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97-92Council File # \ R - � � ordinance # RESOLUTION OF SAINT PAUL,,MI Presented By _ Referred To Green Sheet# 35422 ►_� Committee: Date �9, 5 6 7 S 9 11 13 1 2 3 4 RESOLVED: That application, I4 #80525, for a new Gambling Manaqe='s License by James B Elmquist DBA Region Two Golden Glove Association at Casey's, 2550 w. 7th St., be and the same is hereby appsoved. Requested by Department of: • - -,-- :�.- .,_ ,e. �_ - •. Form Approved by City Attorney gY: _�1�/9 � � �C�a' `=`� By: k�A,CGe�n � �u�rL+�ts Adoption Certified by Council Secretary By: App By: 1 ��_._ _ t—'C. roved by Mayor: Date 2�j z{g 7- ________-�� c Appraved by Mayor for Submission to Council By: Adopted by council: Date �,�,_ S� : . `C�l - `� � DEPAfiTMENT/OFFICEJCqUNCIL DATEINRIA7ED GREEN SHEE N� 35422 LIEPfGambling - - - - CONTACT PERSON & PHONE INITIAL/DA7E INITIALNATE � DEPARTMENT DIPEGTOFi O CITY COUNGIL William F. �unther - 266-9132 A �� N � C(fYATTONNEV � CITYGLERK MUST BE ON CAUNCIL AGENDA BY (DATE) XUMBEA FOR ❑ BUDGET DIRECTOR O FIN. & MGT. SERVICE$ DIR. ROUTING H23TlII : ORDEfl O MAYOR (OR ASSISTANif O TOTAL # OF SIGNATURE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE) ACTION AE-0UES7E�: James B. Elmquist DBA Region 7tao Golden Gloves Association requests Council approval of his application for a new Gambling Manager's License, ID �180525, at Casey's, 2550 W, 7th Street. fiECAMMENDp51oNS; Approva (A) or Xeject (R) pERSONAL SEHVICE CONTBAC7S MUST ANSWER THE FOLLOWING QUESTIONS; _ PLANNWG C�MMISSION _ CML SERVICE COMMISSION 1. Has this personNirm ever worked untler a contract tor Mis department? - _ CIB COMMITTEE _ YES NO _ STAFF 2 Has [his perso�rm ever been a ciry employee? — YES NO _. DISTqICT COUPT _ 3. Doe6 this pe[SONfltfil 5S25S 8 Skill f10f n0[rt181 po ly possessed by eny current city employee? SUPPORTS WHICH COUNCIL OBJECilYE9 YES NO Explain afl yas enswers on separete sheet and etlach to green sheet INITiRTING PROBLEM, ISSUE, OPP�RTUNITY (WFro, What, Whan, Where, Wiry): 1��g C��`�� n� 8:c ,lAM 1 � 1997 ��-� �U �� R�1EY ADVANTAGESIPAPPROVED: �' �� EB ��' 199� "��Yt3R'S �r�lC� DISADVANTAGES IFAPPROVE�: 5 � gO ¢� e�wra.d F,°�,,t•r^.""°�:i S„v.,.'��'.;r' 53�`�°ue�6� CC., _ _ �. 5��4 2 �3 i:��i DISADVANSAGES IF NOT APPflOVED: 2. �� , �615 ,7i1�a �'! "�� TpTqL AMOUNT OF TRANSACTION $ COST7REVENUE BUDGE7ED (CIPCLE OIiE) YES NO fUNDIHG SOURCE ACi1VITV NUMBER FINANCIAL iNFOBMATiON: (E%PLAIN) '� � Greensheet #35�oZo2- In Tracker?_T/a-? 9� Ltcense I Compam Business Contact °f `l-� � L.I.E.P. REVIEW CHECKLIST Date: 1 j+PP'n Aeceived f APP'n Processetl Date to Council Research: J�c27� f Public Hearing Date: ��r .�> 14�7 Notice Sern to Appiicant: ! ��7 �9'7 Labels Ordered: N//� DiStfiCt COUnCiI #: /`J' Notice SeM to Public: 11� j3 Ward #: �.� Department/ Date Inspections Comments Cfty Attorney � � � � /) e 1 �� " � � /�6 f9 r� oK l a"/ � (_ �l �' , � rr Envlronmental Nealth �'1� Fire �� License �� Lease Received: ^ �1l / Paiice S }�t/� ! ! / �C'_COIYY l.�It�C� J'y'��-1'/�U Q � 6 % �`j�f 9� Zoning Nf � -, Gam6ling Control Board Fax�612 Jan 7'97 17=04 P.02�03 � Organization )nformation OlC CEOName `��li"i V!; � G!s i N �,/o oG�� , (Carnotreoembiing manager DaytimePhone(�f� }'I?I D �I� Organizaiion Gambfing Manager Information Firs: �ar2�R ii'� � S �ull SUidd NST° I'�' �" Maiden Name Date of Blrth 1� 1� Sociai Security Home SSreetA� —n o — DaytimePhoneNumber( G /� )��{`� I Became ao active member of this organization on: l atrended the two-day gambling �� nag� emin�� :� w ) e .jf an: Minrzesota LaurfuZ GambZing ��zt2 Gambling �axa.agex A.pplication pa9 � {ncomplete, false, or misiead'ing 2pplication inforrnation may result in deniaf of a license. , o Q ll � Soard 2 LiC i�` # � � ' l o�. � �� i�.�i �� LastName�/1�/` u/ � Check one ofthe boxes � Male � Fema'e Q f Disclosure of � g Sociat Securrty Number "�"�� Yova2requiredtopravideyoursoaaisecu- ritynumberonthisform,YOUr soclalsscu- rity number Nill bz vsad to determme your r compiianCe with the tax laws of MinncSata. �� Authorizationfai requiringyoursociafsecu- nfy number is found af 42 U.S C, a05(clfl. Bond lnformation A$10,00� fidelity bond in favor otthe organization has 6een obtained as required by Minnesota Stafutes, sectian 349,'167, subdivis'ro� 1. insurance Company Nam�: i ( �� Al�o� _L^ ��°mh�l �a� ond Number. �- � 7�/ /�� (DO NOT USE THE AGE(VCY NAME) 'r�GrC L{ntv�e�si -- - --- - --- _ _ _ � 1 R . lhrr��sa41 LG�'1 , s`3 7a S� Gambling Manager Change �en your organ'�zation is' one of fhese sections� Emergency Change - A1tow up to �ve days tor pracessing The chief execufive officer, by signing below, affirms ihst the en�rgency zppficaii�i i; duE to tna �oliowiag reason (check orse and fill in date): � Death of gambiing manager on /,,,/,_ Disability of gambling manager on �I Termination of empfoyment of gamb(ing manager on �_� � 3 j�. NOTE: The new gambling manager may not assume duties untii helshe has received the gambli�g managers license from the Gambting Controi 8oard. Sianature of af Chief Executive Ofricer �eSC�I �X�.4�,�s.�i �A,L � 1'� ! 1', a t"1 ! 1 r'. 1 Q' P.-. Cl [c.�:�ar4 n� JAN-07-1997 16�2 manager, compfete ; Other Chang2 - A{low up to te� weeks for processing ��j ; The new gambling manager's Sicense should become '(i`� ; ePFec#ive (check onej: 1 �(] The tlay after the aurrent gambling manager's iicense �'' j expires forezam te, if jk�ecbi�=�ep,t�'aambiing manager's ( p '�/ , Iicense expires 7/31/9,�,� the ne�w gai��I�ng managers �`�y (icense becomes effe ocn_/1f�6, �pvided that ai �� ; applica6on informa4''on�'PS� ��`�t�). �� ` ; ;� �� When fhe appiicatio'b h�s ti�eh -�ss � y the Gam- i bling ConVo! 6oari�-�(he`�€�',�e dat ' ! be the first � � day of the month. �y y_ ,.1, �G � NOTE: The new gamb?i�g��r�°�jnay not assume ; dufi�s unGl helshe has received a gambling manager's :., I'�cens the Gambling Control6oard. ]Oforfftation. Not3ry Public Scal must �� "•�.�( ryb�'y ` corr'0et,,,s�ea1 may not be aftered. � ea � _� t� ' �� arid swom j j a O + :�b'�e,jne this { � day � . Ai=^a� �K n , 19 _ �� -�- � � � • ' •' = v u�t,� � NoW P ic ^ •,.„y � �� - ta 1 in d on back} . ,.. �„ P�. ' ,n1 1 �� 6�z g�, �05',�� 1��l�7� 6ambling Control Board Fax�612 Gambling Manager Affidavit y a ! nd Co S 1, (print name) .1 A Y'i � S %j/�c� L�. � under oath state that I have never; 1. been convicted of a fefony or a crime invo{ving gam- bling; 2. committed a violation of lGw or Board rule that resuited in the revocation oP a ticense issued by the Board within five years befare the date of fhe license application: 3. been convicted of a criminal violation involving fraud, theft, tax evasion, misrepresentation, orgambling; 4. been convicted of (ij assauit, {ii) a criminai violation invalving the use of a ficearm, or (iii) making terroristic threats. 5, bsen connected with nor angaged in an iliegal bu5i- ness; 6. owed �500 or more in delinquent taxes as defined in section 270.72; 7. had a sales and use tax parmit revoked by the com- missioner of revenue wifhin the past two years; 8. failed to fite, after demand, tax returns required by the commissionerof revenue, In adtlition, ! understand, agree, and heseby irtevocably consent that suits and actions relafing to the subject mat- ter ot the attached gambling manager license appf ication, oracts oromissions arising from such appiication, maybe commenced against me or my organizafion aad I will accEpt the serfice o4 process in any court of competent jurisdiction in Minnesota by service on the Minnesota Secretary of SYate of any summons, process, orpieading aufhofized by the lativs of Minnesota. By signature of this document, the unclersigned author¢es the Departments of Public Safety and Revenue to con- duct a crimina4 antl tax background check or review and to share the resu3ts with the Gambting Con{rol 6oard. Failure fo provide required information or providing false or misleading information may result in the denial or revocation ofthe ficense. . FURTHER AFFIANT SAYETH HOT, excepf that this Affrdavit and Consent StatemenE are submitted in support of the appiication for a gambling manager iicense from the Gambiing Control Board. Sigriature of Gambting A�plicant � �,�� JRN-07-1997 16-21 612 Jan 7 '97 17�05 P. 03iO3 ��—��.. LG252 $/96 Page 2 of 2 This pub(ication wi11 6e made avai!able in alternative fosmat {i.e. large print, Brailfe} upon request. fF you use a M, you can call us using Yhe Minnesota Relay Service at (612) 297-5353 or 1-800-627-3529 and ask them to pface a call to (6'I2) 639�000, The information requested on this form wilf be used by the Gambiing Coniroi Soard (BOard) to defermine your compliance with Minnesota statutes and rules governing lavrful gambling activi6es. Ali of the infos- ma6on that you suppiy Qn fhis form wiil become public information when received by the Board. The information requested on this form (including any atfachments) will be used by the 8oard to determine your qualifica6ons to be invoivetl in lawFui gambling activities in Minnesota, and to assist the Board in conducting a baokground investigation of you. You have the right to refuse fo supply ihe informaiion requested; however, if you refuse to supply this infor- mation, the Board may not be able io determine your qualifications and. as a consequence, may refuse to issue you a ficense. If you supply the informafion required, the Board wili Be abfe to process your appli- caEion. Your name and address wili be pu blic information when received by fhe Board. Ali the other information ahout you that you provide will Be privafe data until the 6oacd issues your license. When the Board issues your license, al! of the information yau have provided to the Board in the process of applying for your license wiil become puolic exceptforyoursocial security num- ber, which remains private. !f the Board does nof issue you a ficense, all the infior- mation you have provided in the process of applying for a license remains private, wiih the excepticn of your name and address, which wi1! remain pubiic. Privat2 data about ydu is available only to the follow- ing: �Board members, statF of the Board whose work assignment requires tfiat they have access to the informat'ron; the Minnesota Department of Pub{ic Safefy; the Minnesota Attorney Generah the Minne- sota Comm"tssioners of Administrativn, Finance, and Revenue; the Legislative Auditor; national and inter- national gambling regulatory agencies; anyone pur- suant to court order; other individuals anU agencies fhaf may be specificaily authorized by state os federal (aw to have access to such information; indivitluafs and agencies forwhych law or (egat orderauthorizes a neva use or sharing of the information after this notice is given; you; and anyone with your written consent. itary Public �nformation. Notary public Seaf must Cuf�ent and correct; seal may not 6e altered. oscrib��d a�nd swam to 6efore me this � � day �_xd_.S � L� � . �9 . " va"�x\., . '��j"•� �a , 97i P.03 Council File # \ R - � � ordinance # RESOLUTION OF SAINT PAUL,,MI Presented By _ Referred To Green Sheet# 35422 ►_� Committee: Date �9, 5 6 7 S 9 11 13 1 2 3 4 RESOLVED: That application, I4 #80525, for a new Gambling Manaqe='s License by James B Elmquist DBA Region Two Golden Glove Association at Casey's, 2550 w. 7th St., be and the same is hereby appsoved. Requested by Department of: • - -,-- :�.- .,_ ,e. �_ - •. Form Approved by City Attorney gY: _�1�/9 � � �C�a' `=`� By: k�A,CGe�n � �u�rL+�ts Adoption Certified by Council Secretary By: App By: 1 ��_._ _ t—'C. roved by Mayor: Date 2�j z{g 7- ________-�� c Appraved by Mayor for Submission to Council By: Adopted by council: Date �,�,_ S� : . `C�l - `� � DEPAfiTMENT/OFFICEJCqUNCIL DATEINRIA7ED GREEN SHEE N� 35422 LIEPfGambling - - - - CONTACT PERSON & PHONE INITIAL/DA7E INITIALNATE � DEPARTMENT DIPEGTOFi O CITY COUNGIL William F. �unther - 266-9132 A �� N � C(fYATTONNEV � CITYGLERK MUST BE ON CAUNCIL AGENDA BY (DATE) XUMBEA FOR ❑ BUDGET DIRECTOR O FIN. & MGT. SERVICE$ DIR. ROUTING H23TlII : ORDEfl O MAYOR (OR ASSISTANif O TOTAL # OF SIGNATURE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE) ACTION AE-0UES7E�: James B. Elmquist DBA Region 7tao Golden Gloves Association requests Council approval of his application for a new Gambling Manager's License, ID �180525, at Casey's, 2550 W, 7th Street. fiECAMMENDp51oNS; Approva (A) or Xeject (R) pERSONAL SEHVICE CONTBAC7S MUST ANSWER THE FOLLOWING QUESTIONS; _ PLANNWG C�MMISSION _ CML SERVICE COMMISSION 1. Has this personNirm ever worked untler a contract tor Mis department? - _ CIB COMMITTEE _ YES NO _ STAFF 2 Has [his perso�rm ever been a ciry employee? — YES NO _. DISTqICT COUPT _ 3. Doe6 this pe[SONfltfil 5S25S 8 Skill f10f n0[rt181 po ly possessed by eny current city employee? SUPPORTS WHICH COUNCIL OBJECilYE9 YES NO Explain afl yas enswers on separete sheet and etlach to green sheet INITiRTING PROBLEM, ISSUE, OPP�RTUNITY (WFro, What, Whan, Where, Wiry): 1��g C��`�� n� 8:c ,lAM 1 � 1997 ��-� �U �� R�1EY ADVANTAGESIPAPPROVED: �' �� EB ��' 199� "��Yt3R'S �r�lC� DISADVANTAGES IFAPPROVE�: 5 � gO ¢� e�wra.d F,°�,,t•r^.""°�:i S„v.,.'��'.;r' 53�`�°ue�6� CC., _ _ �. 5��4 2 �3 i:��i DISADVANSAGES IF NOT APPflOVED: 2. �� , �615 ,7i1�a �'! "�� TpTqL AMOUNT OF TRANSACTION $ COST7REVENUE BUDGE7ED (CIPCLE OIiE) YES NO fUNDIHG SOURCE ACi1VITV NUMBER FINANCIAL iNFOBMATiON: (E%PLAIN) '� � Greensheet #35�oZo2- In Tracker?_T/a-? 9� Ltcense I Compam Business Contact °f `l-� � L.I.E.P. REVIEW CHECKLIST Date: 1 j+PP'n Aeceived f APP'n Processetl Date to Council Research: J�c27� f Public Hearing Date: ��r .�> 14�7 Notice Sern to Appiicant: ! ��7 �9'7 Labels Ordered: N//� DiStfiCt COUnCiI #: /`J' Notice SeM to Public: 11� j3 Ward #: �.� Department/ Date Inspections Comments Cfty Attorney � � � � /) e 1 �� " � � /�6 f9 r� oK l a"/ � (_ �l �' , � rr Envlronmental Nealth �'1� Fire �� License �� Lease Received: ^ �1l / Paiice S }�t/� ! ! / �C'_COIYY l.�It�C� J'y'��-1'/�U Q � 6 % �`j�f 9� Zoning Nf � -, Gam6ling Control Board Fax�612 Jan 7'97 17=04 P.02�03 � Organization )nformation OlC CEOName `��li"i V!; � G!s i N �,/o oG�� , (Carnotreoembiing manager DaytimePhone(�f� }'I?I D �I� Organizaiion Gambfing Manager Information Firs: �ar2�R ii'� � S �ull SUidd NST° I'�' �" Maiden Name Date of Blrth 1� 1� Sociai Security Home SSreetA� —n o — DaytimePhoneNumber( G /� )��{`� I Became ao active member of this organization on: l atrended the two-day gambling �� nag� emin�� :� w ) e .jf an: Minrzesota LaurfuZ GambZing ��zt2 Gambling �axa.agex A.pplication pa9 � {ncomplete, false, or misiead'ing 2pplication inforrnation may result in deniaf of a license. , o Q ll � Soard 2 LiC i�` # � � ' l o�. � �� i�.�i �� LastName�/1�/` u/ � Check one ofthe boxes � Male � Fema'e Q f Disclosure of � g Sociat Securrty Number "�"�� Yova2requiredtopravideyoursoaaisecu- ritynumberonthisform,YOUr soclalsscu- rity number Nill bz vsad to determme your r compiianCe with the tax laws of MinncSata. �� Authorizationfai requiringyoursociafsecu- nfy number is found af 42 U.S C, a05(clfl. Bond lnformation A$10,00� fidelity bond in favor otthe organization has 6een obtained as required by Minnesota Stafutes, sectian 349,'167, subdivis'ro� 1. insurance Company Nam�: i ( �� Al�o� _L^ ��°mh�l �a� ond Number. �- � 7�/ /�� (DO NOT USE THE AGE(VCY NAME) 'r�GrC L{ntv�e�si -- - --- - --- _ _ _ � 1 R . lhrr��sa41 LG�'1 , s`3 7a S� Gambling Manager Change �en your organ'�zation is' one of fhese sections� Emergency Change - A1tow up to �ve days tor pracessing The chief execufive officer, by signing below, affirms ihst the en�rgency zppficaii�i i; duE to tna �oliowiag reason (check orse and fill in date): � Death of gambiing manager on /,,,/,_ Disability of gambling manager on �I Termination of empfoyment of gamb(ing manager on �_� � 3 j�. NOTE: The new gambling manager may not assume duties untii helshe has received the gambli�g managers license from the Gambting Controi 8oard. Sianature of af Chief Executive Ofricer �eSC�I �X�.4�,�s.�i �A,L � 1'� ! 1', a t"1 ! 1 r'. 1 Q' P.-. Cl [c.�:�ar4 n� JAN-07-1997 16�2 manager, compfete ; Other Chang2 - A{low up to te� weeks for processing ��j ; The new gambling manager's Sicense should become '(i`� ; ePFec#ive (check onej: 1 �(] The tlay after the aurrent gambling manager's iicense �'' j expires forezam te, if jk�ecbi�=�ep,t�'aambiing manager's ( p '�/ , Iicense expires 7/31/9,�,� the ne�w gai��I�ng managers �`�y (icense becomes effe ocn_/1f�6, �pvided that ai �� ; applica6on informa4''on�'PS� ��`�t�). �� ` ; ;� �� When fhe appiicatio'b h�s ti�eh -�ss � y the Gam- i bling ConVo! 6oari�-�(he`�€�',�e dat ' ! be the first � � day of the month. �y y_ ,.1, �G � NOTE: The new gamb?i�g��r�°�jnay not assume ; dufi�s unGl helshe has received a gambling manager's :., I'�cens the Gambling Control6oard. ]Oforfftation. Not3ry Public Scal must �� "•�.�( ryb�'y ` corr'0et,,,s�ea1 may not be aftered. � ea � _� t� ' �� arid swom j j a O + :�b'�e,jne this { � day � . Ai=^a� �K n , 19 _ �� -�- � � � • ' •' = v u�t,� � NoW P ic ^ •,.„y � �� - ta 1 in d on back} . ,.. �„ P�. ' ,n1 1 �� 6�z g�, �05',�� 1��l�7� 6ambling Control Board Fax�612 Gambling Manager Affidavit y a ! nd Co S 1, (print name) .1 A Y'i � S %j/�c� L�. � under oath state that I have never; 1. been convicted of a fefony or a crime invo{ving gam- bling; 2. committed a violation of lGw or Board rule that resuited in the revocation oP a ticense issued by the Board within five years befare the date of fhe license application: 3. been convicted of a criminal violation involving fraud, theft, tax evasion, misrepresentation, orgambling; 4. been convicted of (ij assauit, {ii) a criminai violation invalving the use of a ficearm, or (iii) making terroristic threats. 5, bsen connected with nor angaged in an iliegal bu5i- ness; 6. owed �500 or more in delinquent taxes as defined in section 270.72; 7. had a sales and use tax parmit revoked by the com- missioner of revenue wifhin the past two years; 8. failed to fite, after demand, tax returns required by the commissionerof revenue, In adtlition, ! understand, agree, and heseby irtevocably consent that suits and actions relafing to the subject mat- ter ot the attached gambling manager license appf ication, oracts oromissions arising from such appiication, maybe commenced against me or my organizafion aad I will accEpt the serfice o4 process in any court of competent jurisdiction in Minnesota by service on the Minnesota Secretary of SYate of any summons, process, orpieading aufhofized by the lativs of Minnesota. By signature of this document, the unclersigned author¢es the Departments of Public Safety and Revenue to con- duct a crimina4 antl tax background check or review and to share the resu3ts with the Gambting Con{rol 6oard. Failure fo provide required information or providing false or misleading information may result in the denial or revocation ofthe ficense. . FURTHER AFFIANT SAYETH HOT, excepf that this Affrdavit and Consent StatemenE are submitted in support of the appiication for a gambling manager iicense from the Gambiing Control Board. Sigriature of Gambting A�plicant � �,�� JRN-07-1997 16-21 612 Jan 7 '97 17�05 P. 03iO3 ��—��.. LG252 $/96 Page 2 of 2 This pub(ication wi11 6e made avai!able in alternative fosmat {i.e. large print, Brailfe} upon request. fF you use a M, you can call us using Yhe Minnesota Relay Service at (612) 297-5353 or 1-800-627-3529 and ask them to pface a call to (6'I2) 639�000, The information requested on this form wilf be used by the Gambiing Coniroi Soard (BOard) to defermine your compliance with Minnesota statutes and rules governing lavrful gambling activi6es. Ali of the infos- ma6on that you suppiy Qn fhis form wiil become public information when received by the Board. The information requested on this form (including any atfachments) will be used by the 8oard to determine your qualifica6ons to be invoivetl in lawFui gambling activities in Minnesota, and to assist the Board in conducting a baokground investigation of you. You have the right to refuse fo supply ihe informaiion requested; however, if you refuse to supply this infor- mation, the Board may not be able io determine your qualifications and. as a consequence, may refuse to issue you a ficense. If you supply the informafion required, the Board wili Be abfe to process your appli- caEion. Your name and address wili be pu blic information when received by fhe Board. Ali the other information ahout you that you provide will Be privafe data until the 6oacd issues your license. When the Board issues your license, al! of the information yau have provided to the Board in the process of applying for your license wiil become puolic exceptforyoursocial security num- ber, which remains private. !f the Board does nof issue you a ficense, all the infior- mation you have provided in the process of applying for a license remains private, wiih the excepticn of your name and address, which wi1! remain pubiic. Privat2 data about ydu is available only to the follow- ing: �Board members, statF of the Board whose work assignment requires tfiat they have access to the informat'ron; the Minnesota Department of Pub{ic Safefy; the Minnesota Attorney Generah the Minne- sota Comm"tssioners of Administrativn, Finance, and Revenue; the Legislative Auditor; national and inter- national gambling regulatory agencies; anyone pur- suant to court order; other individuals anU agencies fhaf may be specificaily authorized by state os federal (aw to have access to such information; indivitluafs and agencies forwhych law or (egat orderauthorizes a neva use or sharing of the information after this notice is given; you; and anyone with your written consent. itary Public �nformation. Notary public Seaf must Cuf�ent and correct; seal may not 6e altered. oscrib��d a�nd swam to 6efore me this � � day �_xd_.S � L� � . �9 . " va"�x\., . '��j"•� �a , 97i P.03 Council File # \ R - � � ordinance # RESOLUTION OF SAINT PAUL,,MI Presented By _ Referred To Green Sheet# 35422 ►_� Committee: Date �9, 5 6 7 S 9 11 13 1 2 3 4 RESOLVED: That application, I4 #80525, for a new Gambling Manaqe='s License by James B Elmquist DBA Region Two Golden Glove Association at Casey's, 2550 w. 7th St., be and the same is hereby appsoved. Requested by Department of: • - -,-- :�.- .,_ ,e. �_ - •. Form Approved by City Attorney gY: _�1�/9 � � �C�a' `=`� By: k�A,CGe�n � �u�rL+�ts Adoption Certified by Council Secretary By: App By: 1 ��_._ _ t—'C. roved by Mayor: Date 2�j z{g 7- ________-�� c Appraved by Mayor for Submission to Council By: Adopted by council: Date �,�,_ S� : . `C�l - `� � DEPAfiTMENT/OFFICEJCqUNCIL DATEINRIA7ED GREEN SHEE N� 35422 LIEPfGambling - - - - CONTACT PERSON & PHONE INITIAL/DA7E INITIALNATE � DEPARTMENT DIPEGTOFi O CITY COUNGIL William F. �unther - 266-9132 A �� N � C(fYATTONNEV � CITYGLERK MUST BE ON CAUNCIL AGENDA BY (DATE) XUMBEA FOR ❑ BUDGET DIRECTOR O FIN. & MGT. SERVICE$ DIR. ROUTING H23TlII : ORDEfl O MAYOR (OR ASSISTANif O TOTAL # OF SIGNATURE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE) ACTION AE-0UES7E�: James B. Elmquist DBA Region 7tao Golden Gloves Association requests Council approval of his application for a new Gambling Manager's License, ID �180525, at Casey's, 2550 W, 7th Street. fiECAMMENDp51oNS; Approva (A) or Xeject (R) pERSONAL SEHVICE CONTBAC7S MUST ANSWER THE FOLLOWING QUESTIONS; _ PLANNWG C�MMISSION _ CML SERVICE COMMISSION 1. Has this personNirm ever worked untler a contract tor Mis department? - _ CIB COMMITTEE _ YES NO _ STAFF 2 Has [his perso�rm ever been a ciry employee? — YES NO _. DISTqICT COUPT _ 3. Doe6 this pe[SONfltfil 5S25S 8 Skill f10f n0[rt181 po ly possessed by eny current city employee? SUPPORTS WHICH COUNCIL OBJECilYE9 YES NO Explain afl yas enswers on separete sheet and etlach to green sheet INITiRTING PROBLEM, ISSUE, OPP�RTUNITY (WFro, What, Whan, Where, Wiry): 1��g C��`�� n� 8:c ,lAM 1 � 1997 ��-� �U �� R�1EY ADVANTAGESIPAPPROVED: �' �� EB ��' 199� "��Yt3R'S �r�lC� DISADVANTAGES IFAPPROVE�: 5 � gO ¢� e�wra.d F,°�,,t•r^.""°�:i S„v.,.'��'.;r' 53�`�°ue�6� CC., _ _ �. 5��4 2 �3 i:��i DISADVANSAGES IF NOT APPflOVED: 2. �� , �615 ,7i1�a �'! "�� TpTqL AMOUNT OF TRANSACTION $ COST7REVENUE BUDGE7ED (CIPCLE OIiE) YES NO fUNDIHG SOURCE ACi1VITV NUMBER FINANCIAL iNFOBMATiON: (E%PLAIN) '� � Greensheet #35�oZo2- In Tracker?_T/a-? 9� Ltcense I Compam Business Contact °f `l-� � L.I.E.P. REVIEW CHECKLIST Date: 1 j+PP'n Aeceived f APP'n Processetl Date to Council Research: J�c27� f Public Hearing Date: ��r .�> 14�7 Notice Sern to Appiicant: ! ��7 �9'7 Labels Ordered: N//� DiStfiCt COUnCiI #: /`J' Notice SeM to Public: 11� j3 Ward #: �.� Department/ Date Inspections Comments Cfty Attorney � � � � /) e 1 �� " � � /�6 f9 r� oK l a"/ � (_ �l �' , � rr Envlronmental Nealth �'1� Fire �� License �� Lease Received: ^ �1l / Paiice S }�t/� ! ! / �C'_COIYY l.�It�C� J'y'��-1'/�U Q � 6 % �`j�f 9� Zoning Nf � -, Gam6ling Control Board Fax�612 Jan 7'97 17=04 P.02�03 � Organization )nformation OlC CEOName `��li"i V!; � G!s i N �,/o oG�� , (Carnotreoembiing manager DaytimePhone(�f� }'I?I D �I� Organizaiion Gambfing Manager Information Firs: �ar2�R ii'� � S �ull SUidd NST° I'�' �" Maiden Name Date of Blrth 1� 1� Sociai Security Home SSreetA� —n o — DaytimePhoneNumber( G /� )��{`� I Became ao active member of this organization on: l atrended the two-day gambling �� nag� emin�� :� w ) e .jf an: Minrzesota LaurfuZ GambZing ��zt2 Gambling �axa.agex A.pplication pa9 � {ncomplete, false, or misiead'ing 2pplication inforrnation may result in deniaf of a license. , o Q ll � Soard 2 LiC i�` # � � ' l o�. � �� i�.�i �� LastName�/1�/` u/ � Check one ofthe boxes � Male � Fema'e Q f Disclosure of � g Sociat Securrty Number "�"�� Yova2requiredtopravideyoursoaaisecu- ritynumberonthisform,YOUr soclalsscu- rity number Nill bz vsad to determme your r compiianCe with the tax laws of MinncSata. �� Authorizationfai requiringyoursociafsecu- nfy number is found af 42 U.S C, a05(clfl. Bond lnformation A$10,00� fidelity bond in favor otthe organization has 6een obtained as required by Minnesota Stafutes, sectian 349,'167, subdivis'ro� 1. insurance Company Nam�: i ( �� Al�o� _L^ ��°mh�l �a� ond Number. �- � 7�/ /�� (DO NOT USE THE AGE(VCY NAME) 'r�GrC L{ntv�e�si -- - --- - --- _ _ _ � 1 R . lhrr��sa41 LG�'1 , s`3 7a S� Gambling Manager Change �en your organ'�zation is' one of fhese sections� Emergency Change - A1tow up to �ve days tor pracessing The chief execufive officer, by signing below, affirms ihst the en�rgency zppficaii�i i; duE to tna �oliowiag reason (check orse and fill in date): � Death of gambiing manager on /,,,/,_ Disability of gambling manager on �I Termination of empfoyment of gamb(ing manager on �_� � 3 j�. NOTE: The new gambling manager may not assume duties untii helshe has received the gambli�g managers license from the Gambting Controi 8oard. Sianature of af Chief Executive Ofricer �eSC�I �X�.4�,�s.�i �A,L � 1'� ! 1', a t"1 ! 1 r'. 1 Q' P.-. Cl [c.�:�ar4 n� JAN-07-1997 16�2 manager, compfete ; Other Chang2 - A{low up to te� weeks for processing ��j ; The new gambling manager's Sicense should become '(i`� ; ePFec#ive (check onej: 1 �(] The tlay after the aurrent gambling manager's iicense �'' j expires forezam te, if jk�ecbi�=�ep,t�'aambiing manager's ( p '�/ , Iicense expires 7/31/9,�,� the ne�w gai��I�ng managers �`�y (icense becomes effe ocn_/1f�6, �pvided that ai �� ; applica6on informa4''on�'PS� ��`�t�). �� ` ; ;� �� When fhe appiicatio'b h�s ti�eh -�ss � y the Gam- i bling ConVo! 6oari�-�(he`�€�',�e dat ' ! be the first � � day of the month. �y y_ ,.1, �G � NOTE: The new gamb?i�g��r�°�jnay not assume ; dufi�s unGl helshe has received a gambling manager's :., I'�cens the Gambling Control6oard. ]Oforfftation. Not3ry Public Scal must �� "•�.�( ryb�'y ` corr'0et,,,s�ea1 may not be aftered. � ea � _� t� ' �� arid swom j j a O + :�b'�e,jne this { � day � . Ai=^a� �K n , 19 _ �� -�- � � � • ' •' = v u�t,� � NoW P ic ^ •,.„y � �� - ta 1 in d on back} . ,.. �„ P�. ' ,n1 1 �� 6�z g�, �05',�� 1��l�7� 6ambling Control Board Fax�612 Gambling Manager Affidavit y a ! nd Co S 1, (print name) .1 A Y'i � S %j/�c� L�. � under oath state that I have never; 1. been convicted of a fefony or a crime invo{ving gam- bling; 2. committed a violation of lGw or Board rule that resuited in the revocation oP a ticense issued by the Board within five years befare the date of fhe license application: 3. been convicted of a criminal violation involving fraud, theft, tax evasion, misrepresentation, orgambling; 4. been convicted of (ij assauit, {ii) a criminai violation invalving the use of a ficearm, or (iii) making terroristic threats. 5, bsen connected with nor angaged in an iliegal bu5i- ness; 6. owed �500 or more in delinquent taxes as defined in section 270.72; 7. had a sales and use tax parmit revoked by the com- missioner of revenue wifhin the past two years; 8. failed to fite, after demand, tax returns required by the commissionerof revenue, In adtlition, ! understand, agree, and heseby irtevocably consent that suits and actions relafing to the subject mat- ter ot the attached gambling manager license appf ication, oracts oromissions arising from such appiication, maybe commenced against me or my organizafion aad I will accEpt the serfice o4 process in any court of competent jurisdiction in Minnesota by service on the Minnesota Secretary of SYate of any summons, process, orpieading aufhofized by the lativs of Minnesota. By signature of this document, the unclersigned author¢es the Departments of Public Safety and Revenue to con- duct a crimina4 antl tax background check or review and to share the resu3ts with the Gambting Con{rol 6oard. Failure fo provide required information or providing false or misleading information may result in the denial or revocation ofthe ficense. . FURTHER AFFIANT SAYETH HOT, excepf that this Affrdavit and Consent StatemenE are submitted in support of the appiication for a gambling manager iicense from the Gambiing Control Board. Sigriature of Gambting A�plicant � �,�� JRN-07-1997 16-21 612 Jan 7 '97 17�05 P. 03iO3 ��—��.. LG252 $/96 Page 2 of 2 This pub(ication wi11 6e made avai!able in alternative fosmat {i.e. large print, Brailfe} upon request. fF you use a M, you can call us using Yhe Minnesota Relay Service at (612) 297-5353 or 1-800-627-3529 and ask them to pface a call to (6'I2) 639�000, The information requested on this form wilf be used by the Gambiing Coniroi Soard (BOard) to defermine your compliance with Minnesota statutes and rules governing lavrful gambling activi6es. Ali of the infos- ma6on that you suppiy Qn fhis form wiil become public information when received by the Board. The information requested on this form (including any atfachments) will be used by the 8oard to determine your qualifica6ons to be invoivetl in lawFui gambling activities in Minnesota, and to assist the Board in conducting a baokground investigation of you. You have the right to refuse fo supply ihe informaiion requested; however, if you refuse to supply this infor- mation, the Board may not be able io determine your qualifications and. as a consequence, may refuse to issue you a ficense. If you supply the informafion required, the Board wili Be abfe to process your appli- caEion. Your name and address wili be pu blic information when received by fhe Board. Ali the other information ahout you that you provide will Be privafe data until the 6oacd issues your license. When the Board issues your license, al! of the information yau have provided to the Board in the process of applying for your license wiil become puolic exceptforyoursocial security num- ber, which remains private. !f the Board does nof issue you a ficense, all the infior- mation you have provided in the process of applying for a license remains private, wiih the excepticn of your name and address, which wi1! remain pubiic. Privat2 data about ydu is available only to the follow- ing: �Board members, statF of the Board whose work assignment requires tfiat they have access to the informat'ron; the Minnesota Department of Pub{ic Safefy; the Minnesota Attorney Generah the Minne- sota Comm"tssioners of Administrativn, Finance, and Revenue; the Legislative Auditor; national and inter- national gambling regulatory agencies; anyone pur- suant to court order; other individuals anU agencies fhaf may be specificaily authorized by state os federal (aw to have access to such information; indivitluafs and agencies forwhych law or (egat orderauthorizes a neva use or sharing of the information after this notice is given; you; and anyone with your written consent. itary Public �nformation. Notary public Seaf must Cuf�ent and correct; seal may not 6e altered. oscrib��d a�nd swam to 6efore me this � � day �_xd_.S � L� � . �9 . " va"�x\., . '��j"•� �a , 97i P.03