96-82Council File # ���
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Presented By
Referred To
Ordinance �
Green Sheet $ ����
RESOLUTfON
CITY OF SAII�T PAUL, MINNESOTA
Co[nmittee: Date
3�f
1 RESOLVED: That application (ID #41081) for a Cigarette, Grocery-C, and Gas Station
2 License applied £or by Q C Energy II LC DBA Jiffy (David Requet) at 637 Rice
3 Street be and the same is hereby approved.
,___ r--�r---� Requested by Department of:
By:
Appx
By:
Office of License, inspections and
ErivirOnmerit8l PTOtectiori
By: \�i�`!�/J�ri4i� ���
Form Approved by City Attorney
By' -��� �� ,cQ 1 �ay��5
Approved by Mayor for Submission to
Council
By:
Adoption Certified by Council Secretary
LIEP
Bill Gunther, 266-9132
For hearing: J �� !�}
TOTAL # OF SIGNATURE PAGES
GREEN SHEET
qb-�2-
N_ 35251
tNlHB FOR O qTV ATTORNE`/ � CIT' GLEFK ( r
pOUTING Q BUDfiET DIRECTO O FlN. & MGT. SERVICES DiR.
� ONDEP Q MpYOR (OR ASSISTAPff) O
(CLIP ALL LOCATIONS FOR SIGNATURE) .
Energg II L C DBA Jiffy requests Council approval of its application for a Cigarette,
Grocery-C, and Gas Station Licc�`se at 637 Rice Stxeet (ID I141Q81).
_ PLANNING CAMMISSION _ CIVIL SERVICE COMMISSION
_ CIB COMMfTTEE _
_ STAFP _
._ DISTFtiCTCqUFiT _
SUPPOfiTS WHICH COUNqL OBJECTIVE7
PERSONAL SERVICE CONTRACTS MUST ANSWER TXE FOLLOWING DUESTIONS:
1. Has this persoNfirm ever worKed under a coMrect for this department? -
YES NO
2. Has this personHirm evar been a city employee?
YES NO
3. Does this personRirm possess a skill not normally possessed by any curreM ciry employee?
YES NO
Explain all yes answars on separate shcet antl attaeh to Q€�;�VED �
JAN � 2 �
�ERRY BtAK�Y
iF qPPqOVED:
Wa+°v� e....,,_ ' ' _ '
tf. _L (e' ... �. �
IF
AMOUNTOFTRANSACTION S
COST/REVENUE BUDGETED (CIRCLE ONE)
YES NO
FUNDIfdG SOURCE ACTIVITV NUMBER
FINANCIAL INFOFMATION: (EXPLAIN)
Greensneet # 35251 L.I.E.P. REVIEW CHECKLIST Date: 12/26l95 1 y� `�
In Tr8ck2t? App'n Received / App'n Processed
License ID # 41081 License Type: Cigarette Grocerv-G and Gas Stati on
Company Name: Q C EnerQV II LC DBA: Jiff�
Business
Date to Council Research:
PubiiC Hearing Date: " o� � - �L
Notice Sent to Applicant:
. ��j
Notice Seni to Pubiic: �✓?�
Business
Home Phone: 309-234-5373
tabefs Ordered: N��
District Council #: �
Ward
1
Department/ Date Inspections Comments
City Attorney
/- S-g� ��
Environmental
Health
l-S-�l� 6 �.'
F�re
1- S - �� 6 �'
License ��jt,�ItJ6 Sita Plan Received:_
� 1 �-+ — N ! � /� � � � Lease RecBived:
S 4 V G
J4B�'�� /al.e�l.sYElS.
��'Mx��
Same. I , r.ems�s ,�euous �owne r —
Police ��
1- S- q6
Zoning
9- ��g �K
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CLASS III
LICENSE APPLICATION
ffi��� oa
CITY OF SAINT PAUL�G"
Ogce of License, Inspections
znd Em•ironmenta7 Protetvon
i50 Sc Ppc St Suim'>OD
SxieePau4 ��i^naov 55102
(61�'669090 :ax I61.) =6691_i
PLEASE TYPE OR PRTNT I:�I II�TK
' (� O V'
{• i '
�
Type of License(s) bein� applied for:
CompanyATame: Q•C. Ert?rgy ., ..�..,.. �,
Corporation / Parmership 1 Sote Proprietorship
If business is incorporated, �ive date of incorporation:
Doin� Busintss As: J i ffv ., __- �( / Business Phone:
Busiaess P.dd,-ess: /n?i'� 1 C�_ �`"7 P'7
SVeet
C3ry
Stzte Zip
Betu�een what cross streets is the business located? VJhich side of the street?
Arethepremisesnowoccupied? Y2S WhatT}peofBusiness? G35 Sta"•:i0�� {Conv�ni�nc_ S�o�°2 /C1'?aY'�St�
MailToAddress: ?.0. Box '�5^0 R�ck lsland ?i 6720-".-?5�0
Sveet Address Ciry State Zip
App]icant Information:
ATameandTitle: David A. R2c:r_t pri�m"°v'
Fint Middle (Maiden) Last Tiile
HomeAddress: ��'= Becky Cour� Coai "aliey Ti E1244
Sveet.4ddress City Staie Zip
DateofBirth: ?�/25J�4 PlaceofBirth: I1linoi5 HomePhone: ("sC9)23-^,-�??3
Have you ever been convicted of any felony, crime or violation of any city ordinance other than traffic? YES _ NO xX
Date of arrest: Where?
Char�e:
Conviction: Sentence•
List t5e names and residences of three persons oi good moral c�aracter, iiving wimin the Twin Cities ?✓erro Area, not re7ated to t;�e
appiicant or £nancially interested in the premises or business, who may be referred to as to the applicant's character:
NAME ADDRESS PHONE
List licenses which you currently hold, formerly held, or may have an interest in:
�ave any of the above named licenses ever been revoked? _ YES _ NO If yes, list the dates and reasons for revocation:
.re you going to operate this business personally? _ YES XX 230 If not, who will operate it?
Ro�2rt � E • 1a }< ��, Jr 1jft�/�7
First A'ame - Midd�e Jnitial � (Maiden) I,ast Date of Hinh
ime Addresr. . Sveet Name , , � �ry
�:.; � , . ��=- - . �-
c_. . . A.e�„� - , � « - .. , n..�.,,< .� �.c , _ .,�.� . . �
State
:ip Phonc Numbu
� � - �- q - $' 3-
Are you going to have a mana�er or assistant in this business? _ YES ..`�, id0 If the manager is not the same as the op -
please complete the fo]]owin� information: �" °
Robert E. Jackson� Jr. ' �
pjrs[ 7�ame Middle Initia{ (�Sziden) Lu[ Date of Birth'�
1347 Hadlev Avenue N Oakdale MN 55128 (612)739-9727
Home Address: Sveet Narne Cirv State � Zip Phone 7.'umber
Business/Emnlov[n ent
Address
List a11 other officers of the corporation:
OFFICER TITLE HOME HOME BUSINESS DATE OF
NAME (Office Held) ADDRESS PHONE PHONE B1RTH
SFe Ats3ch�d
If business is a partnership, please include the followin� information for each partner (use additional pages if necessary):
First 1.'ame
Home Address: Sveet Name
Fim 1�`ame
Home Address: SVeet Name
T9iddle Initia;
Middle
(\iziden)
City
(DSaiden)
City
Lut
State Zip
Last
State Zip
Date of Birth
Phone NUmber
Dare of Birth
Phone Number
MINNESOTA "fAX IDENTIFICATION A'iJMBER - Pursuant to the Laws of Minnesota, 1984, Chapter 502, Article 8, Section 2
(276.72} (Tax Clearance; Issuance of Licenses), licensing authoritieS are required to provide to the State of Minnesota Commissioner
of Revenue, tha Minnesota business tax identifrcation number and the social security number of each license applicant.
Under the Minnesota Govemment Data Practices Act and the Federai Privacy Act of 1974, we aze required to advise you of the
followin� regarding the use of the Minnesota Tax Identification Number:
- This information may be used to deny the issuance or rene�i�al of your license in the event you owe Minnesota sales,
employer's withholdin� or motor vehicle excise taxes;
- Upon receivin� this information, the licensin� authority will supply it only to the Minnesota Department of Revenue.
However, under the Federal Exchan�e of Information Agreement, the Department of Revenue may supply this information
to the Intemal Revenue Service.
Minnesota Tax Identification Numbers (Sales & Use Tax Number) may be obtained from the State of Minnesota, Business Records
Department, 10 River Park Plaza (612-296-6181).
Soc'salSecurityNumber: ri
Minnesota Tax Identification Number: n2?321?9
If a Minnesota Tax Identification Numbet is not required for the business being aperated, indicate so by placing an "X" in
the box
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CERTIFICATION OF WORKERS' COMPENSATIOAI COVERA6E PURSUANT TO MINNESOTA STATUTE 176.182 � _, ,
I hereby certify that T, or my company, am in compliance w'ith the workers' compensation insurance covera�e requireme of
MinnesotaStamte176.182,subdivision2.IalsounderstandthatprovisionofYalseinformationinthiscertificationconstimtessufricient '
�ounds for advene action a�ainst all Iicenses held, includin� revocation and suspension of said licenses.
NameofInsuranceCompany: �?�=;"3T°� -TnSUt^3nt�
Po]icylQumber: A�o1i�r Fo!' Covera�efrom to
-- ave no emp oyees covered under «•orkers' compensation insurance
ANY FALSIFICATION OF ANSNERS GIVEN OR MATERIAL SUBD4ITTED
WILL RESULT IN DENIAL QF THIS APPLICATION
I hereby state that I have answered all of the precedin� questions, and that the informatlon contained herein is true and correct to the
best of my knowled�e and belief. I hereby state further that I have received no money or other consideration, by way of loan, gift,
contribution, or othern�ise, other than already disclosed in the application which I herewith submitted. I also understand this premise
may be inspected by police, fire, health and other city officizls at any and a11 times when the business is in operation.
Si�nature (REQUIRED `i`or ail applications) Date
'*Note: If this application is Food/Liquor related, p]ease contact a City of Saint Paul Hea]th tnspector, Steve Olson (266-9139), to
revie�v p3ans.
If any substantial changes to structure are anticipated, please contact a City of Saint Paul Plan Examiner at 266-9007 to apply
for building permits.
If there are any changes to the parkin� ]ot, floor space, or for new operations, please contact a City of Saint Paui Zonin�
Inspecior at 266-9008.
Additional application requirements, please aftach:
A detailed description of the design, location and square footage of the premises to be licensed (site pfan).
The following data should be on the site plan (preferably on an 8 1/2" x I1" or 8 1/2" x 14" paper):
- Name, address, and phone number.
- The scale should be stated such as 1" = 20'. ^N should be indicated foward the top.
- Placementof all pertinentfeafures of the interior of the licensed facility such as seating areas, kitchens, affices, 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
expansioa
A copy of your lease agreement or proof of ownership of the prbperty.
FOR SPECIFIC APPLICATION REQUIREMENTS, PLEASE SEE REVERSE >>>.>
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