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97-1333Council File � - 1 1 �,7� Z ordinance # Green Sheet # 50236 1 2 3 4 5 b 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 zs 26 27 28 �: .-, . � - Presented By RESOLUTION �AIT PAUL, MINNESOTA Referred To Committee: Date N3 RESOLVED: That applic 'on D#88112, for a Parking Lot/Ramp License by Healtheast-St. Joseph's Hospital DBA Healtheast-St. Joseph's Hospital (JOhn Reith Reding) at 69 W. Exchange Street, be and the same is hereby approved. Requested by Department of: Adoption Certified by Council Secretary BY= �2 rV�2� Approved by Mayor: Date t�Y'7 By: � ( �.� Office of License Tns�ctions and Environmental Protect-on B ��,9-�.�� } ��-� , Form Approved by City At •�yey gp ��,� � / Approved by Mayor for Submission to Council Hy: C Adopted by Council: Date '� \�,,�j ��q't i N° 50236 °t'1-1�� ^� LIEP/License Christine A. Roaek - 26b-9108 Hearing: ( j � � ( c/ TOTAL # OF SICaNATURE PAGES -- GREEN SHEET INITIAVDATE INITIAIIDATE �DEPARTMENTDIRECTOR �CITYCOUNCIL � CIN ATfORNEY � dN CLERK FOR ❑ BUDGEi DIRECTOF � FIN 8 MG7 SEFVICES DIR. � � MAYOR (OR ASSISTAM) � (CLIP ALL LOCATIONS FOR SIGNATURE) Healtheast-St. Joseph�s Hospital DSA Healtheast-St. Joseph's Hospital requests Council approval of their application £or a Parking LotJRamp License, ID fi88112, (.Tohn Reith R at 69 W. Fxchan�e St. a _ PLANNING GOMMISS�ON _ dVIL SEflVICE _. GB COMMITTEE _ _ STAFF _ _ Di5TRILT COURT _ SUPPORTS WNICH COVNCIL OBJECTIVE? PERSONAI SERVICE CONTRACTS MUST ANSWER THE FOLLOWING OUESTIONS: 1 Haz Ynis personlFrzm ever warked untler a contract For this department> YES NO 2. Has this personffirm ever been a city employee? YES NQ 3. Does this person/ficm possess a skill not normally pessessetl by any current cdy empbyee� YES NO Explaln all yea anawers on saperata aMeet and attaeh to green aheet ISSUE. OPPORTUNITY (NTO. Whet. When. YVhere. Why): �� ot�� ' . a:=:1:4. - ��,� �' � i�`�7 --�_�� 0.L AMOUNT OF TIiAN5ACT10N S COST7REVENUE BUDGE7ED (CIRCIE ONE) YES NO DItdG SOURCE ACTIVITY NUMBER IpA1 INfORHiATIOM (EXPLAIN) . �� CLASS III LICENSE APPLICATION s 3!�=°% � Company Nazne; If business is incotp lloing Business As: Business Address: iration /Pertnenlvp / Sole Propri� give date of incorporation: �� i-�� S ; sc�c naa�s Between what cross streets is the business located? Are the premises now occupied? � Wha Mail To Acldress: � �. �P55 � _��f'�� Applicant Iaformatio�_ Namean3Tifle: —J�/ �'"�° �c�r � �/�� Fine ,�M �� / ,�/ (�te�aea> / � ,t tv't`� �iae '/ Home Address: ` `c�� "f�NFiY //A/ / /(f �i /I[✓6 /`i /1� S��Y � so- naa� ctry s��e ztp Date of Birth: �/ a � Place of Birth: s! -��i9�C �r /�'I7 Home Phone: �S7' �.3�✓" � - � Have you ever b en convicted of zny �lo :-y, c.-:ne cr ;�iolauoa o: any city ord'uiance ofner than traffic? YES NO _� Date of arrest: Where? Charge: Conviction: Sentence: List the names and residences of ihree persons of good moral chazacter, 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 applicanYs chazacter: N�AM ADDRESS PHONE ��l�/ ,`;��,. _- .,_ . _ . _ - J ` � s�33 - '� J 2 Z c�'• hold, formerly held, or ////(/ -(bii /� � ,1 i ZP,/7 � `_' ////� G Have any of the above nazned licenses ever been revoked? � �S�/��-- � -1��3 CITY OF SAINT PAUL off� afu�, t�a�� a &��mtat r�oc��o� 350 Sc Pctx S[ Siim 300 Sa'vif PwI, Ftimewti 35302 (612J 7669090 fi<C617J I6F4133 Business Phone: �� .7 "- 7 / :3 � ' ?r.c/ sv,ne S�a � s�r� q z�p / ,,/f D�� Which side of the sTreet� !� �� " s .%,a �lU �/37 � 5�2� Ry�; ' �f/«� GV�i7Pf" Eh, �i /✓ have an interest in: vofs �'c�n5C.. ` YES �_ NO If yes, list the dates and reasons for rzvocalion: i �? i O � THIS APPLICATION IS SUBJECT TO REVIEW BY Tf� PUBLIC �� PLEASE TYPE OR PRIN"P IN INK �; — . Are you going to operate this business personally? � YES F;ncx�m� M;ea�� ta� HomeAddtei�: Street2yeme CiTy Are you gou� to t�are a manager or assistant in this business? � YES please complete the following inform � 6Hl1ie iYS YY/V.�/< Fust N�e x�� ndd,�: s�e x�� (M+�den) ctTy Please lis[ your employment history for the previous five (5) yeaz period: ��96 List all other officers of the cotporation: OFFICEI2 TITLE NAME , (Office Held) r" NO If not, who will opecate it? 1 �� r�c D� ars�ti State Zip Phone tiunbe, NO If the manager is not the same as the operator, c HOME ADDRESS Address Last sr�m HOME PHONE lleto oi nuth Zip Phonc\umbcr �, .57T�� ss/o�. ST ST. ��u/, �,ei s�i� BUSINESS DATE OF PHONE BIRTH If business is a partnership, please include the following information #'or each partner (use additional pages if necessary): Fint Nemc Home Addre%+: SGeet Nem< Fint 23�c riomeAdl.rcv: S'..�__t?�:se Middtc Initia] City (Maidrn) City State Zip Datc of Birth Phonc\umba Date of Bicth Phonc \�bcr MINNESOTA TAX IDENTIFICATION NUMBER - Pursuant to the Laws of Minnesota, 1984, Chapter 502, Article 8, Section 2(270.72) (TaY Ciearance; Issuance of Licenses), licensing authorities are required to provide to the State of Mianesota Commissioner of Revenue, thz Minnesota business tax identification number and the social security number of each license applicant. Under the Minnesota Government Data Pracfices Act and the Federal Privacy Act of 1974, we are required to advise you of the following regarding the use of the Minnesota TaY Identification Number: - This information may be used to deny the issuance or renewal of your license in the event you o�ve Minnesota sales, emplo} er's withholding or motor vehicle excise taxes; - Upon receiving this information, the licensing authority will supply it only to the Minnesota Department of Revenue. Hon ever, under the Federal Exchange of Information Agzeemrnt, the Departmznt of Revenue may supply this informalion to thz Intemal Revenue Service. Minne�ta Tar ldentification NiunUers (Sales & Use TaY Number) may be obtained frnm thz State of Mumesota, Business Records Department, 10 River Park Plaza (612-296-6181). Social Security Number: 7'7' �(� — I 0 J� j Miimesota Tat Identification Number: �� _ If a Minnesota TaY Identification Number is not required for the businzss being operated, indicate so by placing an "X" in the bot. �_y ! , � ; 2/15;97 I.%ri Stak Zip T-ast � 9'1.1'� �3 CER1 TFICATION OF WORKERS' COMpENSATION CO VERAGE PURSUANT TO MINNESOTA STANTE 176.182 T hereby ceRify that I, or my company, azn in compliance with the workers' compensation insurance covezage requiretnents of Minnesota Sta?ute 176.182, subdivision 2. I also understand that provision of false infonnation in this certification consGitutes sufficient grounds for adverse action against all licenses held, including revocation and suspension of said licznses. � NazneofInsuranceCompany: /�r�/ �iJS7 / SG/t �� Policy Number: �� C�� Coverage I have no employees covered under workers' compensation insurance _ to C �L�/r.,?'/ " ANY FALSIFICATION OF ANSWERS GIVEN OR MATERIAL SUBMTI'TED WILL RESULT IN DE1�iIAL OR TI�S APPLICATION I hereby state that I have answered all of the preceding questions, and that the infomiation contained herein is true and correct to the best of my knowledge and belief I hereby state further that I have received no money or other consideratioq by way of loan, giR, contxibution, or othervri�z, other than already disclosed in the application wtsich I herevrith submitted. I also understand this premise may be inspected by police, fire, health and other city officials at any and all times when the business is in operation. (REQUIItED for all appGcations) :': � will accept payment by cash, check (made pa�able to City of Saint Pau� or credit eard (M!C or V isa). IFPAYING BY CREDIT CARD PLEASE COMPLETE THE FOLLOWING INF'ORMATION: � MasterCard � Visa EXPIRATION DATE: ACCOUNP NUMBER: ❑Cl/Cl❑ ❑C70❑ ❑C��❑ ❑��❑ ❑i��❑ of �i�� all Date **Note: If this application is FoodlLiquor related, please contact a City of Saint Paul Health Inspector, Steve Olson (266-9139), to review plans. If any subsiantial changes to structure are anticipated, please contact a Ciry of Saint Paut Plan Exan�iner at 266-9007 to apply for building permits. ffthere are any changes to the parking lot, floor space, or for new operations, piease contact a City of Saint Paul Zoning Inspector at 266-9008. All applications require the following documents. Please attach these documents when suhmitting your application: i. A dztailed description of the design, location and square footage of the premises to be licensed (site plan). The following data should be on the site plan (preferably on an 8 1/2" x 11" or 8 1/2" x 14" paper): - Name, address, and phone number. - The scale should be stated such as I"= 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, repair area, pazking, rest rooms, etc. - If a request is for an addition or expansion of the licensed facility, indicate both the current area and the proposed expansion. 2. A copy of your lease ageement or proof of ownership of the properiy. SPECIFIC LICENSE APPLICATIONS REQLlIRE ADDTTIONAL INFOItMATION. PLEASE SEE REVERSE FOR DETAII�S >>>> �.; 271 S'97 Council File � - 1 1 �,7� Z ordinance # Green Sheet # 50236 1 2 3 4 5 b 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 zs 26 27 28 �: .-, . � - Presented By RESOLUTION �AIT PAUL, MINNESOTA Referred To Committee: Date N3 RESOLVED: That applic 'on D#88112, for a Parking Lot/Ramp License by Healtheast-St. Joseph's Hospital DBA Healtheast-St. Joseph's Hospital (JOhn Reith Reding) at 69 W. Exchange Street, be and the same is hereby approved. Requested by Department of: Adoption Certified by Council Secretary BY= �2 rV�2� Approved by Mayor: Date t�Y'7 By: � ( �.� Office of License Tns�ctions and Environmental Protect-on B ��,9-�.�� } ��-� , Form Approved by City At •�yey gp ��,� � / Approved by Mayor for Submission to Council Hy: C Adopted by Council: Date '� \�,,�j ��q't i N° 50236 °t'1-1�� ^� LIEP/License Christine A. Roaek - 26b-9108 Hearing: ( j � � ( c/ TOTAL # OF SICaNATURE PAGES -- GREEN SHEET INITIAVDATE INITIAIIDATE �DEPARTMENTDIRECTOR �CITYCOUNCIL � CIN ATfORNEY � dN CLERK FOR ❑ BUDGEi DIRECTOF � FIN 8 MG7 SEFVICES DIR. � � MAYOR (OR ASSISTAM) � (CLIP ALL LOCATIONS FOR SIGNATURE) Healtheast-St. Joseph�s Hospital DSA Healtheast-St. Joseph's Hospital requests Council approval of their application £or a Parking LotJRamp License, ID fi88112, (.Tohn Reith R at 69 W. Fxchan�e St. a _ PLANNING GOMMISS�ON _ dVIL SEflVICE _. GB COMMITTEE _ _ STAFF _ _ Di5TRILT COURT _ SUPPORTS WNICH COVNCIL OBJECTIVE? PERSONAI SERVICE CONTRACTS MUST ANSWER THE FOLLOWING OUESTIONS: 1 Haz Ynis personlFrzm ever warked untler a contract For this department> YES NO 2. Has this personffirm ever been a city employee? YES NQ 3. Does this person/ficm possess a skill not normally pessessetl by any current cdy empbyee� YES NO Explaln all yea anawers on saperata aMeet and attaeh to green aheet ISSUE. OPPORTUNITY (NTO. Whet. When. YVhere. Why): �� ot�� ' . a:=:1:4. - ��,� �' � i�`�7 --�_�� 0.L AMOUNT OF TIiAN5ACT10N S COST7REVENUE BUDGE7ED (CIRCIE ONE) YES NO DItdG SOURCE ACTIVITY NUMBER IpA1 INfORHiATIOM (EXPLAIN) . �� CLASS III LICENSE APPLICATION s 3!�=°% � Company Nazne; If business is incotp lloing Business As: Business Address: iration /Pertnenlvp / Sole Propri� give date of incorporation: �� i-�� S ; sc�c naa�s Between what cross streets is the business located? Are the premises now occupied? � Wha Mail To Acldress: � �. �P55 � _��f'�� Applicant Iaformatio�_ Namean3Tifle: —J�/ �'"�° �c�r � �/�� Fine ,�M �� / ,�/ (�te�aea> / � ,t tv't`� �iae '/ Home Address: ` `c�� "f�NFiY //A/ / /(f �i /I[✓6 /`i /1� S��Y � so- naa� ctry s��e ztp Date of Birth: �/ a � Place of Birth: s! -��i9�C �r /�'I7 Home Phone: �S7' �.3�✓" � - � Have you ever b en convicted of zny �lo :-y, c.-:ne cr ;�iolauoa o: any city ord'uiance ofner than traffic? YES NO _� Date of arrest: Where? Charge: Conviction: Sentence: List the names and residences of ihree persons of good moral chazacter, 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 applicanYs chazacter: N�AM ADDRESS PHONE ��l�/ ,`;��,. _- .,_ . _ . _ - J ` � s�33 - '� J 2 Z c�'• hold, formerly held, or ////(/ -(bii /� � ,1 i ZP,/7 � `_' ////� G Have any of the above nazned licenses ever been revoked? � �S�/��-- � -1��3 CITY OF SAINT PAUL off� afu�, t�a�� a &��mtat r�oc��o� 350 Sc Pctx S[ Siim 300 Sa'vif PwI, Ftimewti 35302 (612J 7669090 fi<C617J I6F4133 Business Phone: �� .7 "- 7 / :3 � ' ?r.c/ sv,ne S�a � s�r� q z�p / ,,/f D�� Which side of the sTreet� !� �� " s .%,a �lU �/37 � 5�2� Ry�; ' �f/«� GV�i7Pf" Eh, �i /✓ have an interest in: vofs �'c�n5C.. ` YES �_ NO If yes, list the dates and reasons for rzvocalion: i �? i O � THIS APPLICATION IS SUBJECT TO REVIEW BY Tf� PUBLIC �� PLEASE TYPE OR PRIN"P IN INK �; — . Are you going to operate this business personally? � YES F;ncx�m� M;ea�� ta� HomeAddtei�: Street2yeme CiTy Are you gou� to t�are a manager or assistant in this business? � YES please complete the following inform � 6Hl1ie iYS YY/V.�/< Fust N�e x�� ndd,�: s�e x�� (M+�den) ctTy Please lis[ your employment history for the previous five (5) yeaz period: ��96 List all other officers of the cotporation: OFFICEI2 TITLE NAME , (Office Held) r" NO If not, who will opecate it? 1 �� r�c D� ars�ti State Zip Phone tiunbe, NO If the manager is not the same as the operator, c HOME ADDRESS Address Last sr�m HOME PHONE lleto oi nuth Zip Phonc\umbcr �, .57T�� ss/o�. ST ST. ��u/, �,ei s�i� BUSINESS DATE OF PHONE BIRTH If business is a partnership, please include the following information #'or each partner (use additional pages if necessary): Fint Nemc Home Addre%+: SGeet Nem< Fint 23�c riomeAdl.rcv: S'..�__t?�:se Middtc Initia] City (Maidrn) City State Zip Datc of Birth Phonc\umba Date of Bicth Phonc \�bcr MINNESOTA TAX IDENTIFICATION NUMBER - Pursuant to the Laws of Minnesota, 1984, Chapter 502, Article 8, Section 2(270.72) (TaY Ciearance; Issuance of Licenses), licensing authorities are required to provide to the State of Mianesota Commissioner of Revenue, thz Minnesota business tax identification number and the social security number of each license applicant. Under the Minnesota Government Data Pracfices Act and the Federal Privacy Act of 1974, we are required to advise you of the following regarding the use of the Minnesota TaY Identification Number: - This information may be used to deny the issuance or renewal of your license in the event you o�ve Minnesota sales, emplo} er's withholding or motor vehicle excise taxes; - Upon receiving this information, the licensing authority will supply it only to the Minnesota Department of Revenue. Hon ever, under the Federal Exchange of Information Agzeemrnt, the Departmznt of Revenue may supply this informalion to thz Intemal Revenue Service. Minne�ta Tar ldentification NiunUers (Sales & Use TaY Number) may be obtained frnm thz State of Mumesota, Business Records Department, 10 River Park Plaza (612-296-6181). Social Security Number: 7'7' �(� — I 0 J� j Miimesota Tat Identification Number: �� _ If a Minnesota TaY Identification Number is not required for the businzss being operated, indicate so by placing an "X" in the bot. �_y ! , � ; 2/15;97 I.%ri Stak Zip T-ast � 9'1.1'� �3 CER1 TFICATION OF WORKERS' COMpENSATION CO VERAGE PURSUANT TO MINNESOTA STANTE 176.182 T hereby ceRify that I, or my company, azn in compliance with the workers' compensation insurance covezage requiretnents of Minnesota Sta?ute 176.182, subdivision 2. I also understand that provision of false infonnation in this certification consGitutes sufficient grounds for adverse action against all licenses held, including revocation and suspension of said licznses. � NazneofInsuranceCompany: /�r�/ �iJS7 / SG/t �� Policy Number: �� C�� Coverage I have no employees covered under workers' compensation insurance _ to C �L�/r.,?'/ " ANY FALSIFICATION OF ANSWERS GIVEN OR MATERIAL SUBMTI'TED WILL RESULT IN DE1�iIAL OR TI�S APPLICATION I hereby state that I have answered all of the preceding questions, and that the infomiation contained herein is true and correct to the best of my knowledge and belief I hereby state further that I have received no money or other consideratioq by way of loan, giR, contxibution, or othervri�z, other than already disclosed in the application wtsich I herevrith submitted. I also understand this premise may be inspected by police, fire, health and other city officials at any and all times when the business is in operation. (REQUIItED for all appGcations) :': � will accept payment by cash, check (made pa�able to City of Saint Pau� or credit eard (M!C or V isa). IFPAYING BY CREDIT CARD PLEASE COMPLETE THE FOLLOWING INF'ORMATION: � MasterCard � Visa EXPIRATION DATE: ACCOUNP NUMBER: ❑Cl/Cl❑ ❑C70❑ ❑C��❑ ❑��❑ ❑i��❑ of �i�� all Date **Note: If this application is FoodlLiquor related, please contact a City of Saint Paul Health Inspector, Steve Olson (266-9139), to review plans. If any subsiantial changes to structure are anticipated, please contact a Ciry of Saint Paut Plan Exan�iner at 266-9007 to apply for building permits. ffthere are any changes to the parking lot, floor space, or for new operations, piease contact a City of Saint Paul Zoning Inspector at 266-9008. All applications require the following documents. Please attach these documents when suhmitting your application: i. A dztailed description of the design, location and square footage of the premises to be licensed (site plan). The following data should be on the site plan (preferably on an 8 1/2" x 11" or 8 1/2" x 14" paper): - Name, address, and phone number. - The scale should be stated such as I"= 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, repair area, pazking, rest rooms, etc. - If a request is for an addition or expansion of the licensed facility, indicate both the current area and the proposed expansion. 2. A copy of your lease ageement or proof of ownership of the properiy. SPECIFIC LICENSE APPLICATIONS REQLlIRE ADDTTIONAL INFOItMATION. PLEASE SEE REVERSE FOR DETAII�S >>>> �.; 271 S'97 Council File � - 1 1 �,7� Z ordinance # Green Sheet # 50236 1 2 3 4 5 b 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 zs 26 27 28 �: .-, . � - Presented By RESOLUTION �AIT PAUL, MINNESOTA Referred To Committee: Date N3 RESOLVED: That applic 'on D#88112, for a Parking Lot/Ramp License by Healtheast-St. Joseph's Hospital DBA Healtheast-St. Joseph's Hospital (JOhn Reith Reding) at 69 W. Exchange Street, be and the same is hereby approved. Requested by Department of: Adoption Certified by Council Secretary BY= �2 rV�2� Approved by Mayor: Date t�Y'7 By: � ( �.� Office of License Tns�ctions and Environmental Protect-on B ��,9-�.�� } ��-� , Form Approved by City At •�yey gp ��,� � / Approved by Mayor for Submission to Council Hy: C Adopted by Council: Date '� \�,,�j ��q't i N° 50236 °t'1-1�� ^� LIEP/License Christine A. Roaek - 26b-9108 Hearing: ( j � � ( c/ TOTAL # OF SICaNATURE PAGES -- GREEN SHEET INITIAVDATE INITIAIIDATE �DEPARTMENTDIRECTOR �CITYCOUNCIL � CIN ATfORNEY � dN CLERK FOR ❑ BUDGEi DIRECTOF � FIN 8 MG7 SEFVICES DIR. � � MAYOR (OR ASSISTAM) � (CLIP ALL LOCATIONS FOR SIGNATURE) Healtheast-St. Joseph�s Hospital DSA Healtheast-St. Joseph's Hospital requests Council approval of their application £or a Parking LotJRamp License, ID fi88112, (.Tohn Reith R at 69 W. Fxchan�e St. a _ PLANNING GOMMISS�ON _ dVIL SEflVICE _. GB COMMITTEE _ _ STAFF _ _ Di5TRILT COURT _ SUPPORTS WNICH COVNCIL OBJECTIVE? PERSONAI SERVICE CONTRACTS MUST ANSWER THE FOLLOWING OUESTIONS: 1 Haz Ynis personlFrzm ever warked untler a contract For this department> YES NO 2. Has this personffirm ever been a city employee? YES NQ 3. Does this person/ficm possess a skill not normally pessessetl by any current cdy empbyee� YES NO Explaln all yea anawers on saperata aMeet and attaeh to green aheet ISSUE. OPPORTUNITY (NTO. Whet. When. YVhere. Why): �� ot�� ' . a:=:1:4. - ��,� �' � i�`�7 --�_�� 0.L AMOUNT OF TIiAN5ACT10N S COST7REVENUE BUDGE7ED (CIRCIE ONE) YES NO DItdG SOURCE ACTIVITY NUMBER IpA1 INfORHiATIOM (EXPLAIN) . �� CLASS III LICENSE APPLICATION s 3!�=°% � Company Nazne; If business is incotp lloing Business As: Business Address: iration /Pertnenlvp / Sole Propri� give date of incorporation: �� i-�� S ; sc�c naa�s Between what cross streets is the business located? Are the premises now occupied? � Wha Mail To Acldress: � �. �P55 � _��f'�� Applicant Iaformatio�_ Namean3Tifle: —J�/ �'"�° �c�r � �/�� Fine ,�M �� / ,�/ (�te�aea> / � ,t tv't`� �iae '/ Home Address: ` `c�� "f�NFiY //A/ / /(f �i /I[✓6 /`i /1� S��Y � so- naa� ctry s��e ztp Date of Birth: �/ a � Place of Birth: s! -��i9�C �r /�'I7 Home Phone: �S7' �.3�✓" � - � Have you ever b en convicted of zny �lo :-y, c.-:ne cr ;�iolauoa o: any city ord'uiance ofner than traffic? YES NO _� Date of arrest: Where? Charge: Conviction: Sentence: List the names and residences of ihree persons of good moral chazacter, 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 applicanYs chazacter: N�AM ADDRESS PHONE ��l�/ ,`;��,. _- .,_ . _ . _ - J ` � s�33 - '� J 2 Z c�'• hold, formerly held, or ////(/ -(bii /� � ,1 i ZP,/7 � `_' ////� G Have any of the above nazned licenses ever been revoked? � �S�/��-- � -1��3 CITY OF SAINT PAUL off� afu�, t�a�� a &��mtat r�oc��o� 350 Sc Pctx S[ Siim 300 Sa'vif PwI, Ftimewti 35302 (612J 7669090 fi<C617J I6F4133 Business Phone: �� .7 "- 7 / :3 � ' ?r.c/ sv,ne S�a � s�r� q z�p / ,,/f D�� Which side of the sTreet� !� �� " s .%,a �lU �/37 � 5�2� Ry�; ' �f/«� GV�i7Pf" Eh, �i /✓ have an interest in: vofs �'c�n5C.. ` YES �_ NO If yes, list the dates and reasons for rzvocalion: i �? i O � THIS APPLICATION IS SUBJECT TO REVIEW BY Tf� PUBLIC �� PLEASE TYPE OR PRIN"P IN INK �; — . Are you going to operate this business personally? � YES F;ncx�m� M;ea�� ta� HomeAddtei�: Street2yeme CiTy Are you gou� to t�are a manager or assistant in this business? � YES please complete the following inform � 6Hl1ie iYS YY/V.�/< Fust N�e x�� ndd,�: s�e x�� (M+�den) ctTy Please lis[ your employment history for the previous five (5) yeaz period: ��96 List all other officers of the cotporation: OFFICEI2 TITLE NAME , (Office Held) r" NO If not, who will opecate it? 1 �� r�c D� ars�ti State Zip Phone tiunbe, NO If the manager is not the same as the operator, c HOME ADDRESS Address Last sr�m HOME PHONE lleto oi nuth Zip Phonc\umbcr �, .57T�� ss/o�. ST ST. ��u/, �,ei s�i� BUSINESS DATE OF PHONE BIRTH If business is a partnership, please include the following information #'or each partner (use additional pages if necessary): Fint Nemc Home Addre%+: SGeet Nem< Fint 23�c riomeAdl.rcv: S'..�__t?�:se Middtc Initia] City (Maidrn) City State Zip Datc of Birth Phonc\umba Date of Bicth Phonc \�bcr MINNESOTA TAX IDENTIFICATION NUMBER - Pursuant to the Laws of Minnesota, 1984, Chapter 502, Article 8, Section 2(270.72) (TaY Ciearance; Issuance of Licenses), licensing authorities are required to provide to the State of Mianesota Commissioner of Revenue, thz Minnesota business tax identification number and the social security number of each license applicant. Under the Minnesota Government Data Pracfices Act and the Federal Privacy Act of 1974, we are required to advise you of the following regarding the use of the Minnesota TaY Identification Number: - This information may be used to deny the issuance or renewal of your license in the event you o�ve Minnesota sales, emplo} er's withholding or motor vehicle excise taxes; - Upon receiving this information, the licensing authority will supply it only to the Minnesota Department of Revenue. Hon ever, under the Federal Exchange of Information Agzeemrnt, the Departmznt of Revenue may supply this informalion to thz Intemal Revenue Service. Minne�ta Tar ldentification NiunUers (Sales & Use TaY Number) may be obtained frnm thz State of Mumesota, Business Records Department, 10 River Park Plaza (612-296-6181). Social Security Number: 7'7' �(� — I 0 J� j Miimesota Tat Identification Number: �� _ If a Minnesota TaY Identification Number is not required for the businzss being operated, indicate so by placing an "X" in the bot. �_y ! , � ; 2/15;97 I.%ri Stak Zip T-ast � 9'1.1'� �3 CER1 TFICATION OF WORKERS' COMpENSATION CO VERAGE PURSUANT TO MINNESOTA STANTE 176.182 T hereby ceRify that I, or my company, azn in compliance with the workers' compensation insurance covezage requiretnents of Minnesota Sta?ute 176.182, subdivision 2. I also understand that provision of false infonnation in this certification consGitutes sufficient grounds for adverse action against all licenses held, including revocation and suspension of said licznses. � NazneofInsuranceCompany: /�r�/ �iJS7 / SG/t �� Policy Number: �� C�� Coverage I have no employees covered under workers' compensation insurance _ to C �L�/r.,?'/ " ANY FALSIFICATION OF ANSWERS GIVEN OR MATERIAL SUBMTI'TED WILL RESULT IN DE1�iIAL OR TI�S APPLICATION I hereby state that I have answered all of the preceding questions, and that the infomiation contained herein is true and correct to the best of my knowledge and belief I hereby state further that I have received no money or other consideratioq by way of loan, giR, contxibution, or othervri�z, other than already disclosed in the application wtsich I herevrith submitted. I also understand this premise may be inspected by police, fire, health and other city officials at any and all times when the business is in operation. (REQUIItED for all appGcations) :': � will accept payment by cash, check (made pa�able to City of Saint Pau� or credit eard (M!C or V isa). IFPAYING BY CREDIT CARD PLEASE COMPLETE THE FOLLOWING INF'ORMATION: � MasterCard � Visa EXPIRATION DATE: ACCOUNP NUMBER: ❑Cl/Cl❑ ❑C70❑ ❑C��❑ ❑��❑ ❑i��❑ of �i�� all Date **Note: If this application is FoodlLiquor related, please contact a City of Saint Paul Health Inspector, Steve Olson (266-9139), to review plans. If any subsiantial changes to structure are anticipated, please contact a Ciry of Saint Paut Plan Exan�iner at 266-9007 to apply for building permits. ffthere are any changes to the parking lot, floor space, or for new operations, piease contact a City of Saint Paul Zoning Inspector at 266-9008. All applications require the following documents. Please attach these documents when suhmitting your application: i. A dztailed description of the design, location and square footage of the premises to be licensed (site plan). The following data should be on the site plan (preferably on an 8 1/2" x 11" or 8 1/2" x 14" paper): - Name, address, and phone number. - The scale should be stated such as I"= 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, repair area, pazking, rest rooms, etc. - If a request is for an addition or expansion of the licensed facility, indicate both the current area and the proposed expansion. 2. A copy of your lease ageement or proof of ownership of the properiy. SPECIFIC LICENSE APPLICATIONS REQLlIRE ADDTTIONAL INFOItMATION. PLEASE SEE REVERSE FOR DETAII�S >>>> �.; 271 S'97