97-1326Council File � 1 � ��
Ordinance #
Green Sheet # 37923
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,- -- .- . . .
Presented By
Re£erred To
RESOLUTIOW
CITY OF SAINT PAUL, MINNESOTA
��
Committee: Date
RESOLVED: That application, ID #89927, for Off-Sale Malt, Cigarette & GroceYy (C)
Licenses by Shong Thao DBA Hmong America Super Market (Shong Thao, Owner) at
861 Payne Avenue, be and the same are hereby approved.
Itequested by Department of:
Adoption Certified by Council Secretary
BY� ��o�� � - I- � _
Approved by MayoY: Date f� /jZ(�i�7—
By: � Li��
office of License Inspgctions and
Environmental Protection
By: l � w� �" Wz,�l.ti
Form Approved by City At ney
By: 7/ �
Approved by Mayor for Submission to
Council
By:
Adopted by Councilc Date �� � \°�q��
� ---_rT.,
LIEP
Christine A. Rozek — 266-9108
TOTAL # OF SIGNATURE PAGES
91 ����4.
GREEN SHEET � 7 5 2�
INRIAt/DATE INRIAUDATE
DEPARTMENT DIRECTOR � CRY COUNCIL �
CITY ATTORNEY � GITY GIERK
BU WET DIRECTOR � FIN. & MGL SERVECES DiR.
MAYOR IOR pSSISLW'� ❑
(CLIP ALl LOCATIONS FOR SIGNATURE)
-��--�--- Shong Thao DBA Hmong America Super Market requests Council approval of Yhe
application for an Off-Sale Malt, Cigarette & Brocery (C) License, ID 4189927, at
861 Payne Avenue (Shong L. Thao).
_ PV+NNING COMMISSION _ CIVIL SEAVIGE LOMMI$SION
_ ae coMM�e _
_ S7AFF _
_ oisraicrcouar _
SUPPORTS WHICH CAUNCIL O&IECTIVE?
PROBLEM,
IFAPPROVE�:
PERSONAI SERYICE CONTRACTS MUST ANSWER THE FOLLOWING �UESTIONS:
7. Has this perso�lFnn ever worked untler a conhact for this department?
YES NO
2. Has this persunffirm ever been a city employee?
YES NO
3. Ooes [his personlfirm possess a skill not normalfy possessed 6y any currert city employee4
YES NO
Explaln all yes answers on separata Sheet and attech to green sheet
Ea��'�'?.:S e....,.�.yea � u�.: o:i�;i
R .e...'� � 1JJ�
�! � i
TOTAL AMOUNT OF THANSACTION $
COST/REVENUE BUDGETED (CIRCLE ONE) YES NO
FUNDIWG SOURCE
FINANCIAI, INfORAi�ATIpN: (EXPWN)
�
'- � � c��.�7.� q�=�-�at�
SAINT
PAVti
�
AAA
CLASS III
/f LICENSE APPLICATION
1 �G� f ! �"J�
�ry i
fiJ/� �
� � �
CITY OF SAIi3T PAUL
O£ce of Licrnu, InspMioas
and Environmrnizl Pro.ection
i50 Sc Pctc: St Se� 3J�
Szc.t 7a:il, y`'.x��oa 55102
(bl� 3669D?0 kz C6i� 35GP!21
S
S o���.
S� � / , �� f3Pi'✓ 1�'tEP .'� 6�L-
S J �. �
Company Name:
i sole Proprietorship
If business is incorporated, give date of incorporation:
Doing Business As ��y�-��y
Business Address:
Business Phone:
so-«� naa� ( c- � c;�y� l � 7-- sr�« Z;�
Between what ctoss streets is the 6usiness located? 7 Ot�Z2p .+�1/� ./iTiYll/� �Af�( �'Wftich side of the street? `�Gi
y v.
Are the premises now occupied7 at Type of Business? � � , V ll7 V �C�-C-Lt.(�
Mail To Address:
Suect Addras
Applicant Tnfomiation:
Name and Title: �%
L
City
State Zip
F'ssse `'� M;ddte (Me;drn) I,ss2 2itle
Home Address: � �7 I�' ./}i�'�- �`� - �p� 1�.� � 6 /
Stred Addma Ciry Stste Zip
Date of Birth: % O��.��� Place of Birth: �✓� Home Phon ��'7`7�f - �iS.'� �j
Have you ever been conricted of any felony, crime or ��iolation of any city ordinance other than traffic? YES NO _�
Date of arrest:
Charge: _
Conviclion:
i�L•f�,ni�
Where?
.��i .
Sentence:
I• •,].L1)�1'J.
Have any of the above named licenses ever been revoked?
YES _,_ j�_ NO If yes, list the dates and reasons for revocation:
, 2/18/97
PLEASE TYPE OR PRINT IN A'K
Ttt�e ofLicense(sl beinQ annlied fnc
List the nsmes and residences of ttuee persons of good moral character, living within the Twin Cities Metro Area, not related to the applicant
or financially interested in the premises or business, who may be referred to as to the applicxnPs character:
, A7e you going to operaTe this business personally? �YES
Fust \ame
HomcAddxcss: Sttcet\amc
Are you going to have a maaacer or assistant in this business?
please comp3ete the followi,�g iltformalion:
HrnaeAdd=ras: SYrcetNffie
Vfiddle Initiei
?�tiddlc Initiel
Ciri�
_ NO If not, u�ho v.•itl operate it? ���,7 � S.
) T.ast DsteofBirth
Stzte Zip Phone\umber
YES � NO If the iaanager is not the same as the operator,
(�leidrn)
CSrv
Please list your employment history for the previous fice (5) c penod:
BusinessJEmnlovment
n�. _ ,d ,
List all other officers of the corporation:
OFFICER TITLE
NAME (Office Held)
HOME
ADDRESS
Address
HOME
PHONE
Las[
State
�
BUSINESS
PHONE
If business is a partnership, please include the following information for each parCner (use additional pages if necessary):
FuAName
.v.;aatc Uuu�
(:biaidcn)
DATE OF
BII2TH
SitcetName CiTy Statr Zip phoneVumber
FirsiTame Middle Initiel .(uiaidrn) I,ast Date of Birth
HomeAdd�ess: Streeti:ame CiTy State Zip PhoneN�ber
IvANNESOTA TAX IDENTIFICATION NUMBER - Pursuant to the Laws of Minnesot� 1984, Chapter 502, Article 8, Section 2(270.72)
(Tax Clearnnce; Issuance of Licenses), licensing authorities are required to provide to the State of Minnesota Commissioner of Revenue, the
Minnesota business tax identification number and the social security nutnber of each license applicant
Under the Minnesota Crove;nwent Data Practices Act and the Federal Privacy Act of 1974, we are required to advise you of the following
regarding che use of the Ivlinvesota Tax Identification Number:
- This informaGon may be used to deny the issuance or renewal of your license in the event you owe Minnesota sales, emp7oyer's
withholding or motor veMcte excise taxes;
- Upon receiving this information, the licensing authority wili supply it only to the Minnesota Aepartment of Revenue. Hower;er,
under the Federal Exchange of 7nformation Agreement, the Departrnent of Revenue may supply this information to the Intemal
Revenue Service.
Minnesota Taz identification Numbecs (Sales & Use 1'aY Number) maybe obtained from the State of Minnesota, Business Records Departrnent,
10 River Park Plaza (612-296-6181).
Social Security Number: 1�7�` cl �' ��7 � Mitmesota Ta�c Identification Number:
Deu of Binl�
Zip Phone\umber
. � /� /l _ �/�i'�)
� If a Minnesota Tae Ident�cation Number is not required for the business being operated, indicate so by placing an"X" in the box.
—, �+.
2/18l91
� ..s
9�—�z��
CERTIFICATION OF WORKERS' COMt'ENSATION COVERAGE PURSUA,'�TI TO MINNESOTA STANTE 176.182
I hereb}' �rufy thai I, or my company, azn in compliance with the �� orke: s' compensation uvsurance co�e; age rsquuements of Minnesota St2tute
176.182, subdivision 2. I 21so understand that pro�nsion of false informzuon in this cerufication constitutes sufficient gounds for zd��erse �ction
agains[ all licenses held, including revocation and suspension of s�;d license�, �„
:�Tame of Insurance ComPanY: t� �' i '— ��'-[' �
Policy Nur.�ber: Coverage from
I have r.o emplo} ees coverul under u•orkers' cAmpznsztion inserv�ce (I\ZT�S)
to
ANY FALSffICATIOI�' OF Al\SWERS GIVEIV OR MATERIAL SUBMITT`ED
WILI, REStiLT IN DER�L OF TH[S APPLICATION
I hereby state that I have ans�;�aed all of the preceding questions, and that the uafoimation contained herein is true and correct to the be� of
my knowledge and belief. I hereby state further that I have received no money or other consideration, by way of loan, gifi, conhibution, or
otheranse, other than airead} disclosed in the applicabon wfiich I hereuith submitted. I also understand this premise may be inspected by police,
fire, hea3th and other city officials at any and all times u�hen the business is in operation.
./.1a_��� SS/7/ P�7
Signature U for all appiications) Date
We will accept pa} ment by cash, check (made payab]e to City of Saint Paul) or credit card (M/C or Visa).
IFPA YINGBYCREDITCARDPLERSECOMPLETETHEFOLLOF3'INGINFORMATION: �MasterCazd �Visa
EXPTRATION DA7E: ACCOUNI' NUMBER
❑C7/0❑ . ❑C�0❑ ❑�C1❑ ❑C��❑ ❑C7C1❑
��e �
of Card Holder(required for aIl
'�xNote: If this application is Food/Liquor related, please contact a City of Saint Paul Health Inspector, Steve Olson (266-9139), to re��ew
plans.
If any substantial changes to sh are anticipated, please contact a City of Saint Paul Plan Eaaminer at 266-9007 to appiy for
buiiding pemuts.
If there are any ch�ages Yo the parking lot, floor space, or for new operations, please contact a City of Saint Paul Zoning Inspector at
266-9008.
Afl appiications mquire the following documents. Please attach these documents nhen submitting your application:
1. A detailed description of the design, lceation and square footage of the premises to be licensed (site plan).
The following data should be on the site plan (preferably on an 8 112" x I I" or 8 7/2" x 14" paper):
- Nazne, address, and phone number.
- The scale should be scated such as 1" = 20'. ^N should be indicated towazd the top.
- Placement of all pertinent £eatures of the interior of the licensed facility such as seating areas, kitchens, offices, repair area,
parking, rest rooms, etc.
- If a request is for an addition or expansion of the ]icensed facility, indicate both the current area and the proposed erpansion.
2. A copy of your lease agreement or proof of ownetship of the property.
SPECIFIC LICENSE A.PPLICATIONS REQUIItE ADDTTIONAL IlVFORMATION.
PLEASE SEE REVERSE FOR AETAILS >>>>
a�is.�s� ,
� ., �,
uti� 12�46 CITY �F ST PRUL LIEP 612 266 9124 P.02
{ / �� �
Greensneet ��3 7 a'.� L.I.E.P. REVfEW CHECKLfST oate: �:� � ���
!n 7racke�?_� ..
/ �� "g /L � �
Ucense 1R # ��9.j,� Ucense Sype: (�Ti - S�2 / �f d l7 � (�19Q� �� � `"'��[2J1�� �'
Company Name: ' 9 / D6A:,��/�' me: �u.�et il'�t�'r, _
Business Addresss: � Q�l/1 l77.� - .'��/G! _ 9uslness Phone:_ 77`� 3 � 7 3 -
Contact Name/Address: �4'+�� tiome Phone: -
DatB to Councd Research: %�1�L� �97 -- j
Public Hearing Date: j� ��9'J� tabels Ordeced: �/ �
NoGce Seni to Appiicant: 1�97 � sp D'�striM Counc,� #: 0�
}�� � ����
Notice Sent to Puhlic: ld � 9 Ward #: G b
DepaRmeni/
City Attomey
Date tnspections
��
Em�ironmental
Health
�`ti�l�n
1
License
Police
1C��1t�
° l lr !19�--
9 �x5�q.�-
Commen2s
� v
�o
N�,� - F ��.
� ��nor�
srte � ae�;�a�
Lease Aec�eivsd:
��V
o.� .
o. �
TOTA� P.02
Council File � 1 � ��
Ordinance #
Green Sheet # 37923
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
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27
28
29
30
,- -- .- . . .
Presented By
Re£erred To
RESOLUTIOW
CITY OF SAINT PAUL, MINNESOTA
��
Committee: Date
RESOLVED: That application, ID #89927, for Off-Sale Malt, Cigarette & GroceYy (C)
Licenses by Shong Thao DBA Hmong America Super Market (Shong Thao, Owner) at
861 Payne Avenue, be and the same are hereby approved.
Itequested by Department of:
Adoption Certified by Council Secretary
BY� ��o�� � - I- � _
Approved by MayoY: Date f� /jZ(�i�7—
By: � Li��
office of License Inspgctions and
Environmental Protection
By: l � w� �" Wz,�l.ti
Form Approved by City At ney
By: 7/ �
Approved by Mayor for Submission to
Council
By:
Adopted by Councilc Date �� � \°�q��
� ---_rT.,
LIEP
Christine A. Rozek — 266-9108
TOTAL # OF SIGNATURE PAGES
91 ����4.
GREEN SHEET � 7 5 2�
INRIAt/DATE INRIAUDATE
DEPARTMENT DIRECTOR � CRY COUNCIL �
CITY ATTORNEY � GITY GIERK
BU WET DIRECTOR � FIN. & MGL SERVECES DiR.
MAYOR IOR pSSISLW'� ❑
(CLIP ALl LOCATIONS FOR SIGNATURE)
-��--�--- Shong Thao DBA Hmong America Super Market requests Council approval of Yhe
application for an Off-Sale Malt, Cigarette & Brocery (C) License, ID 4189927, at
861 Payne Avenue (Shong L. Thao).
_ PV+NNING COMMISSION _ CIVIL SEAVIGE LOMMI$SION
_ ae coMM�e _
_ S7AFF _
_ oisraicrcouar _
SUPPORTS WHICH CAUNCIL O&IECTIVE?
PROBLEM,
IFAPPROVE�:
PERSONAI SERYICE CONTRACTS MUST ANSWER THE FOLLOWING �UESTIONS:
7. Has this perso�lFnn ever worked untler a conhact for this department?
YES NO
2. Has this persunffirm ever been a city employee?
YES NO
3. Ooes [his personlfirm possess a skill not normalfy possessed 6y any currert city employee4
YES NO
Explaln all yes answers on separata Sheet and attech to green sheet
Ea��'�'?.:S e....,.�.yea � u�.: o:i�;i
R .e...'� � 1JJ�
�! � i
TOTAL AMOUNT OF THANSACTION $
COST/REVENUE BUDGETED (CIRCLE ONE) YES NO
FUNDIWG SOURCE
FINANCIAI, INfORAi�ATIpN: (EXPWN)
�
'- � � c��.�7.� q�=�-�at�
SAINT
PAVti
�
AAA
CLASS III
/f LICENSE APPLICATION
1 �G� f ! �"J�
�ry i
fiJ/� �
� � �
CITY OF SAIi3T PAUL
O£ce of Licrnu, InspMioas
and Environmrnizl Pro.ection
i50 Sc Pctc: St Se� 3J�
Szc.t 7a:il, y`'.x��oa 55102
(bl� 3669D?0 kz C6i� 35GP!21
S
S o���.
S� � / , �� f3Pi'✓ 1�'tEP .'� 6�L-
S J �. �
Company Name:
i sole Proprietorship
If business is incorporated, give date of incorporation:
Doing Business As ��y�-��y
Business Address:
Business Phone:
so-«� naa� ( c- � c;�y� l � 7-- sr�« Z;�
Between what ctoss streets is the 6usiness located? 7 Ot�Z2p .+�1/� ./iTiYll/� �Af�( �'Wftich side of the street? `�Gi
y v.
Are the premises now occupied7 at Type of Business? � � , V ll7 V �C�-C-Lt.(�
Mail To Address:
Suect Addras
Applicant Tnfomiation:
Name and Title: �%
L
City
State Zip
F'ssse `'� M;ddte (Me;drn) I,ss2 2itle
Home Address: � �7 I�' ./}i�'�- �`� - �p� 1�.� � 6 /
Stred Addma Ciry Stste Zip
Date of Birth: % O��.��� Place of Birth: �✓� Home Phon ��'7`7�f - �iS.'� �j
Have you ever been conricted of any felony, crime or ��iolation of any city ordinance other than traffic? YES NO _�
Date of arrest:
Charge: _
Conviclion:
i�L•f�,ni�
Where?
.��i .
Sentence:
I• •,].L1)�1'J.
Have any of the above named licenses ever been revoked?
YES _,_ j�_ NO If yes, list the dates and reasons for revocation:
, 2/18/97
PLEASE TYPE OR PRINT IN A'K
Ttt�e ofLicense(sl beinQ annlied fnc
List the nsmes and residences of ttuee persons of good moral character, living within the Twin Cities Metro Area, not related to the applicant
or financially interested in the premises or business, who may be referred to as to the applicxnPs character:
, A7e you going to operaTe this business personally? �YES
Fust \ame
HomcAddxcss: Sttcet\amc
Are you going to have a maaacer or assistant in this business?
please comp3ete the followi,�g iltformalion:
HrnaeAdd=ras: SYrcetNffie
Vfiddle Initiei
?�tiddlc Initiel
Ciri�
_ NO If not, u�ho v.•itl operate it? ���,7 � S.
) T.ast DsteofBirth
Stzte Zip Phone\umber
YES � NO If the iaanager is not the same as the operator,
(�leidrn)
CSrv
Please list your employment history for the previous fice (5) c penod:
BusinessJEmnlovment
n�. _ ,d ,
List all other officers of the corporation:
OFFICER TITLE
NAME (Office Held)
HOME
ADDRESS
Address
HOME
PHONE
Las[
State
�
BUSINESS
PHONE
If business is a partnership, please include the following information for each parCner (use additional pages if necessary):
FuAName
.v.;aatc Uuu�
(:biaidcn)
DATE OF
BII2TH
SitcetName CiTy Statr Zip phoneVumber
FirsiTame Middle Initiel .(uiaidrn) I,ast Date of Birth
HomeAdd�ess: Streeti:ame CiTy State Zip PhoneN�ber
IvANNESOTA TAX IDENTIFICATION NUMBER - Pursuant to the Laws of Minnesot� 1984, Chapter 502, Article 8, Section 2(270.72)
(Tax Clearnnce; Issuance of Licenses), licensing authorities are required to provide to the State of Minnesota Commissioner of Revenue, the
Minnesota business tax identification number and the social security nutnber of each license applicant
Under the Minnesota Crove;nwent Data Practices Act and the Federal Privacy Act of 1974, we are required to advise you of the following
regarding che use of the Ivlinvesota Tax Identification Number:
- This informaGon may be used to deny the issuance or renewal of your license in the event you owe Minnesota sales, emp7oyer's
withholding or motor veMcte excise taxes;
- Upon receiving this information, the licensing authority wili supply it only to the Minnesota Aepartment of Revenue. Hower;er,
under the Federal Exchange of 7nformation Agreement, the Departrnent of Revenue may supply this information to the Intemal
Revenue Service.
Minnesota Taz identification Numbecs (Sales & Use 1'aY Number) maybe obtained from the State of Minnesota, Business Records Departrnent,
10 River Park Plaza (612-296-6181).
Social Security Number: 1�7�` cl �' ��7 � Mitmesota Ta�c Identification Number:
Deu of Binl�
Zip Phone\umber
. � /� /l _ �/�i'�)
� If a Minnesota Tae Ident�cation Number is not required for the business being operated, indicate so by placing an"X" in the box.
—, �+.
2/18l91
� ..s
9�—�z��
CERTIFICATION OF WORKERS' COMt'ENSATION COVERAGE PURSUA,'�TI TO MINNESOTA STANTE 176.182
I hereb}' �rufy thai I, or my company, azn in compliance with the �� orke: s' compensation uvsurance co�e; age rsquuements of Minnesota St2tute
176.182, subdivision 2. I 21so understand that pro�nsion of false informzuon in this cerufication constitutes sufficient gounds for zd��erse �ction
agains[ all licenses held, including revocation and suspension of s�;d license�, �„
:�Tame of Insurance ComPanY: t� �' i '— ��'-[' �
Policy Nur.�ber: Coverage from
I have r.o emplo} ees coverul under u•orkers' cAmpznsztion inserv�ce (I\ZT�S)
to
ANY FALSffICATIOI�' OF Al\SWERS GIVEIV OR MATERIAL SUBMITT`ED
WILI, REStiLT IN DER�L OF TH[S APPLICATION
I hereby state that I have ans�;�aed all of the preceding questions, and that the uafoimation contained herein is true and correct to the be� of
my knowledge and belief. I hereby state further that I have received no money or other consideration, by way of loan, gifi, conhibution, or
otheranse, other than airead} disclosed in the applicabon wfiich I hereuith submitted. I also understand this premise may be inspected by police,
fire, hea3th and other city officials at any and all times u�hen the business is in operation.
./.1a_��� SS/7/ P�7
Signature U for all appiications) Date
We will accept pa} ment by cash, check (made payab]e to City of Saint Paul) or credit card (M/C or Visa).
IFPA YINGBYCREDITCARDPLERSECOMPLETETHEFOLLOF3'INGINFORMATION: �MasterCazd �Visa
EXPTRATION DA7E: ACCOUNI' NUMBER
❑C7/0❑ . ❑C�0❑ ❑�C1❑ ❑C��❑ ❑C7C1❑
��e �
of Card Holder(required for aIl
'�xNote: If this application is Food/Liquor related, please contact a City of Saint Paul Health Inspector, Steve Olson (266-9139), to re��ew
plans.
If any substantial changes to sh are anticipated, please contact a City of Saint Paul Plan Eaaminer at 266-9007 to appiy for
buiiding pemuts.
If there are any ch�ages Yo the parking lot, floor space, or for new operations, please contact a City of Saint Paul Zoning Inspector at
266-9008.
Afl appiications mquire the following documents. Please attach these documents nhen submitting your application:
1. A detailed description of the design, lceation and square footage of the premises to be licensed (site plan).
The following data should be on the site plan (preferably on an 8 112" x I I" or 8 7/2" x 14" paper):
- Nazne, address, and phone number.
- The scale should be scated such as 1" = 20'. ^N should be indicated towazd the top.
- Placement of all pertinent £eatures of the interior of the licensed facility such as seating areas, kitchens, offices, repair area,
parking, rest rooms, etc.
- If a request is for an addition or expansion of the ]icensed facility, indicate both the current area and the proposed erpansion.
2. A copy of your lease agreement or proof of ownetship of the property.
SPECIFIC LICENSE A.PPLICATIONS REQUIItE ADDTTIONAL IlVFORMATION.
PLEASE SEE REVERSE FOR AETAILS >>>>
a�is.�s� ,
� ., �,
uti� 12�46 CITY �F ST PRUL LIEP 612 266 9124 P.02
{ / �� �
Greensneet ��3 7 a'.� L.I.E.P. REVfEW CHECKLfST oate: �:� � ���
!n 7racke�?_� ..
/ �� "g /L � �
Ucense 1R # ��9.j,� Ucense Sype: (�Ti - S�2 / �f d l7 � (�19Q� �� � `"'��[2J1�� �'
Company Name: ' 9 / D6A:,��/�' me: �u.�et il'�t�'r, _
Business Addresss: � Q�l/1 l77.� - .'��/G! _ 9uslness Phone:_ 77`� 3 � 7 3 -
Contact Name/Address: �4'+�� tiome Phone: -
DatB to Councd Research: %�1�L� �97 -- j
Public Hearing Date: j� ��9'J� tabels Ordeced: �/ �
NoGce Seni to Appiicant: 1�97 � sp D'�striM Counc,� #: 0�
}�� � ����
Notice Sent to Puhlic: ld � 9 Ward #: G b
DepaRmeni/
City Attomey
Date tnspections
��
Em�ironmental
Health
�`ti�l�n
1
License
Police
1C��1t�
° l lr !19�--
9 �x5�q.�-
Commen2s
� v
�o
N�,� - F ��.
� ��nor�
srte � ae�;�a�
Lease Aec�eivsd:
��V
o.� .
o. �
TOTA� P.02
Council File � 1 � ��
Ordinance #
Green Sheet # 37923
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
,- -- .- . . .
Presented By
Re£erred To
RESOLUTIOW
CITY OF SAINT PAUL, MINNESOTA
��
Committee: Date
RESOLVED: That application, ID #89927, for Off-Sale Malt, Cigarette & GroceYy (C)
Licenses by Shong Thao DBA Hmong America Super Market (Shong Thao, Owner) at
861 Payne Avenue, be and the same are hereby approved.
Itequested by Department of:
Adoption Certified by Council Secretary
BY� ��o�� � - I- � _
Approved by MayoY: Date f� /jZ(�i�7—
By: � Li��
office of License Inspgctions and
Environmental Protection
By: l � w� �" Wz,�l.ti
Form Approved by City At ney
By: 7/ �
Approved by Mayor for Submission to
Council
By:
Adopted by Councilc Date �� � \°�q��
� ---_rT.,
LIEP
Christine A. Rozek — 266-9108
TOTAL # OF SIGNATURE PAGES
91 ����4.
GREEN SHEET � 7 5 2�
INRIAt/DATE INRIAUDATE
DEPARTMENT DIRECTOR � CRY COUNCIL �
CITY ATTORNEY � GITY GIERK
BU WET DIRECTOR � FIN. & MGL SERVECES DiR.
MAYOR IOR pSSISLW'� ❑
(CLIP ALl LOCATIONS FOR SIGNATURE)
-��--�--- Shong Thao DBA Hmong America Super Market requests Council approval of Yhe
application for an Off-Sale Malt, Cigarette & Brocery (C) License, ID 4189927, at
861 Payne Avenue (Shong L. Thao).
_ PV+NNING COMMISSION _ CIVIL SEAVIGE LOMMI$SION
_ ae coMM�e _
_ S7AFF _
_ oisraicrcouar _
SUPPORTS WHICH CAUNCIL O&IECTIVE?
PROBLEM,
IFAPPROVE�:
PERSONAI SERYICE CONTRACTS MUST ANSWER THE FOLLOWING �UESTIONS:
7. Has this perso�lFnn ever worked untler a conhact for this department?
YES NO
2. Has this persunffirm ever been a city employee?
YES NO
3. Ooes [his personlfirm possess a skill not normalfy possessed 6y any currert city employee4
YES NO
Explaln all yes answers on separata Sheet and attech to green sheet
Ea��'�'?.:S e....,.�.yea � u�.: o:i�;i
R .e...'� � 1JJ�
�! � i
TOTAL AMOUNT OF THANSACTION $
COST/REVENUE BUDGETED (CIRCLE ONE) YES NO
FUNDIWG SOURCE
FINANCIAI, INfORAi�ATIpN: (EXPWN)
�
'- � � c��.�7.� q�=�-�at�
SAINT
PAVti
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AAA
CLASS III
/f LICENSE APPLICATION
1 �G� f ! �"J�
�ry i
fiJ/� �
� � �
CITY OF SAIi3T PAUL
O£ce of Licrnu, InspMioas
and Environmrnizl Pro.ection
i50 Sc Pctc: St Se� 3J�
Szc.t 7a:il, y`'.x��oa 55102
(bl� 3669D?0 kz C6i� 35GP!21
S
S o���.
S� � / , �� f3Pi'✓ 1�'tEP .'� 6�L-
S J �. �
Company Name:
i sole Proprietorship
If business is incorporated, give date of incorporation:
Doing Business As ��y�-��y
Business Address:
Business Phone:
so-«� naa� ( c- � c;�y� l � 7-- sr�« Z;�
Between what ctoss streets is the 6usiness located? 7 Ot�Z2p .+�1/� ./iTiYll/� �Af�( �'Wftich side of the street? `�Gi
y v.
Are the premises now occupied7 at Type of Business? � � , V ll7 V �C�-C-Lt.(�
Mail To Address:
Suect Addras
Applicant Tnfomiation:
Name and Title: �%
L
City
State Zip
F'ssse `'� M;ddte (Me;drn) I,ss2 2itle
Home Address: � �7 I�' ./}i�'�- �`� - �p� 1�.� � 6 /
Stred Addma Ciry Stste Zip
Date of Birth: % O��.��� Place of Birth: �✓� Home Phon ��'7`7�f - �iS.'� �j
Have you ever been conricted of any felony, crime or ��iolation of any city ordinance other than traffic? YES NO _�
Date of arrest:
Charge: _
Conviclion:
i�L•f�,ni�
Where?
.��i .
Sentence:
I• •,].L1)�1'J.
Have any of the above named licenses ever been revoked?
YES _,_ j�_ NO If yes, list the dates and reasons for revocation:
, 2/18/97
PLEASE TYPE OR PRINT IN A'K
Ttt�e ofLicense(sl beinQ annlied fnc
List the nsmes and residences of ttuee persons of good moral character, living within the Twin Cities Metro Area, not related to the applicant
or financially interested in the premises or business, who may be referred to as to the applicxnPs character:
, A7e you going to operaTe this business personally? �YES
Fust \ame
HomcAddxcss: Sttcet\amc
Are you going to have a maaacer or assistant in this business?
please comp3ete the followi,�g iltformalion:
HrnaeAdd=ras: SYrcetNffie
Vfiddle Initiei
?�tiddlc Initiel
Ciri�
_ NO If not, u�ho v.•itl operate it? ���,7 � S.
) T.ast DsteofBirth
Stzte Zip Phone\umber
YES � NO If the iaanager is not the same as the operator,
(�leidrn)
CSrv
Please list your employment history for the previous fice (5) c penod:
BusinessJEmnlovment
n�. _ ,d ,
List all other officers of the corporation:
OFFICER TITLE
NAME (Office Held)
HOME
ADDRESS
Address
HOME
PHONE
Las[
State
�
BUSINESS
PHONE
If business is a partnership, please include the following information for each parCner (use additional pages if necessary):
FuAName
.v.;aatc Uuu�
(:biaidcn)
DATE OF
BII2TH
SitcetName CiTy Statr Zip phoneVumber
FirsiTame Middle Initiel .(uiaidrn) I,ast Date of Birth
HomeAdd�ess: Streeti:ame CiTy State Zip PhoneN�ber
IvANNESOTA TAX IDENTIFICATION NUMBER - Pursuant to the Laws of Minnesot� 1984, Chapter 502, Article 8, Section 2(270.72)
(Tax Clearnnce; Issuance of Licenses), licensing authorities are required to provide to the State of Minnesota Commissioner of Revenue, the
Minnesota business tax identification number and the social security nutnber of each license applicant
Under the Minnesota Crove;nwent Data Practices Act and the Federal Privacy Act of 1974, we are required to advise you of the following
regarding che use of the Ivlinvesota Tax Identification Number:
- This informaGon may be used to deny the issuance or renewal of your license in the event you owe Minnesota sales, emp7oyer's
withholding or motor veMcte excise taxes;
- Upon receiving this information, the licensing authority wili supply it only to the Minnesota Aepartment of Revenue. Hower;er,
under the Federal Exchange of 7nformation Agreement, the Departrnent of Revenue may supply this information to the Intemal
Revenue Service.
Minnesota Taz identification Numbecs (Sales & Use 1'aY Number) maybe obtained from the State of Minnesota, Business Records Departrnent,
10 River Park Plaza (612-296-6181).
Social Security Number: 1�7�` cl �' ��7 � Mitmesota Ta�c Identification Number:
Deu of Binl�
Zip Phone\umber
. � /� /l _ �/�i'�)
� If a Minnesota Tae Ident�cation Number is not required for the business being operated, indicate so by placing an"X" in the box.
—, �+.
2/18l91
� ..s
9�—�z��
CERTIFICATION OF WORKERS' COMt'ENSATION COVERAGE PURSUA,'�TI TO MINNESOTA STANTE 176.182
I hereb}' �rufy thai I, or my company, azn in compliance with the �� orke: s' compensation uvsurance co�e; age rsquuements of Minnesota St2tute
176.182, subdivision 2. I 21so understand that pro�nsion of false informzuon in this cerufication constitutes sufficient gounds for zd��erse �ction
agains[ all licenses held, including revocation and suspension of s�;d license�, �„
:�Tame of Insurance ComPanY: t� �' i '— ��'-[' �
Policy Nur.�ber: Coverage from
I have r.o emplo} ees coverul under u•orkers' cAmpznsztion inserv�ce (I\ZT�S)
to
ANY FALSffICATIOI�' OF Al\SWERS GIVEIV OR MATERIAL SUBMITT`ED
WILI, REStiLT IN DER�L OF TH[S APPLICATION
I hereby state that I have ans�;�aed all of the preceding questions, and that the uafoimation contained herein is true and correct to the be� of
my knowledge and belief. I hereby state further that I have received no money or other consideration, by way of loan, gifi, conhibution, or
otheranse, other than airead} disclosed in the applicabon wfiich I hereuith submitted. I also understand this premise may be inspected by police,
fire, hea3th and other city officials at any and all times u�hen the business is in operation.
./.1a_��� SS/7/ P�7
Signature U for all appiications) Date
We will accept pa} ment by cash, check (made payab]e to City of Saint Paul) or credit card (M/C or Visa).
IFPA YINGBYCREDITCARDPLERSECOMPLETETHEFOLLOF3'INGINFORMATION: �MasterCazd �Visa
EXPTRATION DA7E: ACCOUNI' NUMBER
❑C7/0❑ . ❑C�0❑ ❑�C1❑ ❑C��❑ ❑C7C1❑
��e �
of Card Holder(required for aIl
'�xNote: If this application is Food/Liquor related, please contact a City of Saint Paul Health Inspector, Steve Olson (266-9139), to re��ew
plans.
If any substantial changes to sh are anticipated, please contact a City of Saint Paul Plan Eaaminer at 266-9007 to appiy for
buiiding pemuts.
If there are any ch�ages Yo the parking lot, floor space, or for new operations, please contact a City of Saint Paul Zoning Inspector at
266-9008.
Afl appiications mquire the following documents. Please attach these documents nhen submitting your application:
1. A detailed description of the design, lceation and square footage of the premises to be licensed (site plan).
The following data should be on the site plan (preferably on an 8 112" x I I" or 8 7/2" x 14" paper):
- Nazne, address, and phone number.
- The scale should be scated such as 1" = 20'. ^N should be indicated towazd the top.
- Placement of all pertinent £eatures of the interior of the licensed facility such as seating areas, kitchens, offices, repair area,
parking, rest rooms, etc.
- If a request is for an addition or expansion of the ]icensed facility, indicate both the current area and the proposed erpansion.
2. A copy of your lease agreement or proof of ownetship of the property.
SPECIFIC LICENSE A.PPLICATIONS REQUIItE ADDTTIONAL IlVFORMATION.
PLEASE SEE REVERSE FOR AETAILS >>>>
a�is.�s� ,
� ., �,
uti� 12�46 CITY �F ST PRUL LIEP 612 266 9124 P.02
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Greensneet ��3 7 a'.� L.I.E.P. REVfEW CHECKLfST oate: �:� � ���
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Ucense 1R # ��9.j,� Ucense Sype: (�Ti - S�2 / �f d l7 � (�19Q� �� � `"'��[2J1�� �'
Company Name: ' 9 / D6A:,��/�' me: �u.�et il'�t�'r, _
Business Addresss: � Q�l/1 l77.� - .'��/G! _ 9uslness Phone:_ 77`� 3 � 7 3 -
Contact Name/Address: �4'+�� tiome Phone: -
DatB to Councd Research: %�1�L� �97 -- j
Public Hearing Date: j� ��9'J� tabels Ordeced: �/ �
NoGce Seni to Appiicant: 1�97 � sp D'�striM Counc,� #: 0�
}�� � ����
Notice Sent to Puhlic: ld � 9 Ward #: G b
DepaRmeni/
City Attomey
Date tnspections
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Em�ironmental
Health
�`ti�l�n
1
License
Police
1C��1t�
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9 �x5�q.�-
Commen2s
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Lease Aec�eivsd:
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TOTA� P.02