96-594Council File � 1 � � � �
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Ordinance #
Green Sheet � 3s a 0
Presented By
Referred To
RESOLUTION
CITY OF SAINT PAUL, MINNESOTA
�
Committee: Date
1 RESOLVED: That application (ID #76151) for an Original Container, Restaurant-C,
2 Cigarette, Gas Station, and Auto Repair �arage License by Cleveland 66 DBA
3 Cleveland 66 (Randy Williams, Owner) at 2058 Grand Avenue be and the same is
4 hereby approved.
5
7 Yea Navs Absent Requested by Department of:
8 B a e�� �
9 Guerzn —� Off'ce of License Inspectiona and
10 Harris —��
11 � ard � Fnvironmenta� Protect�on
12 Re t� man IG
13 T un� ✓
14 Bostrom ✓
16 a ` BY:
17 Adopted by Council: Date �
18
19 Adoption Certified by Council Secretary
20 Form Approved by City Attorney
21 �
22 sy: � �
23 /,, � B Y ° � � �U vK,c� l.� \ , c�-��.
24 Approved by Mayor: Date l.V. � F� �
25
z6 �� c_(r�/f ,e_ Approved by Mayor for Submission to
�dr''('if�
Z � BY. \ Council
28
��..�.�.-,.�� f�"�'�_�
By:
y`-sqy
DEPAqTMENT/OFFICFJGOUNCIL OATEINITIATED GREEN SHEE N� 35290
LIEPfLicensin ' iNmnvoa� � � �Nrtv.wn�
CANTAGT PENSON & PHONE � pEPARTMENT DIPECTOR � CRY COUNCIL
Christine Rozek 266- 1 ���N OGTYA770RNEY �qTYCLEflK
MUST BE ON COUNCIL AGENDA BY (DATE7 NUYBER FOW � BUDGET DIRECTOR � FIN. 8 MGT. SEFVICES DIR.
XOVTING
For hearing: (p OXOEN �Mqypp�OFiASSISTANn O
TOTAL # OF SIGNATURE PAGE (CLiP A�L LOCATIONS FOR SIGNATURE)
ACT70N REQUESTED:
Cleveland 66 DBA Cleveland 66 requests Council approval of its application for an Osiginal
Container, Restaurant-C, Cigarette, Gas Station, and Auto Repair Garage License located at
2058 Grand Avenue (ID I176151).
RECOMMENDA710NS: Approve (A) or tiejeet (R) PERSONAL SERVICE CONTRACTS MUST ANSWER THE FOLLOW�NG QUESTIONS:
_ PIANNING COMMISSION _ CIVIL SERVICE COMMISSION �� H35 thls pef50Nfifin eVBf wOfked undef a GontfdCt tof thi5 depaRmeM? -
_ CIB COMMRTEE _ VES NO
_�� 2. Has this persoNfirm ever been a ciry employee?
— VES NO
_ DIS7RIC7 CAUFiT — 3. Does this Derson/firm Dossess a sKill not nortnally Dossessetl by any curtent city empioyce?
SUPPoFTS WHICX COUNCIL O&IECTIVE4 YES NO
Explatn all yes answers on separete sheet and atteeh to green sheet
INITIATING PROBLEM, ISSUE, OPP�pTUNIN (Who, What, W�en, Where, Why�:
i � � . ' _'
� �"
APR 1 � 1996
C ITY �� ���������
ADVANTAGES IFAPPROVED:
DISADVANTAGES �FAPPROVED:
� M �,
d , < . � __ _...� v.._.�:
o ,_ ::� 1 � �,:;�
DISADVAMAGES IF NOTAPPROVED.
TOTAL AMOUNT OFTHANSACTION S COST/REVENUE BUDGETED (CIRCLE ONE) VES NO
FUNDIHG SOURCE ACTIVITV NUMBER
FINANCIAL INFORMATION: (EXPLAIN)
Greensheet# 35290 L.I.E.P. REVIEW CHECKLIS7 Date: 4/8/96 � 9G-S9y
In Tracker? App'n Received / App'n Processed
License ID # 76151 License Type: an Orieinal Container. RE a�ran -c'. ["garPrrP �a�
Company Name:Cleveland 66 Station, and Auto Repa�AGarage Cleveland 66
Business Addresss: z058 Grand Avenue Business Phone: 698-0600
Contact Name/Address: �ndy Williams, Home Phone:
Date to Council Research:
Public Hearing Date:
Notice Sent to Applicant:
Labels Ordered: ���9��
District Council #: �'7` ___
-, �„� . � ,
/I �� � �� 3 } � < � p�/�' � //'S�olra',,J oc�� i�
Notice Sent to Public: � ` 7'� ��L Ward #: 7"
Department/ Date Inspections Comments
City Attorney �• � '
�-2�f . b
Environmental � 2 � . 9 b � ' + ` '
Heaith
Fire q � ) ,�") �
'' • Zp • 1 lP C/
`J
License ,/� ` Site Plan Received:�
� — " —C � Q (�, Lease Received: �
�
Police �'�` '
�( - 2 �-1 � �' lo
Zoning � � _
� . � � Cf/
S
CLASS III
LICENSE APPLICATION
CITY OF SAINT PAUL
Office of Licease, Inspections
and Environmrntal Protection
350 St Pdc Sc Saa 3ao
5ain�Pw4��aur+ 55ta2
(613)266-9090 fa (612)266-9I3d
THIS APPLICATION IS SUBJECT TO REVIEW BY THE PUBLIC
3l1�.t¢ Au.to RePa.
Type of License being applied for: "� �� Ci�g�_
Company Name: G�eU 2 �C�ri� ����
Coryorazion / Parfiership / Soic Roprictnnhip
If business is incorponted, give date of incorporation: _
Doing Business As: C�P ✓� �� n� ��
Business Address:
TYPE OR PRI2dT IN INK
Fia�-�+.yc , �-zY�.z Gas Station,
s,-r�� h
Business Phone: �9 2d'` � � � �
��,�� s-s �os—
Street Address ����... . n City State Zip
Between wGai cross �ireeu �s rhz trusiness i�+�.fiICU? `/U�/ ���� �f11Ct1 Sif�E Oi :I:P. Sli.°i.C:n S�-Co/NCIn
Are the premises now occupied? -i> What Type of Business? ��'!t'�2� S�a t�`oN - Gu � f/�P�A�✓'��
MailToAddress: ��58 G^R�"cQ /� S% �a�/ /Nn. 5`s ios`
Street Address Ciry Stau Zip�
Applicant Informatiory� ��
Name and Title: �'""`�� '' e�J��K. �' � %�` rn S Qw i+e!`-
First Middle (Maiden) I.ast Title
Home Address: �
Stree[ Address City Stete Z�0
Date of BiRh: �' Place of Birth: '- Home Phone:
�
Are you a citizen of the United States?ye�Native? Nahuatized?
If you are not a U.S. citizen, you must have work authorization from the U.S. Immigration & Naturalization Service.
Have you ever been convicted of any felony, crime or violation of any city ordinance other than tra�c? YES _ NO �
Date of arrest:
Charge: _
Conviction:
Sentence:
Lis[ [hC Oaz[l0s aid reSIC¢ltes of .hree persons oi goad tr,a:::i cna:ac.ec, iio�i:.g wiScn :�`�e T.::;: �i.:es ?.::.::o :+r�a, rc: :s:�cea !o !!:e
applicant or financially interested i� the premises or business, who may be referred to as to the applicanPs character:
� NAME
�r,� Sh� quti F
Where?
ADDRESS
�� .
List iicenses which you currently hold, fonnerly he4d, or may have an interest ia:
PHONE
�
Have any of the above named licenses ever been revoked? _ YES � NQ 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?
First Name
Middle Initiai
LaSt
Home Address: Street Name City $tale Z�p
Datc o£ Birth
Phone Number
Are you going to have a manager or azsistant in this business? � YES
please complete [he following informa[ion:
Fvst Name
Home Address: Street Name
Mddle ini5al
(Maiden)
City
Please list your employment his[ory for the previous five (5) year period:
NO If the manager is not the same as the operator,
96-sqy .
Lazt
State Zip
Date of Birth
Phonc Number
Business/Emnlovment Address
�r�.t �e�.� � 6 aQS� ��� a�� .
List all other officers of the corporation:
OFFICER TITLE HOME HOME BUSINESS DATE OF
NAr,E (Office Held) ADDRESS PHONE PHONE BIRTH
If business is a partnership, please inciude the following information for each parmer (use additional pages if necessary):
First Name
HomeAddcess: StrcetName
First Name
Homc Addrcss: Street Name
Middle Initial
Middle Ini6st
(Maiden)
City
(Maiden)
City
Latt
State Zip
Last
Statc Zip
Date of Birth
Phone T3um6er
Date of Birth
Phone Number
MINNESOTA TAX IDENTIFICATION NiJMBER - Pursuant to the Laws of Minnesota, 1984, Chapter 502, Article 8, Section 2
(270.72) (Ta�c Clearance; Issuance of Licenses), ficensing authorities aze required to provide to the State of Minnesota Commissioner
of Revenue, the Minnesota business tax identification number and the social securiry mimhP* �f each l;�e-:se ::;,plica^:.
Under the Minnesota Govemment Data Practices Act and the Federal Privacy Act of 1974, we aze required to advise you of the
following regarding 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 only to the Minnesota Deputment of Revenue.
However, under the Federal Exchange of Information Agreemeni, the Depamnent of Revenue may supply this infortnation
to the Intemal Revenue Service.
Minnesota Tax Identification Numbers (Sales & Use Ta�c Number) may be obtained from the State of Minnesota, Business Records
Departmeni, ]0 River Park Plaza (612-296-6181).
Social Security T�Iumber:
Minnesota Tax Identification Number: �� �/ `' ��
_ If a Minnesnta Tax Identification Number is not required for the business being operated, indicate so by placing an "X" in
the box. .
CERTIFICATION OF WORKERS' COMPENSATION COVERAGE PURSUANT'f0 MINNESOTA STATUTE 176.182�� S9y
I hereby certify that I, or my company, am in compliance with the workers' compensation insurance coverage requiremenu of
Minnesota Statute ] 76.182, subdivision 2. I also understand that provision of false infotmation in this certification constitutes su�cient
gounds for adverse action against all licenses held, including revocation and suspension of said licenses.
Name of Insurance Company: �U �N� - �iT1%ln/S� a'93 — o�f//
Poticy Number: �� a0/ �/ Coyenge from � un � S to ,'^ ^¢ p 6
I have no employees covered under workers' compensation insurance
`ti.^:Y FALS;F➢�9T3�7s �F ANS'.'NE?S �Izlv'td '�vP.15SR.TE�'.fAL �CiS�3'LI;"F::II
WILL RESULT IN DENIAL OF THIS APPLICATION
I hereby state that I have answered all of ihe preceding questions, and that the information contained herein is trve and correct to the
best of my knowiedge and belie£ I hereby state further that I have received no money or other considemtion, by way of loan, gift,
contribution, or otherwise, other than already disclosed in the application which I herywith subrryitted.
� _ � � / � �
Signature (, RED for all applications) Date
Attach to this application:
1) A detailed description ot the design, loca�ion and square footage of the premises to be licensed (site plan).
The following data should be on the site plau (preferably on an 8 1/2" x 11" or 8 1/2" x 14" paper):
- Name, address, and phone number.
- The sca{e shouid be stated such as 1" = 20'. ^N shouVd be indicated toward 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, etc.
- If a request is for an addition or expansion of the licensed facility, indicate both the current area and the
proposed expansion.
2) A copy of your lease agreement or proof of owners6ip of the property.