96-80Council File # � - � 0
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Ordinance �
Green Sheet � .�����
RESOLUTION
Presented By
Referred To
1 RESOLVED: That application (ID #38399) for an Origittal Container, Cigarette, and Gas
2 Station License applied for by Q C Energy II LC DBA Jiffy (David Requet) at
3 400 Dale Street North be and the same is hereby approved.
_�_ Yeas Navs Absent Requested by Department of:
Office of License Insbections and
Environmental Protection
By: ����� �/��(�i`/�—
Adopted by Council: Date
Adoption Certified by Counc
By:
Apps
$yc
Secretary
Form Approved by City Attorney
sy: ���A� �. /�/�ql�s
Approved by Mayor for Submission to
Council
By:
LIEP
Eor hea
TOT/LL # OF
1
\TJ
GREEN SHEET
� DEPAHTMEM DIRECTOfi
O CITV ATfOflNEY
� a BUDGEf DIHECTOR
■ � MAYOR (OP ASSIST
q c -�a
N_ 35252
O CITY CAUNCIL
O CRY CLERK _
� FIN. 8 MGT. SEflVICES Dlq.
❑ _
Q C Energy II L C DBA Jiffy requests Council approval of its application for an Original
Container, Cigarette, and Gas Station License at 400 Dale Street North (ID 1i38399).
_ PLANNINGCAMMISSION __ CIVILSEBVICE
_ CIB COMMITTEE _
_ STAFF _
_ DISTRICTCAURT _
SUPPORTS WHICH COUNCIL OBJECTIVE?
PERSONAL SERVICE CONTRACTS MUST ANSWER THE FOLLOWING �UESTIONS:
1. Has this petsoMirtn ever worketl under a coMract for this dep2rtment?
YES NO
2. Has Mis petsonffirm ever haen a ciTy emp4oyee?
YES NO
3. Does this person/firm possess a skill not normally pouessed by any current ciry emplqree?
YES NO
Explaln all yas answers on separate sheet and attaeh to green sheet
RECEIVED
JAN 12 �
7ERRY BtAKEY
, U�a {p.@
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i J�li1 P (Fi �ww4+
E
TO7AL AMOUNT OF TRANSACTION $
COST/pEVENUE BUDGETED (CIRCLE ONE)
YES NO
FUNDIIdG SOURCE ACTIVITY NUMBER
PINANCIAL INFORMATION: (E%PLAIN)
Greensheet # 3s2sz L.I.E.P. REVIEVI/ CHECKLIST Date: 12/20/95 i qi ���
In Tracker? App'n Aeceived J App'n P�ocessed
UcenselD# 38399 �icenseType: Original Container Cigarette, and Gas Stat;o.,
Company Name: 0 C Energy IT 1 C DBA: Siffv
Business Addresss: 400 Dale Nn,- h Bus' ___
Home Phone: 309-234-5"�7�
Date to Council Researoh:
Public Hearing Date: � - a� � � �1�
Notice Sent to Applicant:
�j / i?'l� .J�
Notice Sent to Public: �
Labels Ordered: �!' _ _ _
District Council #: �
Ward
DeparGnentf Date Inspections Comments
City Attorney 6 �
1- S' q�
Enviro�mental
Heaith
� - .S - �'�G �
Fire
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License � ���w6 �� Sits Plan Fleceivad:_
1 _ $- p �' Lease Reeeived:
B� 1� ,
.� QM�.t, ,X•�-c.(m�n3 Q�J �1x�
lyLvru.N
Police � ^ � G / b . /�
G (� �'�,
Zoning
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CLASS III
Type of License(s) being applied for:
LICENSE APPLICATION
CompanyName: Q•C. En�rqy 1, �..�,.
Corporation 1 Partnership ! So{e Proprietorship
If business is incorporated, give date of incorporation:
Doing Business As:
Business Address:
Sveet AddreSs
Business Phone: �?�9� ��$-"-5�
CITY OF SAINT PAl
O�ce of License, Inspettions
and Environmental Protection
i50 St Pqa $i Svim>O6
Szint Pwl, �innaou 55102
(672)'_6b9Q90 Cu(fit2)2EG9124
Ciry
Between what cross streets is the business located?
Staie
Which side of the street?
Zip
Arethepremisesno�voccupied? v�c WhatT}peofBusiness? u'S S't3t7c:t/Co;9v�7i2rc� Stc�^^/Ci^?�2�'��S
MailToAddress: ° Q Bo" 45�0 R��^ )Si�^'' iilin�t�c f"0`--�.="-Q
Sveet Addre55 City State Zip
Applicant Inforznation:
NameandTitle: p3v��t A ''°-"'�'� �`��m"°�
First Middle (Maiden) Lut Tiile
Home address: �rll Beckv f.ourt Coa1 '!�1 � ev tL 612",Q
Sueet Address Ciry State Zip
Date of Birth: '.? /25/�'� Place of Birth: I? i i�?o' S Home Phone: ,�3G9} ??_
Have you evei been convicted of any felony, crime or violation of any city ordinance other than traffic? YES _ NO yY
Date of arrest:
Charge: _
Conviction:
Where?
Sentence:
List the names and residences of three persons of good morai character, living within the Twin Cities Metro Area, not related to the
applicant or financially interested in the gremises or business, who may be refened to as to the applicant's character.
NAME
ADDRESS
List licenses which you currently ho3d, formerly he3d, or may have an interest in:
f�:Ci)��I
Have any of the above named licenses ever been revoked? _ YES ,_ NO If yes, list the dates and reasons for revocation:
Are you going to operate this business personally?
R�b�rt � E.
first Name Middk Initial
YES xX NO If not, who will operate it?
3ac:son, Jr. 11!?3/57
(Maidenj . Last Date of Bin
7330 Brook?v� 31vd: Broa�c?y� '�r�: °3tS
Home Addrcss: Sucet Name .' City State Zip Phone Numba
v ,
. . N -_ . , _ . , . � -,'_ . .
- _. .d ., « ; . _ �- � .. .
. .. . _.. ,. ._iww.N .. . . - .. ., .. .. ..>.:
TH15 APPLICATION IS SUBIECT TO REVIEW BY THE PUBLIC /Jt� ��
Yj V
PLEASE TYPE OR PRiNT IN I13K /
Are you going to have a manager or assistant in this business? eX YES _ NO If the mana�er is not the same as :he �n�or; �
please complete the following information: � ' �y � Yl�
— ��� ..
Fi75t Neme T7iddlt Initial
Home Address: Street t2une
Please list
Business/Emplovment
('..fziden)
Civ
I.ast
State Zip
Address
List all other officers of the cotporation:
OFFICER TITLE HOME HOME BUSRv'ESS AATE OF
NAME (Office Held) ADDRESS PHONE PHONE BFRTH
�E'°_ �Lt`.dCho�t
If business is a partnership, please include the follow�ing information for each partner (use additiona3 pa�es if necessary):
First Name
Middle Initiai
Home Addres:: Svcet harne
First 1``ame
Aliddie Initial
Home Address: Street Name
(ASaiden)
Ciry
(?.laiden)
cty
Date of Binh
Phone Number
Lut
Sta[e
Laz[
State
Date of BiRh
Zip Phone Number
Date of Birth
Zip Phone Number
MINI3ESOTA 7'AX IDENTIFICATION NIIMBER - Pursuant to the Laws of Minnesota, 198G, Chapter 502, Article 8, Section 2
(270.72) (Tax Clearance; Issuance of Licenses), licensin� authorities are required to provide to the State of Minnesota Commissioner
of Revenue, the Minnesota business tax identificat'ron number and the social security number of each license applicant.
Under the Minnesota Govemment Data Practices Act and the Federal Privacy Act of 1974, we are 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 withholdin� or motor vehicle excise ta�ces;
- Upon receiving this information, the licensing authority will supply it only to the Minnesota Department of Revenue.
However, under the Federal Exchan�e of Information A�reement, the Department of Revenne may supply this information
to the Intemal Revenue Service.
Minnesota TaY Identification Numbers (Sales & Use Tax IQumber) may be obtained from the State of Minnesota, Business Records
Depamnent, 70 River Park P3aza (612-296-6181).
SocialSecurityNumber: s325-"?-7?59
IvlinnesotaTaxldentificationNumber: �r2�321=!3
If a Minnesota Tax Identification Number is not required for the business being operated, indicate so by placing an "X" in
che bo'x. � � � � - '
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i ` C`ERTI�ICAI'ION OF WOftKERS' COMPENSA7IQN COVERAGE PURSUANT TO MINNESOTA S'CATUTE i76.182 ��
I hereby certify that I, or my company, am in compliance uith the workers' compensation insurance coverage requiremenis of
Minnesota Stamte 176.7 82, subdivision 2. I also understand zhat provision of false information in this certification constitutes sufficient
3ounds for adverse action a�ainst all licenses held, includir.� revocation and suspension of said licenses.
Name of Insurance Company: f?�°rai=d I r�SU?"?nce
Policy?��umber: ���1��� ��" Co��eragefrom
insurance
to
ANY FALSIFICATION OF AA'S\VERS G1VEN OR MATERIAL SUBMITTED
�VILL RESULT IN D�\L1L OF THIS APPLICATION
I hereby state that I have answered a11 of the preceding questions, and that the information contained herein is true and conect to the
best of my kno�uledge and belief. I hereby state further that I have received no money or other consideration, by way of ]oan, gift,
coniribution, or otherwise, other than already disclosed in the application which I herewith submitted. 1 also understand this premise
r.iay Se inspected by police, fire, health and other city officials at any and all times when the business is in operation.
(REQUIRED for
Date
**Note: If this application is Food/Liquor related, pleasa contaM a City of Saint Pau3 Hea]th Inspector, Steve Olson (266-9U9), to
review plans.
If any substantial chan�as to structure are anticipated please contact a City of Saint Paul Plan Examiner at 266-9007 to apply
for buiidin� permits.
If there are any changes to the pazking 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 desinn, Iocation and square footage of the premises to be licensed (site plan).
The following data should be on the site plan (preferab3y on an 8 112" x Il" or 8 U2" x 14" paper):
- Name, address, and phone number.
- The scaIe should 6e ststed such as 1" = 20'. ^N should be indicated toward the top.
-Placementof all pertinentfeatures of the interior of the licensed facitity such as seating areas, kitchens, offices, repair
area, parking, rest rooms, etc.
- If a request is for an additian or expansion of the licensed facility, indicate buth the current area and t6e proposed
expansion.
A copy of your lease agreement or proof of ownership of the property.
FOR SPECIFIC APPLICATION REQUIREMENTS, PLEASE SEE REVERSE >>>_>