96-81Council File � ��
���� ����g,��
Ordinance �
Green Sheet # ��
RESOLIlTfON
SAINT PAUL, MINNESOTA
Presented By
Referred To
Com[nittee: Date
1 RESOLVED; That application (ID #14905) for a Cigarette, Grocery-C, and Gas Station
2 License applied for by Q G Energy II LC DBA Siffy (David Requet) at 106�
3 Grand Avenue be and the same is hereby approved.
< < -�r� _,_ , Requested by Department of:
Office of License. Insoections and
Environmental Protection
By: ��/�`�"' i`vl "-�
By:
Approved
By:
i
�; y�j�W�%�i , �5 � 1
Form Approved by City Attorney
BY e vuLl.�A/ �• �P!1 "�K �� /°"//( J
Approved by Mayor for Submission to
Counail
By:
Adopted by Council: Date � 4
Adoption Certi£ied by Council Secretary
_...-_---..g °...-........�_ GREEN SHEET
LIEP/Licensin iNmnware—
,`ONTACT PEFSON 8 PHONE O DEPAAiMENT DIAECSOFi
Bill Gunther, 266-9132 ���N �CINATfORNEY
NUSTBEONCqUNCILAGENOABY( ATE) pOM� �BUDGEf01PECTOF
For heaxing: � a �� ORGEP oMAYOR(ORASSISTANn
TOTAL # OF SIGNATURE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE)
a�-P!
N_ 35253
.c�ncour�cw wmumnre
C
cm c�aK
�', FIN. & MGI SEPVICES DIR.
Q C Energy II L C DBA Siffy requests Council approval of its application for a Gas Station,
Grocery-C, and Cigarette License at 1060 Grand Avenue (ID //14905).
HEGOMMENDATIONS: Approve (A) O� RajBtl (Rj
_ PLqNNING CAMMISSION __ CIVIL
_ CIB CAMMITTEE _ _
_ STAFF _ __
_ DISTRICTfAI}RT _ _
SUPPORTS WHICH CAUNCIL O&IECTIVE?
IF
PERSONAL SERVICE CONTRACTS MUST ANSWER TXE FOLLOWINCa �UESTIONS:
1. Has this parsonfiirm ever wrnked nntler a coMract for this department? -
VES NO
2. Has this personnittn ever been a city employee?
YES NO
3. Does this person/tirm possess a skifl not nortnaliy possessed by any cuneM city employee?
YES NO
Expisin all yes answera on separate sheet and attaeh to green sheet
',��'A'.":.+��. , ... _ _ , .-��
�Yli�i � � .�vY
IF NOT APPROVED:
TOTAL AMOUNT OF TRANSACTION S
COSVREVENUE BUDGE7ED (CIRCLE ONE)
... . _ ..__�J
YES NO
FUNDING SOURCE ACTIVITV
FINANCIAL INFORMATION: (EXPLAIN)
Greensheet # 35253 L.I.E.P. REVIEW CHECKLIST oate: 12/2o/9s _/ ��o '��
In Tracker? App'n Received / npP Processed
License ID # 14905 License Type: Gas Station. Grorer�-C ana r; g a,-orro
Compa�y Name:Q C Enerev II L G DBA: Jiffy
Business
Date to Council Research: - ' "
Public Hearing Date: f�y' 9�i
Notice Sent to Applicant:
Notice Sent to Pubtia �`���/`
Home Phone: 309-234-5373
Labels Ordered: �T�
District Council #: ��
Ward
�
Departmentj Date Inspections Comments
City Attorney �
1-�-��
Env+ronmentai
Health / ^ � ^ �� � �
Fire I �� p� ��
( �
License �j� �^"V`'v�+ Site P4an Received:�
,' � �/� ��,(� �� �ease Recelvea:
� ! � Irlc`1.�"��
��� P�O��IJ 0'_'
,�{,�v�r✓� Cco/
Police
1-L1-�� a�
2oning
d'�� `�� ��
:
o��
SA[NT
tAD1
�
AOAIt
CITY OF SAIi�IT PAUL
Office of License, Inspeaions
and Em�ironmenta] Protection
;:o St Pr.c Sc Surte 3a0
$zintPaui,\lmnaca 551D2
(612)?66-9090 fu (612) 26691:4 �
THIS APPLICATION IS SUBJECT TO REVIEW BY THE PUBLIC
PLEASE TYPE OR PRINT IN II�'K
Type of LScense(s
Company Name:
If business is incorporated, give date of incorporation:
CLASS III
LICENSE APPLICATION
Doin� Business As:
Business Address:
Svee[ Address
Business Phone:
Ciry
State Zip
Between what cross streets is the business located? Which side of the street�
Arethepremisesnowoccupied? ��'S WhatT�PeofBusiness? Gds Std�ien/C,�nv�ni2rc2 StoPe/C'�di^e':i,�
Mail To Address: ?.0. Bex 45?0 ?ock L i a �d I l. 61204' -^ �40
SVce[ Addrets City State Zip
Applicant Information:
r�
NameandTitle: Ddvid A. R'ct!e* ^i°m'?°t^
First Middle (Dlaiden) Last Title
HomeAddress: n?= ?3°cky Co!�r` f,ea' Vali?V 1!. S'_%��0
� Sueet Address Ciry State Zip
DateofBirth: � PlaceofBirth: I11�tl�iS HomePhone: �3Q9)2?"-53?3
Nave you ever been convicted of any felony, crime or vio7ztion of any city ordinance other 2han tra�c1 YES _ NO ,�_
Date of arrest:
Charge• ,_
Conviction:
VJhere?
Sentence:
List the names and residences of tnree persons of �ood moral character, Iiving within tne Twin Cities Metro Area, not related to the
applicant or financially interested in the premises or business, who may be refened to as to the applicant's character:
NAME
ADDRESS
List licenses which you currently hold, formerly held, or may have an interest in:
PHONE
Have any of the above named licenses ever been revoked? _ YES _ NO If yes, ]isi the dates and reasons for revocation:
Are you going to opente this business personally? _ YES XX NO If not, who wil] operate it? v
Ro3ert E: - Jac'.�son, Jr. lifi?1a'7
Fim Name Mddie Snitiai (Maiden) . Last Date of Binh
7330 Broollyn Blvd. �Brooi:l.yn ?ark F1N
Home Addrets: SVeet Name ,. -- Ciq . ' Stale . - Zip ' Pbone Number ,
u �.. �
- .. . - �; � - _ . �- .. . -
��
. - . - � .. . . _ _ _ . „� __ — r . ... - i_ , . . _ ,. . _ .� _�.. .. ,le 7. .aa.z:
Corporation / Pannership / Sole Proprietorship
Are you goin� to have a manager or assistant in this business? X;: YES _ NO
please complete the following informafson:
Frst Name
Home Address: Svee[ Nzme
Mddle
(�tzidrn)
Cirv
If the managcr is not same zs che
k �O '�/'
Last Date of Binh
State
Ptease si i your empioyment history for the previous five (5) ;�ear period:
Business/Em alo��rnent
Address
List all other officers of the corporation:
OFFICER TITLE HOME HOME BUSINESS DATE OF
NAME {Office Held) ADDRESS PHOt�'E PHONE BIRTH
��_ �i.
If business is a partnership, please inciude the followin� information for each partner (use additional pages if necessary):
First 1�'ame
Home Address: Sveet Name
First r*ame
Home Addsess:. Street Name
Middie Initial
Middie Initial
(�laiden)
Cry
(Maiden)
Ciry
Lazt
State
Lut
State
Date of Birth
Zip Phone Number
Date of Birth
Zip Phone Number
MII�'N&SOTA TAX IDENTIFICATION NUMBER - Punuant to the Laws of Minnesota, 1984, Chapter 502, Article 8, Section 2
(270.72) (Tax C]eazance; Issuance of Licenses), licensin� authorities are required to provide to the State of Minnesota Commissioner
of Revenue, the Minnesota business tax identification number and the social security number of each 3icense 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 Ta�c Identification 2vTumber:
- This information may be used to deny the issuance or renewal of your license in the event you owe Minnesota sa3es,
employer's withholding 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 Exchange of Information A� eement, the Depamnent of Revenue may supply this information
to the Intemal Revenue Service.
Minnesota Tax Identification Numbers (Sales & iSse Tax I3umber) may be obtained from the State of Minnesota, Business Records
Departmen; 10 River Park Plazz (612-296-6181).
SocialSecurityNumber:' �?? °
Muu�eso'ta Tax ldenhfication Number �r��3?7 ^ 9
�
'� i
��� ��,rv. �� a�.,... .__, _., .,c .. _n, . . -- � _
_.Y".w ..7�w..r S _ � . y.d { �+A... 4 "x� � _ _
: so by placing an "X" in'
CER7IFIGATION OF \�ORKERS' COMPENSATION CO\'ER4GE PURSUANT TO A9I1�'t�'ES07.4 STATUTE 176.132 �" "`
I hereby cenify that I, or my company, am in compliancz ���ich the �;�orkers' compensation insurznce co��erage reqeirements of
Dlinnesota Statute 1 i6.182, subdivision 2. I also understand ,h�t provision of false inform ation in this cenification constitutes sufficient
grounds for advene action a�ainst all ]icenses held, indudu.g revocation and suspension of said licenses.
T'ame of Insurance Company: F'-�'" i:rS!1!"?'IC2
Policy Number: A��l i?c� Fot^ Cocerage from �
under �corkers' co„�pensatioa :nsurnce
ANY FALSIFICATIOV OF ANS\�"ERS G1VEN OR MATERIAL SUBMITI'ED
1i'ILL RESliLT IN DE\IAL OF THIS APPLICATION
I hereby state that 1 have ansn�ered all of the preceding quesio, s, and that the information contained herein is true and correctto the
bzst of my l:no��]edee and belief. I hereby state further thzt I have received no money or other consideration, by way of ]oan, �ift,
contribution, or othenvise, other than already disclosed in the zpplication «hich I here��•ith submitted. I also understand this premise
m�y be inspec;e3 by po}ice, fre, health and other city offci�ls at zny and a11 times �;�hen the business is in operation.
(REQUIRED far
Date
""Note: If this application is Food�4.iquor related, please contact a City of Saint Paul Health Inspector, S2eve Olson (266-9139), to
review plans.
If any substantial chan�es to sweturz are anticipated,- please contact a City of Saint Paul Plan Eaaminer at 266-9007 to apply
for buildin� permits.
If there are any changes to the parkin� ]ot, floor space, or for new operations, please contact a City of Saint Paul Zoning
lnspectorat 266-9008.
Additional agplication requirements, please attach:
A detailed description of the design, location and square footage of the premises to be licensed (site pian).
The following data shouid be on the site plan (preferabty on an 8 1/2" x il" or 8 IJ2" x 14" paper):
- I�Tame, address, and phone num6er.
- The scale should be stated such as 1" = 20'. ^N should be indicated toward the top.
- Placementof all pertinentfeatures of the interior ofthe licensed facility such as seating areas, l:itchens, offices, repair
area, parking, rest rooms, eta
- If a request is for an addition or expansion of the licensed facility, indicate both the current area and the propased
espansion.
A copy of your lease agreement or proof of ow•nership of the property.
FOR SPECIFIC APPLICATION REQUIRER4ENTS, PLEASE SEE REVERSE >>>>