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97-1327Council File # l7 �� °1� Ordinance # 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 RESOLUTION CITY OF SAINT PAUL, N Presented By Referred To Green Sheet # 50244 � 37 Committee: Date RESOLVSD: That application, ID #19204, for an On-Sale Malt and Wine On-Sale License by E1 Bravo, inc. DBA 81 Bravo, (Manuel Bravo, Owner), at 538 Rice Street, be and the same is hereby approved. Requested by Department of: Adoption Certified by Council Secretary $Y�� 1--� Approved by Mayor: Date lt Q U f}-. B `" �—.._.._ < °� Office of L+'cense Insvections and Environmental Protection By: � � �o � � �.�-�-i Form Approved by City Attorn By: / (. Cc0 Approved by yor for Submission to Council By: Adopted by Council: Date�� S�99� v ° N� 50244 ° l� � t� �-� - - - -__ ___ _ LIEP REEN SHEE bN7ACT PERSON 8 vHONE MITiAVOATE INITIAWATE � OEPARTMEM DIpEGTOF � qTY COUNCII Christine A. Rozek - 266-9108 N MBE FOH �GINATTORNEY �CIT'CLERK AU5i BE ON COUNCIL AGENDA B(DATE) N O J. S p��N� O BUDGET DIRECTOR O FIN. & MG7. SEHVICES DIR. H2'd21Il : l��Z�? � �� ORDER �MAYOR(ORASSISTANT) O TOTAL # OF SIGNATURE PAGES {CLIP ALL LOCATIOSJS fOR S4GNATURE) E1 Bravo, Inc, DBA E1 Bravo, (Manuel Bravo, Owner), requests Council approval of their application for an Qn-Sale Malt and Wine On-Sale License located at 538 Rice S (ID 9�19204) _PIJWNINGCOMMISSION _CNILSERVICECAMMISSI�N _ CIB GOMMITTEE _ _ STAFF _ _ D1STP5CT COURT _ SUPPORTS WHICH COUNCIL OBJECTIVE? ISSUE. ADVANTAGES �FAPPROVED: IF NOTAPPROVED' PERSONAL SERYICE CON7RACTS MUS7 ANSWER THE FOILOWING QUESTIONS: t. Has Ihis personNirm sver workeC under a crontract for fhis tlepartment? VES NO 2. Has this person�rm ever been a ciry employee? YES NO 3. Does this personRirm possess a skill not normally possessed by any current city employee? YES NO Explaln all yea anawers on aeparete sheet enA attach to green aheet wna�. wnare. wn�g �i �'p..-..� ,� . �_;.... �G� (J � �� fOTAL AMOUNT OF TRA4ISACTION S COST/REVENUE BUOGETEO (ClRCIE ONE) YES tJ0 'UNOIWG SOURCE ACTIVITY NUMBER INANCIAL INFORFhAiION' (EXPLAIN) r- � 1 �'' CLASS III LICENSE APPLICATION U !(� E��- Type of License(s) being applied for: Business Phone: �c 1,� -aq �- Q=�� Company Nazne: �� C a� v c� �/� C, Cotpontion! Pazfirnhip / Solc P:oprietonhip If business is incoiporated, gjve date of incorporation: /�1,� j/yQ}2( --��o '?�0 � lloing Business As: Business Address: Strzn Ada� c;ry Yl CIrY OF SAINT PAUL off� atu�, ��o� ana Enviromnertral Protzction 350 SC Pnc SC SWe 3W Ssi.'rtPuJ,Na¢iaoa SSItr2 (613) 3669090 6z (61l) 366-9113 ;/ i �;�'.'r. State Zip Between what cross streets is the business located? Which side of the street� Are the premises now occupied7 What Type of Business? �� C'Fa u C`�.r�� Mail To Address: �__ S�-�,,�, � {�'�� J S� �(1`-� s� naa� ApplicantInfonnation: Natne and Tit1e: ( 6 1 Fim Home Address: Middlc senct nad� , c;c Date of Birth: Piace of $irfn: (�- Have you ever been convicted of any felony, crime or violafion oF any c ordinancz other than traffic. Date of azrest: Charge: _ Convicfion: Sentence: State Zip isat � s�c Hor�e P1:or.°: � YES Titic . . + • List the names and residences of ihree persons of good moral character, living within the Twin Cifies Metro Area, not related io the applicant or financially intereted in the premises or business, who may be referred to as to the applicant's chazacter; List licenses which you currently hold, Formerly held, or may have an interest ��d ciry Where? THIS APPLICATION IS SUBJECT TO REVIEW BY THE PUB IC PLEASE TYPE OR PRINT IN INK jy � _ _ �_ _ _ i "l NAME ADDRESS PHONE Are you going to operate this business personally7 � XES Fint iv�c r.t;aat<�ciet HomcAddress: Strutiyame Are you going to hace a manager ar assistant in ttris business? please complete the following infotmztion: Fi�rtNamc i HomeAddresx: SuedNamc (`faiarn) City YES Please list your emplayment history {or the previous five (5) year period: Business/Em�lovme� List all other officers of the corporation: OFFICER TITLE NAME (Office Held) HOME ADDRESS NO If not, who will operate it? I.att �1'1 �i'J �� Datc of SiM dd*es Statc Zip NO If the manager is not the sasne rs the operator, Laat State Zip HOME BL3SINESS DATE OF PHONE PHONE BII2TH If business is a partnership, please include the following information for each partner (use additional pages if necessazy): FintName MiddlcLutisl (�iaiden) Lavt DateofBirtk� HomeAddrcas: StrcRhem< Fint N�c Middle Liitial (Maidrn) Statc Zip Phonc Numbn 1"Ri� De[e of Hirth Hame Addxcss: Strect tiemc CiTy Statc Zip Phonc Number MIlVNESOTA TAX IDENTIFICATION NUMBER - Pursuant to the I,aws of Minnesota, 1984, Chapter 502, Article 8, Section 2(270J2) (TaY Clearance; Issuance of Licrnses), licensing authorities are required to provide to the State of Minnesota Comuussioner of Revenue, the Minnesota business tax identification number and the social security number of each license applicant. Under the Minnesota Govemment Data Praclices Act and the Federal Privacy Act of 1974, we are required to advise you of the following regazding the use of the Minnzsota Tar ldentificalion Number: - This information may be used to drny the issuance or renewal of your license in the event you owe Minnesota salzs, employer s uithholding or mocor vehicle excise taxes; - Upon receiving this information, the licensing authoriry wi11 supply it only to the Minnesota Department of Revenue_ However, under the Fedzral Exchange of Infocmation Agreetnent, the Department of Revenue may supply this infocmation to the Intemat Revenue Service. Minnesota TaY Idrntification Numbeis (Sales & Use TaY Number} may be obtained from the State of Minnesota, Susiness Itecords Departrnent, 10 River Park Plaza (612-296-6181). Social Security Number: � 1.� �� ' L � D�'1 Minnesota Ta� Idrntification Number: �� t� Y� City _ If a Minnesota Tax Identification Number is not required for the business bzing operated, indicate so by placing an "X" in the box �:-_ 9! 1 R!94 CEfiTIFICATION OF WORKERS' COMPENSATION COVERAGE PURSUANT TO MINNESOTA STANTE 176.182 �� 7 I hereby certify that I, or my company, am in compliance with the workers' compensalion insurance coverage requirements of Minnesota Stature 176.182, subdivision 2. I also understand that provision of faLse information in this cer[ification constitutes s�cient grounds for adverse action against all licenses held, inciuding revocation and suspension of said licenses. Nazne of Insurance Company: E r ri 1a ��. Y't� � n i, C`rR,v`iT c Policy Number: _(� �—� R�� C�E'1— � Coverage from S- ta- q h to S— 1l� - I have no employees covered under workers compensation insurance (I�TITIALS) ANY FALSIFICATION OF ANSWTRS GIVEN OR MATERIAL SUBMiTTED WII,L RESULT IN DENIAL OF THIS APPLICATION I hereby state that I have answered all of the preceding questions, and that the information contained herein is hue and correct to the best of my lrnowled�e and belief. I hereby state fiuther that I have received no money or other consideration, by way of loan, giR, conuibutioq or otherwise, other than already disclosed in the application which I herewith submined. I aiso unders`�and fl-,is p; emise may be inspected by po!ice, fire, health and other ciry officials at any and all times when the business is in operation. Signature (REQUIRED for sII applications) Date We will accept ps� ment by cash, check (made payable to Cify of Saint Paul) or cmdit card (hUC or Vi,e). IFPAYINGBYCREDITCARDPLEASECOMPLETETHEFOLL06J�INGINFOItMATION: ❑MasterCazd � Visa EXPIRATiON DATE: ACCOUNT NUMBER: ❑�/�❑ ❑Cl�❑ ❑C]0❑ ❑0�❑ ❑C7C7❑ of CarA�older of Cazd Holder(required for all **Note: If this application is FoodlLiquor related, please contsct a City of Saint Paul Health Inspector, Steve Olson (266-4134), to review plans. . If any substantial changes to struciure aze anticipa.e3, please :;,atact a Ci?y of S:int Pe�� P!an Exazniner at 266-9007 to apply for building pertnits. If there are any changes to the parking lot, floor space, or for new operations, please contact a City of Saint Paul Zoning Inspector at 2b6-9008. All applications require the following documents. Please attach these documents when submitting your application: I. A detailed description of the design, location artd square footage of the premises to be licensed (site plan). The following data should be on the site plan (preferably on an 8 1J2" x I 1" 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 toward the top. - Placement of all pertinent features of the interior of the licensed facility such as seating areas, kitchens, offices, repau area, parking, rest rooms, ete. '- - If a request is for an addition or expansion of the licensed facIlity, indicate both the currznt azea and the proposed expansion. 2. A copy of your lease agreement or proof of ownership of the property. SPECIFIC LICENSE APPLICATIONS REQITIIZE ADDTTIONAL INFORMATION. PLEASE SEE REVERSE FOR DETAII.S >>>> ;�:' 2/18:97 Council File # l7 �� °1� Ordinance # 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 RESOLUTION CITY OF SAINT PAUL, N Presented By Referred To Green Sheet # 50244 � 37 Committee: Date RESOLVSD: That application, ID #19204, for an On-Sale Malt and Wine On-Sale License by E1 Bravo, inc. DBA 81 Bravo, (Manuel Bravo, Owner), at 538 Rice Street, be and the same is hereby approved. Requested by Department of: Adoption Certified by Council Secretary $Y�� 1--� Approved by Mayor: Date lt Q U f}-. B `" �—.._.._ < °� Office of L+'cense Insvections and Environmental Protection By: � � �o � � �.�-�-i Form Approved by City Attorn By: / (. Cc0 Approved by yor for Submission to Council By: Adopted by Council: Date�� S�99� v ° N� 50244 ° l� � t� �-� - - - -__ ___ _ LIEP REEN SHEE bN7ACT PERSON 8 vHONE MITiAVOATE INITIAWATE � OEPARTMEM DIpEGTOF � qTY COUNCII Christine A. Rozek - 266-9108 N MBE FOH �GINATTORNEY �CIT'CLERK AU5i BE ON COUNCIL AGENDA B(DATE) N O J. S p��N� O BUDGET DIRECTOR O FIN. & MG7. SEHVICES DIR. H2'd21Il : l��Z�? � �� ORDER �MAYOR(ORASSISTANT) O TOTAL # OF SIGNATURE PAGES {CLIP ALL LOCATIOSJS fOR S4GNATURE) E1 Bravo, Inc, DBA E1 Bravo, (Manuel Bravo, Owner), requests Council approval of their application for an Qn-Sale Malt and Wine On-Sale License located at 538 Rice S (ID 9�19204) _PIJWNINGCOMMISSION _CNILSERVICECAMMISSI�N _ CIB GOMMITTEE _ _ STAFF _ _ D1STP5CT COURT _ SUPPORTS WHICH COUNCIL OBJECTIVE? ISSUE. ADVANTAGES �FAPPROVED: IF NOTAPPROVED' PERSONAL SERYICE CON7RACTS MUS7 ANSWER THE FOILOWING QUESTIONS: t. Has Ihis personNirm sver workeC under a crontract for fhis tlepartment? VES NO 2. Has this person�rm ever been a ciry employee? YES NO 3. Does this personRirm possess a skill not normally possessed by any current city employee? YES NO Explaln all yea anawers on aeparete sheet enA attach to green aheet wna�. wnare. wn�g �i �'p..-..� ,� . �_;.... �G� (J � �� fOTAL AMOUNT OF TRA4ISACTION S COST/REVENUE BUOGETEO (ClRCIE ONE) YES tJ0 'UNOIWG SOURCE ACTIVITY NUMBER INANCIAL INFORFhAiION' (EXPLAIN) r- � 1 �'' CLASS III LICENSE APPLICATION U !(� E��- Type of License(s) being applied for: Business Phone: �c 1,� -aq �- Q=�� Company Nazne: �� C a� v c� �/� C, Cotpontion! Pazfirnhip / Solc P:oprietonhip If business is incoiporated, gjve date of incorporation: /�1,� j/yQ}2( --��o '?�0 � lloing Business As: Business Address: Strzn Ada� c;ry Yl CIrY OF SAINT PAUL off� atu�, ��o� ana Enviromnertral Protzction 350 SC Pnc SC SWe 3W Ssi.'rtPuJ,Na¢iaoa SSItr2 (613) 3669090 6z (61l) 366-9113 ;/ i �;�'.'r. State Zip Between what cross streets is the business located? Which side of the street� Are the premises now occupied7 What Type of Business? �� C'Fa u C`�.r�� Mail To Address: �__ S�-�,,�, � {�'�� J S� �(1`-� s� naa� ApplicantInfonnation: Natne and Tit1e: ( 6 1 Fim Home Address: Middlc senct nad� , c;c Date of Birth: Piace of $irfn: (�- Have you ever been convicted of any felony, crime or violafion oF any c ordinancz other than traffic. Date of azrest: Charge: _ Convicfion: Sentence: State Zip isat � s�c Hor�e P1:or.°: � YES Titic . . + • List the names and residences of ihree persons of good moral character, living within the Twin Cifies Metro Area, not related io the applicant or financially intereted in the premises or business, who may be referred to as to the applicant's chazacter; List licenses which you currently hold, Formerly held, or may have an interest ��d ciry Where? THIS APPLICATION IS SUBJECT TO REVIEW BY THE PUB IC PLEASE TYPE OR PRINT IN INK jy � _ _ �_ _ _ i "l NAME ADDRESS PHONE Are you going to operate this business personally7 � XES Fint iv�c r.t;aat<�ciet HomcAddress: Strutiyame Are you going to hace a manager ar assistant in ttris business? please complete the following infotmztion: Fi�rtNamc i HomeAddresx: SuedNamc (`faiarn) City YES Please list your emplayment history {or the previous five (5) year period: Business/Em�lovme� List all other officers of the corporation: OFFICER TITLE NAME (Office Held) HOME ADDRESS NO If not, who will operate it? I.att �1'1 �i'J �� Datc of SiM dd*es Statc Zip NO If the manager is not the sasne rs the operator, Laat State Zip HOME BL3SINESS DATE OF PHONE PHONE BII2TH If business is a partnership, please include the following information for each partner (use additional pages if necessazy): FintName MiddlcLutisl (�iaiden) Lavt DateofBirtk� HomeAddrcas: StrcRhem< Fint N�c Middle Liitial (Maidrn) Statc Zip Phonc Numbn 1"Ri� De[e of Hirth Hame Addxcss: Strect tiemc CiTy Statc Zip Phonc Number MIlVNESOTA TAX IDENTIFICATION NUMBER - Pursuant to the I,aws of Minnesota, 1984, Chapter 502, Article 8, Section 2(270J2) (TaY Clearance; Issuance of Licrnses), licensing authorities are required to provide to the State of Minnesota Comuussioner of Revenue, the Minnesota business tax identification number and the social security number of each license applicant. Under the Minnesota Govemment Data Praclices Act and the Federal Privacy Act of 1974, we are required to advise you of the following regazding the use of the Minnzsota Tar ldentificalion Number: - This information may be used to drny the issuance or renewal of your license in the event you owe Minnesota salzs, employer s uithholding or mocor vehicle excise taxes; - Upon receiving this information, the licensing authoriry wi11 supply it only to the Minnesota Department of Revenue_ However, under the Fedzral Exchange of Infocmation Agreetnent, the Department of Revenue may supply this infocmation to the Intemat Revenue Service. Minnesota TaY Idrntification Numbeis (Sales & Use TaY Number} may be obtained from the State of Minnesota, Susiness Itecords Departrnent, 10 River Park Plaza (612-296-6181). Social Security Number: � 1.� �� ' L � D�'1 Minnesota Ta� Idrntification Number: �� t� Y� City _ If a Minnesota Tax Identification Number is not required for the business bzing operated, indicate so by placing an "X" in the box �:-_ 9! 1 R!94 CEfiTIFICATION OF WORKERS' COMPENSATION COVERAGE PURSUANT TO MINNESOTA STANTE 176.182 �� 7 I hereby certify that I, or my company, am in compliance with the workers' compensalion insurance coverage requirements of Minnesota Stature 176.182, subdivision 2. I also understand that provision of faLse information in this cer[ification constitutes s�cient grounds for adverse action against all licenses held, inciuding revocation and suspension of said licenses. Nazne of Insurance Company: E r ri 1a ��. Y't� � n i, C`rR,v`iT c Policy Number: _(� �—� R�� C�E'1— � Coverage from S- ta- q h to S— 1l� - I have no employees covered under workers compensation insurance (I�TITIALS) ANY FALSIFICATION OF ANSWTRS GIVEN OR MATERIAL SUBMiTTED WII,L RESULT IN DENIAL OF THIS APPLICATION I hereby state that I have answered all of the preceding questions, and that the information contained herein is hue and correct to the best of my lrnowled�e and belief. I hereby state fiuther that I have received no money or other consideration, by way of loan, giR, conuibutioq or otherwise, other than already disclosed in the application which I herewith submined. I aiso unders`�and fl-,is p; emise may be inspected by po!ice, fire, health and other ciry officials at any and all times when the business is in operation. Signature (REQUIRED for sII applications) Date We will accept ps� ment by cash, check (made payable to Cify of Saint Paul) or cmdit card (hUC or Vi,e). IFPAYINGBYCREDITCARDPLEASECOMPLETETHEFOLL06J�INGINFOItMATION: ❑MasterCazd � Visa EXPIRATiON DATE: ACCOUNT NUMBER: ❑�/�❑ ❑Cl�❑ ❑C]0❑ ❑0�❑ ❑C7C7❑ of CarA�older of Cazd Holder(required for all **Note: If this application is FoodlLiquor related, please contsct a City of Saint Paul Health Inspector, Steve Olson (266-4134), to review plans. . If any substantial changes to struciure aze anticipa.e3, please :;,atact a Ci?y of S:int Pe�� P!an Exazniner at 266-9007 to apply for building pertnits. If there are any changes to the parking lot, floor space, or for new operations, please contact a City of Saint Paul Zoning Inspector at 2b6-9008. All applications require the following documents. Please attach these documents when submitting your application: I. A detailed description of the design, location artd square footage of the premises to be licensed (site plan). The following data should be on the site plan (preferably on an 8 1J2" x I 1" 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 toward the top. - Placement of all pertinent features of the interior of the licensed facility such as seating areas, kitchens, offices, repau area, parking, rest rooms, ete. '- - If a request is for an addition or expansion of the licensed facIlity, indicate both the currznt azea and the proposed expansion. 2. A copy of your lease agreement or proof of ownership of the property. SPECIFIC LICENSE APPLICATIONS REQITIIZE ADDTTIONAL INFORMATION. PLEASE SEE REVERSE FOR DETAII.S >>>> ;�:' 2/18:97 Council File # l7 �� °1� Ordinance # 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 RESOLUTION CITY OF SAINT PAUL, N Presented By Referred To Green Sheet # 50244 � 37 Committee: Date RESOLVSD: That application, ID #19204, for an On-Sale Malt and Wine On-Sale License by E1 Bravo, inc. DBA 81 Bravo, (Manuel Bravo, Owner), at 538 Rice Street, be and the same is hereby approved. Requested by Department of: Adoption Certified by Council Secretary $Y�� 1--� Approved by Mayor: Date lt Q U f}-. B `" �—.._.._ < °� Office of L+'cense Insvections and Environmental Protection By: � � �o � � �.�-�-i Form Approved by City Attorn By: / (. Cc0 Approved by yor for Submission to Council By: Adopted by Council: Date�� S�99� v ° N� 50244 ° l� � t� �-� - - - -__ ___ _ LIEP REEN SHEE bN7ACT PERSON 8 vHONE MITiAVOATE INITIAWATE � OEPARTMEM DIpEGTOF � qTY COUNCII Christine A. Rozek - 266-9108 N MBE FOH �GINATTORNEY �CIT'CLERK AU5i BE ON COUNCIL AGENDA B(DATE) N O J. S p��N� O BUDGET DIRECTOR O FIN. & MG7. SEHVICES DIR. H2'd21Il : l��Z�? � �� ORDER �MAYOR(ORASSISTANT) O TOTAL # OF SIGNATURE PAGES {CLIP ALL LOCATIOSJS fOR S4GNATURE) E1 Bravo, Inc, DBA E1 Bravo, (Manuel Bravo, Owner), requests Council approval of their application for an Qn-Sale Malt and Wine On-Sale License located at 538 Rice S (ID 9�19204) _PIJWNINGCOMMISSION _CNILSERVICECAMMISSI�N _ CIB GOMMITTEE _ _ STAFF _ _ D1STP5CT COURT _ SUPPORTS WHICH COUNCIL OBJECTIVE? ISSUE. ADVANTAGES �FAPPROVED: IF NOTAPPROVED' PERSONAL SERYICE CON7RACTS MUS7 ANSWER THE FOILOWING QUESTIONS: t. Has Ihis personNirm sver workeC under a crontract for fhis tlepartment? VES NO 2. Has this person�rm ever been a ciry employee? YES NO 3. Does this personRirm possess a skill not normally possessed by any current city employee? YES NO Explaln all yea anawers on aeparete sheet enA attach to green aheet wna�. wnare. wn�g �i �'p..-..� ,� . �_;.... �G� (J � �� fOTAL AMOUNT OF TRA4ISACTION S COST/REVENUE BUOGETEO (ClRCIE ONE) YES tJ0 'UNOIWG SOURCE ACTIVITY NUMBER INANCIAL INFORFhAiION' (EXPLAIN) r- � 1 �'' CLASS III LICENSE APPLICATION U !(� E��- Type of License(s) being applied for: Business Phone: �c 1,� -aq �- Q=�� Company Nazne: �� C a� v c� �/� C, Cotpontion! Pazfirnhip / Solc P:oprietonhip If business is incoiporated, gjve date of incorporation: /�1,� j/yQ}2( --��o '?�0 � lloing Business As: Business Address: Strzn Ada� c;ry Yl CIrY OF SAINT PAUL off� atu�, ��o� ana Enviromnertral Protzction 350 SC Pnc SC SWe 3W Ssi.'rtPuJ,Na¢iaoa SSItr2 (613) 3669090 6z (61l) 366-9113 ;/ i �;�'.'r. State Zip Between what cross streets is the business located? Which side of the street� Are the premises now occupied7 What Type of Business? �� C'Fa u C`�.r�� Mail To Address: �__ S�-�,,�, � {�'�� J S� �(1`-� s� naa� ApplicantInfonnation: Natne and Tit1e: ( 6 1 Fim Home Address: Middlc senct nad� , c;c Date of Birth: Piace of $irfn: (�- Have you ever been convicted of any felony, crime or violafion oF any c ordinancz other than traffic. Date of azrest: Charge: _ Convicfion: Sentence: State Zip isat � s�c Hor�e P1:or.°: � YES Titic . . + • List the names and residences of ihree persons of good moral character, living within the Twin Cifies Metro Area, not related io the applicant or financially intereted in the premises or business, who may be referred to as to the applicant's chazacter; List licenses which you currently hold, Formerly held, or may have an interest ��d ciry Where? THIS APPLICATION IS SUBJECT TO REVIEW BY THE PUB IC PLEASE TYPE OR PRINT IN INK jy � _ _ �_ _ _ i "l NAME ADDRESS PHONE Are you going to operate this business personally7 � XES Fint iv�c r.t;aat<�ciet HomcAddress: Strutiyame Are you going to hace a manager ar assistant in ttris business? please complete the following infotmztion: Fi�rtNamc i HomeAddresx: SuedNamc (`faiarn) City YES Please list your emplayment history {or the previous five (5) year period: Business/Em�lovme� List all other officers of the corporation: OFFICER TITLE NAME (Office Held) HOME ADDRESS NO If not, who will operate it? I.att �1'1 �i'J �� Datc of SiM dd*es Statc Zip NO If the manager is not the sasne rs the operator, Laat State Zip HOME BL3SINESS DATE OF PHONE PHONE BII2TH If business is a partnership, please include the following information for each partner (use additional pages if necessazy): FintName MiddlcLutisl (�iaiden) Lavt DateofBirtk� HomeAddrcas: StrcRhem< Fint N�c Middle Liitial (Maidrn) Statc Zip Phonc Numbn 1"Ri� De[e of Hirth Hame Addxcss: Strect tiemc CiTy Statc Zip Phonc Number MIlVNESOTA TAX IDENTIFICATION NUMBER - Pursuant to the I,aws of Minnesota, 1984, Chapter 502, Article 8, Section 2(270J2) (TaY Clearance; Issuance of Licrnses), licensing authorities are required to provide to the State of Minnesota Comuussioner of Revenue, the Minnesota business tax identification number and the social security number of each license applicant. Under the Minnesota Govemment Data Praclices Act and the Federal Privacy Act of 1974, we are required to advise you of the following regazding the use of the Minnzsota Tar ldentificalion Number: - This information may be used to drny the issuance or renewal of your license in the event you owe Minnesota salzs, employer s uithholding or mocor vehicle excise taxes; - Upon receiving this information, the licensing authoriry wi11 supply it only to the Minnesota Department of Revenue_ However, under the Fedzral Exchange of Infocmation Agreetnent, the Department of Revenue may supply this infocmation to the Intemat Revenue Service. Minnesota TaY Idrntification Numbeis (Sales & Use TaY Number} may be obtained from the State of Minnesota, Susiness Itecords Departrnent, 10 River Park Plaza (612-296-6181). Social Security Number: � 1.� �� ' L � D�'1 Minnesota Ta� Idrntification Number: �� t� Y� City _ If a Minnesota Tax Identification Number is not required for the business bzing operated, indicate so by placing an "X" in the box �:-_ 9! 1 R!94 CEfiTIFICATION OF WORKERS' COMPENSATION COVERAGE PURSUANT TO MINNESOTA STANTE 176.182 �� 7 I hereby certify that I, or my company, am in compliance with the workers' compensalion insurance coverage requirements of Minnesota Stature 176.182, subdivision 2. I also understand that provision of faLse information in this cer[ification constitutes s�cient grounds for adverse action against all licenses held, inciuding revocation and suspension of said licenses. Nazne of Insurance Company: E r ri 1a ��. Y't� � n i, C`rR,v`iT c Policy Number: _(� �—� R�� C�E'1— � Coverage from S- ta- q h to S— 1l� - I have no employees covered under workers compensation insurance (I�TITIALS) ANY FALSIFICATION OF ANSWTRS GIVEN OR MATERIAL SUBMiTTED WII,L RESULT IN DENIAL OF THIS APPLICATION I hereby state that I have answered all of the preceding questions, and that the information contained herein is hue and correct to the best of my lrnowled�e and belief. I hereby state fiuther that I have received no money or other consideration, by way of loan, giR, conuibutioq or otherwise, other than already disclosed in the application which I herewith submined. I aiso unders`�and fl-,is p; emise may be inspected by po!ice, fire, health and other ciry officials at any and all times when the business is in operation. Signature (REQUIRED for sII applications) Date We will accept ps� ment by cash, check (made payable to Cify of Saint Paul) or cmdit card (hUC or Vi,e). IFPAYINGBYCREDITCARDPLEASECOMPLETETHEFOLL06J�INGINFOItMATION: ❑MasterCazd � Visa EXPIRATiON DATE: ACCOUNT NUMBER: ❑�/�❑ ❑Cl�❑ ❑C]0❑ ❑0�❑ ❑C7C7❑ of CarA�older of Cazd Holder(required for all **Note: If this application is FoodlLiquor related, please contsct a City of Saint Paul Health Inspector, Steve Olson (266-4134), to review plans. . If any substantial changes to struciure aze anticipa.e3, please :;,atact a Ci?y of S:int Pe�� P!an Exazniner at 266-9007 to apply for building pertnits. If there are any changes to the parking lot, floor space, or for new operations, please contact a City of Saint Paul Zoning Inspector at 2b6-9008. All applications require the following documents. Please attach these documents when submitting your application: I. A detailed description of the design, location artd square footage of the premises to be licensed (site plan). The following data should be on the site plan (preferably on an 8 1J2" x I 1" 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 toward the top. - Placement of all pertinent features of the interior of the licensed facility such as seating areas, kitchens, offices, repau area, parking, rest rooms, ete. '- - If a request is for an addition or expansion of the licensed facIlity, indicate both the currznt azea and the proposed expansion. 2. A copy of your lease agreement or proof of ownership of the property. SPECIFIC LICENSE APPLICATIONS REQITIIZE ADDTTIONAL INFORMATION. PLEASE SEE REVERSE FOR DETAII.S >>>> ;�:' 2/18:97