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97-873ORIGINAL Green Sheet S 35349 1 2 3 4 $ 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 31 Presented Referred To Council File � `� f U � ✓ Ordinance # Committee: Date RESOLVED: That application for new Gambling Manager's Licenses by Marilyn Sherrick DBA Harding Area Hockey, ID $66756 at Minnehaha Tavern, 735 White Bear Avenue and ID �22873 at Michaels, 1179 E. 7th Street, be and the same are hereby approved. Requested by Department of: ��_ - -� - t .- .e- _�. � • :_u - r - . . � � � I � Form Approved b City Attorne By: U liwG� �� Approved by Ma or for Submission to Council By: Approved Date RESOLUTION CITY OF SAINT PAUL, MINNESOTA �� By: By: Adopted by Council: Date � Adoption Certified by Councxl Secretary � - �� EPARTME� OATEWRIATED GREEN SHEE N _ 35349 CONTACT PEASON & PHONE INITIAUDATE �NITIAUDATE �DEPARTMENTOIRECTOR OCRYCOUNCIL William F. Gunther — 266-9132 ��eN � arvnrroaNEr � cmc�AK MUST BE ON CAUNCIL AGENDA BV (DA7Ej RU O gUDGET �IRECfOfi O FIN. & MGT. SERVICES Dlfl. H28TlIIg. � /, OflDEP � MAVOR (ORASSISTANT) O TOTAL # OF SIGNATURE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE) ACT10N qEQUESTED: Marilyn Sherxick DBA Harding Area Hockey Association requests Council approval of her application for a Gambling Manager's License, ID �i66786 at Minnehaha Tavern, 735 White Bear Avenue and ID 4122873 at Michaels, 1179 E. 7th Street. qECOMMENDAi1oNS: approve (A) or Reject (H) pERSONAL SERVICE CONTRACTS MUST ANSWER TXE FOLLOWING QUESTIONS: _ PLANNING CAMMISSION _ CIVI� SEflVICE CAMMISSION ti� Has this persoNfirm ever worked unEer a coMract for this tlepartment? - _ CIB COMMITTEE _ YES NO __ STAFF 2_ Has this person/firm ever been a ciry employee? — VES NO , DISTRICTCOURT _ 3. Does Nis persoMirm possess a skil� no[ normall � y possessed by any curteM city employee. SUPPOflTSWHICHCOUNCILO&IECTIVE? YES NO Explain ell yes answers on separete sheet antl attech to green sheet INITIATING PROBIEM, ISSUE.OPPORTUNITV (Who, What. Whan, Where, Why): . �� JUfJ ?7 1997 � �' �� K�� AOVANTAGES IF APPROVED: � DISADVANTAGES IiAPPROVED: DISADVANfAGES IF NOT RPPSiOVEO: � "��_ �i ��JJ TOTAL AMOUNT OF TqANSACTION S COST/REVENUE BUDGETED (CIRCLE ONE) YES NO FUNDIHG SOURCE ACTIVI7Y NUMBER - FINANCIAL INFORMATION: (E%PLAIN) . Greensheet # 35349 L.I.E.P. REVIEW CHECKLIST �ate: /�� — � 3 In TraCkB(?___1TL�� ApP'n Rece'rved / ApP'n Processetl License ID # 66786 & 9�22873 License Type: GamblinQ Mana�er Company Name: Marilvn Sherrick DBA: HardinQ Area Hockev Association Business AddressS: 735 White Beai Ave. (Minnehaha Tavern) BUSiness Phone: 738-3002 Contact Name% Date to Council Home Phone: 738-3002 Public Hearing Date: (�j� G. ISFf� Notice Sent to Applicant: 7�/ ��/ Notice Sent to Public: N A iabefs Ordered: NiA District Council #: O� OcC Ward #: �� Department/ Date Inspections Comments City Attorney o� �/i�/97 Environmental Heatth /V�� Fire /v /� License Site Plan Received: Lease Received: �/� Police J��c-"r�-, l�Y1fL'.� FJ?�i1-(�.LrlGi ` � J Zoning �� Gambling Control Board Fax=612 Mistne.�;nfa LawfuI Gaml>ding Gaxnbling Manager Applica Incomplete, false, or misleadng application infotmation may Organization Information (Cannotbegarnbiing mana9er) �/ DaytimePhone /� � � 7(} "�3y7 OrganizationBaseLicense Gambiing Manager Information Board C e Lic # uence # � First Name Full Middle Name Y/i-c�. �� J L�! �ar.ie w�� MaidenName DakofBirfh1fL/a�/, Checkoneoftheba�es: � Mafe � Female Soaai SeCUrity r. < i � Daytime Phone Number(�C /o! )'/ . Y fj - 1 became an adive member ofthis organization on: f attended fhe two•day gambt;ng manager seminar on: Jun 13 '97 11�53 , �y'� JUi�'1997 D�sctosure of Seclai Security Number Yw are requireC toprovideywr sodal secu- rirynumberonthiskrm.Your soaaisecu- rdy num6er will be used to determir�e your compfiance with tha tax Iaws of Minnesota. Av[horizationfot raquirir�qyoursocialsecu- rity number is found ata2 U.S.C. 40S(c)ii). �Oi1t� �iIfOTCi1&�IOii A$10,000 fidelity bond in favor of fhe organization has been ubtained as re�uired by Minnesota Statutes, seetion 349.167, subdivision 1. 4nsurance Company Name: �L fZ��u�i�r !. Bond Number.��S y (DO NOT USE THE AGENCY NAME) Gam biing Manager Change �en your organization is changing'rts gambling manager, complete one ofFhesa sections: Emargency Change - Altow up to five days for processing The chief �;<��::6ve officer, by signing below, affirms that the ema�gency a�plication is dus tn+he fallowing reason (check one and fill in daYe): ❑ Death of gambling manager on _/ / � Disabiliry of gambling manager on / / �$( Termination ot employment of gambling manager on _�I�Q�� tJOT6: 7he new gambiing manager may. not assume du[ies until he/she has received the gambling manage�s license from the Gambling Control Board. Sigttature of CEO _ C�� //6 Notarized�aureofChiaf tive'Offcor(CEO) �a�, �- � -- 97 . , OthC� ChaOge - Allow up fo ten weeks for processing The new gambling manager's license should become effective (check one): ❑ The day a �r u e curra�t gambling manage�s license expires (forexample, ifthe currentgambling managers (icense expires 7l31/96, the new gambling manager's license 6ecomes effecfive on 8/1/96, provided that ali appfication information is complete). � When the application has been processed bythe Gam- bling CoMrol Baard--the e8ective date wili be the first day of tt�e month. NOTE: The new gambling manager may not assume duties unfif he/she has received a gambting manager's license from the Gambiing Controi Boarci. Notary Publsc lnformation. t�otasy Pubttc sea� must be current and correck seal may not be altered. Subscr d and swom to before me this day of ��_ 19 ' Nohry Pubfic- Mir Commission Fxqices 1 JUN-13-199? 12�15 612 `98r �n� on b ) ]Oy if'tlnGnt/��.�e/ � ��7�6 os.�. .z/�/��2 P. 02/03 �_Y�3 LG212 siss Page 1 of 2 Gambling Control Board Fax�612 Gambling Manager Ap. .ication (continued) Affidavit and Consent Sta#ement: under oath stata that I have never: 1. been convicted of a felony or a crime involving gam- bling; 2. committedaviolationoffaworBoardrulet}tatresulted in the revoca5on ot a license issued by fhe Board within five years before the date of the license applica6on; 3. beeh convitted of a crimina( violation involving fraud, theft, taxevasion, misrepresentation, orgambling; 4. been convicted of (i) assau(t, (ii) a criminai v(olation involving the use of a firearm, or (iii) making terroristic threats. 5. been connecfed with nor engaged in an iilegal busi- ness; 8. owed $500 or more in delinquent taxes as defined in section 270.72; 7, had a sales and use tax permit revoked by the com- missioner of revenue within the past two years; 8. faifed to file, after demand, tax returns required by the commissioner of revenue. in addition, I understand, agree, and hereby irrevocably consent that suits and actions relating to the subject mat- ter of the attachatl gambling manager license application, or aets or omissions arising from such aoplica5on, may be commenced against me or my organization and 1 wi11 accept the service of process in any couri of competent jurisdiction in Minnesota by service on the Minnesota Secretary of State of any summons, process, or pleading authorized byfhe Iaws of Minnesota. Sy signature of this documerrt, the undersigned aufhorizes the Departments of Public Safety and Revenue to con- duct a criminai and tax background check or review and to share thP resuf+s �uiYn ?he G�rmh[ir.� Cor.HO! Boad. Failure to provida required information or providing false or misleading information may result in the denial or revocation of the license. FURTHER AFFIANT SRYET'H NOT, except that this Affidavit and Consent Statement are subm'�tted in sapport of the application for a gambling manager license from the Gamblina Control eoattl. Signature o# Gambling Manager Applicant �-, ' .� . � .��9.,�.��v NotarizedSig atureofApplicant 6-.�-- 9� Date Jun 13 '97 11�53 P.03/03_G��_d•� 8/96 Page 2 of 2 This publication will be made available in alternalive format (i.e. Iarge print, Braille) upon request. If you use a 7TY, you can cail us using the Minnesota Re;ay Service at 1-8�0-627�529 and ask them to place a cali to (612) 639-4000. T�e information requested on this form will be used by the Gambling Control Soarcl (Board) to determine your compliance with Minnesota statutes and rules goveming Iawful gambling activities. AII of the infor- mation that you suppiy on this form will become public information when received by the Board. The information requested on this form (including any attachments) will be used by the Board to determine your qualifications to be involved in lawfui gamb(ing activities in Minnesota, and to assist the Board in conducting a background investigation of you. You have the right to refuse to supply the information requested; however, if you refuse to supply this infor- ma6on, the Board may not be able to determine your qualifications and, as a consequence, may eefuse to issue you a Iicense. If you supply the ir�formafion required, the Board will be able to process your appli- cation. Yourname and address wili be public information when received by the Board, Ali the other information about you that you provide will be private data until the Board issues your license. When the Board issues your ' license, all of the information you have provided to °. the Board in the process of appiying for your license ; will become public exceptfor your social security num- ber, which remains priva4e. if the Board does nof issue you a license, aii the infor- mation you have provided in the process of appiying for a license remains private, wiih the exception of your name and address, which wifl remain public. Private data about you is available only to the foltow- ing: Board members, staff of the Board whose work assignment requires that fhey have access to the information; the Minnesota Departmenf of Public Safety; the Minnesota Attorney General; the Minne- sota Conimissioners of Administration, Finance, and Revenue; the Legislative Auditor; national and inter- national gambling regulatory agencies; anyone pur- suanf to court order, other individuais and agencies fhat may be specifically author'¢ed by state or federat Iaw to have access to such information; individuals and agencies forwhich law or legal order authorizes a new use or sharing of the information after this notice is given; you; and anyone with your written consent Notary Public lnformation. Notary aub�ic Sea� must be curren�� wrrech, seal may not be aitered. ^ �..a. _ _2�. G . . AA MAAAMMM/y�MM/�/� • l �. . . NDTakY VU 9 �'� . RAMSEY CpUNTY My �emm. EzD�r•� Jan. 31, 2000 JUN 12�16 612 98'/. p_q-� ORIGINAL Green Sheet S 35349 1 2 3 4 $ 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 31 Presented Referred To Council File � `� f U � ✓ Ordinance # Committee: Date RESOLVED: That application for new Gambling Manager's Licenses by Marilyn Sherrick DBA Harding Area Hockey, ID $66756 at Minnehaha Tavern, 735 White Bear Avenue and ID �22873 at Michaels, 1179 E. 7th Street, be and the same are hereby approved. Requested by Department of: ��_ - -� - t .- .e- _�. � • :_u - r - . . � � � I � Form Approved b City Attorne By: U liwG� �� Approved by Ma or for Submission to Council By: Approved Date RESOLUTION CITY OF SAINT PAUL, MINNESOTA �� By: By: Adopted by Council: Date � Adoption Certified by Councxl Secretary � - �� EPARTME� OATEWRIATED GREEN SHEE N _ 35349 CONTACT PEASON & PHONE INITIAUDATE �NITIAUDATE �DEPARTMENTOIRECTOR OCRYCOUNCIL William F. Gunther — 266-9132 ��eN � arvnrroaNEr � cmc�AK MUST BE ON CAUNCIL AGENDA BV (DA7Ej RU O gUDGET �IRECfOfi O FIN. & MGT. SERVICES Dlfl. H28TlIIg. � /, OflDEP � MAVOR (ORASSISTANT) O TOTAL # OF SIGNATURE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE) ACT10N qEQUESTED: Marilyn Sherxick DBA Harding Area Hockey Association requests Council approval of her application for a Gambling Manager's License, ID �i66786 at Minnehaha Tavern, 735 White Bear Avenue and ID 4122873 at Michaels, 1179 E. 7th Street. qECOMMENDAi1oNS: approve (A) or Reject (H) pERSONAL SERVICE CONTRACTS MUST ANSWER TXE FOLLOWING QUESTIONS: _ PLANNING CAMMISSION _ CIVI� SEflVICE CAMMISSION ti� Has this persoNfirm ever worked unEer a coMract for this tlepartment? - _ CIB COMMITTEE _ YES NO __ STAFF 2_ Has this person/firm ever been a ciry employee? — VES NO , DISTRICTCOURT _ 3. Does Nis persoMirm possess a skil� no[ normall � y possessed by any curteM city employee. SUPPOflTSWHICHCOUNCILO&IECTIVE? YES NO Explain ell yes answers on separete sheet antl attech to green sheet INITIATING PROBIEM, ISSUE.OPPORTUNITV (Who, What. Whan, Where, Why): . �� JUfJ ?7 1997 � �' �� K�� AOVANTAGES IF APPROVED: � DISADVANTAGES IiAPPROVED: DISADVANfAGES IF NOT RPPSiOVEO: � "��_ �i ��JJ TOTAL AMOUNT OF TqANSACTION S COST/REVENUE BUDGETED (CIRCLE ONE) YES NO FUNDIHG SOURCE ACTIVI7Y NUMBER - FINANCIAL INFORMATION: (E%PLAIN) . Greensheet # 35349 L.I.E.P. REVIEW CHECKLIST �ate: /�� — � 3 In TraCkB(?___1TL�� ApP'n Rece'rved / ApP'n Processetl License ID # 66786 & 9�22873 License Type: GamblinQ Mana�er Company Name: Marilvn Sherrick DBA: HardinQ Area Hockev Association Business AddressS: 735 White Beai Ave. (Minnehaha Tavern) BUSiness Phone: 738-3002 Contact Name% Date to Council Home Phone: 738-3002 Public Hearing Date: (�j� G. ISFf� Notice Sent to Applicant: 7�/ ��/ Notice Sent to Public: N A iabefs Ordered: NiA District Council #: O� OcC Ward #: �� Department/ Date Inspections Comments City Attorney o� �/i�/97 Environmental Heatth /V�� Fire /v /� License Site Plan Received: Lease Received: �/� Police J��c-"r�-, l�Y1fL'.� FJ?�i1-(�.LrlGi ` � J Zoning �� Gambling Control Board Fax=612 Mistne.�;nfa LawfuI Gaml>ding Gaxnbling Manager Applica Incomplete, false, or misleadng application infotmation may Organization Information (Cannotbegarnbiing mana9er) �/ DaytimePhone /� � � 7(} "�3y7 OrganizationBaseLicense Gambiing Manager Information Board C e Lic # uence # � First Name Full Middle Name Y/i-c�. �� J L�! �ar.ie w�� MaidenName DakofBirfh1fL/a�/, Checkoneoftheba�es: � Mafe � Female Soaai SeCUrity r. < i � Daytime Phone Number(�C /o! )'/ . Y fj - 1 became an adive member ofthis organization on: f attended fhe two•day gambt;ng manager seminar on: Jun 13 '97 11�53 , �y'� JUi�'1997 D�sctosure of Seclai Security Number Yw are requireC toprovideywr sodal secu- rirynumberonthiskrm.Your soaaisecu- rdy num6er will be used to determir�e your compfiance with tha tax Iaws of Minnesota. Av[horizationfot raquirir�qyoursocialsecu- rity number is found ata2 U.S.C. 40S(c)ii). �Oi1t� �iIfOTCi1&�IOii A$10,000 fidelity bond in favor of fhe organization has been ubtained as re�uired by Minnesota Statutes, seetion 349.167, subdivision 1. 4nsurance Company Name: �L fZ��u�i�r !. Bond Number.��S y (DO NOT USE THE AGENCY NAME) Gam biing Manager Change �en your organization is changing'rts gambling manager, complete one ofFhesa sections: Emargency Change - Altow up to five days for processing The chief �;<��::6ve officer, by signing below, affirms that the ema�gency a�plication is dus tn+he fallowing reason (check one and fill in daYe): ❑ Death of gambling manager on _/ / � Disabiliry of gambling manager on / / �$( Termination ot employment of gambling manager on _�I�Q�� tJOT6: 7he new gambiing manager may. not assume du[ies until he/she has received the gambling manage�s license from the Gambling Control Board. Sigttature of CEO _ C�� //6 Notarized�aureofChiaf tive'Offcor(CEO) �a�, �- � -- 97 . , OthC� ChaOge - Allow up fo ten weeks for processing The new gambling manager's license should become effective (check one): ❑ The day a �r u e curra�t gambling manage�s license expires (forexample, ifthe currentgambling managers (icense expires 7l31/96, the new gambling manager's license 6ecomes effecfive on 8/1/96, provided that ali appfication information is complete). � When the application has been processed bythe Gam- bling CoMrol Baard--the e8ective date wili be the first day of tt�e month. NOTE: The new gambling manager may not assume duties unfif he/she has received a gambting manager's license from the Gambiing Controi Boarci. Notary Publsc lnformation. t�otasy Pubttc sea� must be current and correck seal may not be altered. Subscr d and swom to before me this day of ��_ 19 ' Nohry Pubfic- Mir Commission Fxqices 1 JUN-13-199? 12�15 612 `98r �n� on b ) ]Oy if'tlnGnt/��.�e/ � ��7�6 os.�. .z/�/��2 P. 02/03 �_Y�3 LG212 siss Page 1 of 2 Gambling Control Board Fax�612 Gambling Manager Ap. .ication (continued) Affidavit and Consent Sta#ement: under oath stata that I have never: 1. been convicted of a felony or a crime involving gam- bling; 2. committedaviolationoffaworBoardrulet}tatresulted in the revoca5on ot a license issued by fhe Board within five years before the date of the license applica6on; 3. beeh convitted of a crimina( violation involving fraud, theft, taxevasion, misrepresentation, orgambling; 4. been convicted of (i) assau(t, (ii) a criminai v(olation involving the use of a firearm, or (iii) making terroristic threats. 5. been connecfed with nor engaged in an iilegal busi- ness; 8. owed $500 or more in delinquent taxes as defined in section 270.72; 7, had a sales and use tax permit revoked by the com- missioner of revenue within the past two years; 8. faifed to file, after demand, tax returns required by the commissioner of revenue. in addition, I understand, agree, and hereby irrevocably consent that suits and actions relating to the subject mat- ter of the attachatl gambling manager license application, or aets or omissions arising from such aoplica5on, may be commenced against me or my organization and 1 wi11 accept the service of process in any couri of competent jurisdiction in Minnesota by service on the Minnesota Secretary of State of any summons, process, or pleading authorized byfhe Iaws of Minnesota. Sy signature of this documerrt, the undersigned aufhorizes the Departments of Public Safety and Revenue to con- duct a criminai and tax background check or review and to share thP resuf+s �uiYn ?he G�rmh[ir.� Cor.HO! Boad. Failure to provida required information or providing false or misleading information may result in the denial or revocation of the license. FURTHER AFFIANT SRYET'H NOT, except that this Affidavit and Consent Statement are subm'�tted in sapport of the application for a gambling manager license from the Gamblina Control eoattl. Signature o# Gambling Manager Applicant �-, ' .� . � .��9.,�.��v NotarizedSig atureofApplicant 6-.�-- 9� Date Jun 13 '97 11�53 P.03/03_G��_d•� 8/96 Page 2 of 2 This publication will be made available in alternalive format (i.e. Iarge print, Braille) upon request. If you use a 7TY, you can cail us using the Minnesota Re;ay Service at 1-8�0-627�529 and ask them to place a cali to (612) 639-4000. T�e information requested on this form will be used by the Gambling Control Soarcl (Board) to determine your compliance with Minnesota statutes and rules goveming Iawful gambling activities. AII of the infor- mation that you suppiy on this form will become public information when received by the Board. The information requested on this form (including any attachments) will be used by the Board to determine your qualifications to be involved in lawfui gamb(ing activities in Minnesota, and to assist the Board in conducting a background investigation of you. You have the right to refuse to supply the information requested; however, if you refuse to supply this infor- ma6on, the Board may not be able to determine your qualifications and, as a consequence, may eefuse to issue you a Iicense. If you supply the ir�formafion required, the Board will be able to process your appli- cation. Yourname and address wili be public information when received by the Board, Ali the other information about you that you provide will be private data until the Board issues your license. When the Board issues your ' license, all of the information you have provided to °. the Board in the process of appiying for your license ; will become public exceptfor your social security num- ber, which remains priva4e. if the Board does nof issue you a license, aii the infor- mation you have provided in the process of appiying for a license remains private, wiih the exception of your name and address, which wifl remain public. Private data about you is available only to the foltow- ing: Board members, staff of the Board whose work assignment requires that fhey have access to the information; the Minnesota Departmenf of Public Safety; the Minnesota Attorney General; the Minne- sota Conimissioners of Administration, Finance, and Revenue; the Legislative Auditor; national and inter- national gambling regulatory agencies; anyone pur- suanf to court order, other individuais and agencies fhat may be specifically author'¢ed by state or federat Iaw to have access to such information; individuals and agencies forwhich law or legal order authorizes a new use or sharing of the information after this notice is given; you; and anyone with your written consent Notary Public lnformation. Notary aub�ic Sea� must be curren�� wrrech, seal may not be aitered. ^ �..a. _ _2�. G . . AA MAAAMMM/y�MM/�/� • l �. . . NDTakY VU 9 �'� . RAMSEY CpUNTY My �emm. EzD�r•� Jan. 31, 2000 JUN 12�16 612 98'/. p_q-� ORIGINAL Green Sheet S 35349 1 2 3 4 $ 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 31 Presented Referred To Council File � `� f U � ✓ Ordinance # Committee: Date RESOLVED: That application for new Gambling Manager's Licenses by Marilyn Sherrick DBA Harding Area Hockey, ID $66756 at Minnehaha Tavern, 735 White Bear Avenue and ID �22873 at Michaels, 1179 E. 7th Street, be and the same are hereby approved. Requested by Department of: ��_ - -� - t .- .e- _�. � • :_u - r - . . � � � I � Form Approved b City Attorne By: U liwG� �� Approved by Ma or for Submission to Council By: Approved Date RESOLUTION CITY OF SAINT PAUL, MINNESOTA �� By: By: Adopted by Council: Date � Adoption Certified by Councxl Secretary � - �� EPARTME� OATEWRIATED GREEN SHEE N _ 35349 CONTACT PEASON & PHONE INITIAUDATE �NITIAUDATE �DEPARTMENTOIRECTOR OCRYCOUNCIL William F. Gunther — 266-9132 ��eN � arvnrroaNEr � cmc�AK MUST BE ON CAUNCIL AGENDA BV (DA7Ej RU O gUDGET �IRECfOfi O FIN. & MGT. SERVICES Dlfl. H28TlIIg. � /, OflDEP � MAVOR (ORASSISTANT) O TOTAL # OF SIGNATURE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE) ACT10N qEQUESTED: Marilyn Sherxick DBA Harding Area Hockey Association requests Council approval of her application for a Gambling Manager's License, ID �i66786 at Minnehaha Tavern, 735 White Bear Avenue and ID 4122873 at Michaels, 1179 E. 7th Street. qECOMMENDAi1oNS: approve (A) or Reject (H) pERSONAL SERVICE CONTRACTS MUST ANSWER TXE FOLLOWING QUESTIONS: _ PLANNING CAMMISSION _ CIVI� SEflVICE CAMMISSION ti� Has this persoNfirm ever worked unEer a coMract for this tlepartment? - _ CIB COMMITTEE _ YES NO __ STAFF 2_ Has this person/firm ever been a ciry employee? — VES NO , DISTRICTCOURT _ 3. Does Nis persoMirm possess a skil� no[ normall � y possessed by any curteM city employee. SUPPOflTSWHICHCOUNCILO&IECTIVE? YES NO Explain ell yes answers on separete sheet antl attech to green sheet INITIATING PROBIEM, ISSUE.OPPORTUNITV (Who, What. Whan, Where, Why): . �� JUfJ ?7 1997 � �' �� K�� AOVANTAGES IF APPROVED: � DISADVANTAGES IiAPPROVED: DISADVANfAGES IF NOT RPPSiOVEO: � "��_ �i ��JJ TOTAL AMOUNT OF TqANSACTION S COST/REVENUE BUDGETED (CIRCLE ONE) YES NO FUNDIHG SOURCE ACTIVI7Y NUMBER - FINANCIAL INFORMATION: (E%PLAIN) . Greensheet # 35349 L.I.E.P. REVIEW CHECKLIST �ate: /�� — � 3 In TraCkB(?___1TL�� ApP'n Rece'rved / ApP'n Processetl License ID # 66786 & 9�22873 License Type: GamblinQ Mana�er Company Name: Marilvn Sherrick DBA: HardinQ Area Hockev Association Business AddressS: 735 White Beai Ave. (Minnehaha Tavern) BUSiness Phone: 738-3002 Contact Name% Date to Council Home Phone: 738-3002 Public Hearing Date: (�j� G. ISFf� Notice Sent to Applicant: 7�/ ��/ Notice Sent to Public: N A iabefs Ordered: NiA District Council #: O� OcC Ward #: �� Department/ Date Inspections Comments City Attorney o� �/i�/97 Environmental Heatth /V�� Fire /v /� License Site Plan Received: Lease Received: �/� Police J��c-"r�-, l�Y1fL'.� FJ?�i1-(�.LrlGi ` � J Zoning �� Gambling Control Board Fax=612 Mistne.�;nfa LawfuI Gaml>ding Gaxnbling Manager Applica Incomplete, false, or misleadng application infotmation may Organization Information (Cannotbegarnbiing mana9er) �/ DaytimePhone /� � � 7(} "�3y7 OrganizationBaseLicense Gambiing Manager Information Board C e Lic # uence # � First Name Full Middle Name Y/i-c�. �� J L�! �ar.ie w�� MaidenName DakofBirfh1fL/a�/, Checkoneoftheba�es: � Mafe � Female Soaai SeCUrity r. < i � Daytime Phone Number(�C /o! )'/ . Y fj - 1 became an adive member ofthis organization on: f attended fhe two•day gambt;ng manager seminar on: Jun 13 '97 11�53 , �y'� JUi�'1997 D�sctosure of Seclai Security Number Yw are requireC toprovideywr sodal secu- rirynumberonthiskrm.Your soaaisecu- rdy num6er will be used to determir�e your compfiance with tha tax Iaws of Minnesota. Av[horizationfot raquirir�qyoursocialsecu- rity number is found ata2 U.S.C. 40S(c)ii). �Oi1t� �iIfOTCi1&�IOii A$10,000 fidelity bond in favor of fhe organization has been ubtained as re�uired by Minnesota Statutes, seetion 349.167, subdivision 1. 4nsurance Company Name: �L fZ��u�i�r !. Bond Number.��S y (DO NOT USE THE AGENCY NAME) Gam biing Manager Change �en your organization is changing'rts gambling manager, complete one ofFhesa sections: Emargency Change - Altow up to five days for processing The chief �;<��::6ve officer, by signing below, affirms that the ema�gency a�plication is dus tn+he fallowing reason (check one and fill in daYe): ❑ Death of gambling manager on _/ / � Disabiliry of gambling manager on / / �$( Termination ot employment of gambling manager on _�I�Q�� tJOT6: 7he new gambiing manager may. not assume du[ies until he/she has received the gambling manage�s license from the Gambling Control Board. Sigttature of CEO _ C�� //6 Notarized�aureofChiaf tive'Offcor(CEO) �a�, �- � -- 97 . , OthC� ChaOge - Allow up fo ten weeks for processing The new gambling manager's license should become effective (check one): ❑ The day a �r u e curra�t gambling manage�s license expires (forexample, ifthe currentgambling managers (icense expires 7l31/96, the new gambling manager's license 6ecomes effecfive on 8/1/96, provided that ali appfication information is complete). � When the application has been processed bythe Gam- bling CoMrol Baard--the e8ective date wili be the first day of tt�e month. NOTE: The new gambling manager may not assume duties unfif he/she has received a gambting manager's license from the Gambiing Controi Boarci. Notary Publsc lnformation. t�otasy Pubttc sea� must be current and correck seal may not be altered. Subscr d and swom to before me this day of ��_ 19 ' Nohry Pubfic- Mir Commission Fxqices 1 JUN-13-199? 12�15 612 `98r �n� on b ) ]Oy if'tlnGnt/��.�e/ � ��7�6 os.�. .z/�/��2 P. 02/03 �_Y�3 LG212 siss Page 1 of 2 Gambling Control Board Fax�612 Gambling Manager Ap. .ication (continued) Affidavit and Consent Sta#ement: under oath stata that I have never: 1. been convicted of a felony or a crime involving gam- bling; 2. committedaviolationoffaworBoardrulet}tatresulted in the revoca5on ot a license issued by fhe Board within five years before the date of the license applica6on; 3. beeh convitted of a crimina( violation involving fraud, theft, taxevasion, misrepresentation, orgambling; 4. been convicted of (i) assau(t, (ii) a criminai v(olation involving the use of a firearm, or (iii) making terroristic threats. 5. been connecfed with nor engaged in an iilegal busi- ness; 8. owed $500 or more in delinquent taxes as defined in section 270.72; 7, had a sales and use tax permit revoked by the com- missioner of revenue within the past two years; 8. faifed to file, after demand, tax returns required by the commissioner of revenue. in addition, I understand, agree, and hereby irrevocably consent that suits and actions relating to the subject mat- ter of the attachatl gambling manager license application, or aets or omissions arising from such aoplica5on, may be commenced against me or my organization and 1 wi11 accept the service of process in any couri of competent jurisdiction in Minnesota by service on the Minnesota Secretary of State of any summons, process, or pleading authorized byfhe Iaws of Minnesota. Sy signature of this documerrt, the undersigned aufhorizes the Departments of Public Safety and Revenue to con- duct a criminai and tax background check or review and to share thP resuf+s �uiYn ?he G�rmh[ir.� Cor.HO! Boad. Failure to provida required information or providing false or misleading information may result in the denial or revocation of the license. FURTHER AFFIANT SRYET'H NOT, except that this Affidavit and Consent Statement are subm'�tted in sapport of the application for a gambling manager license from the Gamblina Control eoattl. Signature o# Gambling Manager Applicant �-, ' .� . � .��9.,�.��v NotarizedSig atureofApplicant 6-.�-- 9� Date Jun 13 '97 11�53 P.03/03_G��_d•� 8/96 Page 2 of 2 This publication will be made available in alternalive format (i.e. Iarge print, Braille) upon request. If you use a 7TY, you can cail us using the Minnesota Re;ay Service at 1-8�0-627�529 and ask them to place a cali to (612) 639-4000. T�e information requested on this form will be used by the Gambling Control Soarcl (Board) to determine your compliance with Minnesota statutes and rules goveming Iawful gambling activities. AII of the infor- mation that you suppiy on this form will become public information when received by the Board. The information requested on this form (including any attachments) will be used by the Board to determine your qualifications to be involved in lawfui gamb(ing activities in Minnesota, and to assist the Board in conducting a background investigation of you. You have the right to refuse to supply the information requested; however, if you refuse to supply this infor- ma6on, the Board may not be able to determine your qualifications and, as a consequence, may eefuse to issue you a Iicense. If you supply the ir�formafion required, the Board will be able to process your appli- cation. Yourname and address wili be public information when received by the Board, Ali the other information about you that you provide will be private data until the Board issues your license. When the Board issues your ' license, all of the information you have provided to °. the Board in the process of appiying for your license ; will become public exceptfor your social security num- ber, which remains priva4e. if the Board does nof issue you a license, aii the infor- mation you have provided in the process of appiying for a license remains private, wiih the exception of your name and address, which wifl remain public. Private data about you is available only to the foltow- ing: Board members, staff of the Board whose work assignment requires that fhey have access to the information; the Minnesota Departmenf of Public Safety; the Minnesota Attorney General; the Minne- sota Conimissioners of Administration, Finance, and Revenue; the Legislative Auditor; national and inter- national gambling regulatory agencies; anyone pur- suanf to court order, other individuais and agencies fhat may be specifically author'¢ed by state or federat Iaw to have access to such information; individuals and agencies forwhich law or legal order authorizes a new use or sharing of the information after this notice is given; you; and anyone with your written consent Notary Public lnformation. Notary aub�ic Sea� must be curren�� wrrech, seal may not be aitered. ^ �..a. _ _2�. G . . AA MAAAMMM/y�MM/�/� • l �. . . NDTakY VU 9 �'� . RAMSEY CpUNTY My �emm. EzD�r•� Jan. 31, 2000 JUN 12�16 612 98'/. p_q-�