat Lounge) Business Phone: 227-9660
Contact
Date to Cotsncil
Pubiic Hearing Date: , `i�', /59]
Notice Sent to Applicant:_� !�9 7
Home Phone: 227-9660
Labels Ordered: N/A
District Council
Notice Sent to Public: N/A Ward #: �a
Department/ Date Inspections Comments
City Attorney
��- ��/��9'7
Environmental
Health
�lA
Fire
N �X�
License si�e Pian aeceived:_
j Lease Received:
�!7/
/
Police S2Q Cbt�-CI1L'U L�COY"' �'et.� �""' "
D � .�/a�/9�
Zoning
���
�East �. . - 1 f -O / �^
STATE OF MINNESOTA �FOR BoARD USE OxLY
- GAM6LING CONTROL BOARD �AMT. PAID
GAMBLING MANAGER LICENSE RENEWAL APPLZCATZON ICHECK #`
LG212GMR PRINTED: 09/OS/95 DATE
s
LICENSE NUMBER: 6-0200� 002 E-FFECTIVE DATE: 03/O1/96 EXPIRATZON DATEt 02/29/96
NAME OF ORGANIZATIONs Climb St Paul
GABSBLINa MANAGER INFORMATION
%arep Lea Wirkus
55:.: crosby Ave E
Inver Grpve 8eighta MN 55076
DAYTIME PHONE NUMBER: 612-227-9660
MEMBER SINCE: 11/07/89
Y
DATE OF BIRTH: 10/26/43
SEX: F
SOCIAL SECURITY NUMBER: 471-48-')872
LAST DATE YOU ATTENDED A GAMBLING MANAGERS SEMINAR/CONTSNUING EDUCATION CLASSs
BOND INFORMATION
SOND COMFANY NAME: North River Zns Co BOND NOMBER: 626011202
ACKNOWLEDGMENT
/l/ / P/9S
11.�3-2%B$
I DECLARE THAT: v
• I HAVE READ TiiIS APPLICATION AND ALL INFORMATION SUBMITTE� TO THE GAMBLING CONTEZOL 80ARD)
� ALL INFORMATSON YS TRUE� ACCURATE AND COMPLETE;
• ALL OTHER REQUZRED INFORMATION HAS BEEN FULLY DISCLOSEDj
• I AM THE ONLY GAMBLING MANAGER OF THE ORCANSZATIONj
• I HAVE BEEN AN ACTIVE MEMBER OF THE ORGANI2ATION FOR AT LEAST TWO YEARSj
• I WILL PAMZLIARIZE MYSELF WITH THE LAWS OF MINNESQTA GOV£RNING LAWFUL GAMBLTNG AND RULES OF
THE GAMBLINC CONTROL BOARD ANA AGREE, IF LICENSED� TO ABXDE THOSE LAWS AND RULES�
INCLUDING AMENDMENTS 1'O THEM)
• ANY CHANGES IN APPLICATION SNFORMATION WILL BE SUBMZTTED TO THE GAMBLSNG CONTROL BOARD AND
LOCAL UNIT OF GOVERNMENT WSTHIN 10 AAYS OF THE CHANGEp
• AN AFFIDAVIT FOR GAMBLING MANAGER HRS BEEN COMPLETED AND ATTACHEDj AND
• S UNDERSTANA TNAT FAILURE TO PROVIDE REQUIRED INFORMATION OR PROVIDING FALSE OR MISLEADING
INFORMATION MAY RESULT IN THE DENIAL OR R$VOCATION OF THE LICENSE.
SIGNATURE OF� CAbfBLIN6 HANAGER
REFER TO THE CBECKLIST FOR REQUZRED ATTACHMENTS
MASL TO� GAILBLIN6 CONTROL SOARD
Y711 WEST COtTNTY ROAD B� SUITE 3003
ROSEVILLE, MIN2tESOTA 55113
8
THZS FORM WILL SE MADE AVAILABLE IN ALTERNATIVE FOF2MAT (I.E. LARGE PRINT� BRAILLE) UPON REQUEST.
DATE
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LG213 lNinnesota Gambling Confrol Board
oar�a�ss Gambling Manager Affidavif
Attach 4o the Gambling Manager App4icacion, Fo[m LG212
�f `l - �� �-
STATE OF � � � AFFIDAVIT OF QUALIFICATION
L ) 5.5. �OR GAMBIfNG MANAGER LiCENSE
COUNTY Oh��K�,�,.�, � a �„ � AND CO`NSENT STATEMENT
�__�..a�� (Pursuant to Minnesota Statutes and Rules)
�� 'tlAhe A� �• �; �.h�u , Under oath state that:
(type/print name)
1. ( have never been convicted of a felony or a crime involving gambling.
2. i have not, within five yea�s before the date of the ficense application, committed a violation oi law or
Board rule that resulted in the revocation oi a license issued by the Board,
3. I have never been convicted of a criminal violation invoiving fraud, theft, tax evasion, misrepresentation,
or gambling.
4. 1 have never been convicted of (i) assauit, (ii) a criminai violation involving the use of a firearm, or (iii)
making terzoristic threats.
5, i am not, nor ever have been connecied with or engaged in an iliegal business.
6, i do not owe 5500 or more in delinquent taxes as defined in section 270.72.
7. I have nol had a sales and use tax permit revoked by the commissioner of revenue within the past hvo
years.
8, I have never, after demand, failed to flfe tax retums required by ihe commissioner of ravenue.
In addition, I understand, agree and hereby irrevocabiy consent that suits and actions relating to fhe subject
matter of the attached gambiing manager license appfication, or acis or omissions arising from such applica-
tion, may be commenced against my organizatio� and f will accept the service of process for my organiza-
tion in any caurt of competent jurisdiction in Minnesota by service on the Minnesota Seceetary of State of any
summons, process or pleadi�g authorized by the laws of Minnesota.
By signature of this document, the undersigned authorizes the Department of Pubiic Safety to conduct a
criminal background check or review and to share the results with the Gambli�g Gontro4 Board.
Failure to provide required information or providing false or misleading informafion may result in the deniai or
revocation o( the Iicense.
FURTHER AFFIANT SAYETH NOT, except that this Affidavit and Consent Statement are submltted In
support of the appiication for a gambling manager license from the Gambiing Control Board.
NOTARYPUBLIC INFORMATlON ��,. ^ n' _ ) / � / / ,
IJ��Uf/�� ��t � /t/J�.A1. A
j Notary Pubfic Seal musi be current and correct. (signature of applica�t)
Seal may not be altered.
Subscribed and swom to betore me t
�`� day of ��'U�Pn'%�C�/
�il�,�,:�v-�
9,��"
ORGANIZA7ION 1NFORMATION
of Organization
t�rnt�sroH exP�aes
IANUAI;'P31, 2000
C�h�B'�(hcaTre J NL
Base l.icense Number
O��C� _-�