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96-1061 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 1'I 18 19 20 21 22 23 24 25 26 27 28 ._ Presented By- Referred To RM�N�Eo ��a�19L Council File $ � � � �� Ordinance # Green Sheet # ��°?�� RESOLUTION SAINT PAUL, MINNESOTA oZ9 Committee: Date RESOLVED: That application (ID #74978) for a Game Room, Cabaret-A, and Restaurant-B License applied for by Club Soda An Alternative Choice, Inc. DBA Club Soda An Alternative Choice at 1301 3essamine Avenue be and the same is hereby approved with the following conditions: 1 2 3 Applicant shall be solely responsible for operation of the business and Mr. Thomas Redmann shall not have any ownership or management responsibilities for the business. (Mr. Redmann may be an employee) Applicant shall submit articles of incorporation and any other documents having to do with ownership of the business as requested by LIEP. LIEP will review the cond.itions for possible revision before July 1, 1996. 4. P332 t3�an-tcvo: There shall be no more than two pool tables two video games and two dart boards. 5. The establishment hours s a1L be limited to 11:00 a.m. until 1:00 a.m. L 7. A security review and report shall be conducted by LIEP by June 1, 1996. No one under 18 years old, may be admitted unless accompanied by a parent or quardian, and all such people under 18 must exit the establishment by 10:00 p.m. 8. Special permission for events involving persons under 18 years old may be granted with the consent of District 2 and LIEP. �� Nr a„R� A�� Requested by Department of: office of License, Inspections and Environmental Protection ��5('L�� / f � /�. By: Approved by MayP3-:T Date By: Form Appz'oved by City Attorney -�-'---°-.'_'; ` � BY= �`�,o'u,�Cc � j� GL-l'�'xP/� Approved by Mayor for Submission to Council By: Adopted by Council: Date a� � Adoption Certi£ied by Council Secretary GREEN SHEET TOTAL # OF SIGNATURE PAGES °tL-to� N_ 35259 . INR)ALIDATE � RSSIC+N O C17Y ATTORNEY O CRV CLERK NUYBENFOR ORDERN6 ❑ BUDGEf DIRECTOR � FlN. & MGT.: a MAYOR (OR ASSISTANn ❑ (CLIP ALL LOCATIONS FOR SIGNATUHE) DIR ri h-Soda-As--:�}Eer�ive-£lioice 3TTSA Choice requests Council approval of its application for a Game Room, Caba'ret-A, and Restaurant-B License at 1301 Jessamine Avenue East (ID �i92181). _ PLANN�NG CAMMISSION _ GVIL SEPVICE COMMISSION __ Ci8 WMMITTEE _ � STAFP _ _ D151AICTCpUHT _ SUPPoRTS WHICH COUNCIL 09JECTIVET ISSUE, (Who. What. IF APPROVED� $3:t+�s'.�y�: '^» ,4'�*. <� .... . is.r._ _. _' ci;�i`` � ,'� � , i _ .. :. „ TOTAL AMOUNT OF TRANSACTiON PEpSONAL SERVICE CANTRACTS MUST ANSWER 7HE FOLLOWiNG �UESTIONS: 7. Has Nis personfittn ever worketl under a conVact for this tlepartment? YES NO 2. Has thi5 person�rm ever been a Ciry employee? YES NO 3. Does this pelsonttirm possess a skill not normally possesseE by any cUrcent city employee? YES NO Explain all yes answers on separeta sheet anC attaeh to grean Sheet WhyJ: COST/REVENUE BUDGETED (C{qCLE ONE) YES NO FUNDING SOUflCE AC7IVITY NUMBER FINANCIALINFOliMATION:(EXPLAIN) Greensheet# - 3 -- 5 7 2 - 5 - 9 L.I.E.P. REVIEW CHECKLIST Date: 11/22/95 L��O'�O� In Trackei? !a[�'n App'n Receivetl / App'n Processed �—�— LicenselD # 92181 License Type:Game Room Cabaret-a and Restaerant-R CompanyName: Club Soda An Alternative Choice. Inc. DBA: ('7nH Soda An AItP,-.,at;..P ct,�;�o BUSiness Addresss: 1301 Jessamine Avenue East Business Phone: ��4-�82$ ---- - ----------- - --- — GDntact NameJftddress: DouQ2as 0eteri; Pres 3001 Hame Road Home Phone: 4n�-q�n6 Date to Council Research: Medina 55340 Public Hearing Date: �,_. F ,, � ��(� Labels Ordered: ��/ � Notice Sent to Applicant: �ll�jjD District Council #: a _/�, . 3_Zd . -- --. - � Notice Sent to Public: �f� ��4 �la �� Ward #: Department/ Date inspections Commerns City Attomey /-Ll , g6 � (�' i� Environmental Health f� Y 6 O� Fire j M � r �� L License 67� f �'�� a a��d ��— ` - `� - `'/� L'pzv.tSi77q,tJs Police O I ` � - a�- ��v " Zoning 1-y �K CLASS III c1� oF satrrT PAVr_ LICENSE APFL1Cr`�TiON osr« „s �;��, a,� and Environmental Protcction i50 St Pna A Swi<3W SsintPaul.?tiomuu 55101 (61])=669090 (u(6II)]6691.i THIS APPLICATION IS SUBJECT TO REVIE�V BY THE PUBLIC - - - - - - - -- - - - -- -- - PLEASE TYPE OR PRINT IN INK T}'pe of Licznse(s) bzing applied for: �✓ CompanyNamz: C�1-�- `.�jbqLt Corporation / Partnetship / $ole Propric[orship If business is incorporaced, �ive date of incorporation: � Doing Business As: Business Address: Business Phonz: 77 y- 7�a� Sveet Add:ess City Sta;e Zip Betwzen what aoss streets is the busi�n located? 1 ��n Soi.- /'✓rICUJU �/ �Vhich side uf thz sveet? /�l�r �l✓2�' Are the premises now occupied? 7-' S \�hat T�pz of Busine n f�/�// / D/ ��/U� �"/CQi ��/1 �Gla�i- MailToAddress: /J J'C�SG��/It2 ��vn, ��7. /'Gu� �Ol/ SS /�� Sutti Address City � / Applicant Informatio� � 9 �1 J rPCc r�� ukr --,">!,� - ✓� Sta�e L Y Name and Tnle: _ /(/.� �S 1 //y7-�i'� (/�/C�///�i'�/�1 First htiddle � ( � y J � faiden) Last 'Titie Home Address: .3G'v/ ��G�-G� /SOQ� �/" //��/.!�� J}N �,jy() Strcet ddress � �- Ciey Sizie Lip Datz of Birth: _ a S,�S�- Place of Birt1�: �%ti ,/�/'✓ Home Phone: �D�" ! 'J6 �� Have you ever been convicted of any felony, crime or violation of any city ordinance other than traffic? YES _ NO � Date of arrest: Wlierz? Charge: Conviction: Sentence: List the names and residences of three pzrsons of good moral character, living within the T�vin Cities Metro Area, not related to the applicant or financially intzrested in the premises or business, �vho may be referred to as to the applicant's character: Have any of the above named ]icenses ever been revoked? YES r. G-"�ir.e �,ce rve NO If yes, list the dates and reasons for revocation: Are you going to operate this business personally? � YES Fim Name MidJle Initial (Ma;den) Home Address: S�rcet Name Cry NO IF not, who will operate it? Lbtt Statt Dau ef Binh Zip Phone Num6u �J� List licenses which you currently hold, formerIy held, or may have an interest in: First Name Homc Adcrs:s: �Je-? Tame Middle Initial (�iaiden) Cc� Please list your employment history for the previous five (5) ��ear period: Lut Statt � � a� — Da¢ot8itth� �v -= Z Q � Z+p Phont Num�e: � 1�`,�� \� //2- c�7�—//.��,? i _9�'S9 � �"_S _�i7zer�GQ� �xL: . 7ia�LV-G��,��r �c%-Imp�,e:,./ (-g�/nb" r, �� /9�Z-�3�r��m4r��-�'�c. !�3/ A� `:/o� �r. i��S. i'ylo✓ SSya� G�� _.Sy%-B�cY� List all other officers of the corporation: OFFICER TITLE HOME HOD7E � BUSINESS DATE OF NAhIE (Office He d} ADDRESS PHONE PH013E BJRTH ��cs�vrlP� �r�s.�.��rr�3 �ome%//%p�/ra �i�,/.v3�� 4'ds�- 96t5/� y�s-oba3 se If business is a pannership, please includz the following infonnation for each partner (use additional pa�zs if necessary): First Name Home Address: Sucet hame Firtt tvame Home Address: Sveet Narne Middle I�itial Middle Initial (�faiden) Ciry (Alaiden)� Ciry Lut Stata Zip Last Stam 2ip Date of Binh Phone Number Date oi Birth Phone Number MINNESOTA TAX IDENTIFICA7'ION Iv'UMBER - Pursuant to the Laws of tviinnesota, 1984, Chapter 502, Article 8, Section 2 (270.72) (Tax Clearance; Tssuance of Licenses), licensing authorities are required to provide to the State of Minnesota Commissioner of Revenue. the Minnesota business tax identification number and the social security number of each license applicant. Under the Minnesota Government Data Practices Act and the Federat Privacy Act of 1974, we are required to advise you of the following regardina the use of the Minnesota Tax Identification Number: - This information may be used to deny the issuance or renewal of your license in the event you owe Minnesota sales, employer's withholdin� or motor vehicle excise taxes; - Upon receivin� this information, the licensing authority wi11 supply it only to the Minnesota Department of Revenue. However, under the Federal Exchan�e of Information Agreement, the Department of Revenue may suppiy this information to the Intemal Revenue Service. Minnesota Tax Identification Numbers {Sales & Use Tax Number) may be obtained from the State of Minnesota, Business Records Department, 10 River Park Plaza (612-296-6181). Social Security Number: �� Minnesota Tax Identification Number: �c� `fc� y7a � _ If a Minnesota Tax Identification Number is not required for the business being operated, indicate so by placing an in the box. qT10N OF WORKERS' COMPENSATION COVERAGE PURSUANT TO MINNESOTA STATUTE 176.182 p� _ cenify that I, or my company, am in compliance �cith the workers' compensation insunnce coverage requiremenu of A `o�. e ota Statute ] 76. ] 82, subdivision 2. I also understand that provision of false information in this certificationconstitutes sufficient �'�� • ds for adversn action aaainst all licenses held, including revocation and suspension of said licenses. a / t � 6 r t e of Insurance Company: /�h ! - pa � 1llSur��Ge �o t `e ' `� � _ f ,No]icy Number: �C L aiDO7S�70 Coti•era�e from /d- � � to � � y� �I have no employees covered under workers' compensation insurance � i •— -� - - - - - - - - - - -- -- - - ANY FALSIFICATION OF ANS\i'ERS GIVEN OR MATERIAL SUBMITTED WILL RESULT IN DENIAL OF THIS APPLICATION I hereby state that ] have answered all of the preceding questions, and that the information contained herzin is true and correct to the best of my knowled�e and belief. I hereby state funher that I have received no money or other consideration, by way of loan, gifr, contribution, or othenvise, other than already disclosed in the application which I herewith submitted. I also understand this premise may be inspected by police, fire, hzalth and other ciry oSficials at any and ail times ��fien the business is in operation. (REQUIRED for all applications) *�Iv'ote: If this application is Food/Liquor related, p{ease contact a City of Saint Paul Health ]nspector, Steve Olson (266-91i9), to review plans. If any substantial chan�es to structure are anticipated, please contact a City of Saint Paul Plan Examiner at 266-9007 to apply for buildin� permits. If there are any chanaes to the pazking lot, floor space, or for new operations, please contact a City of Saint Paul Zoning Inspector at 266-9008. Additionai application requirements, piease attach: 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 ll2" x 11" or S 1/2" x 14" paper): - Name, address, and phone number. - The scale ahould be stated such as 1" � ZO'. ^N should be indicated toward the top. - Placement of all pertinent features of the interior of the licensed facility such as seating areas, kitc6ens, offices, repair area, parking, rest rooms; etc. - If a request is for an addition or expansion of the licensed facility, indicate both the current area and the proposed eapansion. A copy of your lease agreemen[ or proof of ownership of the property FOR SPECIFIC APPLICATION REQUIREMENTS, PLEASE SEE REVERSE >>>> CLASS III LICENSE APPLICATION CITY OF SAINT PAUL Otlice of License, Inspections and Em ironmental pro�ection isp ci Paa Si Suim 3W Au:Pzcl.!dincno�a 5<)G2 �6q) =61AP� fu (61?) �1�6-91]i __ -- THIS A�P�IEA�10Tv'-fS S�3B3�G�'9�fl R�Vfif�'� SY TF�E FUBtI� --� — f PLEASE TYPE OR PRINT 7N I]VK �� ti l T�•pe of Licznse(t) bzii�� applied for: _ C�l[�C�Y27 � �C�i2 /SLb� L/C21�SQ CompanyName: �1�� S'�� /�ti ry`�Q/nd�iV� �ildif� ��TI'/G CorporatSon ! Pannuship / So)e Propsittocsh�p If business is incorporated, give date of incorpor //�� Doing Business As: �(12 ,Op� ��T/�-�r��PY�I a��'ye C�70GC� � G Business Phonz: 77y � 7So2� Business Address: Suc+�t AddresS Bztwzen what cross streets is the business located? ,�0��l�kiJ.. l�Of�L Are the premises now occupied� ��S 1�hat of Business? 11ai1 To Addrzss: f.3�` J�$SC�I'�1�-Pi /TVC� ,�� Svzet .Address Ciry Gty S��c �� / Zip side of thz sVZet? /l/o/f�1�25! � State Zip Applicant Information: /� Name and Tiile: 6��/Q$ �. (�Q25Q� Lp'djfjyJ�y- Firit Dtiddie (p4aidcn) Lzct Titk HomeAddrzss: .3/� !///lG�IL7 �L• /v. ��-S. �J/v ..S.Sy/Z Strret Address � Cip� Stz;c Zip Date of Bitth; 3�e��fSl Place of Birth: /o//i�rlC'a� Home Phonz: 6�a — S� — l�lo/ � Have you ever been com�icted of any felony, crime or violation of any ciiy ordinance other than traffic? YES _ NO /� Date of arres2: Char�e: _ Conviction: iL'here? Sentence: List the names and residences of three pzrsons of �ood moral charscter, livin� within the Twin Cities Metro Arza, not related to the applicant or financially interested in the premises or business, H�ho may be referred to as to the applicaqt's character: NAME ADDRESS f PHONE �� e 0 � /d vr/� `�'l 3�53 List licenses which you currentiy �old, formerly he1d, or may have an in2erest in: a d �� b " Have any of the above namzd ]icenses ever been revoked? _ YES �NO If yes, list the dates and reasons for revocation: Are you �oin� to operate this business personally? X YES � NO If not, �vho will operate it? First Name Middle Initial (Maiden) I,azt Homc qddress: Svicet Tame Ciry Sute 2ip � , Date of Binh Phone Numba Are you going to have a mana�er or assistant in this business? ` YES � NO if thz mana�er is not the same as the operatur please complete the following information: First Name M1fiddle Initial Home Addrezs: Svee[ Namc (?7zidzn) Cin Please list � our employment history for the previous fve (i) ; ear period: Lazt Stait Zip � a ,.e.... Uaic af Binh Phone t�umber List all othzr officers of the corporat�on: OFFICER TITLE HOME HOD4E BUSINESS DATE OF NAIviE (Oftice Held) ADDRESS PHONE PHONE BIRTH 6�,s �ler G. ea�a yz y��A�e. St.�owl ,ssi ygy-F�Ga/ ��5'- a8 ie' � ��u�as �' ��en., 3v�3 tlorne%�D /�t2d*.� �/.✓�s3No �!�/-96ob H7S-d633 .�� ]f business is a partnzrship, please include che foilo��•ing information for each partnzr (usz additional pages if necessaq�): Firs[ Name �t�ddlz Im�ial (?fxidzn) Cin (Alaidtn) , Cin' Lait State Lait Sute D'atz ot Sirth Zip Phone NumL�r Date of Birth Home Address: $vee[ Nsmr First tiame A1iddlt Initial Home 9ddress: Sveet Name Zip Phone Number MINNESOTA TAX IDEN7IFICATION NUb4BER - Pursuant to the Laws of Minnesota, 1954, Chapter �02, Anicle 8, Section 2 (270.72) (Tax Clearancz; Issuance of Licenses), licensin� authorities arz required to provide to the State of Minnesota Commissioner of Revenue, the Minnesota business tax identification number and the social security number of each license applicant. Under the Minnesota Govemment Data Practices Acc and che Federa7 Privacy Act of 1974, we are required to advise you of the following re�azding the use of the Minnesota Tax Identification Number: - This information may be used to deny the issuance or renewal of your license in the event you owe Minnesota sales, employer's �+�ithholdin� or motor vehicle excise taxes; - Upon receiving this information, the licensing authoriry �a•ill suppty it only to the Minnesota Department of Revenue. Ho�vever, undzr the Fedenl Exchange of Information Agreement, the Department of Revenue may supply this information tQ the ]ntemal Revenue Service. Minnesota Tax Identification Numbers (Sa1es & Use Tax Number} may be o6tained from che State of Minnesota, Business Records Department, 10 River Park Plaza (612-296-6181). Social Securiry Number: y — �a — � 7 .�� Minnesota Tax ldentification Nnmber: ��ay7� If a Minnesota Taa ]dentification Number is not required for the business being operated, indicate so by placing an "X" in she box. C�i:TIFlCAT10N OF WORKERS' COMPENSATION COVERAGE PURSUANT TO b91NNES0"fA STAIUTL- 17G.IS2 1 tZereby cenify that I, os my cwnpany, am in compliance ��ith the �vorkzrs' compensation insurance tovera�e rzquirements of Minnesota Statutz 176.182, subdivision 2. I also understand ihzt provision of false information in this czrtification constitutzs sufficient �rounds for adverse action against all licenses held, including rzvocation and suspension of said licenses. �� t O /' n „ � ro Name of Insurance Company: �q�Gr�C /7m2�/�(rIL .�d5. �'ib Policy Numbzr: �'G — P — �trJ7�7o Coceragz from / �S� to i �, '�! I have no emp]o}•zzs covered under �corkers' compensation insurance ANY FALSIFICATION OF ANS\YERS GNEN OR RS.�+.TERI.�L SGBb11T7 ED WILL RESULT IN DE\IAL OF THIS APPLICATION 1 hereby state that 1 have answered a11 of the preceding questions, and tha[ the information contained hzrzin is true and correct to the best of my knowledge and bzlief. I hereby state funher that I have receivzd no money or ocher considzration, by way of loan, gifr, contribution, or othenvise, ocher 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 officizls at any and all times �tihen the business is in operation. Signamrz (REQUIRED for all applications) Date •"Note: If this application is Food�'Liquor related, please concact a City of Saint Paul Heakh Inspector, Steve Olson (266-9139), to review plans. If any substantial changes to structure are anticipated, please contact a City of Saint Pau] Plan Examiner at 266-9007 2o apply for buildin� permits. If there are any changes to the parkin� lot, floor space, or for ne�v operations, please contact a City of Saint Paul Zoning Inspector at 266-9008. Additional applicafion requirements, please attach: A detailed description of the design, location and square footage of the premises to be licensed (site plan). The follo�cing data should be on the site plan (preferably on an 8 1!2" x 11" 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. - Placement of all pertinent features otthe interior of the licensed facility such as seatingareas, kitchens, offices, repair area, parking, rest rooms, etc. - If a request is for an addition or espansion of the licensed facility, indicate boih the rvrrent area and ihe proposed eapansion. A copy of your lease agreement or proof of ownership of the property. FOR SPECIFIC APPLICATION REQUIREn4ENTS, PLEASE SEE REVERSE >>>> [f appl?'ing for, � Cabare[ aduit, pleast attach ��'ritten proof that each emplo?'ee is at least 18 years old. Conversation/Rap parlor adult, please attach �+rittzn proof that each employee is at least IS }'zars old. Entertainment, ptease spzcifydass A, B, or C licensz; obtain and attach sianatures of approval from 90% of }our nei�hbors within 350 feet of ihe establishmznt. This licensz must be applied for in conjunction wich a Liquor, Wine, hialt On Sa1e or RentallDance Hall license. Firearms, please attach a letter with the follo�i�in� ir.?urmation: state if szlling or only repairing, Federa] Firearms License Number, rype of Armed Services dischar�e (Honorable, General, Bad Conduct, Undesirable, Dishonorable, or no military service. (NOTE: Establishment must he commercially zonzd.) Came room, please provide the iollowing informazion: name of machine and iist price. (NOTE: A Pool Hall lirense is requirzd if there are any pool tables in the establishmznt.) Health/Sports club adult, please attacli written proeT chat each emplo��ee is at Izast 18 }�ears old. Liquor otflon safe, 2fer to attached tiquor apptica[ion. Lock opening ser�'ices, please attach a list of all e�r,plo;�ezs (�vith home address and tzlephorz number) who «�ill be doing the tock opening service. Alassage center, pleasz actach a detailed desaiption of the services being provided. blassave centeradult, plzas� attach µ'ritten proof th2t each zmployee is at least IS years old. Massage practitioner, please attach a copy of letter for approval from Health; prooi of insurance cuvzra�e of 51,000,000.00 each gener2! ]iability and profzssional liability �vith t},e City of Saint Paul named as an additional insured, and a 30 day notice of cancellation; a le�ter from pour emplo}'er to verif;• empio��ment �+ith a license masszge center. biotorc}'�fe dealer, pieasz include State of n9inne�eca Dealer Number. New motor cehicle dealer, plzase indude State of .'.linnesota Dealer Number. Parking lot/ramp, please include the number of parking spaces, and attach plans containin� a general dzscription of che security provided at the loc�rzmp, a site plan showing driveways of the proposed lot and the le�al description of the propzrty (this requirement necessary only if no site plan is currzntly on file). Attach a cover ]ztter describing your plans to comply �j•ith the lightin� and paintin� requirements. Pa�cnbroker, plzase attach 5�,000.00 Surety Bo:. _ Second hand dealer-motor �'ehicle, please indud: �cate of Minnesota Dealer Number. Second fiand deater-motor �'ehicle parts, pieas� anach 5�,000.00 Surety Bond. Steamroom/bath house adult, please attach ��•rinen proof that each employee is at least 18 years old. Theater adult, please attach ti�ritten proof that each emplo}'ee is at least l8 years old. CLASS III LICENSE APPLICATION C1TY OF S�INT PAUL 011ice of Licznsq Inspenions xnd Enrironmcnlal Protection 350 R Pnc St Suim i00 S:in�Pvl.?finncsou 35102 (61C) 366�9490 fu (61?) =ld-9t]6 06 — — -- - ---- THISAPPLICATIOAI_LS_SUBJECT-'FDl2€v=1€W-B-Y--F3�£-P�}BtfE-- f - - PLEASE TYPE OR PRINT IN I2�K 1 �J T;�pe of Licznse(s) bzin� applied for: �G(. PG7 � t `,�. C�liJ71� /��i� L%�'Q y� 6� CompanyName: �lll� �6Gf ry y�rQ/A 1✓� G�tUlG�� yhL. Corporation / Partnership / Sole Proprictouhip If business is incorporated, �ive date of incorporation: � Doing Business As: Business Address: Svzet Addass Bztween �vhat cross streets is the businzss located? ./04/i.�l� (/Of� .4re the premises no�v occupizd? _____� What T�'pz of Busi h1ailToAddress: �,3U/_ ,�e�C{�hlA-� rIU2. �1� � Sta�c �{n . Applicant Information / � / Name and Tiriz: C� 0!','S T0�//2{'' C. �/eaco�C CO - �//l�2✓' Firit // pliddle (Maiden) /J Last Tile Home Address: y� fYa�C� /1`1�P ��, �G/.t� /l�//v ,S,S//7 Strezt / ,4ddress Ciry Sta�e Zip Date of Binh: 7�SJ G J Place of Birth: /iioA�;StIA , �t/L Home Phone: �/S� �"�.3I Have you ever bzen convicted of any felony, crime or violation of any ciry ordinance other than traffic? YES _ NO � Date of arrest: _. __ 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 applicant or financially intzrested in the przmises or business, «ho may be referred to as to the applicant's character: r � NAME ADDRESS ' PHONE o� / Sr'. S�.�wUI 7�6 i��IkP� �fau51��' S5"�3 �1`�' A�P SuJ. 6JEw3r� �Otiv-ar� +�{IJ 5'Sl�a �33-7�Go __�2o,�e Sz'e�� 535 9� �e.5,,�. ��e� c�a h�coh �tPJ 55�� 3� � 0�9� � List licen which �ou / c�urre�'tly / �ho�ld�, D form // erly h or may have an interest in: ` sG �Ole� (,P�t/?'/�LC �Gdl� �G�q,t.�l L/C2I1S2 �4'/!� Have any of the above named licenses ever been revoked? _ YES � NO If yes, list the dates and reasons for revocation Are � ou going to operate this business personally? � YES _ NO If not, who wifl operate it? FirSi Name Middlc 7nitial (Alaiden) Lazt Homc Address: Svcct Name Ciry � Sia�e Business Phone: �7`/- ��i�� Date of Binh Zip Phone Numbcr Svicei Address Oiy Stz�e Zip Are you going to have a manager or assistant in this business? please complete the fol(owin� infomiation: First Name Home Address: Svzet Ka�nc �fiddte Inicixl (\taidrn) Cin' YES � i�'O !f the manager is noi the same as Ihe operaiur, Please list your employment history for the previous five (�) year period: Business/Emolovmznt Lait State Zip Address Da�c of ➢inh Phone Number i` l- 45�6 7-1-4� ..� F��tto 30o t�}�,nnP��n J�Ue 1��nneuPalts in-i�4s� i-t--�s !V �c-al{ 2 1.-S f��d rn v� � C��C v✓1 5T M� n n ec� R�e 1 i s � � - �.3 - `t 3�o �n-�v� i�,,,c4olc�h's ?4s �-a�e C�at i�er �Ic,z�. s� �G.,I �-ti�p��o-l�-zzr� I os� s�u� eoc�nTNl cl�b �Z5'o 5,1�(�,� NeN�r�al rh��_ �a�c�� -�r�YB � List all other officers of chz corporation: OFFICER TITLE HQME HOA4E BUSINL'SS DATE OF NADIE (Office }ield) ADDRESS PHONE PHONE BIRT n -'��t5� ��Ch .�ifs�ur �ki3 f�srp��iP�//vmellh�+/Hay-�'i6D(� '>75-063.3 �/�15'� If business is a partnzrship, plzase include ihe follo�cin� infonnation for zach partner (usz additional pa�zs if neczssary): First Name Homz Address: Svee[ !�-mz First \ame Home Address: Suzec Name Aliddlz initial Middlt Initial (Vziden) Gn (>fa�dzn) Cirv Last Scait Lai[ Stau Datc of Binh Zip Phonz Numbtr Date of Binh Zip Phone Numbec MINNESOTA TAX IDENTIFICATION NUMBER - Pursuant to the La��•s of Minnesota, 195�, Chapter �02, Articlz 8, Section 2 (Z70.72} (Tax Clearance; Issuance of Licenses), ]icensing auchorities are required to provide to the Siate of Minnesota Commissioner of Revenue, the Minnesota business tax identification number and the social security number of each license applieant. Under the Minnesota Govemment Data Practices Act and the Federal Privacy Act of 1974, �ve are required to advise you of the follo�'ing regardin� the use of the Minnesota Tax Identification Number: - This information may be used to deny 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 information, the licensing authority will supply it onJy m the Minnesota Department of Revenue. However, under the Federal Exchan�e of Information A�reement, the Department of Revenue may supply this information to the Intemal Revenue Service. Minnesota Tax Identification Numbers (Sales & Use Tax 7dumber) may be obtained from the State of Minnesota, Business Records Deparunent, ]0 River Park Plaza (613-296-6181). SocialSecurityNumber: y77—�'9g MinnesotaTaxldentificationNumber. ��ay�ag � If a Minnesota Tax ldentification Number is not required for the business being operated, indicate so by placing an "X" in the box. C�: OF WORKERS' COtifPENSATION CGVERAGE PURSUAtiT TO A91NA'ESOTA STATUTE 176.152 1 hereby cenify that I, or my company, am in compliancz �+ith the nrorkers' compensation insurancz caverage requirzments of Minnesoca Statute 176.182, subdivision 2. I also understandthzt provision of false infom�ation in [his certificationconscimres sufficient �rounds for adverse action against al] licznses held, including rzvocation and suspension of said licenses. �� r �� / /l b Name of Insurance Company: �Q/I�/lJ2!'!� /!J�/�CQI� �Jt $, �A Policy Number: �C P'�Od��7 Coczrage from / � Q to /a�- � r'/�/O I have no emplo; ees covered under ��orkers' compensation insurance ANY FALSIFICATION OF ANS\1'ERS GIVEN OR niATERIAL SliBMITTED \VILL RESULT IN DE\IAL OF THIS APPLICATION 1 hereby state that I ha��e answered all of thz preczdin� quescions, and that the infonnation contained hzrein is true and conzct to the best of my knou-ledge and belief. I hereby state funher 2hzc I have received no money or other consideration, by way of loan, gift, contribution, or othenvise, othzr than already disclosed in thz application which I herewi[h submitted. I also understand this premise may be Snspected by police, fire, health and other city officizis at any and all times when the business is in operation. Signaturz (REQUfRED for ail applications) l Daie "`Note: If this application is Food,'Liquor related, please contact a City of Saint Paul Hzalth lnspector, Steve Oison (266-9159), to review plans. If any substantial changes to structure are anticipated, please contact a City of Saint Paul Plan Esaminer at 266-9007 to apply for building permits. lf there are any changes to the parking lot, floor space, or for new operations, please contact a City of Saint Paul Zonin� Inspector at 266-9008. Additional application requirements, please attach: A detailed description of the design, tocation and square footage of the premises to be ticensed {site plan}. The follo�ring data should be on the site plan (preferably on an 8 1/2" x 11" or 8 1!2" x 14" paper): - Name, address, and phone number. - The scafe should be stated such as 1" = 20'. ^N should be indicated to�vard the top. - Placement of all pertinent features of the interior of the licensed facility such as seating areas, kitchens, offices, repair area, parking, rest rooms, ete. - If a request is for an addition or eapansion of the Iicensed facility, indicate both the current area and the proposed eapansion. A copy of your lease agreement or proot ot ownership of ihe property. FOR SPECIFIC APPLICATION REQUIREMENTS, PLEASE SEE REVERSE >>>> If applling for, Cabaret adult, piease attach �rritten proof that each employee is at least 18 yzars old. Concersation/liap parlor adult, please attach written proof that each employee is at least IS ye2rs o]d. Entertainment,please specify class A, B or C licznse; obtain and attach signamres of approval from 90%of your neighbors within 3�0 fzet of the establishmznt. This license must bz applied for in conjunction with a Liquor, Wine, Maii On Sate or RentaVDance Hall license. Firearms, please attach a lettzr �cith the follo�aing information: state if sellin� or only repairine, Federal Firearms License Numbzr, ppe of Armed Seniczs discharge (Honorable, Gzneral, Bad Conduct, Undesirable, Dishonorable, or no military service. (1VOTE: Establishment must be commercially zoned.) Game room, please providz the following informarion: name of machine and ]ist price. (I�OTE: A Pool Hall license is rzquired if there are any pool tables in the establishment.) Health/Sports club adult, please attach �vitten proof that each employee is at lzast 18 }'ears old. Liquor ofL'on sale, refzr to attachzd liquor application. Lock opening ser� ices, plzasz attach a list of all empio; ees («ith homz addrzss and telzphone numbzr) who H ill be doing the lock opzning service. Massage center, plzasz attach a dztailed description of the sen�iczs beine provided. �Tassage centeradulE, pleas: at[ach wri[ten proof th2t each employee is at least 1S }'ean old. 1llassage practitioner, plzase anach a copy of lettzr for approval from Health; prool of insurancz co�zr;ge of 51,000,000.00 eacfi �eneral (iability and proFessionat 2iability with thz Ciry of Saint Pau] named as an additional insured, and a 30 day notice oF cancellatio�; a te�cer from � our employer to veri'ry emplo} men[ w ith a license massa�e cei;ter. 9lotorcycle dealer, pleasz indude St2tz of ?vlinnesota Dealer Number. New motor � ehicle dealer, please include State of Alinnesota Dzaler Numbzr. Parking loUramp, please include the number of parking spaces, and attach plans contzinir.g a general dzscription of the security provided at che lou'rmp, a site plan sho�i�ing driveways of the proposed lot and the le�al description of the property (this requirement necessary only if no site plan is currently on file). Attach a cover Iztter describing }'our ptans to comply �;�ith the liehting and painting requirements. Pawnbroker, piease attach 5�,000.00 Surety Bond. Second hand dealer-motor ��ehicle, please include State of Minnesota Deater Number. Second hand dealer-motor � ehicle parts, pleas� attach 55,000.00 Surety Bond. Steamroom/bath house adult, please attach written proof that each employee is at least 18 years old. Theater adult, please attach �+�rirten proof that each employee is at 2east 18 years old. z