96-591Council File # �
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Ordinance #
Green Sheet # �-S�/ �
Presented By
Referred To
Committee: Date
1 RESOLVED: That application (ID #94696) for a Gas Station, Grocery-C, and Cigarette
2 License by Citgo Market DBA Citgo Market (Bee Vanq, OWnex) at 719 Payne
3 Avenue be and the same is hereby approved.
4
5 Requested by Department of:
6 Yeas Nays Absent
7 B a e �
8 GsserT_ � �—
9 Harr.zs
10 Megard
11 Rettman
12 T un� �
13 Bostrom —�-
is
16 Adopted by Council: Date �
17
18 adoption Certified by council Secretary
19
20 `
21 By: _ ti —�
22 � � ��
23 Approved by Mayor: Date
24
25 `''��� `
26 By: / �/� �G
27
RESOLUTION
CITY OF SAINT PAtJL, MINNESOTA
�
Office of License Ir}�pections and
Environmental Protection
B _� G� ��z.i
Form Approved by City Attorney
sye '�/.. � xz � i � a�� g
Approved by Mayor for Submission to
council
BY=
LIEP
Christine Rozek, 266-9108
For hearing: (� + s + Q
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TOTAL # OF $IRNATURE PAGES
g�•594
GREEN SHEET N� 33293
INfTIqVDATE INRInWA7E
OEPARTMEMDfftECTOft aCfi'YCOUNCiI
CfiV ATI'ORNEY � CITY CLERK
BUDOET DIRELTO � FIN. 8 MGT. SEMIC D1R.
MqYOR (Ofl ASSISTANT� O
ALL LOCATIONS FOR SIGNATURE)
Citgo Market DBA Citgo Market requests Council appxoval of its application for a Gas Station,
Grocery-C, and Cigarette License located at 719 Payne Avenue (ID 94696).
_ CIB COMMITTEE V ___ _
_ STAFF _ _
_DISTRICTCAURT _.
SUPPORTS Wl11CN COUNCIL O&1ECT7VE7
PERSONAL SEpY10E CONTHACTS MUST ANSWER THE FOLIOWING �UESTION3:
7. Na5 this persoNfirm ever worked untler a conVact for this department? �
YES NO
2. Has this perso�rm ever been a ciry employee?
YES NO
3. Does this persoNfirm possess a skill not normally posSessetl by any curtent city employee?
YES NO
Explefn sll yes enswers on separate aheet and ariach to green sheet
r
.. Si � . " K i' .
: �� +3 r�
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TOTAL AMOUNT OF TRANSACTION $
COS7/qEVENUE BUDGETE� (CIRCLE ONE)
YES NO
FUNDIHG SOURCE ACTIYlTY NUMBER
PINANCIAL INFORMATION: (EXPLAIN)
Greensheet # 35295
In Tracke(?�
L.I.E,P. REVIEW CHECKLIST Date: 4/23/96 ���`
APP'n Recerved / APP n Processed
LicenselD # 94b96 License Type: Gas Station Grocery—C and C;garPrrP
Company Name: Citgo Market DBA: same
Business Addresss: 719 Pavne Avenue Business Phone: 530-7816
Contact Name/Address: Bee Vaaa. Home Phone:
Date to Council Research:
Public Hearing Date: �O
Notice Sent to Applicant: �
/ / t � `/� (pr�,
Notice Sent to Public: �" ' �/ `� �B ��
Department/
Attorney
Environmental
Heaith
Fire
License
Police
Zoning
Date lnspeciions
�•�•��
�. ��'-°�b
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51
Labels Ordered; ���
District Council #: �-�
Ward #: ! D
Comments
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Siie Plan ReceiW
� tzmu.� � Lease Received:
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O• K
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O•K.
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Type of
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Company Name;
CLASS III
LICENSE APPLICATION
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THIS APPLICATION IS SUBJECI' TO REVIEW BY Tf� PUBLIC � �
PLEASE TYPE OR PRINT IN INK
il 4Af/�A
If business is iacorporated, give date of
Doing Business As: � '�
Business Address: � L� pa i i y
Business Phone: �i' l l��
�bli)n�iesclrn �Slo!'��SS
SVeetAddress� City Sia1e Zip
$etween what cross streeu is the business located? Pct�ri o Avv `�- (��� � u�U �tci ��n Which side of the street? �A! F,� �
Are the premises now occupied? � o s What Type of Business? �n < C� �f.. } r � v�
n
Mail To Address: =/ / j Ya,/ r7 P�? +/ C �� -
sveet
Applicant Inforsnauon:
Name and TiUe: T
.d
City
�
Frst Middle (Maiden) � t Title
Home Address: _� - ��!- ,
Srceet Address City State Zip
Date of Birth: Place of Birth: �- Home Phone: �(
Have you ever been convicted of any felony, crime or violation of any city ord"enance othec than iraffc? YES _ NO �
Date of acres[:
Chazge: �
Co�vic6on:
Sentence:
List the names and residences of three persons of good tnoral chazacter, living within the Twin Cities Metto Area, noi related to the
applicaat or fmancially interested in the premises or business, who may be refeired to as to the applicant's chazaciec:
NAME . �_ ADDRESS
List licenses cuirendy / ho � ld, formeriy helcl, or may have an in: �
v� /i.h Iv� t-YIXC S�t 1 i� r r�e- ff}�L4'•�nfr
Have any of the above named licenses ever been revoked? _ YES ,.,�, NO If yes, list the
CITY OF SAINT PAUL
Office of License, Inspcxuons
ana Fn�uonm�,ta� t'�ocea�on
350 Sl Pac S�t Sviie :iOD
Sv�AU�Mi ec.wn 55102
j6lnibb90� fu(612)266-972a
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State Zip
PHONE
.-
and reasons for revocaiion:
Are you going to operate this business persona[ly? ,� YES _ NO If not, who will operate it?
FrscName Middlelnicial (Maiden) Last 6atea(Bitth
Home pddress: Street Name Gry State Zip Phone Number
Sole Proprierorship
,nran��•.n . �
Where?
�Iw��m� � —_
Are you going to have a manager or assistant in this business?
complete the fol��ng infomtation:
�.
Middle Initial
:�.-� : �,-,
� XFS _ NO If the manager is not the same as the operatox, ple
� 94-Sq�
v(� r� ��
(bSaiden) Last �� Date of Birth
- �
Floine Addc�s: Sheet Nart� City State Zip Phone Numbe[
Please list your employment }nstory foc the previous five (5) yeaz period:
BusinesslEm�lovment A ss
C"? tT! nclr'e � `�� ',�r7 "- 1tS�t �'af� l/ tb, c� C f-- P-r��l /�tY-. S-c��,� �
List all other officers of the corporation:
OFFICER TITLE HOME
NAME (Office Held) ADDT2ESS
HOME BUSINESS DATE OF
PHONE PHOr`E BIItTH
ff business is a pazmershlp, please include the following information for each partner (use additional pages if necessary):
Middle Initial
Home Address: Street Name
(Maiden)
Iast
State Zip
Dale of Bir(h
Phone Number
PrstName Middlelnitial (Maiden) Last DaceofBinh
tiome Address: Street IVame City S[ate Zip Phone Number
MIlVNESOTA TAX IDFNTIFICATION NUMBER - Pursuant to the Laws of Minnesota, 1984, C6apier 502, Article 8, Section 2(270.72)
(Tax Cleazance; Issuavce of Licenses), licensing authoriues aze required to piovide to tk�e State of Minnesota Commissioner of Revenue,
the Minnesota business tax idep[ification number and the social security number of each license applicant.
Under the Minnesota Govemn�ent Data Prac6ces Acf and the Federat Privacy Act of I974, we aze required ro advise you of the following
regarding the ase of the Minnesota Ta�: Identification Number: _
- This informaGou may be used m deny the issuance or renewal of your license in th����ent you owe Minnesota sales, employer s
wit6holding or motor vehicle excise iaxes;
- Upon receiving Uris information, the licensing authority will supply it only to tfie Minnesota Departn�ent of FZevenue. However,
under the Federal Exchange of Information Agreement, the Depaztcuent of Reve4ve may supply rhis informaGon to the Intemal
Revenue Service.
MInnesota Tax TdentificaGon Numbers (Sales & Use Tax Number) may be obtained from the State of Minnesota, Business Records
Department, 10 River Pazk Plaza (612-296-6181).
Social Security Number � ���- � ''�
Minnesota Tax tdenafication Number: �� U ��'a J�
If a Minnesoia Ta�c Identification Nuruber is noi requ'ued for the business being opemte$ indicate so by p3acing an "X" in the
boz.
�
CERTIFICATION OF WORKERS' COMPENSAT[ON COVERAGE PURSUANT TO MINNESOTA STATUTE 176.IS2 _` �� 59 `
I hereby cer[i[y fhat T, or my company, am in compiiance with the workers' compensation insurance covenge requiremenu of Minnesota
Statute 176.182, subdivision 2. I also u�adersrand that pmvision of fatse inforcnafion in this certificatioo consiitntes snfficiebt grounds for
adverse action against att }icenses field, including revocation and suspension of said liceases.
Name of Insuraace CoT"P�Y� �tQ�.� o c- ! ,n�- . - � -- -- - — M � _c .
Policy Number: 1 ' � � �
Coverage from�'� (_�y� to S= A—/� 7
I have no employees covered under workers compensation insurance A/(1
ANY FALSIFICATION OF ANSR'ERS GIVEN OR MATEItL4L SUBNIITTED
WII.L RESULT IN DENIAL OF TfIIS APPLICATION
I hereby state that I 6ave answered a11 of the preceding questions, and thai the information contained hereiu is true and coneci to the best
of my knowledge and belief. I hereby stafe fnrthet that I have received no money or ot6er considera6on, by way of loan, gifr, contdbution,
or othenvise, other than aiready disclosed in the application wfuch I herewich submitted. I also understand this premise may be inspected
by police, fre, health and other city officials at any and all times when the business is in opecadon.
.___ ,. � '
Signature (REQUIRED
• ,�
app]ications) Date
"*Nate: If ttils applicaGon is Food/Liquor related, please contact a City of Saint Paul Health Inspector, Steve Olson (266-9139), to review
ptans.
If any substantiai changes to strucmre are anticipated, please contact a City of Saint Paul Plan Fxaminer at 26G9607 to apply for
buiiding permits.
If t6ere are any changes to the pazking lot, floor space, or for new opetations, please contact a City of Saini Paul Zoning Inspector
at 266-9008,
Additionai appiication requirements, please attach:
A deYailed descriptlon of the design, [ocation and square footage of the premises to he licensed (site pian).
T'he following dafa should be on the site plan (preferably on an S U2" x 11'• or 8 22" x 14" paper):
• Name, address, and phone number.
- The scale should be stafed svch as I" = 20'. ^N shouid 6e incL'qted toward the top.
- Placement of al[ pertinent features of the interior of the licensed facility such as seating areas, kitchens, offices, repair
azea, parking, rest rooms, etc
- If a request is for an addition or expansion of the licensed facilify, indicate twtii the current azea and the proposed
axpansion.
A copy ot your Iease agreement or proof oC ownership of the property,
FOi2 SPECIFIC APPLICATION REQUIREMENTS, PLEASE SEE REVERSE >>>>,
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