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98-94flRIGlNAL Presented By Re£erred To Council File� \ J - \� Ordinance $ Green Sheet $ LP 60006 37 Com¢nittee: Date RSSOLVED: 1 That application (ID �19970000202) for a Second Hand Dealer - 2 Motor Vehicle (lst) License(s) by CAPITOL CAR COMPANY DBA CAPITOL 3 CAR COMPANY at 321 COMO AVE be and the same is hereby approved. Yeas Nays Absent Requested by Department of: Benanav � Blakev Bostrom Coleman J � Harris � Lantrv Reiter � Adopted by Council: Date �.,�.� l�. Adoption Certified by Council Secretary $y= �--�� Approved by Ma By: � r� �`l, RESOLUTION CITY OF SAINT PAUL, MINNESOTA Office of License, Inspections and Environ[nental Piotection By: �1�"�� / ✓ � Form Ap roved by City Attorney ? � s /I D' at+.0 i'l3'9� --�_ Approved by Mayor for Submission to Council By: DEPARTMENT/OFFICFJCOUNCIL on7Ex+mniEo �� GREEN SHEET No. LP68006 � $ � � � ONTACT PERSON 8 PHONE InitlsuDaro Initiauoa6e LOOM JAMES (JIM1� (612)2669W3 � � UST BE ON COUNCIL AGENDA BY (DATE) � 21N98 �� ❑2 COUnalRes�rch ROUTNG 0� TOTAL # OF SiGNATURE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE7 ACTION REQUESTED: Camcil approva� oEMe foltaNing Gcense appGcatia�: Lice�ue � 19470006202. fa CAPITOL CAR COMPANY, Doing Business A5 CAPITOL CAR COMPANY, at 321 COMO AVE, and type of business(es): Secwid Hand Daler- AAator Vehicle (tst). RECOMMENDATIONS: Approve(A) Reject(R) ERSONAL SERVICE CONiRAC7S MUST ANSWER THE FOLLOWING WESTIONS: t. Fies Mis persoMrm ever v.orked uMer a contracl for Nis departmenY! ,PLANNINGCOMMISSION YES NO CIB COMMITTEE 2. hles this perso�rtn ever been e city employee? CIVIL SVC CINN, vES NO 3. Does this person/firm possess a slull nof nortnaiN possessed by erry currer�t city employee? YES NO 4. Is this persoMrm a fargeted vendoR YES NO Ecplsin al� yes answers M aeparote aheet and atWeh to green s�eet INITIATING PROBLEM, ISSUE, OPPORTUNITY (VJho, What, When, Where, Why): Requesting Council approval fw Capitd Car Company DBA Capitol Car Company for a Second Harrcl Deaier-Motor Vehicle Lieense at 321 Corcw Avenue. ADVANTAGES IF APPROVED: V�l�� ', Jr1,'� 2 6 1�98 ISADYANTAGESIFAPPROVED: , _"_'--..�s„�,^---.�. - '- -_- DISADVANTAGES IF NOT APPR0IFED: 70TAL AMOUNT OF TR4NSACTION S COST/REVENUE BUDGETED (CIRCLE ONE) YES NO PUNDING SOURCE ACTIVITY NUMBER FINANCIAL INFORMATION: (EXPLAIN) 9 �- ao�- CLASS III LICENSE APPLICATION � � ' � � � �� PLEASE TYPE OR PRINT IN INK G applied for: CITY OF SAINT PAUL � g�� � Offia of liame, Impectioas ,�a ��m r�c«v� 3w S[ PeoaSt Aeee]00 Sd�¢ Pml, Mwwah 33102 (6fn266//09J LX(6I�M¢9 ]/ �� � v S S �/��� � Company Name: Co'pontion / Partnenhip / Sole Proprietanhip If business is incacporated, give date of incorporatiun: Doing Business As: /r � /� � / Business Phone: BusinessAddress: `�� C.OMn .Qc/� JT/"o�, / �.,tl SVCetAddma City StAc Zip �ae'`° Between what cross streets is the business locatedl, �� �oa n�,aR�6�"'oN Y�Ab_ n°" Which side of the sVeet7 �p�:7� Are the premises now occupied7 What Type of Business7 ..rn.�ur���e / L'�eaniaG, �4Pn fs Sts/FS a'��G MailToAddress: L`+as Prp✓�du5 VSC S4eet Addren Applicant Infonnation: Neme and Title: = � City SUU Zip Pint , � 7 Middic (Maidm) � �/ LW Titla HomeAddresx ���/� C�/ (�Ur'�tC2 '=�"f � �Tc✓� l�il/ S.S/!�? T Strcet A City Sh/e Zip Date of 13irth: j�JS/T 7� Place of 13inh: .�Y' ��i ��, � Home Phone: e�X —/�I7�I Have you ever been convicted of any felony, crime or violation of any ciTy ordinance otl�er than tr�c7 YES NO � Date of azrest: Chazge: _ Conviction: Sentence: List the names and residences of tivice persons of good moral character, living within the Twin Cities Metro Area, not related to the applicant ot financially interested in Ihe premises or business, who may be refeaed to as to the applicanYs character: NAME ADDRESS PHONE List licenses whi�h you current� hold, formerlp held, or may havc an interest in: Have any of the above named licrnses ever bezn revokzcil YGS ..,� NO If yes, list the dates and reasons far revacaRon: Where? vas�ra —tn. /I!, ke ll�io„� o n� Z6 'L7 C�u� N�-r,�D ./YJy� IY1ni S'o2 �_ d SGL3 Are you going to operate this business personally7 X 1'GS NO If not, who will operate it1 � s'' —q � Fin[N�e MiddleLutid (Meidrn) Lrt UYSdB'v16 HomeAddw: SlmetName City SWe 7.ip PImcN�ber Aceyou going to have a manager a assistant in this business7 YES �_ NO If the manager is not the same as the operator, please complete the following infomtation: F'vuxeme r.5aakh»c;at f�am) uu u.�eo£ein6 Home �: Sheet Name City State Zip P6omN�bv Please lis� your employment history for the previous five (5) year period: �f List all other officers of the cmporation: OFFICER TITLE NAME (Office Held) If business is a please HOME HOME BIISINESS DATE OF ADDRESS PHONE PHONE BIItTFI the following information for each paAner (use additionel pages if necessary): � Home Addreae: Sireet Name Fint Nune Flomc Addre�s: S4eot Namc Middi<Initid City suk I.ul Date ofBiMh Zip !'lanc Number MINNESOTA TAX IDENTIFICATION NUME3GR - Pursuant to lhe Laws of Minnesota, 1984, Chapter 502, Article 8, SecUOn 2(270.72) (Tex Clearance; Issuance of Licenses), Iicensing authorities are required to provide to �}te State of Minnesota Cortunissioner of Revenue, the Minnesota business tax identification number and the sxial security number of each license applicant. Under the Minnesota Government Data Practices Act and the Pederal Privacy Act of 1974, we are required to advise you of the following regarding the use of the Minnesota Tax Identification Number: - This information may be used to drny the issuance or renewal of your license in the event you owe Minnesota sales, employer's withholding or motor vehicle excise taxes; - Upon receiving this infom�ation, the licensing authoriry will supply it only to the Minnesota DepaRment of Revrnue. However, under the Pederal Exchange of Information Agreement, the Departmrnt of Revenue may supply ilris infotmapon to the lntemal Revenue Service. Minnesota Tax Identification Nwnbers (Sales & Use TaY Number) may be obtained from the State of Minnesota, Business Records Depattment, 10 River Pazk Plaza (612-296-6181). Social Security Number, /��`✓�/�'�� S�Lr -�-/ 6�� e ota'fa Id� fication Number: _ If a Minnesota Tax Ide.mtification Number is not required for the business being operated, indicate so by placing an "X" ia the bo7c. City 2iasr�a Ri�cinrcclFmnlnvmrnt Address CERTIFICATION OF WORKERS' COMPENSATION C�VERAGE PURSUANT TO MIN23ESOTA STATUTE 176.182 I hereby ceRify that I, or my comPanY, am in compliance with ihe workers' compensation insurance coverage requirements of Ivf.innesota Statute 176.182, subdiv'ssion 2. I aLso undecstand that provision of False infoanation in this ceRification constiaues sufficient grounds for adverse actioa against all licenses held, including revocation and suspension of said licenses. Q��i —q y Name of Insurance Company: Policy Number: Covera e om to I have no employees covered under workers' compensation insurance (INITIAI.S) ANY FAISIFICATION OF ANSWERS GIVEN OR MATERIAL SUBMITTED WILL RESULT IN DEPiIAL OF THIS APPLICATION I hereby state that I have answered alt of the preceding questions, and that ihe infoimation contained herein is true and crnxect to the best of my }aowledge and belief. I hereby state further that I have received no money or other consideration, by way of loan, gift, cantribution, or otherwi�, other than already disclosed in the applicalion which I henwvith submiued. I also understand this premise may be inspected by police, £re, health and other ciry o�cials at any end all times when the business is in operation Signature (REQUIRED for all appticatlons) Date We wil! accept payment by caeh, check (made payable to City of Saint Paul) or credit card (M/C or Visa). IFPAYJNG BY CREDlT CARD PLEASE COMPI.ETE THE FOLLOWING INFORMATION: � MasterCerd � Visa EXPIl2ATION DATE: ACCOUNT NUMBER: aoio❑ ❑oo❑ ❑ooa ❑oo❑ ❑000 **Note: If this application is Food/l.iquor related, please contact a City of Saint Paul Health Tnspector, Steve Olson (266-9139), to review plans. If eny substantial changes to structure nre anticipated, please contact a City of Saint Paul Plan Examiner at 266-9007 to apply for building pettnits. If there are nny changes to the parking lot, floor space, or for new operations, please contact a City of Saint Paul Zoning Inspectot at 266-9008. All applications rcqulre the following documents. Please attach thesc documents when aubmitting your appllcation: 1. A detailed description of the design, location and square footage of the premises to be licensed (site plan). The following data should be on the site plan (preferably on an 8 1I2" x I 1" or 8 1/2" x 14" paper): - Name, address, and phone number. - The scale should be stated such as 1"= 20'. ^N should be indicated toward the top. - P(acemrnt of all pertinent teatures of the intecior of the licensed faciliry such as seating areas, kitchens, offices, repair acea, pazking, rest rooms, etc. - If a request is for an addition or expansion of the ]icensed facility, indicate both the cuaent area and the proposed expansion. 2. A copy of your lease agreement or proof of ownership of the propeRy. SPECIFIC LICENSE APPLICATIONS REQUII2E ADDTTIONAL INFORMATION. PLEASE SEE REVERSE FOR DETAILS >>>> a�asi� flRIGlNAL Presented By Re£erred To Council File� \ J - \� Ordinance $ Green Sheet $ LP 60006 37 Com¢nittee: Date RSSOLVED: 1 That application (ID �19970000202) for a Second Hand Dealer - 2 Motor Vehicle (lst) License(s) by CAPITOL CAR COMPANY DBA CAPITOL 3 CAR COMPANY at 321 COMO AVE be and the same is hereby approved. Yeas Nays Absent Requested by Department of: Benanav � Blakev Bostrom Coleman J � Harris � Lantrv Reiter � Adopted by Council: Date �.,�.� l�. Adoption Certified by Council Secretary $y= �--�� Approved by Ma By: � r� �`l, RESOLUTION CITY OF SAINT PAUL, MINNESOTA Office of License, Inspections and Environ[nental Piotection By: �1�"�� / ✓ � Form Ap roved by City Attorney ? � s /I D' at+.0 i'l3'9� --�_ Approved by Mayor for Submission to Council By: DEPARTMENT/OFFICFJCOUNCIL on7Ex+mniEo �� GREEN SHEET No. LP68006 � $ � � � ONTACT PERSON 8 PHONE InitlsuDaro Initiauoa6e LOOM JAMES (JIM1� (612)2669W3 � � UST BE ON COUNCIL AGENDA BY (DATE) � 21N98 �� ❑2 COUnalRes�rch ROUTNG 0� TOTAL # OF SiGNATURE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE7 ACTION REQUESTED: Camcil approva� oEMe foltaNing Gcense appGcatia�: Lice�ue � 19470006202. fa CAPITOL CAR COMPANY, Doing Business A5 CAPITOL CAR COMPANY, at 321 COMO AVE, and type of business(es): Secwid Hand Daler- AAator Vehicle (tst). RECOMMENDATIONS: Approve(A) Reject(R) ERSONAL SERVICE CONiRAC7S MUST ANSWER THE FOLLOWING WESTIONS: t. Fies Mis persoMrm ever v.orked uMer a contracl for Nis departmenY! ,PLANNINGCOMMISSION YES NO CIB COMMITTEE 2. hles this perso�rtn ever been e city employee? CIVIL SVC CINN, vES NO 3. Does this person/firm possess a slull nof nortnaiN possessed by erry currer�t city employee? YES NO 4. Is this persoMrm a fargeted vendoR YES NO Ecplsin al� yes answers M aeparote aheet and atWeh to green s�eet INITIATING PROBLEM, ISSUE, OPPORTUNITY (VJho, What, When, Where, Why): Requesting Council approval fw Capitd Car Company DBA Capitol Car Company for a Second Harrcl Deaier-Motor Vehicle Lieense at 321 Corcw Avenue. ADVANTAGES IF APPROVED: V�l�� ', Jr1,'� 2 6 1�98 ISADYANTAGESIFAPPROVED: , _"_'--..�s„�,^---.�. - '- -_- DISADVANTAGES IF NOT APPR0IFED: 70TAL AMOUNT OF TR4NSACTION S COST/REVENUE BUDGETED (CIRCLE ONE) YES NO PUNDING SOURCE ACTIVITY NUMBER FINANCIAL INFORMATION: (EXPLAIN) 9 �- ao�- CLASS III LICENSE APPLICATION � � ' � � � �� PLEASE TYPE OR PRINT IN INK G applied for: CITY OF SAINT PAUL � g�� � Offia of liame, Impectioas ,�a ��m r�c«v� 3w S[ PeoaSt Aeee]00 Sd�¢ Pml, Mwwah 33102 (6fn266//09J LX(6I�M¢9 ]/ �� � v S S �/��� � Company Name: Co'pontion / Partnenhip / Sole Proprietanhip If business is incacporated, give date of incorporatiun: Doing Business As: /r � /� � / Business Phone: BusinessAddress: `�� C.OMn .Qc/� JT/"o�, / �.,tl SVCetAddma City StAc Zip �ae'`° Between what cross streets is the business locatedl, �� �oa n�,aR�6�"'oN Y�Ab_ n°" Which side of the sVeet7 �p�:7� Are the premises now occupied7 What Type of Business7 ..rn.�ur���e / L'�eaniaG, �4Pn fs Sts/FS a'��G MailToAddress: L`+as Prp✓�du5 VSC S4eet Addren Applicant Infonnation: Neme and Title: = � City SUU Zip Pint , � 7 Middic (Maidm) � �/ LW Titla HomeAddresx ���/� C�/ (�Ur'�tC2 '=�"f � �Tc✓� l�il/ S.S/!�? T Strcet A City Sh/e Zip Date of 13irth: j�JS/T 7� Place of 13inh: .�Y' ��i ��, � Home Phone: e�X —/�I7�I Have you ever been convicted of any felony, crime or violation of any ciTy ordinance otl�er than tr�c7 YES NO � Date of azrest: Chazge: _ Conviction: Sentence: List the names and residences of tivice persons of good moral character, living within the Twin Cities Metro Area, not related to the applicant ot financially interested in Ihe premises or business, who may be refeaed to as to the applicanYs character: NAME ADDRESS PHONE List licenses whi�h you current� hold, formerlp held, or may havc an interest in: Have any of the above named licrnses ever bezn revokzcil YGS ..,� NO If yes, list the dates and reasons far revacaRon: Where? vas�ra —tn. /I!, ke ll�io„� o n� Z6 'L7 C�u� N�-r,�D ./YJy� IY1ni S'o2 �_ d SGL3 Are you going to operate this business personally7 X 1'GS NO If not, who will operate it1 � s'' —q � Fin[N�e MiddleLutid (Meidrn) Lrt UYSdB'v16 HomeAddw: SlmetName City SWe 7.ip PImcN�ber Aceyou going to have a manager a assistant in this business7 YES �_ NO If the manager is not the same as the operator, please complete the following infomtation: F'vuxeme r.5aakh»c;at f�am) uu u.�eo£ein6 Home �: Sheet Name City State Zip P6omN�bv Please lis� your employment history for the previous five (5) year period: �f List all other officers of the cmporation: OFFICER TITLE NAME (Office Held) If business is a please HOME HOME BIISINESS DATE OF ADDRESS PHONE PHONE BIItTFI the following information for each paAner (use additionel pages if necessary): � Home Addreae: Sireet Name Fint Nune Flomc Addre�s: S4eot Namc Middi<Initid City suk I.ul Date ofBiMh Zip !'lanc Number MINNESOTA TAX IDENTIFICATION NUME3GR - Pursuant to lhe Laws of Minnesota, 1984, Chapter 502, Article 8, SecUOn 2(270.72) (Tex Clearance; Issuance of Licenses), Iicensing authorities are required to provide to �}te State of Minnesota Cortunissioner of Revenue, the Minnesota business tax identification number and the sxial security number of each license applicant. Under the Minnesota Government Data Practices Act and the Pederal Privacy Act of 1974, we are required to advise you of the following regarding the use of the Minnesota Tax Identification Number: - This information may be used to drny the issuance or renewal of your license in the event you owe Minnesota sales, employer's withholding or motor vehicle excise taxes; - Upon receiving this infom�ation, the licensing authoriry will supply it only to the Minnesota DepaRment of Revrnue. However, under the Pederal Exchange of Information Agreement, the Departmrnt of Revenue may supply ilris infotmapon to the lntemal Revenue Service. Minnesota Tax Identification Nwnbers (Sales & Use TaY Number) may be obtained from the State of Minnesota, Business Records Depattment, 10 River Pazk Plaza (612-296-6181). Social Security Number, /��`✓�/�'�� S�Lr -�-/ 6�� e ota'fa Id� fication Number: _ If a Minnesota Tax Ide.mtification Number is not required for the business being operated, indicate so by placing an "X" ia the bo7c. City 2iasr�a Ri�cinrcclFmnlnvmrnt Address CERTIFICATION OF WORKERS' COMPENSATION C�VERAGE PURSUANT TO MIN23ESOTA STATUTE 176.182 I hereby ceRify that I, or my comPanY, am in compliance with ihe workers' compensation insurance coverage requirements of Ivf.innesota Statute 176.182, subdiv'ssion 2. I aLso undecstand that provision of False infoanation in this ceRification constiaues sufficient grounds for adverse actioa against all licenses held, including revocation and suspension of said licenses. Q��i —q y Name of Insurance Company: Policy Number: Covera e om to I have no employees covered under workers' compensation insurance (INITIAI.S) ANY FAISIFICATION OF ANSWERS GIVEN OR MATERIAL SUBMITTED WILL RESULT IN DEPiIAL OF THIS APPLICATION I hereby state that I have answered alt of the preceding questions, and that ihe infoimation contained herein is true and crnxect to the best of my }aowledge and belief. I hereby state further that I have received no money or other consideration, by way of loan, gift, cantribution, or otherwi�, other than already disclosed in the applicalion which I henwvith submiued. I also understand this premise may be inspected by police, £re, health and other ciry o�cials at any end all times when the business is in operation Signature (REQUIRED for all appticatlons) Date We wil! accept payment by caeh, check (made payable to City of Saint Paul) or credit card (M/C or Visa). IFPAYJNG BY CREDlT CARD PLEASE COMPI.ETE THE FOLLOWING INFORMATION: � MasterCerd � Visa EXPIl2ATION DATE: ACCOUNT NUMBER: aoio❑ ❑oo❑ ❑ooa ❑oo❑ ❑000 **Note: If this application is Food/l.iquor related, please contact a City of Saint Paul Health Tnspector, Steve Olson (266-9139), to review plans. If eny substantial changes to structure nre anticipated, please contact a City of Saint Paul Plan Examiner at 266-9007 to apply for building pettnits. If there are nny changes to the parking lot, floor space, or for new operations, please contact a City of Saint Paul Zoning Inspectot at 266-9008. All applications rcqulre the following documents. Please attach thesc documents when aubmitting your appllcation: 1. A detailed description of the design, location and square footage of the premises to be licensed (site plan). The following data should be on the site plan (preferably on an 8 1I2" x I 1" or 8 1/2" x 14" paper): - Name, address, and phone number. - The scale should be stated such as 1"= 20'. ^N should be indicated toward the top. - P(acemrnt of all pertinent teatures of the intecior of the licensed faciliry such as seating areas, kitchens, offices, repair acea, pazking, rest rooms, etc. - If a request is for an addition or expansion of the ]icensed facility, indicate both the cuaent area and the proposed expansion. 2. A copy of your lease agreement or proof of ownership of the propeRy. SPECIFIC LICENSE APPLICATIONS REQUII2E ADDTTIONAL INFORMATION. PLEASE SEE REVERSE FOR DETAILS >>>> a�asi� flRIGlNAL Presented By Re£erred To Council File� \ J - \� Ordinance $ Green Sheet $ LP 60006 37 Com¢nittee: Date RSSOLVED: 1 That application (ID �19970000202) for a Second Hand Dealer - 2 Motor Vehicle (lst) License(s) by CAPITOL CAR COMPANY DBA CAPITOL 3 CAR COMPANY at 321 COMO AVE be and the same is hereby approved. Yeas Nays Absent Requested by Department of: Benanav � Blakev Bostrom Coleman J � Harris � Lantrv Reiter � Adopted by Council: Date �.,�.� l�. Adoption Certified by Council Secretary $y= �--�� Approved by Ma By: � r� �`l, RESOLUTION CITY OF SAINT PAUL, MINNESOTA Office of License, Inspections and Environ[nental Piotection By: �1�"�� / ✓ � Form Ap roved by City Attorney ? � s /I D' at+.0 i'l3'9� --�_ Approved by Mayor for Submission to Council By: DEPARTMENT/OFFICFJCOUNCIL on7Ex+mniEo �� GREEN SHEET No. LP68006 � $ � � � ONTACT PERSON 8 PHONE InitlsuDaro Initiauoa6e LOOM JAMES (JIM1� (612)2669W3 � � UST BE ON COUNCIL AGENDA BY (DATE) � 21N98 �� ❑2 COUnalRes�rch ROUTNG 0� TOTAL # OF SiGNATURE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE7 ACTION REQUESTED: Camcil approva� oEMe foltaNing Gcense appGcatia�: Lice�ue � 19470006202. fa CAPITOL CAR COMPANY, Doing Business A5 CAPITOL CAR COMPANY, at 321 COMO AVE, and type of business(es): Secwid Hand Daler- AAator Vehicle (tst). RECOMMENDATIONS: Approve(A) Reject(R) ERSONAL SERVICE CONiRAC7S MUST ANSWER THE FOLLOWING WESTIONS: t. Fies Mis persoMrm ever v.orked uMer a contracl for Nis departmenY! ,PLANNINGCOMMISSION YES NO CIB COMMITTEE 2. hles this perso�rtn ever been e city employee? CIVIL SVC CINN, vES NO 3. Does this person/firm possess a slull nof nortnaiN possessed by erry currer�t city employee? YES NO 4. Is this persoMrm a fargeted vendoR YES NO Ecplsin al� yes answers M aeparote aheet and atWeh to green s�eet INITIATING PROBLEM, ISSUE, OPPORTUNITY (VJho, What, When, Where, Why): Requesting Council approval fw Capitd Car Company DBA Capitol Car Company for a Second Harrcl Deaier-Motor Vehicle Lieense at 321 Corcw Avenue. ADVANTAGES IF APPROVED: V�l�� ', Jr1,'� 2 6 1�98 ISADYANTAGESIFAPPROVED: , _"_'--..�s„�,^---.�. - '- -_- DISADVANTAGES IF NOT APPR0IFED: 70TAL AMOUNT OF TR4NSACTION S COST/REVENUE BUDGETED (CIRCLE ONE) YES NO PUNDING SOURCE ACTIVITY NUMBER FINANCIAL INFORMATION: (EXPLAIN) 9 �- ao�- CLASS III LICENSE APPLICATION � � ' � � � �� PLEASE TYPE OR PRINT IN INK G applied for: CITY OF SAINT PAUL � g�� � Offia of liame, Impectioas ,�a ��m r�c«v� 3w S[ PeoaSt Aeee]00 Sd�¢ Pml, Mwwah 33102 (6fn266//09J LX(6I�M¢9 ]/ �� � v S S �/��� � Company Name: Co'pontion / Partnenhip / Sole Proprietanhip If business is incacporated, give date of incorporatiun: Doing Business As: /r � /� � / Business Phone: BusinessAddress: `�� C.OMn .Qc/� JT/"o�, / �.,tl SVCetAddma City StAc Zip �ae'`° Between what cross streets is the business locatedl, �� �oa n�,aR�6�"'oN Y�Ab_ n°" Which side of the sVeet7 �p�:7� Are the premises now occupied7 What Type of Business7 ..rn.�ur���e / L'�eaniaG, �4Pn fs Sts/FS a'��G MailToAddress: L`+as Prp✓�du5 VSC S4eet Addren Applicant Infonnation: Neme and Title: = � City SUU Zip Pint , � 7 Middic (Maidm) � �/ LW Titla HomeAddresx ���/� C�/ (�Ur'�tC2 '=�"f � �Tc✓� l�il/ S.S/!�? T Strcet A City Sh/e Zip Date of 13irth: j�JS/T 7� Place of 13inh: .�Y' ��i ��, � Home Phone: e�X —/�I7�I Have you ever been convicted of any felony, crime or violation of any ciTy ordinance otl�er than tr�c7 YES NO � Date of azrest: Chazge: _ Conviction: Sentence: List the names and residences of tivice persons of good moral character, living within the Twin Cities Metro Area, not related to the applicant ot financially interested in Ihe premises or business, who may be refeaed to as to the applicanYs character: NAME ADDRESS PHONE List licenses whi�h you current� hold, formerlp held, or may havc an interest in: Have any of the above named licrnses ever bezn revokzcil YGS ..,� NO If yes, list the dates and reasons far revacaRon: Where? vas�ra —tn. /I!, ke ll�io„� o n� Z6 'L7 C�u� N�-r,�D ./YJy� IY1ni S'o2 �_ d SGL3 Are you going to operate this business personally7 X 1'GS NO If not, who will operate it1 � s'' —q � Fin[N�e MiddleLutid (Meidrn) Lrt UYSdB'v16 HomeAddw: SlmetName City SWe 7.ip PImcN�ber Aceyou going to have a manager a assistant in this business7 YES �_ NO If the manager is not the same as the operator, please complete the following infomtation: F'vuxeme r.5aakh»c;at f�am) uu u.�eo£ein6 Home �: Sheet Name City State Zip P6omN�bv Please lis� your employment history for the previous five (5) year period: �f List all other officers of the cmporation: OFFICER TITLE NAME (Office Held) If business is a please HOME HOME BIISINESS DATE OF ADDRESS PHONE PHONE BIItTFI the following information for each paAner (use additionel pages if necessary): � Home Addreae: Sireet Name Fint Nune Flomc Addre�s: S4eot Namc Middi<Initid City suk I.ul Date ofBiMh Zip !'lanc Number MINNESOTA TAX IDENTIFICATION NUME3GR - Pursuant to lhe Laws of Minnesota, 1984, Chapter 502, Article 8, SecUOn 2(270.72) (Tex Clearance; Issuance of Licenses), Iicensing authorities are required to provide to �}te State of Minnesota Cortunissioner of Revenue, the Minnesota business tax identification number and the sxial security number of each license applicant. Under the Minnesota Government Data Practices Act and the Pederal Privacy Act of 1974, we are required to advise you of the following regarding the use of the Minnesota Tax Identification Number: - This information may be used to drny the issuance or renewal of your license in the event you owe Minnesota sales, employer's withholding or motor vehicle excise taxes; - Upon receiving this infom�ation, the licensing authoriry will supply it only to the Minnesota DepaRment of Revrnue. However, under the Pederal Exchange of Information Agreement, the Departmrnt of Revenue may supply ilris infotmapon to the lntemal Revenue Service. Minnesota Tax Identification Nwnbers (Sales & Use TaY Number) may be obtained from the State of Minnesota, Business Records Depattment, 10 River Pazk Plaza (612-296-6181). Social Security Number, /��`✓�/�'�� S�Lr -�-/ 6�� e ota'fa Id� fication Number: _ If a Minnesota Tax Ide.mtification Number is not required for the business being operated, indicate so by placing an "X" ia the bo7c. City 2iasr�a Ri�cinrcclFmnlnvmrnt Address CERTIFICATION OF WORKERS' COMPENSATION C�VERAGE PURSUANT TO MIN23ESOTA STATUTE 176.182 I hereby ceRify that I, or my comPanY, am in compliance with ihe workers' compensation insurance coverage requirements of Ivf.innesota Statute 176.182, subdiv'ssion 2. I aLso undecstand that provision of False infoanation in this ceRification constiaues sufficient grounds for adverse actioa against all licenses held, including revocation and suspension of said licenses. Q��i —q y Name of Insurance Company: Policy Number: Covera e om to I have no employees covered under workers' compensation insurance (INITIAI.S) ANY FAISIFICATION OF ANSWERS GIVEN OR MATERIAL SUBMITTED WILL RESULT IN DEPiIAL OF THIS APPLICATION I hereby state that I have answered alt of the preceding questions, and that ihe infoimation contained herein is true and crnxect to the best of my }aowledge and belief. I hereby state further that I have received no money or other consideration, by way of loan, gift, cantribution, or otherwi�, other than already disclosed in the applicalion which I henwvith submiued. I also understand this premise may be inspected by police, £re, health and other ciry o�cials at any end all times when the business is in operation Signature (REQUIRED for all appticatlons) Date We wil! accept payment by caeh, check (made payable to City of Saint Paul) or credit card (M/C or Visa). IFPAYJNG BY CREDlT CARD PLEASE COMPI.ETE THE FOLLOWING INFORMATION: � MasterCerd � Visa EXPIl2ATION DATE: ACCOUNT NUMBER: aoio❑ ❑oo❑ ❑ooa ❑oo❑ ❑000 **Note: If this application is Food/l.iquor related, please contact a City of Saint Paul Health Tnspector, Steve Olson (266-9139), to review plans. If eny substantial changes to structure nre anticipated, please contact a City of Saint Paul Plan Examiner at 266-9007 to apply for building pettnits. If there are nny changes to the parking lot, floor space, or for new operations, please contact a City of Saint Paul Zoning Inspectot at 266-9008. All applications rcqulre the following documents. Please attach thesc documents when aubmitting your appllcation: 1. A detailed description of the design, location and square footage of the premises to be licensed (site plan). The following data should be on the site plan (preferably on an 8 1I2" x I 1" or 8 1/2" x 14" paper): - Name, address, and phone number. - The scale should be stated such as 1"= 20'. ^N should be indicated toward the top. - P(acemrnt of all pertinent teatures of the intecior of the licensed faciliry such as seating areas, kitchens, offices, repair acea, pazking, rest rooms, etc. - If a request is for an addition or expansion of the ]icensed facility, indicate both the cuaent area and the proposed expansion. 2. A copy of your lease agreement or proof of ownership of the propeRy. SPECIFIC LICENSE APPLICATIONS REQUII2E ADDTTIONAL INFORMATION. PLEASE SEE REVERSE FOR DETAILS >>>> a�asi�