96-761.c� ����f���L
Council File ¥ ��
ordinance #
Green Sheet # �" ��/
Presented By
Referred To
RESOLUTION
CITY OF SAINT PAUL, MINNESOTA
5�
Committee: Date
1 RESOLVED: That application (ID #24322) for a Cigarette, Of£ Sale Malt, and Grocery C
2 License by Adam�s Food, Inc. DBA Adam's Food (Ahmad Khatib, President) at 361
3 Ear1 Street be and the same is hexeby approved.
4
5 Requested by Department of:
6 Y� Navs Absent
7 B ak� _��
8 Guerin �� Office of L'cense Ins and
9 Harrss
10 Me a��� Env�ron*nental Protection
11 Re t� man
12 T un� � —�
15 Bostrom
� \ By: �i�� �l� y��
16 Adopted by Council: Date �,a ���p
17
18 Adoption Certified by Council Se tary
19 Form Approved by City Attorney
20
21 By: � � . �� � ssy � � . �C� e n n
z2 , �Z4
23 Approved by Mayor: Date � '
24 ��� I�^"°�
ZS � rC Approved by Mayor for Submission to
26 BY: � Council
27
By:
� � � I �'
DEPARTMENT/OFFIC UNCIL DATEINIrIATED �REEN SHEE N � �����
LIEP/Licensing iNmawnrE wrrwwn�
CONTACi PERSON 8 PNONE O DEPAR'fMEM DIRECTOR � CITV CAUNCIL
Christine Rozek, 266-9118 AS'�� �CRYATfORNEY OCITVCLERK
MUST BE ON COUNpL AGENOA BY (DAiEj RUY O BUDGET DIRECfOfl O FIN. & MGT. SERVICES DIR
r'O'L hearin :��. � fe OROER � MpYOP (ORASSIS7ANn O
TOTAL # OF S�CaNAStlRE PAGES (CLIP ALL LOCAT10�3S FOR SiGNATUA�
ACT10N RE�,IUESTEp:
Adam s Food, Inc. DBA Adam's Food requests Council approval of its application for a
Cigarette, Off Sale Malt, and Grocery C License iocated at 361 Earl Street (ID �124322).
RECOMMENDA7�ONS: Aqxova (A) or Raject (a) pEHSONAL SERVICE CONTRACTS MUST ANSWER THE FOLLOWING �UESTIONS:
_ PL4NNING CAMMISSION _ CIVIL SERVICE COMMISSIpN �• Has Mis persoMrtn ever worked under a coMract fm fhis tlepazhneM? �
_ CIB COMMI7TEE
YES NO
_ STnfF 2. Has this personHirm ever been a city employee?
— YES NO
_ DISTpICT COUfiT _ 3. Does this personHirm possess a skill not normally possessetl by any current city employee?
SUPPORTSWHICNCOUNCILO&IECTIVE7 VES NO
Explain all yes answera o� seperate sheet antl ettach to green sheet
INITIATING PIiOBLEM, �SSUE, OPP�RTUNITV (Who, What, When, Where, Why):
��C����w�
A �� 15 1996
��`�`�. �r �� ��.���
ADVANTAGES IFAPPROVED: -
DISADVqNTAGES 1F APPROVEO:
. Aa�+ av�.,r.:§ Y��e•^1:q y'G�c',�ffs3
kS1so:. �. �,5. . e
Jlit� �, y� :�a�
.a:.��
DISADVANTAGESIFNOTAPPROVED: ,.� '""��' " �
TOTAL AMOUNT OF TRANSACTION S COS7/REVENUE BUDGE7ED (CIRCLE ONE) YES NO
FUNDIHG SOURCE ACTIVITY NUMBER
FINANCIAL INFOflMAT10N: (EXPLAIN)
�-.Y-.
!Q
` 9.C-�C
�s CLASS III CITY OF SAINT PAUL
/1 LICENSEAPPLICATION orr"°f�`°'�.'"�`°°"s
� and Environmaital Proteaion
350SCPeaSCSuiw300
SaisAul,Minrcsda 55102
(612) ]b6W60 fu (613) 26�91?A
THIS APPLICATION IS SUB7ECT TO REVI BY TFIE p BLIC
PLEASE TYPE OR PRINT IN INK
Type of License(s) being applied for: ��
d► 217� p¢'(.'Sal� Me l.t 1189 �'
Company Name:
Co�poraUon
� �
�
' 'ara�.=°
� �
/ Sole Pmprietorship
?f business is ivcocporxted, give date of incorpora6on:
Doing Business As: �(�'0 Q p s1 � r �, r� .
��� ' Business Phone: 1 7-Z
Business Address: �(' l�ran (� t, 5 i QA�( M n/ C,�I G�
SveetAddress City SWte Zip
Between what cross streeu is the business located? �-,���� {/��- o „� (L.a W�ch side of the street? f[7 f n fr�/f�i,tJ
Are the premises now occnpied? \i �_ What Type of Business� G- f'0 (� e�.� V�� O t'� .
Mail To Address: c. �,,,,`p �
SVcet Address
Applicant Informauon:
Name and Tide: �rhCl rl !/�
ABDicESS
City '
Frst � �ei ••v.i,
Middle (Maiden) Last Title
Home Address: '.�.�/l �//Q /_ S T .�i �Ad/ � y 5{o G
StreetAddress City State Zip
Date of Birth: i� - 1�� <<� � Place of Birth: �!/,n ,�� n� Home Phone: �y-�/ry(, �
Have you ever been convicted of auy felony, crime or violation of any city ordinance other than haffic? YES NO
Date of arrest: �
Chazge: _
Cooviction:
Sentence:
List t6e names and residences of three persons of good moral chazacter, living within the Twin Cities Metro Area, not related to the
applicant oc financially interested in the premises or business, who may be referted to as to We applicanPs chazacter:
NAME
Have any of t6e above named licenses ever 6een revoked? _ YES NO If yes, list T — the dates and
Are you going to operate this business personally? _ YES _ NO If not, who will operate it?
_.! n r._ . ,o � �
first Name
Home Address:
Middle Initiai
State Zip
�
.i7'Ti�'�
for revocation:
Date ot Bitth
CiTy
State
Z+p Phone Number
��� _
Li� li which you currently hold, formerly held, or may have an interest in:
�YL�L_C�t'c��e„Y �6,2rs,� 1 �( r l� n�rc�lu NA F (�a1 9.�i.[! n,.,- --.st,,(z �rs U�}
��, � �
• � f v,
Are yau going [o have a manager or usistani in this business? _.YES � NO f the manager is no[ the satne as tt�e opecatoc;p V
complete the foilowing information: a �
L �' /�t
Frs[ Narne Middle initial (Ivfaiden) Las[ Date of Binh
SVeet Name
CiTy
Swte Zip Pirone Numba
Please list youc employment hismry for the pcevious five (� yeaz period:
�1'=
List ali other officers of rhe corporadon:
OFFTCER TITLE HOME
NAME (Office Held) ADDRE
IItl�narfill�,t,, �,.-�c��c�.t,�� �ltip
HOIr1E &USIir'ESS DATE OF
PHONE PHONE BIRTH ✓
J?>. ??f 1 �9 � 7 �� 9 �� ��" _ SS
N����n h'�/,=! � �« L 4 ru . �. ., �� ii l� 7 �-
If business is a paztnership, please include the foltowing infocmaUOn for each paztner (use additionat pages if necessary):
Arst Name
Home Address: Sireet Name
first Name
Home Address: S�reet Name
Middle Initial
Middle Initial
(Maiden)
Ciry
(Maiden)
City
Last
State Zip
Iast
Sute Zip
Date of Binh
Phone Number
Date of Birth
Phone Number
MINNESOTA TAX IDENTII-ZCATiON NUMBER - Pursuant to the Laws of Mitmesota, 198d, Chapter 502, Article 8, Section 2(270.72)
(Taz Clearance; Issuance of Licenses), licensing authorities are requited to provide to the State of Minnesota Couunissioner of Revenue,
the Minnesota business tax identiHcalion numbei avd the social securiYy number cf each licease appL'c?!+!.
Under the MInnesota Govemment Data Practices Act and the Federal Privacy Act of 1974, we aze required to advise you of the following
regazding the use of the Minnesota Tax Identificadon Number: .
- This information may be used to deny the issuance or renewal of your license in the event3�ou owe Minnesota sales, employei s
withholding or motor vefucle excise taxes;
- Upon receiving this infoemation, the licensing authority will supply it only to the Minnesota Depaztmeot of Revenue. Howevec,
under the Federal Exchange of Information Agreement, the Depamuent of Revenue may supply this information to the Intemal
Revenue Service.
Minnesota Taz Identification Numbers (Sales & Use Tax Number) may be obtained from the State of Minnesota, Business ftecords
DepaRment, 10 River Pazk Ptaza (612-296-6181). '' '
Social Security Number: .1 �(�- D �l- l ry.30 /� ! � - �� �V . _ - ' - - . .
� r � ,!q , � y
MinnesotaTaxIdenbficauonNumber: I.S��� ��J 9 D� tTY OS �' Q$"�
_ If a Minuesota Taz Iden�cation Number is not required for t6e business being opetated, in�cate sa �i}��acing an "X" in [he
boz. ��� .k i ', � .�� d'� �
.,s ; ; ...� F .aY
4.
Business/Emplovment Address •
P � ''^/�._ �16 -�G 1
,/ �CERTIFSCATION OF WORKERS' COMPEAISATSON COVERAGE PURSUANT TO MINNESOTA STAT[ITE 176.182
/ I hereby cer[ify t6a[ I, or my company, am in compliance with the workers compensation insurance coverage requiremenfs of Minnesota
� Siatute 176.1 S2, subdivision 2. I also understand that provision of false informafion in this cettification coastitutes sufficient grounds for
adverse action against all licenses held, including ievocaGon and suspension of said licenses.
Name of Insurance Company:
Policy Number: 9.3 � Z�/ —% h'� _�_ Coverage from � 1 - Z Z-`! � to 1�. -.2:- ��
I have no employees covered under workers' compensation ivsurance
ANY FALSIFICATION OF ARSS�'ERS GIVEN OR MATERIAL SUBMPI'TED
WILL RESULT IN DEIv7AL OF TFIIS APPLICATIOI3
I hereby state that I have answered all of the preceding questions, and that the information contained herein is true and coaut to the best
of my knowledge ac�d belief. I heceby state furthec that I have received no money or other considecaGon, by way of loan, gift, contribution,
or otherwise, other than already disclosed in the application which I herewith submitted. I also understand this premise may be inspecced
by police, fire, health and other city officials at any and all Gmes when the business is in operation.
fot ali applications)
6
Date
**Note: If ttus appiication is Food/Liquor related, please cootact a City of Saint Paul Heaith Inspector, Steve Olson (266-9139), to review
p]ans.
If any substantial changes to strucaue are anucipated, please contact a City of Saint Paul Plan Examiner at 266-9007 to apply for
building pemuu.
If there aze aoy changes ro the pazking ]ot, floor space, or for new operations, please contact a Ciry of Saint Paul Zoning Inspector
at266-9CC3.
Additional application requirements, please attach:
A detailed description of the design, location and square footage of the pretnises to be licensed (site pian).
The following data should be on the site plan (preferably on an 8 U2" x 11" or 81/2" x 14" paper):
- Name, address, and phone number.
- The scale should be stated such as 1" = 2A'. ^N should be indicated towazd the top.
- Placement of all pertinent features of the interior of the licensed facility such as seating areas, idtchens, offices� repair
azea, parking, rest rooms, etc.
- If a request is for an addition or expansion of the licensed facilitp, indicate 6oth the current area and the proposed
expansion
A copy of your lease agreement or proof of ownership of the property.
FOR SPECIFIC APPLICATION REQUIREMEr'TS, PLEASE SEE REVERSE >>>>.
Greensheet# 35289 L.I.E.P. REVIEW CHECKLIST Date: 4/9/96 >�( -7�. �
IR TfaCke[? App'n Received ( App'n Processed
License ID # 24322 Ucense Type: Ci�arette, Off Sale Malt, and Grocerv C
COmp3ny NBme: Adam`s Food, Inc. DBA: Adam's Food
BusinessAddresss:361 Earl Sereet BusinessPfione:�72–z229
Coniact Name/Address:�ad Rhaeib, 241 Earl Str, 106 Home Phone: 774-7761
Date to Council Research: /�
Public Hearing Date: /�/ ��(J Labels Ordered: �7/
Notice Sent to Applicant:_ �///J '�� District Council #:
Notice Se�t to
DepartmentJ
Ciry Attomey
Environmental
Health
Fire
Date lnspections
�'
y•Zy •`icP
l�.Z�-{•�j�o
y. 24� •°(L�
Ward #: �
Comments
o• K
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�•�
License
Io � !z� �t to
(? /G.
Site Plan Received:
i.ea� aece��ea: –�—
Police
Zoning
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y_z�f •`��o
O•'K
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