96-1247 Council File # �� �� 1 y�
�� i \ � � 1 �,i �� � Ordinance #`
Green Sheet # �����
RESOLUTION
CI F SAINT PAUL, MINNESOTA �(a
Presented By
Referred To Committee: Date
1 RESOLVED: That application (ID #17805) for a Grocery-C, Laundry/DC Pick Up Station,
2 Cigarette, and Off Sale Malt License by Scott Dixon DBA Kellogg Square Market
3 (Scott Dixon, Owner) at 111 Kellogg Boulevard be and the same is hereby
4 approved.
5
6 Requested by Department of:
7 Yeas Nays Abse
8 B a e,y
9 Guerin —� Office of License, inspections and
10 Harris
11 Me Environmental Protection
12 Re tma �
13 une ✓
15 Bostrom �
16 ' �L�� � � /
17 Adopted by Council: Date �_�. a ,��� BY'
18
19 Adoption Certified by Council Secretary Form Approved by City Attorney
20
21 (�
22 BY���_ �' . \��,..
23 BY°
24 Approved by Mayor: Date ;� � G�/
25 ,
26 �j ,+ ,, Approved by Mayor for Submission to
27 By: / �'�,c�j . ,Ue�� Council
28
By:
ac. -��-�t'1
-
LIEP/Licensin� DATE INITIA ED �REEN SHEET N_ 3�519
� �DEPARTMENT D(RECTOR m�� �Cm cour�Ci� �N��
Christine Rozek, 266-9108 �N 0 cm��ev �CITYCLERK
IL AO N BY( 1 ROIITIlki� �BUDOET DIRECTOR �FIN.6 MOT.SERVICES DIR.
For hearin : Z �p ❑"""'��OR"��T""T� ❑
TOTAL#t OF SIGNATURE PA (CUP ALL LOCATIONS FOR SIGNATURE)
A�.TION REOUE8'TEO:
Scott Dixon DBA Rellogg Square Mar�Cet requests Council approval of its application for a
Grocery-C, Laundry/DC Fick Up Station, Cigarette, and Off Sale Malt License at 111 Kellogg
Blvd (ID #17805) .
RECOMMFN�TIONB:Appow(A)a Ft�.ti(Fi) pERSONAL SERVICE CONTRAC'f8 MUBT ANdWBR THE FOLLOWINO CUESTION8:
_PlA1M�11PN�COMMI8810N _CNq..8ERVICE COMM18810N 1. Has this person/firm ever worked undsr a cofllrad for tl�is departmeM? -
_CIB�OMMITTEE _ YES �NO
2. Mas Mis penon/Nrm evx bssn a cily employes,?
—� — YE3 NO
_DISTRIC'i WuRT _ 3. Doss this psnorVHrtn possees a sklll not normally Pospssed try enY c�rroM dtY emPbYes?
8UPPORTB WHICH COUt�IL OB�CTIVE? YES NO
Explaln all yp�nsw�rs on�rab shNt and�oh to On�n aMrt
INITIARN�K�PROBL�EM.ISSUE.OPPORTUNITY(Who.Wlut.WMn�VYhere.WhY):
� RE��IV�D �
JUL QS �
1�
a�p�N�Y
ADVANTAOES iF APPRONED:
DISADVANTAf3E81F APPROYED:
� COUfiC{) RBS�df(�'i �'ItK
SEP 16 1996
���8��,�,�o: �- -
TOTAL AMOtlNT OF TRANBACTION = C08TIREVENUE BUDAETEO(CIRCIE ONE) YES NO
FUNDIHO 30URC8 ACTIVITY NUMBER
FINANCIAL INFORMATION:(EXPLAIN)
Greensheet # 35519 L.I.E.P. REVIEW CHECKLIST Date: 6I27/96 L
In Trackel? App'n Rec:eived / App'n Processed
�� ���"l�
License ID # 17805 License Type: Grocerv-C, Laundrv/DC Pick Up Station, Cigarette,
Company Name: Scott Dixon Off Sale Ma1�BA: Kellogg Square Ma.rket
Business Addresss: 111 Kellogg Bivd 230, 101 Business Phone: 293-9327
Contact Name/Address: Scott Dixon, Home Phone:
Date to Council Research: �j�- ��p-%1��°���U�a 73 �
Public Hearing Date: �� ?� Labels Ordered: ,�
Notice Sent to Applicant: District Council #: � �
, ��
Notice Sent to Public: ��%?U/ �/� Ward #:
Department/ Date Inspections Comments
�
City Attorney
9 ' � '`�� O� .
Environmental
Health
� • � •�(>i D• 1� .
Fire
�• ��� c��� .
License Site Plan Received:
Lease Received:
�1 12 I �j(p �/�
Police
� � 3• !� O• K
Zoning
� •3•� (� n. K .
. . . - ._ . _ . . . i..�
.. . __`�, . � �� C�S
CLASS III CITY OF SAINT PAUL
LICENSE APPLICATION o�aofL'�'5�,��bonS
and Em�"vonmental Protection
i�0 5�Pe:er St.Suiu±:1�
- Srim Paul,Miooesw 53)02
(612)1b69090 fu(612)266-9121'���
__._, a� - ,
��
�i�� THIS APPLICATIO�'IS SUBTECT TO REVIEW BY THE PUBLIC
�� Ca���
PLEA E TYPE O PRINT IN INK �
��� o�-'�Sr�,l� /�'Iw� '�3t?•°� (a�Uy� ���.�� ���1? `�
, , Groc� —
Type of License(s)being applied for:
Company Name: J c.0"� W � �1 �� ..
Corporation/Pazma^ship ole Proprietorship
r
If business is incorporated,give date of incorporation:
Doing Business As: k E��-��� ��pl�:E �Arc.(.�� 1 Business Phone: �q�'�3��
BusinessAddress: ��� K��S� g�v(l� s��'L° d��0 �. (�Ul,� �� :s5�0�
Strxt Address City State Zip
Between a=hat cross streets is the bus��' es�s�located? k�L��� � ��� Which side of the street? W
�~�� ...���.,�, � �
Are the premises now occupied. at ype of Business. Gc�N V �d✓( A�L� "� G V'0 GU^�1 _
Mail To Address: �1� �l.(,,Oq�i Q�v� 5�-'�'�'Q, pZ3� �,f�c.l� /�� '�J s l ��
Street Addras Ciry State Zip
Applicant Information: �
:�'ame and Tide: S C.O'�"-� W . ��X�/J G lr�0�-'E D2
First Middle (Maiden) Last ' Title
Home Address• � � �'{• �
Straet Address Ciry State Zip
Date of Birth: �" � ' Place of Birth: Home Phone:
Have you ever been nvic of any felony,crime or violation of any city ordinance other than traffic? YES_ NO�
Dau of arnest Where?
Charge:
Conviction: Sentence:
List the names and residences of three persons of good moral character, living within the Twin Cities Metro Area, not related to the
applicaat or financially interested in the premises or business,who may be referred to as to the applicant's chuactsr:
°---NAME ADDRESS PHONE
o�t�so�,�
List licenses which you curre y hold,for�rly held,or may haye an interest in: `AS ��� h,���g��
C,� c�,rE. -E� SC+.�'Q M(�C� � c�ro�_et�! `�— �Y ��nt�r-�'p41 , MN
Have any of the above namod licenses ever been revoked? YES �NO If yes,list the dates and reasons for revocation:
Are you going to operate this business personally? � YES NO If not,who will operate it?
,
a
first Name Middle Initi�l (Maiden) Last Date of Birth
Home Address: Strru Name Gry 5ute Zip Phone Number
Are you going to ha��e a manager or assistant in this business? YES �NO If the manager is not the same as the operatc.
complete the following information: �r . l�,y�
1r
�
Fust Nazne Middle Initial (2.isiden) Last Date of Birth� .
Home Address: Sura Name City Stau Zip Phone Number
Ple�se list your employment history for the previous five(�}�ear period:
Business/Em�lovment cs}p{Zr, Address "Z �f �9 5�
� � � ��- ' d �4 T
� t`^A �`g � �4 w. M N • A � oe� M N 5 3 ��
���� wA�-D �ooc�s �' S�E� a� +�e� 55l 3 -� � --� `t ��95
L.��c,� SalQS
List all other o�cers of the corporation:
OFFTCER TITT.� HOME HO�� BliSI:�'ESS DATE OF
�Tp.,� (Office Held) ADDRESS PHONE PHO;�'E B��
___��—�—
If business is a parmerstup,please include the following information for each partner(use additional pa�es if necessary):
__�
Fust Name Middle Initial (Maiden) Last Date of Birth
Home Address: Sueet:�ame City State Zip Phone Number
�t�� �y�e�u� (Maiden) Last Date of Birth
Home Address: Sveet Name City State tip Phone Number
MII�'I�TESOTA TAX IDENTIf�ICATION NiTMBER-Pursuant to the Laws of Minnesota, 1984,Chapter 502,Atticle 8,Section 2(270.72)
(Taz Clearance;Issuance of Licenses),licensing authorities aze required to provide to the State of Minnesota Commissioner of Revenue,
the M'innesota business taz identification number and the social security number of each license applicant
Under the M'innesota Government Data Practices Act and the Federal Privacy Act of 1974,we are required to advise you of the following
regarding t6e use of the lviinnesota Taz Identification Number:
-This.information may be used to deny the issuance or renewal of your license in t6e event you owe Minnesota sales,employer's
withholding or motor vehicle ezcise taxes;
-Upon receiving this informatioq the licensing authority will supply it only to the Minnesota Depa�tment of Revenue. However,
under the Federal Ezchange of Information Agreement,the Department of Revenne may supply this information to the Intemal
Revenue Service. '
Minnesota Taz Identificafion Numbers (Sales &Use Taz Number) may be obtained from the State of Minnesota, Business Records
Department, 10 River Pazk Plaza(612-296-6181). .
s���s��ty x�:
Minnesota Taz Idenafication Number. �
If a Minnesota Tax Identification Number:is�not required for tbe business being operated,indicate so by placing an"X"in the
boz.
- - - ;,. ,">
. . '
.FICATI0IT OF WORKERS'CO?�'iPENSATION COVERAGE PURSUA?�"T TO r'IL\TNESOTA STATUI'E 176.182
eby cer[ify that I,or my com�any,am in compliance with the workers'compensation insurance coverage requirements of Minnesota
�tute 176.182,subdivision 2. I also understand that provision of false information in this certification constitutes su�cient grounds for
sdverse action against all licenses held,including revocation and suspension of said licenses. ��' I��^
Name of Insurance Company: , `'
Policy Number: Coverage from to
I have no employees covered under workers'compensation insurance�
(_ �( w;t,l o+�Ec,�,;.,� �-� v pot+a 1•,i.-��c, c�•.� {�►.�.������
-tl�R:v Aw�e.rCC�N �t�,-k9� svrsv►-a nc,� .
ANY FAISIFICATION OF A.'�S�i'ERS GI�EN OR A'IATERIAL SUBAIITTED
R'II.L RESULT IN DENU�L OF TffiS APPLICATION
I hereby state that I have answered aIl of the preceding questions,and that the information contained herein is tn�e and correct to the best
of my knowledge and belief. I hereby state fiuther that I have received no money or other consideration,by w�ay of loan,gift,contribution,
or otherwise,other than already disclosed in the application which I herewith submitted: .I.also understand this premise may be inspected
by police,fire,health and other city officials at any and all times when the business is in operation.
� ��
� Signature(REQUIRED for all ap lications) Date
**A'ote: If this application is Food/L.iquor relatr,d,please contact a City of Saint Paul Health Inspector,Ste��e Olson(266-9139),to re��iew
plans.
If any substantial changes W structure are.anticipated,please contact a City of Saint Paul Plan Ezaminer at 266-9007 to apply for
building permits.
ff there are any changes W the pazking lot,floor space,or for new operations,please contact a City of Saint Paul Zoning Inspector
at 266-9008.
Additional application requirements,please attach:
A detailed description of the design,location and square footage of the pretnises to be licensed(site plan).
The following data should be on the site plan(preferably on an S 1/2"x 11"or 81/2"x 14"paper):
-Name,address,and phone number. .
-The scale should be stated such as 1"=20'.^N should be indicated toward the top.
-Placement of all pertinent features of the interior of the licensed facility such as seating areas,ldtchens,offices,repaic
area,parldng,rest rooms,etc.
- If a request is for an addition or expanslon of the licensed facitity, indicate both the current area and the proposed �
expansion
,
A copy of your leasc agreement or proof of o�r►ership of the property.
FOR SPECIFIC APPLICATION REQUIREMENTS, PLEASE SEE REVERSE >>>>,