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97-1325Council File � • � S ordinance # Green Sheet # 50232 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 ��_- Presented By Referred To RESOLVED: That application, ID �31224, for an Off-Sale Malt License by Supervalu Aoldings, Inc. DBA Cub Foods, (Kim E. Erickson, Sr. VP of Finance), at 1440 University Ave. W., be and the same is hereby approved. RESOLUTION C1TY OF SAINT PAUL, MINNESOTA 35 Committee: Date Requested by Department of: Adopted by Council: Date � Adoption Certified by Council Secretary B Y � a \ a . 1""+- �.�._r�, Approved by Mayp� �j (!2/5 �-- Bys � Office of License inspections and Environmental Protection BY' ��p�, ��'�'1i(r.J Form Approv�ed by City A ar y By: C,GC� Approved b Mayor for Submission to Council By: N� 50232 I GREEN SHEET O OEPARTMENT DIRECi�R - 266-9108 ASSiGN � �ITYATfORNE1' XUMBERfOP � ROUTING OBUDGETDIRECTOR �/� � ONOEfl � MAYOfY (OR 0.5515TANn TOTAL # OF (CLIP ALL LOCATIONS FOR SIGNATURE) °�'j �� a,.5 INfTiAUDATE � CI7YC�UNGL Q CR1'CLERK � FIN 8 MGT SEFVICES OIR. O u3 aEWESTED: Supervalu Holdings, Inc. DBA Cub Foods, ID 9f31224, requests Council approval ot its application for an Off-Sale Malt License located at 1440 University Avenue,W. (Kim M. Erickson, Sr. CrP of Finance). RECOMMENDATIONS: ApP�'e (A) or RelecY (R) _ PIANNING CAMMISSION _ GVIL _ CIS COMMITfEE _ _ __ STAFF _ _ __ OISTRiGTGOURT _ _ SUPPORTS WHICH COUNCIL OBJECTIVE? &3'Y��:+��%� ��v: .;� 6,0:,; _ �s'�' d� � ��' i�� DISAO�/ANTqGES IF APPROVEA' IF fpTAL AMOUN7 OF TRANSACTION $ 'UNDIfdG SOURCE INANCIAL INFORfi5AT10N. (E%PL0.1N) PERSONAL SERVIGE COtiTHACTS MUST ANSWER THE FOILOWING �UESTfONS: /. Has th7s person/firm ever worked under a contrect for fhis department� YES NO 2. Has this personKrm ever been a c�ty empioyee? YES NO 3. DOeS this person/tirm possess a skill not norma�ly pOSSessetl Gy any current ciry employee� YES NO Explaln all yes answers on separate aheet antl attaeh to green aheet COS7lREVENUE BUDGE7EU (CIRCLE ONE) VES NO ACTIVITY NUMBER y . � . , � ( �- �- � Sw�NS i PAUC I �� Al1AA CLASS III LICENSB APPLICATION CITY OF SAINT PALZ �ce of Liteau, Iaspe4iOnc � �C ana &ivirom�crtal rrocectioq] r' , � 350SLPc[aSLSwc300 '� c=^� Pwl, hfvmesab 55102 (fiI2)26b#190 Sz(6i3)]66972J THIS APPLICATION IS SUBJECT TO REVIEW BY THE PUBLIC PLEASE TYPE OR PRIN'P IN INK Type of License(s) being applied for. �� F� — S �A" C C � r�� LT 1�� S O/•� O CompanyName: _ J��PL,�Vftt_.t/� ��' ration Pnrtncra(up / Sole P:oprictonhip If business is incorporated, give date of incorporation: � lioing Business As: �.0 l� �OD � S n Business Address: ��U (� V1 � U�Q-�j�f �'U t7� PJII.G( F�s:�r•r.� Between what cross s*seets is the b Are the premises now cupi� � Mail To Address: -�� . (Xl X Suect Address Applicant Information: Name and Title: �. Fint Home Address: located? 5 S $ � v��s_ Inc � 0 9� Business Phone: J 2 6 - f 6 3 �St• — S}.Pzu.( , i1i1n1 �Siot}- c«y ' sr�« z� Which side of the street? siness� P��al � ��YDC'�VU ;vl �TA�Y� G�7. � i v� h P� � � i S. /I/1 nl .�53 t�-� I`/ � • � � Middlc (.ylaiden) 1 v � u�e. — M, v� su�� naa� � r, ctty DateofBirth: � � �� PiaceofBirth:�"YINC�'t7)YI, � ��n�te50-E� Have you ever been �co cted of any felony, crime or violaIIo of any city ordinance other than tramc. Date of arrest: r�' I t'C Where? ��/'1 ______ ' State Zip C'.IC�S� �1 .SENioQ. UiC��f� L„c ��Cf M�1 ss3os sc� z; Home Phone� � 2" �Z � YES NC x Chazge: 1�1 �'t Conviction' � � Sentence /� Lis[ the nunes and residenaes of three persons of good moral character, living within the Twin Cities Metro Area, not related to the applicant or financially interested in thz premises or business, who may be referred to as to the applicanYs character; NAME ADDRESS PAONE List licenses Gvhich you currendy ho1� formerly held, or may have an interest in: .�� Have any of the above named licenses ever been revokedY YES _� NO If yes, list the dates and reasoas for revocation: t�=) Are you going to operaze this business personally7 YES �` NO If not, who will operate it? �a��i�t. � W-rS — �,�+�e t F ' irstNamc Ie�Initial ,, I (�tai'�.n.) �7 ��(' ��b� WO�n�� xom�aamY,�: s�� c�ry Are you going to have a manager ar assistant in this busir.ess? x YES please complete the following information: nyam� �;ri�t �,a�n) xomenaa�cv: secccx,m< Please list your employment history for the previous five {5) year period: $usinessfEmnlovment Address List all other officers of the corporation: OFFICER TITLE HOME HOME BUSINESS DATE OF NAME (Office Hzld) ADDRESS PHONE PHONE BIItTH �� C� L��TItil.��C';4-l�l`� • is a partnership, please include the following information for each pariner (use additional pages if necessary): City �N �t�-t7�-S �_c�l ` (25 , �3�- Zqo� Zip Pb ue Numbcr NO If the manager is not the same as the operator, �� SWe Zip �rr Home Addmas: Strcet Name -�—. iwaa�� „�s� Middlc I�utial (,widen) City . (.M%�d�n) ia,c Statc Zip I,ast Phone Number Datc o{Birth ffome Addre.ca: Strcct Namc City Stntc Zip Phor.e Nuciber IvIINNESOTA TAX IDENTIFICATION NIJMBER - Pursuant to the Laws of Minnesata, 1984, Chapter 502, Article 8, Section 2(27072) (Tax Clearance; Issuance of Licenses), licensing authorities are required to provide to the State of Minnesota Commissioner of Revenue, the Minnesota business taY identification number and the social security number of each ]icense applicant. Under the Minnesota Govemment Data Practices Act and the Federal Pricacy Act of 1974, we are required to advise you of the following reguding the use of the Minnesota Tati Identification Number: - This information may be used to deny the issuance or renewal of pour license in the event you owe Minnesota sales, emplo}'er s withholding or motor vehicle excise taxes; - Upon receiving this information, ihe licensing authority will supply it only to the Miimesota Department of Revenue. Howe�•er, under the Federal Exchange of Information Agreement, the Department of Revenue may supply this information to the Intzrnal Revenue Service. Mitmesota TaK Identification Numbas (Sales & Use Tat Numbzr) may be obtainai from the State of Minnesota, Business Records Department, 10 River Pazk Plaza (612-296-6181). Social Security Number: �/A Minnesota TaY Idrntification Number: - T" J" U� o�l l�� V If a Minnesota TaY Tdentification Numbzr is not required for the business being operated, indicate so by placing an"X" in the box <'�. 2/18/97 y CE?27IfTCATIO'�' OF WORKERS' CO?�'.PENSA7ION COVERr1GE PURSUA.\T 70.�TTESOTA STANTE 176.182 �' �� I hr, e'�� cejtif} thu I, or m}� comp�v, zcn in ca�pliance with the �ra};ers' cAmpe�ztion vnsurznce co� erage requirz :izau of M'v Siztu?e 176. ] 82, subdi�ision 2. I zs� undast�d thxt pro�is'son of ialse i*li`o:mation in this certific�tion constitutes suf�`icieat �ounds for zd� erse actioa ag��ast 2ll licc�:�-s hzl� including re�•ocation and siupension o`said lic..�nses. „ :��.zeor��.c� uc�r�n� nnu�u� ru�ur�i Poicc'_vtt�ber. ��Tz ��3� Cove:agefro;n I hz� e no enplo}��s coce*ui u�der ��o;ke; s compznsation is.L i�ce l(L�ZTIALS) to A:\'Y FAI SIFICATIDih OF AKSA°EILS GTVE\ OR M4TERL4L SUBAIITS'ED Vr7LL RESLZT Lti DE\ OF THIS APPLICATTON I be:zbp state that I hzre enswered r11 of the preceding questio.�s, and tbat the information contzined herein is true and correct to tt�e best of m}� Isoc�'ledge end belief I bereby state fiuther that I have ; r,..zi��ed no money o; othr, consideration, by ��a} of ]oen, gift, consibutioa, or oth_,t�ise, otha th2n 2lready �sclos� in the 2pplication ufiich i Sw ewith submitted I also understznd this premise mz} be inspectz3 b}• police, fire, bezlth z�d otner cit} o�cials at zay 2�d xll times u•hen the business is in ope; ation. for al[ applications) R'e nill accept pa}ment b�� cash, cbeck (made pa}�able to City of Saint Paun or credit card (M/C or Visa). IFPAYING$YCREDITCARDPLE.4SECOMPLETBTHEFOLLON'INGIATFORMATION: � MzS�erCard � Visa EXPiRATION DAIE: ❑o/o❑ :�ame of Catd6oldu ror av '*Nofe: ffthis application is Food/Liquorrelated please contact a Cin� of Saint Paul Healtl� Inspector, Steve Olson (266-9139), to re�tiew plans. If any substantial changes to structure ue anticipated, please contact a Ciry of Saint Paul PIan Examiner at 266-9007 to apply for building permiu. Iftbere are azry cl�znges to the par'Ang lot, 400r space, or for new operations, piease contact a City of Saint P aul Zoning Inspector at 266-9008. At! applicariona mquite the folloning documents. PIease attach these documents R•hen s¢bmitting your apptication: i. A detailed deseription of t6e design, localion and squsre footage of the premises to be licensed (site plan). T t�e following data should be on the site plan (preferably on an 8 1/2" x 11" or 8 1/Z" x 14" paper): - Name, address, and phone number. - The scale should be stated such as 1"= 20'. ^N should be indicated toward the top. - PSacemevt of all pestinent feattmes of the interior of the Iicensed facility such as seatmg areas, kitcbens, offices, repair are� parlang, rest rooms, etc. - If a request is for an addition or e�paasian of the licensed facitity, indicate both the currrnt azea and the proposed e�pansion. 2. A cop} ofyour lease agrcemwt or proof of ouve�hip of tbe property. ACCOL'N'L NtTMBER: ■■■■ ■■■■ ■■■■ ■■■■ SPECIFIC LICENSE APPLICATIONS REQL'IItE ADDITIONAL INFORMATION. PLEASE SEE REVERSE FOR DETAII.S >>>> Council File � • � S ordinance # Green Sheet # 50232 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 ��_- Presented By Referred To RESOLVED: That application, ID �31224, for an Off-Sale Malt License by Supervalu Aoldings, Inc. DBA Cub Foods, (Kim E. Erickson, Sr. VP of Finance), at 1440 University Ave. W., be and the same is hereby approved. RESOLUTION C1TY OF SAINT PAUL, MINNESOTA 35 Committee: Date Requested by Department of: Adopted by Council: Date � Adoption Certified by Council Secretary B Y � a \ a . 1""+- �.�._r�, Approved by Mayp� �j (!2/5 �-- Bys � Office of License inspections and Environmental Protection BY' ��p�, ��'�'1i(r.J Form Approv�ed by City A ar y By: C,GC� Approved b Mayor for Submission to Council By: N� 50232 I GREEN SHEET O OEPARTMENT DIRECi�R - 266-9108 ASSiGN � �ITYATfORNE1' XUMBERfOP � ROUTING OBUDGETDIRECTOR �/� � ONOEfl � MAYOfY (OR 0.5515TANn TOTAL # OF (CLIP ALL LOCATIONS FOR SIGNATURE) °�'j �� a,.5 INfTiAUDATE � CI7YC�UNGL Q CR1'CLERK � FIN 8 MGT SEFVICES OIR. O u3 aEWESTED: Supervalu Holdings, Inc. DBA Cub Foods, ID 9f31224, requests Council approval ot its application for an Off-Sale Malt License located at 1440 University Avenue,W. (Kim M. Erickson, Sr. CrP of Finance). RECOMMENDATIONS: ApP�'e (A) or RelecY (R) _ PIANNING CAMMISSION _ GVIL _ CIS COMMITfEE _ _ __ STAFF _ _ __ OISTRiGTGOURT _ _ SUPPORTS WHICH COUNCIL OBJECTIVE? &3'Y��:+��%� ��v: .;� 6,0:,; _ �s'�' d� � ��' i�� DISAO�/ANTqGES IF APPROVEA' IF fpTAL AMOUN7 OF TRANSACTION $ 'UNDIfdG SOURCE INANCIAL INFORfi5AT10N. (E%PL0.1N) PERSONAL SERVIGE COtiTHACTS MUST ANSWER THE FOILOWING �UESTfONS: /. Has th7s person/firm ever worked under a contrect for fhis department� YES NO 2. Has this personKrm ever been a c�ty empioyee? YES NO 3. DOeS this person/tirm possess a skill not norma�ly pOSSessetl Gy any current ciry employee� YES NO Explaln all yes answers on separate aheet antl attaeh to green aheet COS7lREVENUE BUDGE7EU (CIRCLE ONE) VES NO ACTIVITY NUMBER y . � . , � ( �- �- � Sw�NS i PAUC I �� Al1AA CLASS III LICENSB APPLICATION CITY OF SAINT PALZ �ce of Liteau, Iaspe4iOnc � �C ana &ivirom�crtal rrocectioq] r' , � 350SLPc[aSLSwc300 '� c=^� Pwl, hfvmesab 55102 (fiI2)26b#190 Sz(6i3)]66972J THIS APPLICATION IS SUBJECT TO REVIEW BY THE PUBLIC PLEASE TYPE OR PRIN'P IN INK Type of License(s) being applied for. �� F� — S �A" C C � r�� LT 1�� S O/•� O CompanyName: _ J��PL,�Vftt_.t/� ��' ration Pnrtncra(up / Sole P:oprictonhip If business is incorporated, give date of incorporation: � lioing Business As: �.0 l� �OD � S n Business Address: ��U (� V1 � U�Q-�j�f �'U t7� PJII.G( F�s:�r•r.� Between what cross s*seets is the b Are the premises now cupi� � Mail To Address: -�� . (Xl X Suect Address Applicant Information: Name and Title: �. Fint Home Address: located? 5 S $ � v��s_ Inc � 0 9� Business Phone: J 2 6 - f 6 3 �St• — S}.Pzu.( , i1i1n1 �Siot}- c«y ' sr�« z� Which side of the street? siness� P��al � ��YDC'�VU ;vl �TA�Y� G�7. � i v� h P� � � i S. /I/1 nl .�53 t�-� I`/ � • � � Middlc (.ylaiden) 1 v � u�e. — M, v� su�� naa� � r, ctty DateofBirth: � � �� PiaceofBirth:�"YINC�'t7)YI, � ��n�te50-E� Have you ever been �co cted of any felony, crime or violaIIo of any city ordinance other than tramc. Date of arrest: r�' I t'C Where? ��/'1 ______ ' State Zip C'.IC�S� �1 .SENioQ. UiC��f� L„c ��Cf M�1 ss3os sc� z; Home Phone� � 2" �Z � YES NC x Chazge: 1�1 �'t Conviction' � � Sentence /� Lis[ the nunes and residenaes of three persons of good moral character, living within the Twin Cities Metro Area, not related to the applicant or financially interested in thz premises or business, who may be referred to as to the applicanYs character; NAME ADDRESS PAONE List licenses Gvhich you currendy ho1� formerly held, or may have an interest in: .�� Have any of the above named licenses ever been revokedY YES _� NO If yes, list the dates and reasoas for revocation: t�=) Are you going to operaze this business personally7 YES �` NO If not, who will operate it? �a��i�t. � W-rS — �,�+�e t F ' irstNamc Ie�Initial ,, I (�tai'�.n.) �7 ��(' ��b� WO�n�� xom�aamY,�: s�� c�ry Are you going to have a manager ar assistant in this busir.ess? x YES please complete the following information: nyam� �;ri�t �,a�n) xomenaa�cv: secccx,m< Please list your employment history for the previous five {5) year period: $usinessfEmnlovment Address List all other officers of the corporation: OFFICER TITLE HOME HOME BUSINESS DATE OF NAME (Office Hzld) ADDRESS PHONE PHONE BIItTH �� C� L��TItil.��C';4-l�l`� • is a partnership, please include the following information for each pariner (use additional pages if necessary): City �N �t�-t7�-S �_c�l ` (25 , �3�- Zqo� Zip Pb ue Numbcr NO If the manager is not the same as the operator, �� SWe Zip �rr Home Addmas: Strcet Name -�—. iwaa�� „�s� Middlc I�utial (,widen) City . (.M%�d�n) ia,c Statc Zip I,ast Phone Number Datc o{Birth ffome Addre.ca: Strcct Namc City Stntc Zip Phor.e Nuciber IvIINNESOTA TAX IDENTIFICATION NIJMBER - Pursuant to the Laws of Minnesata, 1984, Chapter 502, Article 8, Section 2(27072) (Tax Clearance; Issuance of Licenses), licensing authorities are required to provide to the State of Minnesota Commissioner of Revenue, the Minnesota business taY identification number and the social security number of each ]icense applicant. Under the Minnesota Govemment Data Practices Act and the Federal Pricacy Act of 1974, we are required to advise you of the following reguding the use of the Minnesota Tati Identification Number: - This information may be used to deny the issuance or renewal of pour license in the event you owe Minnesota sales, emplo}'er s withholding or motor vehicle excise taxes; - Upon receiving this information, ihe licensing authority will supply it only to the Miimesota Department of Revenue. Howe�•er, under the Federal Exchange of Information Agreement, the Department of Revenue may supply this information to the Intzrnal Revenue Service. Mitmesota TaK Identification Numbas (Sales & Use Tat Numbzr) may be obtainai from the State of Minnesota, Business Records Department, 10 River Pazk Plaza (612-296-6181). Social Security Number: �/A Minnesota TaY Idrntification Number: - T" J" U� o�l l�� V If a Minnesota TaY Tdentification Numbzr is not required for the business being operated, indicate so by placing an"X" in the box <'�. 2/18/97 y CE?27IfTCATIO'�' OF WORKERS' CO?�'.PENSA7ION COVERr1GE PURSUA.\T 70.�TTESOTA STANTE 176.182 �' �� I hr, e'�� cejtif} thu I, or m}� comp�v, zcn in ca�pliance with the �ra};ers' cAmpe�ztion vnsurznce co� erage requirz :izau of M'v Siztu?e 176. ] 82, subdi�ision 2. I zs� undast�d thxt pro�is'son of ialse i*li`o:mation in this certific�tion constitutes suf�`icieat �ounds for zd� erse actioa ag��ast 2ll licc�:�-s hzl� including re�•ocation and siupension o`said lic..�nses. „ :��.zeor��.c� uc�r�n� nnu�u� ru�ur�i Poicc'_vtt�ber. ��Tz ��3� Cove:agefro;n I hz� e no enplo}��s coce*ui u�der ��o;ke; s compznsation is.L i�ce l(L�ZTIALS) to A:\'Y FAI SIFICATIDih OF AKSA°EILS GTVE\ OR M4TERL4L SUBAIITS'ED Vr7LL RESLZT Lti DE\ OF THIS APPLICATTON I be:zbp state that I hzre enswered r11 of the preceding questio.�s, and tbat the information contzined herein is true and correct to tt�e best of m}� Isoc�'ledge end belief I bereby state fiuther that I have ; r,..zi��ed no money o; othr, consideration, by ��a} of ]oen, gift, consibutioa, or oth_,t�ise, otha th2n 2lready �sclos� in the 2pplication ufiich i Sw ewith submitted I also understznd this premise mz} be inspectz3 b}• police, fire, bezlth z�d otner cit} o�cials at zay 2�d xll times u•hen the business is in ope; ation. for al[ applications) R'e nill accept pa}ment b�� cash, cbeck (made pa}�able to City of Saint Paun or credit card (M/C or Visa). IFPAYING$YCREDITCARDPLE.4SECOMPLETBTHEFOLLON'INGIATFORMATION: � MzS�erCard � Visa EXPiRATION DAIE: ❑o/o❑ :�ame of Catd6oldu ror av '*Nofe: ffthis application is Food/Liquorrelated please contact a Cin� of Saint Paul Healtl� Inspector, Steve Olson (266-9139), to re�tiew plans. If any substantial changes to structure ue anticipated, please contact a Ciry of Saint Paul PIan Examiner at 266-9007 to apply for building permiu. Iftbere are azry cl�znges to the par'Ang lot, 400r space, or for new operations, piease contact a City of Saint P aul Zoning Inspector at 266-9008. At! applicariona mquite the folloning documents. PIease attach these documents R•hen s¢bmitting your apptication: i. A detailed deseription of t6e design, localion and squsre footage of the premises to be licensed (site plan). T t�e following data should be on the site plan (preferably on an 8 1/2" x 11" or 8 1/Z" x 14" paper): - Name, address, and phone number. - The scale should be stated such as 1"= 20'. ^N should be indicated toward the top. - PSacemevt of all pestinent feattmes of the interior of the Iicensed facility such as seatmg areas, kitcbens, offices, repair are� parlang, rest rooms, etc. - If a request is for an addition or e�paasian of the licensed facitity, indicate both the currrnt azea and the proposed e�pansion. 2. A cop} ofyour lease agrcemwt or proof of ouve�hip of tbe property. ACCOL'N'L NtTMBER: ■■■■ ■■■■ ■■■■ ■■■■ SPECIFIC LICENSE APPLICATIONS REQL'IItE ADDITIONAL INFORMATION. PLEASE SEE REVERSE FOR DETAII.S >>>> Council File � • � S ordinance # Green Sheet # 50232 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 ��_- Presented By Referred To RESOLVED: That application, ID �31224, for an Off-Sale Malt License by Supervalu Aoldings, Inc. DBA Cub Foods, (Kim E. Erickson, Sr. VP of Finance), at 1440 University Ave. W., be and the same is hereby approved. RESOLUTION C1TY OF SAINT PAUL, MINNESOTA 35 Committee: Date Requested by Department of: Adopted by Council: Date � Adoption Certified by Council Secretary B Y � a \ a . 1""+- �.�._r�, Approved by Mayp� �j (!2/5 �-- Bys � Office of License inspections and Environmental Protection BY' ��p�, ��'�'1i(r.J Form Approv�ed by City A ar y By: C,GC� Approved b Mayor for Submission to Council By: N� 50232 I GREEN SHEET O OEPARTMENT DIRECi�R - 266-9108 ASSiGN � �ITYATfORNE1' XUMBERfOP � ROUTING OBUDGETDIRECTOR �/� � ONOEfl � MAYOfY (OR 0.5515TANn TOTAL # OF (CLIP ALL LOCATIONS FOR SIGNATURE) °�'j �� a,.5 INfTiAUDATE � CI7YC�UNGL Q CR1'CLERK � FIN 8 MGT SEFVICES OIR. O u3 aEWESTED: Supervalu Holdings, Inc. DBA Cub Foods, ID 9f31224, requests Council approval ot its application for an Off-Sale Malt License located at 1440 University Avenue,W. (Kim M. Erickson, Sr. CrP of Finance). RECOMMENDATIONS: ApP�'e (A) or RelecY (R) _ PIANNING CAMMISSION _ GVIL _ CIS COMMITfEE _ _ __ STAFF _ _ __ OISTRiGTGOURT _ _ SUPPORTS WHICH COUNCIL OBJECTIVE? &3'Y��:+��%� ��v: .;� 6,0:,; _ �s'�' d� � ��' i�� DISAO�/ANTqGES IF APPROVEA' IF fpTAL AMOUN7 OF TRANSACTION $ 'UNDIfdG SOURCE INANCIAL INFORfi5AT10N. (E%PL0.1N) PERSONAL SERVIGE COtiTHACTS MUST ANSWER THE FOILOWING �UESTfONS: /. Has th7s person/firm ever worked under a contrect for fhis department� YES NO 2. Has this personKrm ever been a c�ty empioyee? YES NO 3. DOeS this person/tirm possess a skill not norma�ly pOSSessetl Gy any current ciry employee� YES NO Explaln all yes answers on separate aheet antl attaeh to green aheet COS7lREVENUE BUDGE7EU (CIRCLE ONE) VES NO ACTIVITY NUMBER y . � . , � ( �- �- � Sw�NS i PAUC I �� Al1AA CLASS III LICENSB APPLICATION CITY OF SAINT PALZ �ce of Liteau, Iaspe4iOnc � �C ana &ivirom�crtal rrocectioq] r' , � 350SLPc[aSLSwc300 '� c=^� Pwl, hfvmesab 55102 (fiI2)26b#190 Sz(6i3)]66972J THIS APPLICATION IS SUBJECT TO REVIEW BY THE PUBLIC PLEASE TYPE OR PRIN'P IN INK Type of License(s) being applied for. �� F� — S �A" C C � r�� LT 1�� S O/•� O CompanyName: _ J��PL,�Vftt_.t/� ��' ration Pnrtncra(up / Sole P:oprictonhip If business is incorporated, give date of incorporation: � lioing Business As: �.0 l� �OD � S n Business Address: ��U (� V1 � U�Q-�j�f �'U t7� PJII.G( F�s:�r•r.� Between what cross s*seets is the b Are the premises now cupi� � Mail To Address: -�� . (Xl X Suect Address Applicant Information: Name and Title: �. Fint Home Address: located? 5 S $ � v��s_ Inc � 0 9� Business Phone: J 2 6 - f 6 3 �St• — S}.Pzu.( , i1i1n1 �Siot}- c«y ' sr�« z� Which side of the street? siness� P��al � ��YDC'�VU ;vl �TA�Y� G�7. � i v� h P� � � i S. /I/1 nl .�53 t�-� I`/ � • � � Middlc (.ylaiden) 1 v � u�e. — M, v� su�� naa� � r, ctty DateofBirth: � � �� PiaceofBirth:�"YINC�'t7)YI, � ��n�te50-E� Have you ever been �co cted of any felony, crime or violaIIo of any city ordinance other than tramc. Date of arrest: r�' I t'C Where? ��/'1 ______ ' State Zip C'.IC�S� �1 .SENioQ. UiC��f� L„c ��Cf M�1 ss3os sc� z; Home Phone� � 2" �Z � YES NC x Chazge: 1�1 �'t Conviction' � � Sentence /� Lis[ the nunes and residenaes of three persons of good moral character, living within the Twin Cities Metro Area, not related to the applicant or financially interested in thz premises or business, who may be referred to as to the applicanYs character; NAME ADDRESS PAONE List licenses Gvhich you currendy ho1� formerly held, or may have an interest in: .�� Have any of the above named licenses ever been revokedY YES _� NO If yes, list the dates and reasoas for revocation: t�=) Are you going to operaze this business personally7 YES �` NO If not, who will operate it? �a��i�t. � W-rS — �,�+�e t F ' irstNamc Ie�Initial ,, I (�tai'�.n.) �7 ��(' ��b� WO�n�� xom�aamY,�: s�� c�ry Are you going to have a manager ar assistant in this busir.ess? x YES please complete the following information: nyam� �;ri�t �,a�n) xomenaa�cv: secccx,m< Please list your employment history for the previous five {5) year period: $usinessfEmnlovment Address List all other officers of the corporation: OFFICER TITLE HOME HOME BUSINESS DATE OF NAME (Office Hzld) ADDRESS PHONE PHONE BIItTH �� C� L��TItil.��C';4-l�l`� • is a partnership, please include the following information for each pariner (use additional pages if necessary): City �N �t�-t7�-S �_c�l ` (25 , �3�- Zqo� Zip Pb ue Numbcr NO If the manager is not the same as the operator, �� SWe Zip �rr Home Addmas: Strcet Name -�—. iwaa�� „�s� Middlc I�utial (,widen) City . (.M%�d�n) ia,c Statc Zip I,ast Phone Number Datc o{Birth ffome Addre.ca: Strcct Namc City Stntc Zip Phor.e Nuciber IvIINNESOTA TAX IDENTIFICATION NIJMBER - Pursuant to the Laws of Minnesata, 1984, Chapter 502, Article 8, Section 2(27072) (Tax Clearance; Issuance of Licenses), licensing authorities are required to provide to the State of Minnesota Commissioner of Revenue, the Minnesota business taY identification number and the social security number of each ]icense applicant. Under the Minnesota Govemment Data Practices Act and the Federal Pricacy Act of 1974, we are required to advise you of the following reguding the use of the Minnesota Tati Identification Number: - This information may be used to deny the issuance or renewal of pour license in the event you owe Minnesota sales, emplo}'er s withholding or motor vehicle excise taxes; - Upon receiving this information, ihe licensing authority will supply it only to the Miimesota Department of Revenue. Howe�•er, under the Federal Exchange of Information Agreement, the Department of Revenue may supply this information to the Intzrnal Revenue Service. Mitmesota TaK Identification Numbas (Sales & Use Tat Numbzr) may be obtainai from the State of Minnesota, Business Records Department, 10 River Pazk Plaza (612-296-6181). Social Security Number: �/A Minnesota TaY Idrntification Number: - T" J" U� o�l l�� V If a Minnesota TaY Tdentification Numbzr is not required for the business being operated, indicate so by placing an"X" in the box <'�. 2/18/97 y CE?27IfTCATIO'�' OF WORKERS' CO?�'.PENSA7ION COVERr1GE PURSUA.\T 70.�TTESOTA STANTE 176.182 �' �� I hr, e'�� cejtif} thu I, or m}� comp�v, zcn in ca�pliance with the �ra};ers' cAmpe�ztion vnsurznce co� erage requirz :izau of M'v Siztu?e 176. ] 82, subdi�ision 2. I zs� undast�d thxt pro�is'son of ialse i*li`o:mation in this certific�tion constitutes suf�`icieat �ounds for zd� erse actioa ag��ast 2ll licc�:�-s hzl� including re�•ocation and siupension o`said lic..�nses. „ :��.zeor��.c� uc�r�n� nnu�u� ru�ur�i Poicc'_vtt�ber. ��Tz ��3� Cove:agefro;n I hz� e no enplo}��s coce*ui u�der ��o;ke; s compznsation is.L i�ce l(L�ZTIALS) to A:\'Y FAI SIFICATIDih OF AKSA°EILS GTVE\ OR M4TERL4L SUBAIITS'ED Vr7LL RESLZT Lti DE\ OF THIS APPLICATTON I be:zbp state that I hzre enswered r11 of the preceding questio.�s, and tbat the information contzined herein is true and correct to tt�e best of m}� Isoc�'ledge end belief I bereby state fiuther that I have ; r,..zi��ed no money o; othr, consideration, by ��a} of ]oen, gift, consibutioa, or oth_,t�ise, otha th2n 2lready �sclos� in the 2pplication ufiich i Sw ewith submitted I also understznd this premise mz} be inspectz3 b}• police, fire, bezlth z�d otner cit} o�cials at zay 2�d xll times u•hen the business is in ope; ation. for al[ applications) R'e nill accept pa}ment b�� cash, cbeck (made pa}�able to City of Saint Paun or credit card (M/C or Visa). IFPAYING$YCREDITCARDPLE.4SECOMPLETBTHEFOLLON'INGIATFORMATION: � MzS�erCard � Visa EXPiRATION DAIE: ❑o/o❑ :�ame of Catd6oldu ror av '*Nofe: ffthis application is Food/Liquorrelated please contact a Cin� of Saint Paul Healtl� Inspector, Steve Olson (266-9139), to re�tiew plans. If any substantial changes to structure ue anticipated, please contact a Ciry of Saint Paul PIan Examiner at 266-9007 to apply for building permiu. Iftbere are azry cl�znges to the par'Ang lot, 400r space, or for new operations, piease contact a City of Saint P aul Zoning Inspector at 266-9008. At! applicariona mquite the folloning documents. PIease attach these documents R•hen s¢bmitting your apptication: i. A detailed deseription of t6e design, localion and squsre footage of the premises to be licensed (site plan). T t�e following data should be on the site plan (preferably on an 8 1/2" x 11" or 8 1/Z" x 14" paper): - Name, address, and phone number. - The scale should be stated such as 1"= 20'. ^N should be indicated toward the top. - PSacemevt of all pestinent feattmes of the interior of the Iicensed facility such as seatmg areas, kitcbens, offices, repair are� parlang, rest rooms, etc. - If a request is for an addition or e�paasian of the licensed facitity, indicate both the currrnt azea and the proposed e�pansion. 2. A cop} ofyour lease agrcemwt or proof of ouve�hip of tbe property. ACCOL'N'L NtTMBER: ■■■■ ■■■■ ■■■■ ■■■■ SPECIFIC LICENSE APPLICATIONS REQL'IItE ADDITIONAL INFORMATION. PLEASE SEE REVERSE FOR DETAII.S >>>>