The URL can be used to link to this page

98-144ORIGINAL Presented By Referred To Committee: Date RESOLVED: 1 That application (ID �19980000003) for a Gambling Manager License(s) 2 by SARBARA DOTTY-THOM2IS DSA SE%UAL VIOLENCE CENTER/BILLY'S 3 oN GRAND at 857 GRAND AVE be and the same is hereby approved. Requested by Department of: Office of License, Inspections and Environmental Protection By: ��AF.t�- �,�' Form Approved by�it� Attorney By: By: Date �� Council File� p ` '7 ordinance � Green Sheet # LP60020 � , RESOLUTION � (TY OF SAINT L, MINNESOTA , � � � � Z- Approved by Mayor for Submiasion to Council By: Adopted by Council: Date � x� .�S �Q�� Adoption Certified by Council Secretary aa-►`+� LIEP/Licensing (B�LL) BE ON COUNCIL ACaENDA BY (DAT� � , J fp� FOR ROIIiR�G � GREEN SHEET l❑ GlyAtt°mey 2❑ Counal Res�rch No. LP60020 TOTAL # OF SIGNATURE PA6ES (CLIP ALL IOCATiONS FOR SIGNATURE) REQUESTED: �pprwa� of fhe fofbwing ficense a�cation: License # 79980000003, fa BARBARA DOTTY-THOMAS �� . Doing Busir�ess As SEXUAL :E CENTERlBILlT5 ON GRAND, at 85T GRAND AVE, including tbe tdbwing business type(s): Gambling Ma�ger. RECOMMENDATlONS: Approve(A) Reject(R) 1. Has this pern�rm ever vrorked under a coniract iw iliis depnrtment? ,PLANNtNGCOMMiSSION yEg p�p , CIB COMMITTEE 2. Has iMs peraavfirtn ever men a ciry empfoyeea CML SYC CINN, YES NO 3. Does this personlfum possass e sldu not ram�auy possess�ad by a�ry curtert ciry emptoyea? YES NO . is Nts perso�ttn a targ&ed vandoR ' VES NO Ezpiain a�l res answers on separffie sheet and attach to areen stMM apprwal for Sarbara Dotty-Thomas irn a Gambiing Managers License ffi 857 Grand Avenue. ��3s?'§:;<} G�g�a±�; ; n ', ;:x aa. ' � . �. NOTAPPROVED: DTAL AMOUNT OF TRANSACTION E )NDING SOURCE NANCWL INFORMATION: XPLAIN) COSTIREVENUE BUDGETED {CIRCLE ONE) YES NO ACTIVITY NUMBER �"� ,l �,a � � . I ,� � � . �:r'.. . _:= Y � \ MinnesotcxLawfuIGambling .-=`._.."...:-_.._....__.._._,. Gambling Manager Application lncompiete, false, or misleading application information may result in denial of a license. Organization Infarmation CEO Name T (Cannot be gambling manager) Daytime Phone �( � c�) �� a- � a� � l% Organization Base �icense Gamb{ing Manager Information First Name � F12�n f� �� 6uA Middle Name MaidenName �6� � �., ,� Sociai Security Home StreetA� Daytime Phone Number ( 1A I d-� ) d r-7. i-1 " I became an active member of this organization on: I attended the two-day gambting manager seminar on � a�` '�� P� `_ � Boan. �1� b e Lic # � uence # e.K Paid� � ck#�ly'�` ils � � � �� \ � . Last Name'✓O U �l ' Yl (J YYl G1.5 Check one of the boxes: � Male � Female � � `� Disclosure of ��_ , SocialSecurityNumber � ZiP Youarerequiretltoprovideyoursocialsecu- � rity number on this fortn. Your sociai secu- rity number will be used to determine your ��j compliance wHh the tax laws of Minnesota. �; � � Authoruationfor requinngyoursocialsecu- iity number is found at 42 U.S.C. 405(c)(i). Bond lnformation A$10,000 fidelity bond in favor of the organization has been obtained as required by Minnesota Statute�, section 249.167, subdivi�ion 1. insurance Company Name: �1_,, 1��,�� ,{'f n�r�,.(�0.RIf��Bond Number: � K(> j� �n f) .� �( ��. {p0 NOT USE THE AGENCY NAME) Gambling ManagerChange Emergency Change - 1+i�ow up eo rve days tor processing ' The chief executive officer, by sig�ing below, affirms that the emergency appfication is due to the following reason (check oae and fili in date): fJ Death of gambiing manager on _____;_f_ � Disability of gambling manager on / /_ � Termination of employment of 9ambling manager on �_� 3C i �t�. NOTE: The new gambling manager may not assume duties untii he/she has received the gambiing manager's I+cense from the Gambling Control Board. >ignature of ��a �� C . 7l-t-ill..l.i l � otarizadSignatur fChiefExecutiv �cer(CEO) ate: 1 _. J .._ _. g � manager, com� y� � Qther Chanc�e - A!low up to ten e�e�k The new gambiing manager's license s effective (check one): [] The ciay after the current gambiing man v�� Ii�aFs� expires (for exampfe, if the current gambling I+cense expires 7(31/96, the ne�v gambling manager's license becomes effective on 8/7/9&, provided that aii application information is complete). ❑ When the application has baen processed by the Gam- bling Controi Board--the effective date will be the first day of the month. NOTE: The new gambling manager may not assume duties unti{ he/she has received a gambling manager's license from the Gambling Control Board. Notary Pubiic lnformation. Notary Public Sea1 musc be current and correct; Seal may not be alter� Subscrib and sworn to before me ihis ��(� day O' lJ. _ _ _ A'�MA�AAnM(WV� . � ' /��.:� DEUA M. � t� l�` / A �q ,�� Q J .r `y' �g„� �� y 'Xh�Slb�t-- �' �� S;2^"'n.i.nc,^ � i `i�x '. �c�'cC. °'ff'.?-,1'�1 �2 ' ='.'��CO�Ghftt�lafPR�ztlg i _ � YW�V��J�l1.l\1Ll\M.M/11.4�.�V�II. '��^�Y ;�awr-r r�z:l f:, �,1.{c.��, � c�n�.�.� C.r nl-�. rnzLt� H-t � (j ��awd�i n.+,,,i'Y� f v U. �- i�-9 � Gambiing Manager Ak�lication (continuedj Affidavit and Consent St I,(Prinfrtame)�C��`JA_`�A,. �41\��lY under oath state that i have neve� 1. been convicted of a felony or a crime involviny gam- bling; 2. committed a violation of law or Board rule that resulted in the revocation of alicense issued by the Board within five years before the date of the license application; 3. been convicted of a criminal violation invoiving fraud, theft, tax evasion, misrepresentation, or gambling; 4. been convicted of (i) assauit, {ii) a criminal vioiation involving the use ofa firearm, or (iii) making terroristic threats. 5, been connected with nor engaged in an illegal busi- ness; 6, 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. failed to file, after demand, tax retums required by the commissioner of revenue, In addition, f understand, agree, and hereby irrevocably consent that suits and actions relating to the subject mat- ter of the attached gambiing manageriicense appiication, or acts or omissions arising from such application, may be commenced against me or my organization and ! wili accept the service of process in any court of cpmpetent jurisdiction in Minnesota by service on the Minnesota Secretary of State of any summons, process, or pieading aufhorized by the laws of Minnesota. By signature of this document, the undersigned authorizes the Departments of Public Safety and Revenue to con- duct a criminal and tax background check or review and to share the results with the Gambiing Controf Board. Failure to provide required information or providing false or misleading i�for•na;ion m;y -esutt in the c;enial or revocation of the �icense. FURTHER AFFlANT SAYETH NOT, except that this A�davit and Consent Statement are submitted in support of the application for a gambfing manager iicense from the Gambling Control Board. Signature of Gambiing Manager Appticant 13c., bc ,' - — Notanzed Signature ofApplicant ��t �9/96 aqe 2 0( 2 . This publication will be made availabie in alternative format (i.e. large print, Brafilej upon request. If you use a TTY, you can call us u�ing the Phinnesota Relay Service at 1-800-627-3529 �nd a�k them to p{ace a call to (612) 638-4400. The ir.'�rmation requested on this form wiii be used by the Gambiing Control Board (Board) to determine your compliance with Minnesota statutes and ru)es governing lawful gambling activities. Al! of the infor- mation that you supply on this form will become pubiic 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 lawful gambling activities in Minnesota, and to assist the Board in conducting a background investigation of you. You have the right to refuse to suppfy the information i requested; however, if you refuse to suppfy this infor- �� Ri�i�C�, :ilc uGaiG' �Ticiy' lGi v2 8�`.iE V GCtG �OU� qualifications and, as a consequence, may refuse to issue you a license. If you supply the information required, the Board wiil be able to process your appii- cation. Yourname and address wiil be pubiic information when received by the Soard. All the other information about you that you provide will be private data until the Board issues your Iicense. When the 8oard issues your ; iicense, .all of the information you have provided to ! the Board in the process of applying for yout license wili become publiC except foryoursocial security num- ber, which remains private. if the Board does not issue you a license, ail the infor- mation you have provided in the process of applying for a license remains private, with the exception of your name and address, which wil! remain pubiic. Private data about you is avai(ab(e only to the foilow- ing: Board members, staff of the Board whose work assignment requires that they have access to the information; the Minnesota Department of Public Safety; the Minnesota Attorney General; the Minne- sota Commissioners of Administration, Finance, and Revenue; the Legislative Auditor; nationai and inter- n=` ^nai ya�+ u�ir�g � ayulatory agencies; anyone pur- suant to court order; other individuals and agencies that may be specifically authorized by state or federaf !aw to have access to such information; individuals and agencies for which law or legai order authorizes a new use or sharing of the intormation after this notice is given; you; and anyone with your written consent. Notary Publ(c information. Notary Pubrc Seal must be current and correct seal may not be altered. SubscYb and sworn to be(ore me this T7 day o�- � ^� , t s�. ORIGINAL Presented By Referred To Committee: Date RESOLVED: 1 That application (ID �19980000003) for a Gambling Manager License(s) 2 by SARBARA DOTTY-THOM2IS DSA SE%UAL VIOLENCE CENTER/BILLY'S 3 oN GRAND at 857 GRAND AVE be and the same is hereby approved. Requested by Department of: Office of License, Inspections and Environmental Protection By: ��AF.t�- �,�' Form Approved by�it� Attorney By: By: Date �� Council File� p ` '7 ordinance � Green Sheet # LP60020 � , RESOLUTION � (TY OF SAINT L, MINNESOTA , � � � � Z- Approved by Mayor for Submiasion to Council By: Adopted by Council: Date � x� .�S �Q�� Adoption Certified by Council Secretary aa-►`+� LIEP/Licensing (B�LL) BE ON COUNCIL ACaENDA BY (DAT� � , J fp� FOR ROIIiR�G � GREEN SHEET l❑ GlyAtt°mey 2❑ Counal Res�rch No. LP60020 TOTAL # OF SIGNATURE PA6ES (CLIP ALL IOCATiONS FOR SIGNATURE) REQUESTED: �pprwa� of fhe fofbwing ficense a�cation: License # 79980000003, fa BARBARA DOTTY-THOMAS �� . Doing Busir�ess As SEXUAL :E CENTERlBILlT5 ON GRAND, at 85T GRAND AVE, including tbe tdbwing business type(s): Gambling Ma�ger. RECOMMENDATlONS: Approve(A) Reject(R) 1. Has this pern�rm ever vrorked under a coniract iw iliis depnrtment? ,PLANNtNGCOMMiSSION yEg p�p , CIB COMMITTEE 2. Has iMs peraavfirtn ever men a ciry empfoyeea CML SYC CINN, YES NO 3. Does this personlfum possass e sldu not ram�auy possess�ad by a�ry curtert ciry emptoyea? YES NO . is Nts perso�ttn a targ&ed vandoR ' VES NO Ezpiain a�l res answers on separffie sheet and attach to areen stMM apprwal for Sarbara Dotty-Thomas irn a Gambiing Managers License ffi 857 Grand Avenue. ��3s?'§:;<} G�g�a±�; ; n ', ;:x aa. ' � . �. NOTAPPROVED: DTAL AMOUNT OF TRANSACTION E )NDING SOURCE NANCWL INFORMATION: XPLAIN) COSTIREVENUE BUDGETED {CIRCLE ONE) YES NO ACTIVITY NUMBER �"� ,l �,a � � . I ,� � � . �:r'.. . _:= Y � \ MinnesotcxLawfuIGambling .-=`._.."...:-_.._....__.._._,. Gambling Manager Application lncompiete, false, or misleading application information may result in denial of a license. Organization Infarmation CEO Name T (Cannot be gambling manager) Daytime Phone �( � c�) �� a- � a� � l% Organization Base �icense Gamb{ing Manager Information First Name � F12�n f� �� 6uA Middle Name MaidenName �6� � �., ,� Sociai Security Home StreetA� Daytime Phone Number ( 1A I d-� ) d r-7. i-1 " I became an active member of this organization on: I attended the two-day gambting manager seminar on � a�` '�� P� `_ � Boan. �1� b e Lic # � uence # e.K Paid� � ck#�ly'�` ils � � � �� \ � . Last Name'✓O U �l ' Yl (J YYl G1.5 Check one of the boxes: � Male � Female � � `� Disclosure of ��_ , SocialSecurityNumber � ZiP Youarerequiretltoprovideyoursocialsecu- � rity number on this fortn. Your sociai secu- rity number will be used to determine your ��j compliance wHh the tax laws of Minnesota. �; � � Authoruationfor requinngyoursocialsecu- iity number is found at 42 U.S.C. 405(c)(i). Bond lnformation A$10,000 fidelity bond in favor of the organization has been obtained as required by Minnesota Statute�, section 249.167, subdivi�ion 1. insurance Company Name: �1_,, 1��,�� ,{'f n�r�,.(�0.RIf��Bond Number: � K(> j� �n f) .� �( ��. {p0 NOT USE THE AGENCY NAME) Gambling ManagerChange Emergency Change - 1+i�ow up eo rve days tor processing ' The chief executive officer, by sig�ing below, affirms that the emergency appfication is due to the following reason (check oae and fili in date): fJ Death of gambiing manager on _____;_f_ � Disability of gambling manager on / /_ � Termination of employment of 9ambling manager on �_� 3C i �t�. NOTE: The new gambling manager may not assume duties untii he/she has received the gambiing manager's I+cense from the Gambling Control Board. >ignature of ��a �� C . 7l-t-ill..l.i l � otarizadSignatur fChiefExecutiv �cer(CEO) ate: 1 _. J .._ _. g � manager, com� y� � Qther Chanc�e - A!low up to ten e�e�k The new gambiing manager's license s effective (check one): [] The ciay after the current gambiing man v�� Ii�aFs� expires (for exampfe, if the current gambling I+cense expires 7(31/96, the ne�v gambling manager's license becomes effective on 8/7/9&, provided that aii application information is complete). ❑ When the application has baen processed by the Gam- bling Controi Board--the effective date will be the first day of the month. NOTE: The new gambling manager may not assume duties unti{ he/she has received a gambling manager's license from the Gambling Control Board. Notary Pubiic lnformation. Notary Public Sea1 musc be current and correct; Seal may not be alter� Subscrib and sworn to before me ihis ��(� day O' lJ. _ _ _ A'�MA�AAnM(WV� . � ' /��.:� DEUA M. � t� l�` / A �q ,�� Q J .r `y' �g„� �� y 'Xh�Slb�t-- �' �� S;2^"'n.i.nc,^ � i `i�x '. �c�'cC. °'ff'.?-,1'�1 �2 ' ='.'��CO�Ghftt�lafPR�ztlg i _ � YW�V��J�l1.l\1Ll\M.M/11.4�.�V�II. '��^�Y ;�awr-r r�z:l f:, �,1.{c.��, � c�n�.�.� C.r nl-�. rnzLt� H-t � (j ��awd�i n.+,,,i'Y� f v U. �- i�-9 � Gambiing Manager Ak�lication (continuedj Affidavit and Consent St I,(Prinfrtame)�C��`JA_`�A,. �41\��lY under oath state that i have neve� 1. been convicted of a felony or a crime involviny gam- bling; 2. committed a violation of law or Board rule that resulted in the revocation of alicense issued by the Board within five years before the date of the license application; 3. been convicted of a criminal violation invoiving fraud, theft, tax evasion, misrepresentation, or gambling; 4. been convicted of (i) assauit, {ii) a criminal vioiation involving the use ofa firearm, or (iii) making terroristic threats. 5, been connected with nor engaged in an illegal busi- ness; 6, 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. failed to file, after demand, tax retums required by the commissioner of revenue, In addition, f understand, agree, and hereby irrevocably consent that suits and actions relating to the subject mat- ter of the attached gambiing manageriicense appiication, or acts or omissions arising from such application, may be commenced against me or my organization and ! wili accept the service of process in any court of cpmpetent jurisdiction in Minnesota by service on the Minnesota Secretary of State of any summons, process, or pieading aufhorized by the laws of Minnesota. By signature of this document, the undersigned authorizes the Departments of Public Safety and Revenue to con- duct a criminal and tax background check or review and to share the results with the Gambiing Controf Board. Failure to provide required information or providing false or misleading i�for•na;ion m;y -esutt in the c;enial or revocation of the �icense. FURTHER AFFlANT SAYETH NOT, except that this A�davit and Consent Statement are submitted in support of the application for a gambfing manager iicense from the Gambling Control Board. Signature of Gambiing Manager Appticant 13c., bc ,' - — Notanzed Signature ofApplicant ��t �9/96 aqe 2 0( 2 . This publication will be made availabie in alternative format (i.e. large print, Brafilej upon request. If you use a TTY, you can call us u�ing the Phinnesota Relay Service at 1-800-627-3529 �nd a�k them to p{ace a call to (612) 638-4400. The ir.'�rmation requested on this form wiii be used by the Gambiing Control Board (Board) to determine your compliance with Minnesota statutes and ru)es governing lawful gambling activities. Al! of the infor- mation that you supply on this form will become pubiic 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 lawful gambling activities in Minnesota, and to assist the Board in conducting a background investigation of you. You have the right to refuse to suppfy the information i requested; however, if you refuse to suppfy this infor- �� Ri�i�C�, :ilc uGaiG' �Ticiy' lGi v2 8�`.iE V GCtG �OU� qualifications and, as a consequence, may refuse to issue you a license. If you supply the information required, the Board wiil be able to process your appii- cation. Yourname and address wiil be pubiic information when received by the Soard. All the other information about you that you provide will be private data until the Board issues your Iicense. When the 8oard issues your ; iicense, .all of the information you have provided to ! the Board in the process of applying for yout license wili become publiC except foryoursocial security num- ber, which remains private. if the Board does not issue you a license, ail the infor- mation you have provided in the process of applying for a license remains private, with the exception of your name and address, which wil! remain pubiic. Private data about you is avai(ab(e only to the foilow- ing: Board members, staff of the Board whose work assignment requires that they have access to the information; the Minnesota Department of Public Safety; the Minnesota Attorney General; the Minne- sota Commissioners of Administration, Finance, and Revenue; the Legislative Auditor; nationai and inter- n=` ^nai ya�+ u�ir�g � ayulatory agencies; anyone pur- suant to court order; other individuals and agencies that may be specifically authorized by state or federaf !aw to have access to such information; individuals and agencies for which law or legai order authorizes a new use or sharing of the intormation after this notice is given; you; and anyone with your written consent. Notary Publ(c information. Notary Pubrc Seal must be current and correct seal may not be altered. SubscYb and sworn to be(ore me this T7 day o�- � ^� , t s�. ORIGINAL Presented By Referred To Committee: Date RESOLVED: 1 That application (ID �19980000003) for a Gambling Manager License(s) 2 by SARBARA DOTTY-THOM2IS DSA SE%UAL VIOLENCE CENTER/BILLY'S 3 oN GRAND at 857 GRAND AVE be and the same is hereby approved. Requested by Department of: Office of License, Inspections and Environmental Protection By: ��AF.t�- �,�' Form Approved by�it� Attorney By: By: Date �� Council File� p ` '7 ordinance � Green Sheet # LP60020 � , RESOLUTION � (TY OF SAINT L, MINNESOTA , � � � � Z- Approved by Mayor for Submiasion to Council By: Adopted by Council: Date � x� .�S �Q�� Adoption Certified by Council Secretary aa-►`+� LIEP/Licensing (B�LL) BE ON COUNCIL ACaENDA BY (DAT� � , J fp� FOR ROIIiR�G � GREEN SHEET l❑ GlyAtt°mey 2❑ Counal Res�rch No. LP60020 TOTAL # OF SIGNATURE PA6ES (CLIP ALL IOCATiONS FOR SIGNATURE) REQUESTED: �pprwa� of fhe fofbwing ficense a�cation: License # 79980000003, fa BARBARA DOTTY-THOMAS �� . Doing Busir�ess As SEXUAL :E CENTERlBILlT5 ON GRAND, at 85T GRAND AVE, including tbe tdbwing business type(s): Gambling Ma�ger. RECOMMENDATlONS: Approve(A) Reject(R) 1. Has this pern�rm ever vrorked under a coniract iw iliis depnrtment? ,PLANNtNGCOMMiSSION yEg p�p , CIB COMMITTEE 2. Has iMs peraavfirtn ever men a ciry empfoyeea CML SYC CINN, YES NO 3. Does this personlfum possass e sldu not ram�auy possess�ad by a�ry curtert ciry emptoyea? YES NO . is Nts perso�ttn a targ&ed vandoR ' VES NO Ezpiain a�l res answers on separffie sheet and attach to areen stMM apprwal for Sarbara Dotty-Thomas irn a Gambiing Managers License ffi 857 Grand Avenue. ��3s?'§:;<} G�g�a±�; ; n ', ;:x aa. ' � . �. NOTAPPROVED: DTAL AMOUNT OF TRANSACTION E )NDING SOURCE NANCWL INFORMATION: XPLAIN) COSTIREVENUE BUDGETED {CIRCLE ONE) YES NO ACTIVITY NUMBER �"� ,l �,a � � . I ,� � � . �:r'.. . _:= Y � \ MinnesotcxLawfuIGambling .-=`._.."...:-_.._....__.._._,. Gambling Manager Application lncompiete, false, or misleading application information may result in denial of a license. Organization Infarmation CEO Name T (Cannot be gambling manager) Daytime Phone �( � c�) �� a- � a� � l% Organization Base �icense Gamb{ing Manager Information First Name � F12�n f� �� 6uA Middle Name MaidenName �6� � �., ,� Sociai Security Home StreetA� Daytime Phone Number ( 1A I d-� ) d r-7. i-1 " I became an active member of this organization on: I attended the two-day gambting manager seminar on � a�` '�� P� `_ � Boan. �1� b e Lic # � uence # e.K Paid� � ck#�ly'�` ils � � � �� \ � . Last Name'✓O U �l ' Yl (J YYl G1.5 Check one of the boxes: � Male � Female � � `� Disclosure of ��_ , SocialSecurityNumber � ZiP Youarerequiretltoprovideyoursocialsecu- � rity number on this fortn. Your sociai secu- rity number will be used to determine your ��j compliance wHh the tax laws of Minnesota. �; � � Authoruationfor requinngyoursocialsecu- iity number is found at 42 U.S.C. 405(c)(i). Bond lnformation A$10,000 fidelity bond in favor of the organization has been obtained as required by Minnesota Statute�, section 249.167, subdivi�ion 1. insurance Company Name: �1_,, 1��,�� ,{'f n�r�,.(�0.RIf��Bond Number: � K(> j� �n f) .� �( ��. {p0 NOT USE THE AGENCY NAME) Gambling ManagerChange Emergency Change - 1+i�ow up eo rve days tor processing ' The chief executive officer, by sig�ing below, affirms that the emergency appfication is due to the following reason (check oae and fili in date): fJ Death of gambiing manager on _____;_f_ � Disability of gambling manager on / /_ � Termination of employment of 9ambling manager on �_� 3C i �t�. NOTE: The new gambling manager may not assume duties untii he/she has received the gambiing manager's I+cense from the Gambling Control Board. >ignature of ��a �� C . 7l-t-ill..l.i l � otarizadSignatur fChiefExecutiv �cer(CEO) ate: 1 _. J .._ _. g � manager, com� y� � Qther Chanc�e - A!low up to ten e�e�k The new gambiing manager's license s effective (check one): [] The ciay after the current gambiing man v�� Ii�aFs� expires (for exampfe, if the current gambling I+cense expires 7(31/96, the ne�v gambling manager's license becomes effective on 8/7/9&, provided that aii application information is complete). ❑ When the application has baen processed by the Gam- bling Controi Board--the effective date will be the first day of the month. NOTE: The new gambling manager may not assume duties unti{ he/she has received a gambling manager's license from the Gambling Control Board. Notary Pubiic lnformation. Notary Public Sea1 musc be current and correct; Seal may not be alter� Subscrib and sworn to before me ihis ��(� day O' lJ. _ _ _ A'�MA�AAnM(WV� . � ' /��.:� DEUA M. � t� l�` / A �q ,�� Q J .r `y' �g„� �� y 'Xh�Slb�t-- �' �� S;2^"'n.i.nc,^ � i `i�x '. �c�'cC. °'ff'.?-,1'�1 �2 ' ='.'��CO�Ghftt�lafPR�ztlg i _ � YW�V��J�l1.l\1Ll\M.M/11.4�.�V�II. '��^�Y ;�awr-r r�z:l f:, �,1.{c.��, � c�n�.�.� C.r nl-�. rnzLt� H-t � (j ��awd�i n.+,,,i'Y� f v U. �- i�-9 � Gambiing Manager Ak�lication (continuedj Affidavit and Consent St I,(Prinfrtame)�C��`JA_`�A,. �41\��lY under oath state that i have neve� 1. been convicted of a felony or a crime involviny gam- bling; 2. committed a violation of law or Board rule that resulted in the revocation of alicense issued by the Board within five years before the date of the license application; 3. been convicted of a criminal violation invoiving fraud, theft, tax evasion, misrepresentation, or gambling; 4. been convicted of (i) assauit, {ii) a criminal vioiation involving the use ofa firearm, or (iii) making terroristic threats. 5, been connected with nor engaged in an illegal busi- ness; 6, 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. failed to file, after demand, tax retums required by the commissioner of revenue, In addition, f understand, agree, and hereby irrevocably consent that suits and actions relating to the subject mat- ter of the attached gambiing manageriicense appiication, or acts or omissions arising from such application, may be commenced against me or my organization and ! wili accept the service of process in any court of cpmpetent jurisdiction in Minnesota by service on the Minnesota Secretary of State of any summons, process, or pieading aufhorized by the laws of Minnesota. By signature of this document, the undersigned authorizes the Departments of Public Safety and Revenue to con- duct a criminal and tax background check or review and to share the results with the Gambiing Controf Board. Failure to provide required information or providing false or misleading i�for•na;ion m;y -esutt in the c;enial or revocation of the �icense. FURTHER AFFlANT SAYETH NOT, except that this A�davit and Consent Statement are submitted in support of the application for a gambfing manager iicense from the Gambling Control Board. Signature of Gambiing Manager Appticant 13c., bc ,' - — Notanzed Signature ofApplicant ��t �9/96 aqe 2 0( 2 . This publication will be made availabie in alternative format (i.e. large print, Brafilej upon request. If you use a TTY, you can call us u�ing the Phinnesota Relay Service at 1-800-627-3529 �nd a�k them to p{ace a call to (612) 638-4400. The ir.'�rmation requested on this form wiii be used by the Gambiing Control Board (Board) to determine your compliance with Minnesota statutes and ru)es governing lawful gambling activities. Al! of the infor- mation that you supply on this form will become pubiic 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 lawful gambling activities in Minnesota, and to assist the Board in conducting a background investigation of you. You have the right to refuse to suppfy the information i requested; however, if you refuse to suppfy this infor- �� Ri�i�C�, :ilc uGaiG' �Ticiy' lGi v2 8�`.iE V GCtG �OU� qualifications and, as a consequence, may refuse to issue you a license. If you supply the information required, the Board wiil be able to process your appii- cation. Yourname and address wiil be pubiic information when received by the Soard. All the other information about you that you provide will be private data until the Board issues your Iicense. When the 8oard issues your ; iicense, .all of the information you have provided to ! the Board in the process of applying for yout license wili become publiC except foryoursocial security num- ber, which remains private. if the Board does not issue you a license, ail the infor- mation you have provided in the process of applying for a license remains private, with the exception of your name and address, which wil! remain pubiic. Private data about you is avai(ab(e only to the foilow- ing: Board members, staff of the Board whose work assignment requires that they have access to the information; the Minnesota Department of Public Safety; the Minnesota Attorney General; the Minne- sota Commissioners of Administration, Finance, and Revenue; the Legislative Auditor; nationai and inter- n=` ^nai ya�+ u�ir�g � ayulatory agencies; anyone pur- suant to court order; other individuals and agencies that may be specifically authorized by state or federaf !aw to have access to such information; individuals and agencies for which law or legai order authorizes a new use or sharing of the intormation after this notice is given; you; and anyone with your written consent. Notary Publ(c information. Notary Pubrc Seal must be current and correct seal may not be altered. SubscYb and sworn to be(ore me this T7 day o�- � ^� , t s�.