91-2328��tG�i�1A�1� . �I �Z3Z8 ✓
IqI Council File #
Green Sheet # 17673
RESOLUTION
CITY OF SAINT PAUL, MINN OTA
Presented By
Referred To Committee: Date
RESOLVED: That application (ID #B-02653-002) for renewal of a State Class B
Gambling Premise Permit by Lower East Side Football Association at
Shenanigan's, 499 Payne Avenue. , be and the same is hereby
approved.
Yeas Navs Absent Requested by Department of:
smon
oswz z
on License & Permit Division
acca ee
e man
une
i son � BY� � �
Adopted by Council: Date Form Approved by City Attorney
Adoption Certified by Council Secretary
; ;� � / By: /� "�5��!/
By: `'�/�.�GL�
Approved by�kl or: Date Approved by Mayor for Submisaion to
Council
By: /1�/i�/d�'`����
By:
�8����� J�;� � '92
q� 23�j ✓
DERARTMENT FFICE/COUNCIL DATE INITIATED N° 17 6 7 3
Finan�e�Li�ense GREEN SHEET -
CONTACT PERSON 8 PHONE INITIAUDATE INITIAUDATE
�DEPARTMENT DIRECTOR a CITV COUNCIL
Christine Rozek/298-5056 AgSIGN �CITYATTORNEY �CITYCLERK
NUMBERFOR
MUST BE ON COUNCIL AGENDA BY(DATE) City Clerk ROUTING �BUDGET DIRECTOR �FIN.&MCiT.SERVICES DIR.
Hearin � B / ORDER �MAYOR(OR ASSISTAN� ��Q�� R
TOTAL#OF SIGNATURE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE)
ACTION RE�UESTED:
Approval of an application for renewal of a State Class B Gambling Premise Permit.
Notification 12-6-91 Hearin / 1 -
RECOMMENDA710NS:Approve(A)or Reject(R) PERSONAL SERVICE CONTRACTS MUST ANSWER THE FOLLOWING GUESTIONS:
_PLANNINQ COMMISSION _ CIVIL SERVICE COMMISSION �• Has this person/firm ever worked under a contract for this department9
_CIB COMMITTEE _ YES NO
2. Has this person/firm ever been a city employee?
_STAFF
— YES NO
_DISTRIC7 COURT _ 3. Does this person/firm possess a skill not normally possessed by any current city employee?
3UPPORTS WHICH COUNCIL OBJECTIVE? YES NO
Explain all yes answers on separate sheet and attach to gresn sheet
INITIATING PROBLEM,ISSUE,OPPORTUNITY(Who,What,When,Where,Why):
Jane Hyland on behalf of Lower East Side Football Association requests Council
approval of their application for renewal of a State Class B Gambling Premise
Permit at Shenanigan's, 499 Payne Avenue. Proceeds from the pulltab sales are
used for football equipment, donations, etc. -
ADVANTAQES IF APPROVED:
If Council approval is given, Lower East Side Football Association will continue
to operate a pulltab booth at Shenanigan's, 499 Payne Avenue.
DISADVANTAGES IF APPROVED:
DISADVANTAGES IF NOT APPROVED:
RECEIVED CQ�E-:�'s �9� �-� �i t�r
— .. ����r�
DEC � 9 ��91 DEC 09 1991
� CITY CLERK
.
TOTAL AMOUNT OF TRANSACTION S COST/REVENUE BUDGETED(CIRCLE ONE) YES NO
FUNDING SOURCE ACTIVITY NUMBER
FINANCIAL INFORMATION:(EXPLAIN) ��
NOTE: COMPLETE DIRECTIONS ARE INCLUDED IN THE GREEN SHEET INSTRUCTIONAL
MANUAL AVAILABLE IN THE PURCHASING OFFICE(PHONE NO. 298-4225).
ROUTING ORDER:
Below are correct routings for the five most frequent types of documents:
CONTRACTS(assumes authorized budget exists) COUNCIL RESOLUTION (Amend Budgets/Accept. Grants)
1. Outside Agency 1. Department birector
2. Department Director 2. Ciry Attorney
3. Ciry Attorney 3. Budget Director
4. Mayor(for contracts over$15,000) 4. Mayor/Assistant
5. Human Rights(for contracts over$50,000) 5. City Council
6. Finance and Ma�agement Services Director 6. Chief Accountant, Finance and Management Services
7. Finance Accounting
ADMINISTRATIVE ORDERS(Budget Revision) COUNCIL RESOLUTION (all others, and Ordinances)
_ 1. Activiry Manager 1. Department Director
2. Department Accountant 2. Ciry Attorney
3. Department Director 3. Mayor Assistant
4. Budget Director 4. City Council
5. City Clerk
6. Chief Accoun�ant, Finance and Management Services
. ADMINISTRATIY�ORDERS(all others)
� 1. Department I�irector
2. City Attorney
3. Finance and Management Services Director
4. City Clerk
TOTAL NUMBER OF SIGNATURE PAGES
Indicate the#of pages on which signatures are required and paperclip or flag
esch of these pages.
ACTION REQUESTED
Describe what the projecUrequest seeks to accomplish in either chronologi-
cal order or order of importance,whichever is most appropriate for the
issue. Do not write complete sentences. Begin each item in your list with
a verb.
RECOMMENDATIONS
Complete if the issue in question has been presented before any body, public
or private.
SUPPORTS WHICH COUNCIL OBJECTIVE?
Indicate which Council objective(s)your projecVrequest supports by listing
the key word(s)(HOUSING, RECREATION, NEIGHBORHOODS, ECONOMIC DEVELOPMENT,
BUDGET, SEWER SEPARATION). (SEE COMPLETE LIST IN INSTRUCTIONAL MANUAL.)
PERSONAL SERVICE CONTRACTS:
This information will be used to determine the city's liability for workers compensation claims,taxes and proper civfl service hiring rules.
INITIATING PROBLEM, ISSUE, OPPORTUNITY
Explain the situation or conditions that created a need for your project
or request.
ADVANTAGES IF APPROVED
Indicate whether this is simply an annual budget procedure required by Iaw/
charter or whether there are specific ways in which the City of Saint Paul
and its citizens will benefit from this projecUaction.
DISADVANTAGES IF APPROVED
What negative effects or major changes to existing or past processes might
this projecUrequest produce if it is passed (e.g.,traffic delays, noise,
tax increases or assessments)?To Whom?When?For how long?
DISADVANTAGES IF NOT APPROVED
What will be the negative consequences if the promised action is not
approved? Inabiliry to deliver service?Continued high traffic, noise,
accident rate?Loss of revenue?
FINANCIAL IMPACT
Although you must tailor the information qou provide here to the issue you
are addressing, in general you must answer two questions: How much is it
going to cost?Who is going to pay?
� � q� - Z3Z� ✓
DIVISION OF LICENSE AND PERMIT ADMINISTRATION DATE /� !9 9r /
INTERDEPARTMENTAL REVIEW CHECKLIST Appn Processed/Received by
,/ Lic Enf jud
O GICC` �`��1G� �t/�/�Qr/a�`�i��PS. /
Applicant�OlG��i� �S`f Si�q� �4T ! /`l°��Home Address ��,(� �,�r�G�/cCJ/ �.S%jJ,�
Business Name �tE�ta1' �t�S7" q� �Iome Phone �f/—�,fl �'�
S nQri f �C�7 `
Business Address �, Type of License(s) ,�s��4S.S� �i'y��/�l�j
./
Business Phone �7/ -�02�� ��L���+mi� —r���4J
Public Hearing Date « �j 9� License I.D. � ,�-- Oo2-�p�� �^dQo2
at 9:00 a.m. in the Council Chambers,
3rd floor City Hall and Courthouse State Tax I.D. �� �o a�9i�
Date Notice Sent; / � � Dealer � �v//q'
to Applicant /o�//�a/q�
r � Federal Firearms 4� � �
Public Hearing C� / ��
v
DATE INSPECTION
REVIEW VERFIED (COMPUTER) COrIl�IENTS
A roved Not A roved
Bldg I & D I
�r�.
Health Divn. �
��� I
Fire Dept. �
�'i'4 I
Police Dept. �� I � ((�j �4'
License Divn. i 75 '� ;nQC�uir�n� �s bQ-Q� �'►''-�-'�
I���I 1 I � f`
City Attorney �
���a�'�� I �,,�
Date Received:
Site Plan 11 � �'
To Council Research �� G ��
Lease or Letter C Date
from Landlord �� l �
9I- �,32� �/
� - FOR BOARD USE ONLY
.
LG214 BASE#
(���!
PP#
FEE
M�nnesota Lawfui Gambiing CHECK
Premises Permit Application - Part 1 of 2 �NITIALS
DATE
'�':����;i>;;i?2:;?:>i:i:�:;i:;:i:?';i:;?:7i:':i�:;i'i�i:;;i%::;ii::{:';ii::i�;::::::::;�.?r:�::;:;'::`;i::;:�it:;::::`:i:i:�:::;::i:i;i:�;�;'i:::ri:?i::;:::;?:::;;:i:i;??:i3.i';:<'::�i>::;>:i:i�i;i;;i;;;::;:;:;�;i;:?i!>::�i`::i:i:i:;;i;i?`Sik;:?:ii;>[;::��i:;::::;:i>�:2`�i;`:;;<i:;i:;?
: e.o � ;>.>:;....._._"`:a< .
:
.:
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� Class of premises permit
Renewal (check one)
Organization base license number�-O�1v�3 � A($400) Puil-tabs,tipboards,paddlewheels,raffles,bingo
Premises permit number��?�,'J,/��3 -c�.l [L]�B($250) Pull-tabs,tipboards,paddiewheels,raffles
� New ❑ C($200) Bingo only
❑ D($150) Raffles only
,.:t..;
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rt t T'ni fi �:::::>::>:<::::::�:':::::�:��:�:::�::::�:�::.'>.::::::�::°�:�::::�::::�:���:�: ;:.;;:.:;::.::;;.:;<.:.::::<:.:.::.:;.;,:;.;:.;:
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.: ..: .. .. ...::.. ..:.... .
.. .
Name of Organization
��{�C=�P E/9 ST.s//7[= �C� Rf�Lc. �9 S`S'
Business Address of Organization-Street or P.O Box(Do not use the address of your gambling manager)
City State Zip Coda County Daytime phone number
— f� c.l /�'I / �9/n S� (G/�2)
Name of chief executive officer(cannot be your gambling manager) Tide Daytime phone number
T,� N� �►. ��,�� nR ES, ,�E,�T ����� �� _���
Bingo Occasions
If applying for a class A or C peimit, fill in days and beginning& ending hours of bingo occasions:
No more than seven bingo occasions may be conducted by your organization per week.
Day Begiruiing/Ending Houis Day Begiruiing/Ending Hours Day Beginning/Ending Hours
� � to
to to to
to If bingo�vill not be conducted.chec]�here �'
GamblingPrem�seg Information__ s_ - ::::;>;.:
... ,:::���.>;:
. . . .
Name o establishment where gambling wil be conducted Sueet A dress(do not use a post office box number)
S h/E n�/��tJ/� G ��v's 5�oRTs ,�3� ,2 � �99 x��,v.v� .5► �.�-
Is the premises located within city limits? p'Yes O No If no,is township �organized � unorganized p unincorporated
Ciry and County where gambling premises is located OR Township and Counry where gambling premises is bcated if outside of city limits
� �nS� I
Nam�,a a ress legal c�nrner����ejs,_�•C'O N i State Zp Code
X �- U ,� �s �
o s �or orgarn on own the buildng where th gambling witl conducted? p YES �NO
If no,attach the folbwing:
• a copy o(the lease(form LG202)with terms for at least one year.
• a copy of a sketch of the floor plan with dmensions,showing what portion is being leased.
A lease and sketch are not required for Class D applica6ons.
:.;;:.; :: . .. .:
:::: � : . : ; • < : .. ..
.:
.: .. • : : :. �. • .
Address of storage;space:'of gainbling�equipinent-. ��ritt�g Po�x��m�� . ;.. .. : �:
____
Address City State Zip code
� Minnesora Lawfui Gambiing �� "�32� ✓
� Premise Permit Application - Part 2 of 2
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—
_ c�. rck Ac�ount:r formatcon ::<::;::>>:<:::;.;:::: :.:.:.:;>:>::>::::::>::::<
: . .. :_ . ,:, ... ..:.:..:...::. . ....:.
Bank Name Bank Account Number
�voRcvES7- Oo /� � ��
n ress iy �� p
�7.� �; /�7 /itJ.V,�.c,lA�1�9 /�v S T�i9�rG /)i,U .5,�/cs�-
lV�an�e,addfess.arrd�otpersnrrs avrhaazad to srg��iecks ar��nak+a dep�csr�acni wnthdrawel�,
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.;>�,:::;:..<>:.:. __ ;�; ;<:, ,>:: :>;Oroamrabons b8asurer:niaX noE�randla''a"a+i�b�fu+x�
• �.::; ;: �:.::.. ..... ..
:�;: . ��::
Name ss �tTe
G'A�n oLi,vG Alit�v�iLSE�?
/Y/A R L/_=ic,/€ S ?N/L •v � 5'(0 ��'So7`o Sf .S �c R E-�-.o�e/
S� Na Rc � � �3 �,� ,vE�;-
,o�,.bs,
- s - � o�4r s, —
,
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Ac owl``';:::; `:::`:m``�`'````:
"``e en"�:
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� .. : . ::::::::... .. ..: : .
::;:::.;::<::.:::.>........ ..:.:.:.:::..�::. ..... . ....:....:...::
. ::..::.,:::.:�:..::::::.
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.. _ ... .. .
Gamb g Site Autho oa •I am the chief executive officer of the organization;
I hereby consent that local law enforcement officers,the •I assume full responsibility for the fair and lawful opera-
board or ageMs of the board,or the commissioner of tion of all activities to be conducted;
revenue or public safery,or agents of the commissioners, .�Wi��familiarize myself with the laws of Minnesota
may enter the premises to enforce the law, governing lawful gambling and rules of the board and
Bank Records Informatioa agree,if licensed,to abide by those laws and rules,
The board is author¢ed to insped the bank records of the including amendments to them;
gambling accouM whenever necessary to fulfill •any changes in application information will be submitted
requirements of current gambling rules and law. to the board and local unit of government within 10 days
Oath of the change;and
I declare that: •I understand that failure to provide required information
•I have read this application and all informatbn submitted or providing false or misleading information may result in
to the board is true, accurate and complete; the denial o�revocation of the license.
•all other requi�ed information has besn fully disclosed;
Signature ot chief executive officer Date
X �--.� 3,� - ��I�a�� � I 1 � I � — �l 1
<<::�
'I�c�a�:::;:>:<>::�;::::::<:�:<:�::<::::><:<:>:::;<:::;::;�::<::::>>:<::::::;:.:.;::::>:<:::.<:::::;.::::.<.:::::«::;<:::::>.<:>::»:>::;<::<::<:�:::<:«:�:::�:::::::��;::�:::;:��:�:;::'::<::::;':;��::;:::`:j:��`::<:�:�'::::=;<''<:::���>::>:`:::::::��>::�::::«::�<::=:>:�:':::��:�:�:<�:::»:<:>::::::�::':>::�:>:'�:�::::::<��<�;':;;`:>:�:>:���:;':;<::«:�:�:::�:>:::�::.,
............... ..: Gouernment.Ackrcowt�d ment :.�:.::::::::::::::::::::.�.::.:.:::.�:::::::.:::.:::...�::.::::::::::::::::::::.::.::::.:::.:�::::.
.::..�::.::,:::::.::::::..,:.:.::::::::::::.,::.:............:.................::..�::::..:.:.9e:::::::.: .:..::...:.:::.::..::..�.:..:::..:::.�:.::::::::._::::::.::..::::....:.::.:::..::._:.:�:::.:.:,...........:................::...:...�:.:::�._}
1. The city'must sign this application'rf the gambling prem- 4. A co�y of the local unR of qovernmenYs resolution aa
ises is located within city limits. �vin9 this ao�lication must be attached to this aoolication.
2. The courity••AND township'•must sign this application if 5. N this application is denied by the local unit of government,
the gambling premises is bcated wfthin a township. �should not be submitted to the Gambling Control Board.
3. The bcal unit government(city or county)must pass a Township: By signature below,the township acknowledges
resolution specifically approving o�denying this application, that the organization is applying for a premises permit within
township limits.
Cit ' or Count " Townshi '•
City or County Name Township:Name
Signature of person receiving appGca6on Signature of person receiving application
rtie ( Date Reoi ved Tide I Date Received
� %9 �/
Refer to the instrucxions for required attachments.
Mail to: Gambtlnp Control Board
Rosewood Pla=a South,3rd Floor
1711 W.County Road B
Rosev111e,lAN SSt13 LG214(Pa►t 2) ,
�a«�rzs9i)
. . .
C��lC�r���1�. - q� � Z32q `�
• � � Council File #
,�
--_f Green Sheet #` '17672
RESOLUTION
CITY OF SAINT PAUL, MINNESOTA
Presented By
Referred To Committee: Date
RESOLVED: That application (ID #77230) for renewal of a Gambling Manager's
License by Marlene J. Thilgen DBA Lower East Side Football
Association at Shenanigan's, 499 Payne Avenue. , be and the same
is hereby approved.
Y_ea�, _ Nava Absent Requested by Department of:
imon —T-
oswz z �
�on f License & Permit Division
-a, e� ,.-
e ma � ����M /VG����d'/�-�"
une — �
s son � By�
Adopted by Council: Date - ' `� Form Approved by City Attorney
Adoption Cert' 'ed b�y Counci Se retary � �
�� ` ��� By� ��" ZS—l/
By: ; /
� i, Approved by Mayor for Submission to
Approved b M yo�r`s � Date Council
i�" �
B Z�f.lc,"`t/f7:-��
y° By:
e
PUeUSBED ��AN 4 '�2
q I-23Zq/�
D PARTMENT/OFFICE/COUNCIL DATE INITIATED NO 17 6?2
' Finance/License GREEN SHEET -
CONTACT PERSON&PHONE INITIAUDATE INITIAUDATE
�DEPARTMENT DIRECTOR �CITY COUNCIL
Christine Rozek-298-5056 ASS�aN Q CITYATfORNEY �CITYCLEAK
MUST BE ON COUNCIL AGENDA BY(DATE) NUMBER FOR gUDGET DIRECTOR FIN.&MQT.SERVICES DIR.
City Clerk ROUTING � �
Hearing/ 12-19-91 $y� 12-12—C�1 ORDER �MAYOR(ORASSISTANT) ���R
TOTAL#OF SIGNATURE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE)
ACTION REQUESTED:
Approval of an application for renewal of a Gambling Manager's License.
Notification/ 12-6-91 Hearin / 12-19-91
RECOMMENDATIONS:Approve(A)or Re�ect(R) PERSONAL SERVICE CONTRACTS MU8T ANSWER THE FOLLOWINCi GUESTIONS:
_ PLANNIN(i COMMISSION _ CIVIL SERVICE COMMISSION �• Has this person/firm ever worked under a cOntreCt for this department9
_CIB COMMITfEE _ YES NO
2. Has this person/firm ever been a city employee?
_STAFF _
YES NO
_ DISTRIC7 COUR7 _ 3. Does this person/firm possess a skfll not normally possessed by any current city employee?
SUPPORTS WHICH COUNCIL OBJECTIVE7 YES NO
Explaln all yes answers on seperate shsst and attach to yreen ah�st
INITIATINO PROBLEM,ISSUE,OPPORTUNITY(Who,What,When,Where,Why):
Marlene J. Thilgen DBA Lower East Side Football Association requests Council
approval of her application for renewal of a Gambling Manager's License at
Shenanigans, 499 Payne Avenue.
ADVANTAGES IFAPPROVED:
If Council approval is given, Marlene J. Thilgen will continue to manage the
pulltab sales for Lower East Side Football Association at Shenanigans,
499 Payne Avenue.
DISADVANTAOES IF APPROVED:
DISADVANTAGES IF NOT APPROVED:
�RECEIVED
�EC 0 91991 Cour�cil R�r������� �����r
�iTY CLERK DEC 0 9 1991
TOTAL AMOUNT OF TRANSACTION S COST/REVENUE BUDGETEp(CIRCLE ONE) YES NO
FUNDING SOURCE ACTIVITY NUMBER
FINANCIAL INFORMATION:(EXPLAIN) �� ,t
W
NOTE: COMPLETE DIRECTIONS ARE INCLUDED IN THE GREEN SHEET INSTRUCTIONAL
MANUAL AVAILABLE IN THE PURCHASING OFFICE(PHONE NO.298-4225).
ROUTING ORDER:
Below are correct routings for the five most frequent types of documents:
CONTRACTS(assumes authorized budget exists) COUNCIL RESOLUTION (Amend Budgets/Accept. Grants)
1. Outside Agency 1. Department Director •
2. Department Director 2. City Attorney
3. City Attorney 3. Budget Director
4. Mayor(for contracts over$15,000) 4. Mayor/Assistant
5. Human Rights(for contracts over$50,000) 5. City Council
8. Finance and Management Services Director 6. Chief Accountant, Finance and Management Services
7. Finance Accounting
ADMINISTRATIVE ORDERS(Budget Revision) COUNCIL RESOLUTION (all others, and Ordinances)
1. Activity Manager 1. Department Director
�-- 2. Department Accountant 2. Ciry Attorney
a.' 3. Department Director 3. Mayor Assistant
4. Budget DireCtor 4. Ciry Council
5. City Clerk =
6. Chief Accou�tant, Finance and Management Services
" ADMINISTRATIVE ORDERS(all others)
1. Department Director
2. City Attorney
` 3. Finance ancC Management Services Director
4. Ciy Clerk
TOTAL NUMBER OF SIGNATURE PAGES
Indicate the#of pages on which signatures are required and paperclip or flag
each of these pages.
ACTION REQUESTED
Describe what the projecUrequest seeks to accomplish in either chronologi-
cal order or order of importance,whichever is most appropriate for the
issue. Do not write complete sentences. Begin each item in your list with
a verb.
RECOMMENDATIONS
Complete if the issue in question has been presented before any body, public
or private.
SUPPORTS WHICH COUNCIL OBJECTIVE?
Indicate which Council objective(s)your projecUrequest supports by listing
,, the key word(s):(HOUSING, RECREATION, NEIGHBORHOODS, ECONOMIC DEVELOPMENT,
BUDGET, SEWER SEPARATION). (SEE COMPLETE LIST IN INSTRUCTIONAL MANUAL.)
PERSONAL SERVICE CONTRACTS:
This information will be used to determine the citys liability for workers compensation claims,taxes and proper civil service hiring rules.
INITIATING PROBLEM, ISSUE, OPPORTUNITY
Explain the situation or conditions that created a need for your project
or request.
ADVANTAGES IF APPROVED
Indicate whether this is simply an annual budget procedure required by law/
charter or whether there are specific ways in which the City of Saint Paul
and its citizens will benefit from this project/action.
DISADVANTAGES IF APPROVED
What negative effects or major changes to existing or past processes might
this projecUrequest produce if it is passed(e.g.,traffic delays, noise,
tax increases or assessments)?To Whom?When?For how long?
DISADVANTAGES IF NOT APPROVED
What will be the negative consequences if the promised action is not
approved?Inability to deliver service?Continued high traffic, noise,
accident rate?Loss of revenue?
FINANCIAL IMPACT
Although you must tailor the information you provide here to the issue you
are addressing, in general you must answer two questions: How much is it
gofng to cost?Who is going to pay?
. . 9�-2329 ►/
DIVISION OF LICENSE AND PERMIT ADMINISTRATION DATE �� Cg �/ /
INTERDEPARTMENTAL REVIEW CHECKLIST Appn Processed/Received by
Lic Enf Aud
Applicant m(,�,�'`��l�T � I l Q�°j� Home Address tj�6 �� , ��f�Q'/
Business Name f.Q�P.�' ��S%�� �b�t�J��( Home Phone �`��—�016�
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Business Address � �ue. Type of License(s) �n /�'(4�/1 �'—
Business Phone ������ ��j��C��
Public Hearing Date J� � 9 f License I.D. # '��r��a
at 9:00 a.m. in the Council ham ers,
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Date Notice Sent; Dealer � /V l/�'
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Federal Firearms 4� /� /�
Public Hearing ✓ „7
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DATE INSPECTION
REVIEW VERFIED (COMPUTER) CONIl�4ENTS
A roved Not A roved
Bldg I & D �
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Health Divn. �
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Fire Dept. �
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License Divn. �
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Date Received:
Site Plan % � �
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Lease or Letter G D te
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LG212� � �j '�� FOR OFFICE USE ONLY !✓
, (Rev.7/29/91) BASE UC�
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Minnesota Lawful Gambiing FEE
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Gambling Manager Application DATE
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�New Give date that the two-day gamb6ng manager seminar was cflmpleted. / /
Loca6on of training
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�Renewal Give date of training received witlun three years prior to the date of the application to�newal.y�/�/�Q
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--A$10,000 fidelity bond in favor of the oryanization must be abtained for the gamblinp manager.
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�dectare thac
• I have read this application and all information submitted t�the board;
• all information is true,accurate and complete;
• aq olfier required infom�ation has been iully disdosed;
• 1 am the only gambling manager of the cxganizatiom,
• I wiA famifiarize myself with 1he laws ot Mnnesota govemi�y lawful gambfing and rules of the board and agree,ff I'icensed,to
abide by those laws and rules,induding amendments to them;
• any changes in appl'ica6on information will be submitted so the board and bcal unit of govemment within 10 days of the change;
• An affidavit tor gambfing manager has been completed and attached,and
• I understand that failure to provide required infortnation or providing false information may result in the denial or revocation of the
Goense.
Signature of Gambling Manager . ( Date
z� ///�—f'
Send the oompleted application,gambling manager's aff' avit,and a100 check made payable to Stata of Minnesota to:
Gambling Control Board
Aosewood Plaza South,3rd Floor
1711 W.County Road B �
Rosevllla,MN 55113