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97-1329Council File # t � �� ordinance # Green Sheet # v�� Presented By Re£erred To Committee: Date i 2 3 RESOLVED: That applicarion (ID #15580) for an Auto Body Repair Gazage License by Benson Aganmayo DBA P& B Auto Body Repair (Benson Aganmayo, Owner) at 933 Atlanfic Street be and the same is hereby approved. 4 5 _� Requested by Department of: 6 Yea Nav 7 B a fe� 8 Bostrom 9 Harszs 10 Meaar 11 Morton 12 T un� 13 Co ins 14 15 16 Adopted by Council: Date 17 18 Adoption Certified by Council 19 20 21 By: � , Secretary 22 23 Approved by Mayor: Date {� � 24 25 �� 26 By: 27 RESOLUTION CITY OF SAINT PAUL, MINNESOTA 39 Office of License. Insnections and Environmental Protection By: (�,�►��.�. �- � Form Approved by City Attorney Approved by Mayor for Submission to Council sy: N°_ 50314 )EPARTMENiqFFICErt%7UNCIL DATEWRIATED GREEN SHEE � � �� LIEP f Licensing IN171AVDAiE INRIAVOATE ;ONTACTPERSOIJBPHONE �DEPARTMENTDIRECTOR OpTYCOONCIL Christine. Aozek, 266-9108 ASSIGN OCITYATfORNEY �LITYCLERK �UST BE ON COUNGiI AGENOA BY (�ATE7 NUMBEfl FOA O gUDGET OIRECTOR � FIN. 8 MGT $EHVICES DIR. pOUTiNG For hearing: // ,S f � O MAYpA (OR ASS15TAtJ7) � TOTAL # OF SIGNA7URE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE) Benson Aganmayo DBA P 5 B Auto Body Repair requests Council approval of its application for an Auto Body Repair Garage located at 933 Atlantic Street.(ID 461558Q). __ PLANNIkfi COMMiSSfOM _ CIVIL SEFiVICE CAMMISSION _ CB COMMITfEE _ _ STAFF _ _ D�STRICT COURT _ SUPPORTS WHICH CAUNCIL OBJECTIVE? What. APPROVEO PERSONAL SERVICE CONTRACTS MUS7 ANSWER THE FOLLOWING QUESTIONS: 1_ Has this person�rm ever worked under a contract for this tlepartment? YES NO 2. Has ihis persoNfirm ever besn a city employee? VES NO 3. Does this personttirm possess a skill rrot nortnally possessetl by any cunent ciry employee? YES NO Explaln all yes answers on separate aheet antl etteeh to green aheet WnYI: � l5a S. �r`c F <. � .,. _ s .. �� °--.__ __ APPROVEO' TOTAL AMOUNT OF TRANSACTiON COSTlREVENUE eU4GETED (CIRCLE ONE) YES Ii0 •llNDIHG SOUHCE 0.CTIVITY NUMBER iNANCIAL INFORRfATION� (EXPIAIN) � � -- : Coiporat;ou� ; ''tncn�u,-' THIS APPL?CATION IS SUB7ECT TO REVIEW BY TF� PUBLIC T}pe of License(s) being applied for: Company Name: ff business is incoiporated, give dace of incorporation: Doing Basuiess As: p Business Address: ! 3 Ben��een xhat cross s7cets is tl�e b Are the premises now occupied7 _ �aii To Address: ��J �� -Applicant Infon Name and Tiile: CLASS III LICENSE APPLICATION PLEASE TYPfi OR PRINT IN INK .. . , _ � located? > Whaf Type of Business? �' - -�- ^_ c;Ty �J SO � t��.oLa r � s�6 �� -�a�.� CITY OF SAI!�TT PAUL ofi;ce otLicrnse, I�spenions and Emaomnmtal Proter.ion swscrnar smmxo sz'vrtew�,]im.�ao•a ssin (61I)266904J fuC61Z)26FO1'a< s �I�= �� Which side of the street? �oc��i �-�c� onf,�a M 55IE State Zip �rGfl-�m�o �� Fixat Middle (Maidcn) I,avt Tide Home Address: .�� C ��-OU�! �✓ (� !o n/ ��K � �' M� NN��hPQLCJ'� �v 5'„S�Cp j / sr naarcs, �/� c s�� zsp Date of Birth: +� w � Place of Birth: ��-( j � s f/lf �V�� Home Phone: �o� �� - �ISJ Have you ever been comicted of any felony, crime or violation of any city ordinance other than traffic? YES NO � Date of azrest: Charge: _, Convictiou Sentence: Lizt the names and residences of three persons of good moral character, living within the Twin Cities Metro Area, noi related to the applicant or financially interested in the preuuses or business, who may be referred to as to the applicant's character: NAME ADDRESS ( �� p � ��PHONE �a.,�-y _ � ane�s �� : � � 01 Q+�,�e,� ,, `7�� {� �� List licenses which you currently hold, formerly held, or may ha��e an interest in: ` NO Have any of the above named licenses ever been revoked? YES � NO If yes, list the dates and reasons for revocation: �> Where? 1 2l18/97 stmt Addiesv CiTy State Zip Are }'ou going to operate this business personally? F� �� Home �dd�ccc: Street\ame �va;a�> Ci:y Are }ou going to ha��e a manaeer or assistant in this bus+nes? __ _ YES plezse ^omplete the folloiiing information: F� �*�� Homc.4dd�css: Sfrcct\ame ��aa�� iafl� . (-�a_-nl — --- Cirv Please list your employment history for the previous five (5) } eaz period: � � Stat< 2 > q�a3a Date of Birth Zip plione\�Ixz ^ NO If the manaeer is not the same as ihe onerator, � Statc Zip nv� orB�s Phane \�mmber �np J � ' � List all other officers of the corporation: OFFICER TITLE HOME I�TAME (OfficeHeld) ADDRESS HOME BUSINESS DATE OF PHONE PHO:�IE BIRIH If b� �ness is a partriership, p]ease include the following information for each parmer (use additional pages if necessary): . � FistAame _ , !�!fiddielnifial (Vle;den) , �Last � Datro£Birtli . : a _ _y.S�.�:.�. [ ..__ _ : ,Y ., . ` . �— , �' . � _ ' . . _`.}� . HomeAddlcss: Strati�amc City State Y Zip PhoneNumba Middte Initiel Home Add�r,s: Street Nemo (!vfaidrn) City I,ast Sta4 Datc ofBirth Phone Nimher MA':�'ESOTA TAX IDEI�'TIFICATION NUMBER - Pursuant to the Iaws of Mianesot� 1984, Chapter 502, Article 8, Section 2(270.72) (Tat Clearance; 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 number of each license applican[ Under the Minnesota Crovemment Data Practices Act and the Federal Privacy Act of 1974, we are required to advise you of Le following regarding the vse of the Minnesota Tax Identificalion Number: - This infoimation may be used to deny the issuance or renewal of your license in the event you o�re Minnesota sales, employer's withholding or motor vehicle excise taxes; - Upon receiving this infom-,alion, the licensing authority wrill supply it only to the Minnesota Department of Revrnue. However, under the Federa] Exchange of Tnformation Agreement, the Department of Revenue may supply this information to the intemal Revenue Service. Mimesotx Tax Identification Numbers (Sales & Use TaY Niunber) may be obtained from the State of Minnesota, Business Records Department, 10 River Park Plaza (612-29b-6181). Sociai Security Number: �'Y'� �' � `� � � Minnesota Tax Identification Number: ,� � 1 ( ) � ,� _ If a Minnesota Tax Identification Number is not required for the business being operated, indicate so by placing an"X" in the box. t;€. � �s 2/1$/97 S ^^ � f �YES NO If not, w�ho k�ill operate it? BusinessJEmplovment � Address g� 1� a CERTIFICATION OF WORKERS' COMPENSATION CO VEftAGE PURSUANT TO MINNESOTA STATUTE 176.182 � ` I hereby certifg that I, or my company, azn in compliance with the "'orkers compensation insurznce coverage requirements of Minnesota Statute 176.182, subdi��sion 2. I also understand that pro��ision of false information in this certi5cation constitutes s�cient grounds for adverse action against all licenses held, including revocation 2nd suspension of said licenses. Name of Insivance Company: PolieyNumber: Coveragefrom to I have no emplo}�ees cocered undzr workers' compensation insurance �(INITIALS) ANY FALSTFTCATION OF Ai�`SWERS GIVEIV OR MATERIAL SUBMITI'ED WILI, RESIILT IN DENIAL OF THiS APPLICATION I hereby state that I have answered all of the preceding ques[ions, and that the infoimation contained herein is true and correct to the best of my lmowledge and belief I hereby state further that I have recxived no money or other consideratio� by �cay of loan, gift, conhibution, or otherwise, other th� already disclosed in the applicarion ufiich I herew�ith submitted I also understand this premise may be inspected by police, fire, health and other city officials at any and all tunes when tt�e business is in operation. Signature ail applications) We will accept pa}'ment by cash, check (made payable to City of Saint Paul) or credit card (M/C or Visa). 7-25- Date IF PAYING &Y CREDZT CARD PLEASE COMPLETE THE FOLLOWING INFORMATION: � MasterCard � Visa DATE: ❑=.i�� \ame of CarA�older all '*Note: If this applicalion is Food/I.iquor related, please contact a City of Saint Paul Health Inspector, Steve Olson (266-9139), to review plans. If any substantial changes to shvcture aze anticipated, please contact a City of Saint Paul Plan Examiner at 266-9007 to apply for building pecmits. Iftbere are any changes to ihe pazking lot, floor space, or for new operations, please contact a City of Saint Paul Zoning Inspector at 266-9008. All applications rnquire the follow3ng documents. Please attach these documents n�hen submitting your application: 1. A detailed description of the desigo, location and squsre footage of the premises to be licensed (site plan). The foflowing data shoutd be on the site ptan (preferably on an 8 1/2" x 11" or 81l2" x 14" papu): - Nazne, address, and phone number. - The scale sbould be stated sucb as 1" = 20'. ^N should be indicated toward the top. - Placement of al] peninent features of the interior of the licensed facility such as seating areas, kitchens, offices, repair azea, parking, rest rooms, etc. - If a request is for an addition or expansion of the licensed facility, indicate both the curtent area and the proposed expansion. 2. A copy of your lease agreement or proof of owne:sbip of the property. SPECIFIC LICENSE APPLICATIONS REQI7II2E ADDTTIONAL INFORMATION. PLEASE SEE REVERSE FOR AETAII.S >>>> ACCOUNT NtJMBER: n�C�❑ ��❑ ❑�� ❑C�C�n �� , 2/18/97 Council File # t � �� ordinance # Green Sheet # v�� Presented By Re£erred To Committee: Date i 2 3 RESOLVED: That applicarion (ID #15580) for an Auto Body Repair Gazage License by Benson Aganmayo DBA P& B Auto Body Repair (Benson Aganmayo, Owner) at 933 Atlanfic Street be and the same is hereby approved. 4 5 _� Requested by Department of: 6 Yea Nav 7 B a fe� 8 Bostrom 9 Harszs 10 Meaar 11 Morton 12 T un� 13 Co ins 14 15 16 Adopted by Council: Date 17 18 Adoption Certified by Council 19 20 21 By: � , Secretary 22 23 Approved by Mayor: Date {� � 24 25 �� 26 By: 27 RESOLUTION CITY OF SAINT PAUL, MINNESOTA 39 Office of License. Insnections and Environmental Protection By: (�,�►��.�. �- � Form Approved by City Attorney Approved by Mayor for Submission to Council sy: N°_ 50314 )EPARTMENiqFFICErt%7UNCIL DATEWRIATED GREEN SHEE � � �� LIEP f Licensing IN171AVDAiE INRIAVOATE ;ONTACTPERSOIJBPHONE �DEPARTMENTDIRECTOR OpTYCOONCIL Christine. Aozek, 266-9108 ASSIGN OCITYATfORNEY �LITYCLERK �UST BE ON COUNGiI AGENOA BY (�ATE7 NUMBEfl FOA O gUDGET OIRECTOR � FIN. 8 MGT $EHVICES DIR. pOUTiNG For hearing: // ,S f � O MAYpA (OR ASS15TAtJ7) � TOTAL # OF SIGNA7URE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE) Benson Aganmayo DBA P 5 B Auto Body Repair requests Council approval of its application for an Auto Body Repair Garage located at 933 Atlantic Street.(ID 461558Q). __ PLANNIkfi COMMiSSfOM _ CIVIL SEFiVICE CAMMISSION _ CB COMMITfEE _ _ STAFF _ _ D�STRICT COURT _ SUPPORTS WHICH CAUNCIL OBJECTIVE? What. APPROVEO PERSONAL SERVICE CONTRACTS MUS7 ANSWER THE FOLLOWING QUESTIONS: 1_ Has this person�rm ever worked under a contract for this tlepartment? YES NO 2. Has ihis persoNfirm ever besn a city employee? VES NO 3. Does this personttirm possess a skill rrot nortnally possessetl by any cunent ciry employee? YES NO Explaln all yes answers on separate aheet antl etteeh to green aheet WnYI: � l5a S. �r`c F <. � .,. _ s .. �� °--.__ __ APPROVEO' TOTAL AMOUNT OF TRANSACTiON COSTlREVENUE eU4GETED (CIRCLE ONE) YES Ii0 •llNDIHG SOUHCE 0.CTIVITY NUMBER iNANCIAL INFORRfATION� (EXPIAIN) � � -- : Coiporat;ou� ; ''tncn�u,-' THIS APPL?CATION IS SUB7ECT TO REVIEW BY TF� PUBLIC T}pe of License(s) being applied for: Company Name: ff business is incoiporated, give dace of incorporation: Doing Basuiess As: p Business Address: ! 3 Ben��een xhat cross s7cets is tl�e b Are the premises now occupied7 _ �aii To Address: ��J �� -Applicant Infon Name and Tiile: CLASS III LICENSE APPLICATION PLEASE TYPfi OR PRINT IN INK .. . , _ � located? > Whaf Type of Business? �' - -�- ^_ c;Ty �J SO � t��.oLa r � s�6 �� -�a�.� CITY OF SAI!�TT PAUL ofi;ce otLicrnse, I�spenions and Emaomnmtal Proter.ion swscrnar smmxo sz'vrtew�,]im.�ao•a ssin (61I)266904J fuC61Z)26FO1'a< s �I�= �� Which side of the street? �oc��i �-�c� onf,�a M 55IE State Zip �rGfl-�m�o �� Fixat Middle (Maidcn) I,avt Tide Home Address: .�� C ��-OU�! �✓ (� !o n/ ��K � �' M� NN��hPQLCJ'� �v 5'„S�Cp j / sr naarcs, �/� c s�� zsp Date of Birth: +� w � Place of Birth: ��-( j � s f/lf �V�� Home Phone: �o� �� - �ISJ Have you ever been comicted of any felony, crime or violation of any city ordinance other than traffic? YES NO � Date of azrest: Charge: _, Convictiou Sentence: Lizt the names and residences of three persons of good moral character, living within the Twin Cities Metro Area, noi related to the applicant or financially interested in the preuuses or business, who may be referred to as to the applicant's character: NAME ADDRESS ( �� p � ��PHONE �a.,�-y _ � ane�s �� : � � 01 Q+�,�e,� ,, `7�� {� �� List licenses which you currently hold, formerly held, or may ha��e an interest in: ` NO Have any of the above named licenses ever been revoked? YES � NO If yes, list the dates and reasons for revocation: �> Where? 1 2l18/97 stmt Addiesv CiTy State Zip Are }'ou going to operate this business personally? F� �� Home �dd�ccc: Street\ame �va;a�> Ci:y Are }ou going to ha��e a manaeer or assistant in this bus+nes? __ _ YES plezse ^omplete the folloiiing information: F� �*�� Homc.4dd�css: Sfrcct\ame ��aa�� iafl� . (-�a_-nl — --- Cirv Please list your employment history for the previous five (5) } eaz period: � � Stat< 2 > q�a3a Date of Birth Zip plione\�Ixz ^ NO If the manaeer is not the same as ihe onerator, � Statc Zip nv� orB�s Phane \�mmber �np J � ' � List all other officers of the corporation: OFFICER TITLE HOME I�TAME (OfficeHeld) ADDRESS HOME BUSINESS DATE OF PHONE PHO:�IE BIRIH If b� �ness is a partriership, p]ease include the following information for each parmer (use additional pages if necessary): . � FistAame _ , !�!fiddielnifial (Vle;den) , �Last � Datro£Birtli . : a _ _y.S�.�:.�. [ ..__ _ : ,Y ., . ` . �— , �' . � _ ' . . _`.}� . HomeAddlcss: Strati�amc City State Y Zip PhoneNumba Middte Initiel Home Add�r,s: Street Nemo (!vfaidrn) City I,ast Sta4 Datc ofBirth Phone Nimher MA':�'ESOTA TAX IDEI�'TIFICATION NUMBER - Pursuant to the Iaws of Mianesot� 1984, Chapter 502, Article 8, Section 2(270.72) (Tat Clearance; 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 number of each license applican[ Under the Minnesota Crovemment Data Practices Act and the Federal Privacy Act of 1974, we are required to advise you of Le following regarding the vse of the Minnesota Tax Identificalion Number: - This infoimation may be used to deny the issuance or renewal of your license in the event you o�re Minnesota sales, employer's withholding or motor vehicle excise taxes; - Upon receiving this infom-,alion, the licensing authority wrill supply it only to the Minnesota Department of Revrnue. However, under the Federa] Exchange of Tnformation Agreement, the Department of Revenue may supply this information to the intemal Revenue Service. Mimesotx Tax Identification Numbers (Sales & Use TaY Niunber) may be obtained from the State of Minnesota, Business Records Department, 10 River Park Plaza (612-29b-6181). Sociai Security Number: �'Y'� �' � `� � � Minnesota Tax Identification Number: ,� � 1 ( ) � ,� _ If a Minnesota Tax Identification Number is not required for the business being operated, indicate so by placing an"X" in the box. t;€. � �s 2/1$/97 S ^^ � f �YES NO If not, w�ho k�ill operate it? BusinessJEmplovment � Address g� 1� a CERTIFICATION OF WORKERS' COMPENSATION CO VEftAGE PURSUANT TO MINNESOTA STATUTE 176.182 � ` I hereby certifg that I, or my company, azn in compliance with the "'orkers compensation insurznce coverage requirements of Minnesota Statute 176.182, subdi��sion 2. I also understand that pro��ision of false information in this certi5cation constitutes s�cient grounds for adverse action against all licenses held, including revocation 2nd suspension of said licenses. Name of Insivance Company: PolieyNumber: Coveragefrom to I have no emplo}�ees cocered undzr workers' compensation insurance �(INITIALS) ANY FALSTFTCATION OF Ai�`SWERS GIVEIV OR MATERIAL SUBMITI'ED WILI, RESIILT IN DENIAL OF THiS APPLICATION I hereby state that I have answered all of the preceding ques[ions, and that the infoimation contained herein is true and correct to the best of my lmowledge and belief I hereby state further that I have recxived no money or other consideratio� by �cay of loan, gift, conhibution, or otherwise, other th� already disclosed in the applicarion ufiich I herew�ith submitted I also understand this premise may be inspected by police, fire, health and other city officials at any and all tunes when tt�e business is in operation. Signature ail applications) We will accept pa}'ment by cash, check (made payable to City of Saint Paul) or credit card (M/C or Visa). 7-25- Date IF PAYING &Y CREDZT CARD PLEASE COMPLETE THE FOLLOWING INFORMATION: � MasterCard � Visa DATE: ❑=.i�� \ame of CarA�older all '*Note: If this applicalion is Food/I.iquor related, please contact a City of Saint Paul Health Inspector, Steve Olson (266-9139), to review plans. If any substantial changes to shvcture aze anticipated, please contact a City of Saint Paul Plan Examiner at 266-9007 to apply for building pecmits. Iftbere are any changes to ihe pazking lot, floor space, or for new operations, please contact a City of Saint Paul Zoning Inspector at 266-9008. All applications rnquire the follow3ng documents. Please attach these documents n�hen submitting your application: 1. A detailed description of the desigo, location and squsre footage of the premises to be licensed (site plan). The foflowing data shoutd be on the site ptan (preferably on an 8 1/2" x 11" or 81l2" x 14" papu): - Nazne, address, and phone number. - The scale sbould be stated sucb as 1" = 20'. ^N should be indicated toward the top. - Placement of al] peninent features of the interior of the licensed facility such as seating areas, kitchens, offices, repair azea, parking, rest rooms, etc. - If a request is for an addition or expansion of the licensed facility, indicate both the curtent area and the proposed expansion. 2. A copy of your lease agreement or proof of owne:sbip of the property. SPECIFIC LICENSE APPLICATIONS REQI7II2E ADDTTIONAL INFORMATION. PLEASE SEE REVERSE FOR AETAII.S >>>> ACCOUNT NtJMBER: n�C�❑ ��❑ ❑�� ❑C�C�n �� , 2/18/97 Council File # t � �� ordinance # Green Sheet # v�� Presented By Re£erred To Committee: Date i 2 3 RESOLVED: That applicarion (ID #15580) for an Auto Body Repair Gazage License by Benson Aganmayo DBA P& B Auto Body Repair (Benson Aganmayo, Owner) at 933 Atlanfic Street be and the same is hereby approved. 4 5 _� Requested by Department of: 6 Yea Nav 7 B a fe� 8 Bostrom 9 Harszs 10 Meaar 11 Morton 12 T un� 13 Co ins 14 15 16 Adopted by Council: Date 17 18 Adoption Certified by Council 19 20 21 By: � , Secretary 22 23 Approved by Mayor: Date {� � 24 25 �� 26 By: 27 RESOLUTION CITY OF SAINT PAUL, MINNESOTA 39 Office of License. Insnections and Environmental Protection By: (�,�►��.�. �- � Form Approved by City Attorney Approved by Mayor for Submission to Council sy: N°_ 50314 )EPARTMENiqFFICErt%7UNCIL DATEWRIATED GREEN SHEE � � �� LIEP f Licensing IN171AVDAiE INRIAVOATE ;ONTACTPERSOIJBPHONE �DEPARTMENTDIRECTOR OpTYCOONCIL Christine. Aozek, 266-9108 ASSIGN OCITYATfORNEY �LITYCLERK �UST BE ON COUNGiI AGENOA BY (�ATE7 NUMBEfl FOA O gUDGET OIRECTOR � FIN. 8 MGT $EHVICES DIR. pOUTiNG For hearing: // ,S f � O MAYpA (OR ASS15TAtJ7) � TOTAL # OF SIGNA7URE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE) Benson Aganmayo DBA P 5 B Auto Body Repair requests Council approval of its application for an Auto Body Repair Garage located at 933 Atlantic Street.(ID 461558Q). __ PLANNIkfi COMMiSSfOM _ CIVIL SEFiVICE CAMMISSION _ CB COMMITfEE _ _ STAFF _ _ D�STRICT COURT _ SUPPORTS WHICH CAUNCIL OBJECTIVE? What. APPROVEO PERSONAL SERVICE CONTRACTS MUS7 ANSWER THE FOLLOWING QUESTIONS: 1_ Has this person�rm ever worked under a contract for this tlepartment? YES NO 2. Has ihis persoNfirm ever besn a city employee? VES NO 3. Does this personttirm possess a skill rrot nortnally possessetl by any cunent ciry employee? YES NO Explaln all yes answers on separate aheet antl etteeh to green aheet WnYI: � l5a S. �r`c F <. � .,. _ s .. �� °--.__ __ APPROVEO' TOTAL AMOUNT OF TRANSACTiON COSTlREVENUE eU4GETED (CIRCLE ONE) YES Ii0 •llNDIHG SOUHCE 0.CTIVITY NUMBER iNANCIAL INFORRfATION� (EXPIAIN) � � -- : Coiporat;ou� ; ''tncn�u,-' THIS APPL?CATION IS SUB7ECT TO REVIEW BY TF� PUBLIC T}pe of License(s) being applied for: Company Name: ff business is incoiporated, give dace of incorporation: Doing Basuiess As: p Business Address: ! 3 Ben��een xhat cross s7cets is tl�e b Are the premises now occupied7 _ �aii To Address: ��J �� -Applicant Infon Name and Tiile: CLASS III LICENSE APPLICATION PLEASE TYPfi OR PRINT IN INK .. . , _ � located? > Whaf Type of Business? �' - -�- ^_ c;Ty �J SO � t��.oLa r � s�6 �� -�a�.� CITY OF SAI!�TT PAUL ofi;ce otLicrnse, I�spenions and Emaomnmtal Proter.ion swscrnar smmxo sz'vrtew�,]im.�ao•a ssin (61I)266904J fuC61Z)26FO1'a< s �I�= �� Which side of the street? �oc��i �-�c� onf,�a M 55IE State Zip �rGfl-�m�o �� Fixat Middle (Maidcn) I,avt Tide Home Address: .�� C ��-OU�! �✓ (� !o n/ ��K � �' M� NN��hPQLCJ'� �v 5'„S�Cp j / sr naarcs, �/� c s�� zsp Date of Birth: +� w � Place of Birth: ��-( j � s f/lf �V�� Home Phone: �o� �� - �ISJ Have you ever been comicted of any felony, crime or violation of any city ordinance other than traffic? YES NO � Date of azrest: Charge: _, Convictiou Sentence: Lizt the names and residences of three persons of good moral character, living within the Twin Cities Metro Area, noi related to the applicant or financially interested in the preuuses or business, who may be referred to as to the applicant's character: NAME ADDRESS ( �� p � ��PHONE �a.,�-y _ � ane�s �� : � � 01 Q+�,�e,� ,, `7�� {� �� List licenses which you currently hold, formerly held, or may ha��e an interest in: ` NO Have any of the above named licenses ever been revoked? YES � NO If yes, list the dates and reasons for revocation: �> Where? 1 2l18/97 stmt Addiesv CiTy State Zip Are }'ou going to operate this business personally? F� �� Home �dd�ccc: Street\ame �va;a�> Ci:y Are }ou going to ha��e a manaeer or assistant in this bus+nes? __ _ YES plezse ^omplete the folloiiing information: F� �*�� Homc.4dd�css: Sfrcct\ame ��aa�� iafl� . (-�a_-nl — --- Cirv Please list your employment history for the previous five (5) } eaz period: � � Stat< 2 > q�a3a Date of Birth Zip plione\�Ixz ^ NO If the manaeer is not the same as ihe onerator, � Statc Zip nv� orB�s Phane \�mmber �np J � ' � List all other officers of the corporation: OFFICER TITLE HOME I�TAME (OfficeHeld) ADDRESS HOME BUSINESS DATE OF PHONE PHO:�IE BIRIH If b� �ness is a partriership, p]ease include the following information for each parmer (use additional pages if necessary): . � FistAame _ , !�!fiddielnifial (Vle;den) , �Last � Datro£Birtli . : a _ _y.S�.�:.�. [ ..__ _ : ,Y ., . ` . �— , �' . � _ ' . . _`.}� . HomeAddlcss: Strati�amc City State Y Zip PhoneNumba Middte Initiel Home Add�r,s: Street Nemo (!vfaidrn) City I,ast Sta4 Datc ofBirth Phone Nimher MA':�'ESOTA TAX IDEI�'TIFICATION NUMBER - Pursuant to the Iaws of Mianesot� 1984, Chapter 502, Article 8, Section 2(270.72) (Tat Clearance; 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 number of each license applican[ Under the Minnesota Crovemment Data Practices Act and the Federal Privacy Act of 1974, we are required to advise you of Le following regarding the vse of the Minnesota Tax Identificalion Number: - This infoimation may be used to deny the issuance or renewal of your license in the event you o�re Minnesota sales, employer's withholding or motor vehicle excise taxes; - Upon receiving this infom-,alion, the licensing authority wrill supply it only to the Minnesota Department of Revrnue. However, under the Federa] Exchange of Tnformation Agreement, the Department of Revenue may supply this information to the intemal Revenue Service. Mimesotx Tax Identification Numbers (Sales & Use TaY Niunber) may be obtained from the State of Minnesota, Business Records Department, 10 River Park Plaza (612-29b-6181). Sociai Security Number: �'Y'� �' � `� � � Minnesota Tax Identification Number: ,� � 1 ( ) � ,� _ If a Minnesota Tax Identification Number is not required for the business being operated, indicate so by placing an"X" in the box. t;€. � �s 2/1$/97 S ^^ � f �YES NO If not, w�ho k�ill operate it? BusinessJEmplovment � Address g� 1� a CERTIFICATION OF WORKERS' COMPENSATION CO VEftAGE PURSUANT TO MINNESOTA STATUTE 176.182 � ` I hereby certifg that I, or my company, azn in compliance with the "'orkers compensation insurznce coverage requirements of Minnesota Statute 176.182, subdi��sion 2. I also understand that pro��ision of false information in this certi5cation constitutes s�cient grounds for adverse action against all licenses held, including revocation 2nd suspension of said licenses. Name of Insivance Company: PolieyNumber: Coveragefrom to I have no emplo}�ees cocered undzr workers' compensation insurance �(INITIALS) ANY FALSTFTCATION OF Ai�`SWERS GIVEIV OR MATERIAL SUBMITI'ED WILI, RESIILT IN DENIAL OF THiS APPLICATION I hereby state that I have answered all of the preceding ques[ions, and that the infoimation contained herein is true and correct to the best of my lmowledge and belief I hereby state further that I have recxived no money or other consideratio� by �cay of loan, gift, conhibution, or otherwise, other th� already disclosed in the applicarion ufiich I herew�ith submitted I also understand this premise may be inspected by police, fire, health and other city officials at any and all tunes when tt�e business is in operation. Signature ail applications) We will accept pa}'ment by cash, check (made payable to City of Saint Paul) or credit card (M/C or Visa). 7-25- Date IF PAYING &Y CREDZT CARD PLEASE COMPLETE THE FOLLOWING INFORMATION: � MasterCard � Visa DATE: ❑=.i�� \ame of CarA�older all '*Note: If this applicalion is Food/I.iquor related, please contact a City of Saint Paul Health Inspector, Steve Olson (266-9139), to review plans. If any substantial changes to shvcture aze anticipated, please contact a City of Saint Paul Plan Examiner at 266-9007 to apply for building pecmits. Iftbere are any changes to ihe pazking lot, floor space, or for new operations, please contact a City of Saint Paul Zoning Inspector at 266-9008. All applications rnquire the follow3ng documents. Please attach these documents n�hen submitting your application: 1. A detailed description of the desigo, location and squsre footage of the premises to be licensed (site plan). The foflowing data shoutd be on the site ptan (preferably on an 8 1/2" x 11" or 81l2" x 14" papu): - Nazne, address, and phone number. - The scale sbould be stated sucb as 1" = 20'. ^N should be indicated toward the top. - Placement of al] peninent features of the interior of the licensed facility such as seating areas, kitchens, offices, repair azea, parking, rest rooms, etc. - If a request is for an addition or expansion of the licensed facility, indicate both the curtent area and the proposed expansion. 2. A copy of your lease agreement or proof of owne:sbip of the property. SPECIFIC LICENSE APPLICATIONS REQI7II2E ADDTTIONAL INFORMATION. PLEASE SEE REVERSE FOR AETAII.S >>>> ACCOUNT NtJMBER: n�C�❑ ��❑ ❑�� ❑C�C�n �� , 2/18/97