96-153Council File #�I�i� � S 3
�Et- .
RESOLUTION
CITY OF SAINT Pq�JL, MINNESOTA
Presented By
Referred To
Committee: Date
a�
1 RESOLVED: That application (ID #22082) for an On Sale Malt (3.2) and Restaurant-B
2 License applied for by Saykham Sen�avong DBA Family Lao-Thai Restaurant
3 (Saykham Sengmavong) at 501 University Avenue West be and the same is hereby
4 approved.
�.___ r—,� _—� Requested by Department of:
Adopted by Council:
By:
Appr
By:
Office of License, Insoections and
Environmental Protection
By: (/� "�'�' `�" ' e " �'J
Form Approved by City Attorney
BY= . dJ /z -/ •1�
—�
Approved by Mayor for Submission to
Council
By:
Green Sheet ���� �
Ordinance #
Adoption Certified by Council Secretary
9�-ts3
DEPAHTMEMIOFFlGE/COUNGIL DA7EINRIATED GREEN SHEET N� 3 5 5 4 8
LIEP/Licensing -
CONTACTPERSON&PMONE �DEPPATMENTQIRE OCITYCOUNCIL ��� �
Bill Gunther, 266-9132 nssicx OCINATTOqNEV OCRYCLEflK
NUYBER FOiI ❑ BUDGET DIRECTOR O FIN. & MGT. SERVU ES DIF.
MU5f BE ON CAUNGIL AGENDA BY (DATE) /� ROUTING
r' OT Hearing: a �(� J� �rr OADER O MpyOR (Oq ASSISTANn O
TOTAL # OF SIGNATURE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE)
ACTION REQUE5fE0:
Saykham Sengmavong DBA Family Lao-Tfiai Restaurant requests Council approval of its applicatio
for an On Sale Malt (3.2) and Restaurant-B License at 501 IIniversity Avenue West (ID 9I22082).
AECOMMENDA11pNS: Apprave (A) w Reject tRl PERSONAL SEFiVICE CONTRACTS MUST ANSWER TXE FOLLOWING �UESTIONS:
_ PLANNING CAMMISSION _ GVILSEFVICE COMMISSION 1. Has this personttirm ever worketl untler a coMrad for this department? -
_CreCOMMITSEE VES NO
— 2. Has this person/firm ever been a ciry employee?
— YES NO
_ �ISTRICTCqUflT _ 3. Does this perSaMirm
possess a skill not nortnalry possessed by any current ciry empioyee?
SUPPORT$ WHICH COUNCIL OBJECTIVE? YES NO
Explatn all yes answen on separMe sheat and atteeh to graen sheet .
INITIATING PROBLEM, ISSUE, OPPOR7UNIN (WM1O, What, When, Where, Why): ED
�aar2�
� �L41fEy
ADVANTAGES IFAPPflOVED:
DISA�VANTAGES IF APPROVED:
�'' "' _.>._,._.._, "^•"`"�'�'
�i��W. �
«�r�:s � � 1�;�,�
DISADVANTAGES IF NOT APPRO�ED'
TO7AL AMOUNT OF TRANSACTION S COST/REVENUE BUDGETED (CIRCLE ONEJ YES NO
FUNDING SOURCE ACTIVITY NUMBEH
FINANCIAL INFORMATION: (EXPIAIN)
Greensheet # 25548
In TrackeR
License ID # ZZ�Bz
L.I.E.P. REVIEW CHECKLIST Date: 12-8-95 Lq�i"�
APP'n �� J 11 PA�n Processed
License Type: On Sale Malt (3.2) and Restaurant-B
Company Name: Savkham Sengmavong_ DBA: Fam; l�T an—Th�i uA�ra,,, r
Business Addresss: 501 University Avenue West, 103 Business Phone:
Contact Name/Address: Home Phone: $$$-4059
B oomington, 55437
Date to Council Research:
Public Hearing Date: �- 1� " 4� Labels Ordered: /����.�
Notice Sent to Appticant: ��9 � District Council #: /
� /_ n-r � � s�i9
im••i, •� - -• /
Notice Sent to Public: ���� � Ward #:
Department/ Date Inspections Commenis
Ciry Attorney
/�-/S-9S �
Environmental
Health � � � / � g S � �
G
Fire J� _ l S`- g.S' ��
License � Site Plan Received:_
j — �/ � � o� � �-� o� �, �e� ����ed:
Sa.m e. i� c�-� s e� � �� s
A s`� r2 ��II us Dcc.v1,e v �
Police f� , � - �,..5, 6� �D �'FC� �UN,(S
Zoning
l�- is- qs o�
CLASS III
LTCENSE APPLICATION
.NCiv2)
THIS APPLICATION IS SUBJEC7 TO REVIEW BY THE PUBLIC
PLEASE T�"PE OR PRINT IN II3K
Type of License(s) bein� applied for: / \R �dY
Company Name: �cc wi i�-a j L tt O— l
Corporation / Peruiership / Sole Proprietorshia
If business is incorporated, �ive date of incorporation;
n i_ � �
Doing Business As: 1
Business Address:
!� 4r"'�
$Veet Addres5 Ciry State Zip
Between what cross streets is 2he business located? �t�( 11 � fl� �t_ Which side of the street? �/�i ✓��il � lY
Are the premises now occupied? �.S What T�pe of Business? �T ���� !-
Mai1 To Address: � � �A nli v�P s i s� !1 � 1 w• �('1'/3L1� M� �1� � 6�
Sueet Address
Applicant Information:
Name and Title: `��
Ficst
Home Address: ��a � �
Middte
City
(Maiden)
-il.�
���
CITY OF SAI\T PAUL
Offce of License, Inspenions
and Environmental Procec[ion
35o si Pe:a sc sune ;M
Sain:PZUi,\finnaou 5<l02
(61])266-9090 Rx(6L'):E691'_J
Stale
�
S�i�/Gr�� t/oiv�
Lut
man� �`a ✓
Tide
�'- Sveet Address �ry � State Z'p
Date of Birth: � S- 0 �- �D Place of Birth: ��� Home Phone: 6�2 "� �-�/O�
Have you ever been convicted of any felony, crime or violation of any city ordinance other than traffic? YES , NO �
Date of arrest: Where?
Char�e:
Conviction: Sentence:
List the names and residences of three persons of �ood moral character, livin� within the Twin Cities Metro Area, not related to the
applicant or financiaily interested in the premises or business, «°ho may be referred to as to the applicant's character:
NAME ADDRESS ' PH02�'E
i3a �, .Q<-v � �,-�-r �v� �, � ,t� Li i �� �i�iv) ��3 - 3 3� 2
�
Lo'D m / �»
List licenses which you currently hold, formerly held, or may have an interest in:
�` %���
Have any of the above named licenses ever been revoked?, YES '�NO If yes, list the dates and reasons for revocation:
Are you goin� to operate this business personally? , YES �O If not, who will operate it?
� -
First Name - M�ddlo Initiat (Maiden)
Bome Address: Street Name . . " Gry
;.irs, _ . - � _ .
!�i
Stau
Date of Birth
Zip " , Plwne Number
kH3fm S�i✓G.n�vo✓�
/ a `fi
•�l���➢.0
Are you goin� to have a mana�er or assistant in this business? _�YES �_ 1�0 If the manager is not the same as the op��u
please complete the follo�ving information:
`� 6-1
Firs[ t�ame Middle Initial (?iziden) Latt Datc of Binh
Home Address: Street Name
Ciy
State Zip Phone Number
Please list your employment history for the previous five (5) ; ear period:
BusinessJEmnlo��nent / Address
///�La �� rz.P f/JB�(�a'TD �� f�l�J YJ �« -/��[ l L G `fY'
— i . � i .-�, i ; — 7 . ,
List all other officers of the corporation:
OFFICER TITLE HOME HOME BUSINESS DATE OF
NAME (Office Held) ADDRESS PHONE PHONE BIRTH
If business is a partnership, please include the follo�i�ing information for each partner (use additional pages if necqss�): �
�����-vEN� �I��(v''
fl�'�f�>� Gtt- S �
First Name Midd�l I�nitial � / Lazt D �o �BirOt
Q �° �� /�'1 ,�S / �bs-9mJr�5'o`d -- r'.__ .. �N .S��U b->7"�%�/c
HomeAddress: Sveet?�arne
First I�arne
Home .4ddress: Sveet Name
A9iddle
Cin�
('.7ziden)
City
State Zip
Last
State Zip
Phone Number
of B'uth
Phone Number
MINNESOTA TAX IDENTIFICATION NUMBER - Pursuant to the Laws of Minnesota, 1984, Chapter 502, Article 8, Section 2
(270.72) (Tax Clearance; Issuance of Licenses), licensing authorities are required to provide to the State of Minnesota Commissioner
of Revenue, the Minnesota business tax identification number and the socia] security number of each ]icense applicant.
Under the Minnesota Govemment Data Practices Act and the Federal Privacy Act of 1974, we are required to advise you of the
following regardin� the use of the Minnesota Tax Identification Number:
- This information may be used to deny the issuance or rene�;�al of your license in the event you owe Minnesota sales,
employer's withholding or motor vehicle excise taxes;
- Upon receivin� this information, the ]icensin� authority will supply it only to the Minnesota Department of Revenue.
Ho�vever, under the Federal Ezchange of Information Agreement, the Department of Revenue may supply this information
to the Intemal Revenue Service.
Minnesota Tax Identification Numben (Sales & Use Tax 1�Tumber) may be obtained from the State of Minnesota, Business Recozds
Department, 10 River Park Plaza (612-296-6181).
Social Security Number: ��D — 06 — 7/�� 3
Minnesota Tax Identification Number: ��""�^
If a Minnesota Tax Identification Numtier is not required for the business bein� operated, indicate so by placin� an "X" in
� the box.
�_
q Y
'l _��.. � . ,. YL9�e�FA.A.�2 k�zrv�:P°
CERTIFICATION OF WORKERS' COMPENSA7"ION GOVERAGE PURSUANT TO MINNESOTA STATUTE 176.182� �` � �
I hereby certify that I, or my company, am in compliancz ��izh the �vorkers' compensation insurance covera�e requirements of
Minnesota Stamte 176.182, subdivision 2. I also understandthat provision of false information in this certificationconstitutes sufficient
�ounds for adverse action a�ainst all ]icenses heSd, inc3udin� revocation and suspension of said iicenses. ,
Name of Insurance Company:
Policy T��umber. Cotiera�e from�� to
I have no employees covered under workers' compensation iacurance "-»
ANY FALSIFICATION OF AI�'SNERS GIVEN OR MATERIAL SUBMITTED
WILL RESULT IN DE\IAL OF THJS APPLICATION
I hereby state that I have answered all of the preceding questions, and that the information contained herein is true and corzect to the
best of my knowled�e and belief. I hereby state further that I have received no money or other consideration, by way of loan, gifr,
conttibution, or othenvise, other than already disclosed in the application which I here���ith submitted. I also understand this premise
may be inspected by police, fire, health and other city officials at any and all times �i�hzn the business is in operation.
i2 - d'� �1^
for all applications) Date
**Note: If this application is Food/Liquor related, please contact a City of Saint Paul Health Inspector, Steve Olson (266-9139), to
review plans.
If any substantial changes to structure aze anticipated, please contact a City of Saint Paul Plan Examiner at 266-9007 to apply
for building permits.
If there are any changes to the pazking lot, floor space, or for new operations, please contact a City of Saint Pau] Zoning
Inspector at 266-9008.
Additional application requirements, please attach:
A detailed description of the design, location and square footage of the premises to be licensed (site plan).
The follow�i�s data should be on the site p3an (preferabfy on an 8 112" x 11" or S 1t2" 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 ail pertinentfeatures of the interior of the licensed facility such as seating areas, kifchens, 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
espansion.
A copy of your lease agreement or proof of ownership of the property.
FOR SPECIFIC APPLICATION REQUIREMENTS, PLEASE SEE REVERSE >>>?