97-1559Council File # 1 /� q
Ordinance #
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flRIGINAL
RESOLUTION
Green Sheet $ 50237
�
Presented
Referred To
Committee: Date
�
RESOLVED: That application, ID #33570, for a Restaurant (B), Entertainment - Class A,
Sunday On-Sa1e Liquor, Liquor-On-Sale C, Gambling Location (Class C) and
Cigarette Licenses by JRR, Inc. DBA Joe and Stan's (Revin J. ICelly), located
at 949 7th Street West, be and the same is hereby approved.
Requested by Department of:
Adoption Certified by Council Secretary
$Y� ��—� e�- . �
Approved by Mayor: Date 'L4 �
By: !-G
Office of License Insoections and
nv+ o m ntal Protection
BY� <C���<S!�'� l�I� �
Form Approved by City Attorne
BY: (/ �w�GZ� � h
Approved by yor for Submission to
Council
By:
Adopted by Council: Date fl, a..a ��q*�
LIEPfLicense
Christine A. Rozek - 266-9108
Hearing:
TOTAL # OF SIGNATURE PAGES
N�
IGREEN SHEET
� D£PARTMENT DIRECTOR
� GIN ATCORNEY
FOk ❑BUDGETO�tiECTOR
. O MAYOF (OR ASSISTANT�
(CLIP ALL �OCATIONS FOR SIGNATURE)
O CITY COUNCIL
O CITY CIERK
O FIN- & MG7. SE
�
50237
q�-�SSq
INITIAUDATE
�"""""`°"° 3RR, Inc. DBA Joe and Stan's (Kevin J. Re11y), ID �E33570, requests Council
approval o£ their application for a Restaurant (B), Enteztainment - Class A, Sunday On-Sale
Liquor, Liquor-On-Sale.C, Gambling Location (Class C), and Cigarette licenses at
949 7th Street W.
OMMENDATIONS: npo�we IA) w Aeject IA) pERSONAL SERVICE GONTpACTS MUST ANSWEB THE FOLLOWING QUESTIONS:
. PLANNING COMMISSION _ CIVIL SERVICE COMMISSION �� Ha5 thi5 personttifm ¢ver worked Under a Contract fo� thi5 tlBpartment?
_ CIB COMMITTEE _ YES NO
2. Has fhis personffi�m ever been a ciry employee�
. STAFf
— VES NO
_ DISiRiCT CoVar _ 3. Does this personNirm possess a skill not norma�ly possassed by any current city employea�
PORTS WHICH fAUNCIL OBJEGTIVE? YES NO
Explein a11 yes answers on separate shaet and ettach to green sheet
IFAPPROVED: .
IF
NOV 10 1997
AMOUNT OF TFiAN5ACT10N
FUNp11dG SOURCE
F�NANCIAL INFOqfuSATIpN. (EXPLAIN)
�,. `.
COSTBEVENUE BUDGETED�CIACIE ONE) YES NO
ACTIVITY NUMBER
� �
CLASS III
LICENSE APPLICATION
THIS APPLICATION IS SLBJECT TO REVTEW BY THE pUBLIC
PLEASE TYPE OR PRIN"T IN INK
Type ofLicense(s) being applie3 for:
Company Nazne:
Corporation / Partnrnhip / $ole Proprietorship
CITY OF SAINT PA�
06ce of License, I�spettions
and En�vonmmial Prottction
350 St Pnc St Svi¢ 3C0
Sx:.it na•.Q Nv��tz 55103
(6]])]669pgp (�(612)26S9134
If business is incorporated, give date of i �i � i J'��
Doing Business As: �O� r�- tJ c� � q- J � Susiness Phone: � 7, ���`j (
BusinessAddress: Q� C� {� `j`� � �,�- -�p�,�,� rn pJ ss l� c�
Street Address . City State Zip
Beh��een what cross �ireets is the basiness located?
Are the premises now
Mail To Address: �
Applicant InfomiaGon:
Name and Title: _ '"�
��� VJhat Type of Business?
� ` 4,�. <
Stmt Addreas
�
Which side of the street?
'01�
'� ��rv� ,� S S f � �
Citl' Sta�e yip
F� �tiddlc � (*daidrn) S.ari f � Title
Home Address � � q � � � � � )� j,� ,�'�q� rn � C rl
s��caaa�, , csry suu zia
Date of Birth: d3 I� 1 J�' Place of Birth: S�' Pfk(,L Homa Phone; �E573 R.2 z�'
Have you ever been convicted of any felony, cnme or esolation of any city ordinance other than traffic? YES NO �
Date of arrest:
Chazge: _
Conviction:
Sentence:
List the names and residences of ihree 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 referted to as to the applicant's chazacter:
NAME ADDR� , /� PHONE
i � _ ��v7"� ('S D •'v ''F (� ck � .Pi9 Ft, � c n ^!-�A,� p � Fn �, rt _ t - / _ ci� v. , � : 1
r.-�
List licenses uhich you currrntly hold formerly heId, or
-- �/�`�C�"t �
have aninterestin:
�{ �63 j
Have any of the above named licenses ever been revoked? YES
Wherz?
_.,�_ NO If yes, list the dates and reasons for revocation:
2/IS/97
�se you going to operaTe this business personally? `Z YES NO If not, who u7ll operate it?
°1�1 �55�
Fis[\ame :Jud8lclxuUet (,bia�dcn) Last DatcofHirth
Home Addreu: Strcet \nme City Sfatc Zip Phone \umber
Are you going to have a manager or assistant in this business� YES �_ NO If the man2ger is not the seme as the operator,
piease comQlete the following informxtion:
Fust N�e
Home Addresx: Strect \�eme
csTy
Please list your employment history for the previous five (5) } ear period:
BusinessJEir�3ovment Address
List all other officers of the corporation:
OFFICER TITLE HOME
N� (Office Held) ADDI2ESS
Iast
sr�m
HOME SUSTNESS
PHONE PHONE
a°�a �ia� �-4 -,
�c�� 73a—�s—r9 ��
Zip
- � e. r
If business is a partnership, please include the foltowing information for each paztner (use additional pages if necessary):
Date of Birth
Phone N�ba
DATE OF
F'vstNamc Middlclnitial (Maiden) Lazt
Datc of Bir(h
Home Addms: 54ut Name - .
.. __ ._h , ,,,,��..,,_ _.�.,._.
. . ..._ _ _., . -
Fustl�*ame ... MiddicInitisl - �
Home Addmss: - Streetl3ame -' - _ ..
CiTy
��)
C;Ty
State yip
I.est
slatc zip.
Phone Numba
FI��i1
Phone Nirmber
MII�INESOTA TAX IDENTIFICATIOI3 NIIMBER - Pursuanf to the Iaws of Minnesota, 1984, Chapter 502, Article 8, Section 2(270.72)
(TaY Cleazance; Issuance of Licenses), licensing authorities are required to provide to the State of Minnesota Commissioner of Revenue, the
Minnesota business taY identification number and the social security munber of each licetvse applicant
Under the Minnesota Government Data Practices Act and the Federal Privacy Act of I 974, we are required to advise you of the following
regarding the use of the Minnesota Tas Identification Number:
- This information may be used to deuy the issuance or renewal of your license in the event you owe Mumesota sales, employer's
wittrholding or motor vehicle �cise tases;
- Upon receiving this infoimation, the licensing authority will supply it only to the Minnesota Department of Revenue. However,
under the Federal Exchange of Infotmation Agreemrnt, the Department of Revenue may supply this information to the Intemai
Revenue Service.
Minnesota Tax Identification Ntunbe� (Sa]es & Use Tax Number) may be obtained &om the State of Minnesota, Business Records Department,
I 0 River Park Plaza (612-296-6 ]$1).
Social Secuxity I3umber Minnesota Ta�c Identi&cation Number:
If a Minnesota Tax Identification Number is pot required for the business being operated, indicate so by placing an"X" in the box.
L�4
;�'fiddlc Snitial (!daidcn)
_- ... 2/18/97
Lc agplyi�g for,
Cabaret adutt, p]ease attach written proof that each employee is at ]east 18 }'ears old.
q�1 �SS9
Conversation/Itap parlor adult, please attach tz�ritten proof that each emplo}�ee is at least 18 yeazs old.
Entertainzvent, please sp�u`y class 1� B, or C]icense; obtzin asid attach si�atues of approval from 90% oi }'ou neighbors tx�ithin 350
feet of the estab]isbment Tlus licznse must be applied for in conjunc5on with a Liqnor, Wine, Malt On Sale or RrntaUDance Hall license.
Firearms, please aftach a letter �;ith the following infomiation: state if selling or only repauing, Federal Fireazms License Number, t}pe
of ATmed Services discharge (Honorable, Generai, Bad Conduct, Undesirabie, Dishonorable, or no military seclice. (NOIE:
Establisbment must be commercially zoned.)
Game room, please provide ihe foliotving infoimalion: name of machine and list price. (NOTE: A Poo1 Ha11 license is required if there
ue any pool tables in the establishment.)
HealthlSports dub adult, please attach written proof that each employee is at le2st 18 years old.
Liquor off/on sate, refer to attached liquor application.
I.ock oQening senices, please attach a list of all employees (with homz adchess and te]ephane number) who wi11 be doing the 3ock opening
service; attach $10,000 Surety Bond.
Massa;e center, please attach a detailed description of the sere�ices being pro��ided.
Massage center adult, please attach written proof that each employee is at least 18 yeazs old,
Massage practitioner, please submit proof of successfiil comp7etion of written and practical esams from the City of Saint Paul authorized
e��amin inswance certificate showing coverage of S 1,000,000.00 each general liability and professional liability k2th the City of Szint
Pau1 named as an additional insuree� and a 30 day notice of cancellation; proof of affiliation from a licensed City of Saint Paul therapeutic
massage center or state licensed health facility ,
Matomycle dea3er, please include State of Minnesota Dealer Number.
New motor ��ehide dealer, please include State of Minnesota Dealer Number.
Parldng bUramp, glease include the number ofparking spaces, and attach plans containing a genzral descriplion of the securify provided
at the lot/ramp, a site plan showing driven�a}'s of the pmpos�l lot and the lega] description of the property (this requirement necessary only
if no site plan is cunently on file). Attach a cover letter dexribing your plans to comply with the lighting and pzinting requirements.
PaRV6roker, please attach $5,000.00 Surety Bond.
Second hand dealer-motor vehicie, please include State of Minnesota Deala Nwnbet.
Second hand deaEer-motor vehicle parts, please attach $5,000.00 Surety Bond.
Steam room/bath house adutt, please attach written proof that each employee is at least 18 years oid.
Tf�eater adult, please attach written proof that each empioyee is at least 18 yeus old
2/1 s/97
CLASS III
LICENSE APPLICATION
TF3IS APPLICATION IS SUBJECT TO REVIEW BY Tfic PUBLIC
PLEASE TYPE OR PRINT IN Ii�TK
�t't -t.
CITX OF SAINT PAUL
�ce ofLicrnse, Lupec�ou
end Er.vironmrnial Protetion
3X+Ston� St 51'm� ]00
Sz:.it?ev7�Macvws 55:0]
�s�a7assso90 �(s�z7los�
�p2t '/ �
T}peofLicense(s)beingapplie3for:o`2�SS'C� �1�.�� _sRF}N iaS`t 9j'S 5 °��.5.�d
° o�-�k2. �n7�''r2y"y�-iev171GN'i- C1.�4�1� � S �t �.60
s ,��_vv
�1 �Y� . c� r�
s . cs �
�.i�-
Cmporation / Partnmk�ip / Sole Proprietonk�ip �'�T��� � �G
If business is incotporated, give date of iucorporation: R'� ��` p �� 3 ��'��
Doing Business As: _.� c`� �- t9 ti%C1 �1 C Business Phone: � `1S - 7 /
,. � � - �—,-
Business Address:
3trcctAdd=rss City State Zip
Behveen what cross streets is the business located�
Are the premises now occupied? _� Wfiat Type of Business?
Mail To Address: �^�I' -�v 1� `2�' S�`" >`
Stre� AadRss
�Applicant Infoimation:
Name and Title: _ _
c�ry
Statc Zip
+ �F�t ?.s;aai� ��a�) �t r,n�
Home Address: 1�PJ � � ft`� l4 O a4 �l p��� �cA L� �"1 � ��( a-�/
StreQ Addttss CiTy Statc Zip
Date of Birth: 1� .� (n .�� � Place of Birth: nl.� �rj Home Phone: '7 .3Z� � d� 11
Have you ever been com-icted of any felcny, crime or �riolatioa of any city ordinance other than+*affic? YES NO �_
Date of azrest:
Charge: _
Conviction:
Sentence:
W�T�7
Lisc ffie names and tesidences of tl�ree 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 applicanYs character:
�
e��;_
Which side of the street?
`�' � ) !�
E
Have any of the above named licenses ever been
33
PHONE
YES _�_ NO If }'es, list the dates and reasons for revocation:
� �: :
4 2/18N7
List licenses u�hich you curtentiy hold, formerly held, or may have an interest in:
��?,0 �'( �' ��R.-
�� ,
Are you going to operate chis business personally? �_ YES
Fint \*amc
Struttiemc
M;aai� 1rit,�t
c:�;�>
Cin�
NO If not, vrho titill operate it?
I.aR
Statc
g � —15.5�
nam oea;ccl,
Zip Phonc Number
Are you going to have a manager or zssistant in this business?
ptease compiete the foltowing information:
Fixst tirmc
Home Adt�ices: Strect'.�ame
Ci:y
Please list yosr employment his[ory for the previous five (5) }'eu period:
Business/Emp]otiment Address
List a11 other officers of the corporation:
OFFICER TITLE
NAME (Office Held)
HOME
ADDRESS
Last
State
HOME BiJSINESS
PHONE PHOI�TE
-5'a,
DATE OF
BII2TH
If business is a partnership, please include the fdlowing infarmation for each partner (use additianal pages if neczssary):
Fustl�*ame Middlelnitial (Maidcn) Last DateofBirth
Homc Addiess: SGeet Name
FirstN�e
fIamtAddrese: StmtNmmc
YES �._ NO If the manager is not ihe same as ihe operator,
?�fiddle initisl (�qai�-n)
ciTy
Middlc Tnitisl
.(Viaidrn)
ciTy
State Zip
S.aS.
Siate Zip
Phone Number
IIetc
Phone N�ber
MINNESOTA TAX IDENTIFICATION NUMBER - Pursuant to the Laws of Muu�esota, 1984, Chapter 502, Articie 8, Seclion 2(270.72)
(Ta�c Cleazznce; Issuance of Licenses), licensing authorities are required to provide to the State of Minnesota Couunissioner of Revenue, the
Minnesota business ta�c idemification number and the social security number of each license applicant.
Under the t�iinnesota Govemment Data Practices Act and the Federal Privacy Act of 1974, we are required to ade�ise you of the folloa�ing
regazding the use of the Minnesota Tax Identification Number:
- This information may be used to deiry the issuance or renewai of your license in the evrnt you owe Miimesota sales, employer's
withholding or motor vehicle excise taxes;
- Upon receiving this infomiation, the licensing authority will supply it only to the Minnesota Department of Revenue. However,
under the Federal Exchange of Information Agreement, the Departrnent of Revenue may supply this information to ihe Intemal
Revenue Service.
Minnes�ta Tax Identificarion Numbees (Sales & Use Tau Numher) may be obtained from the State of Minnesota, Business Records Departrnent,
16 River Park Plaza (612-296-6181).
Social Security Number:
Minnesota Tax Identification Number:
Date of Buth
Zip Phonc \'�bcr
�5J
�.s"
`3)
_ If a Nunnesota Tax Identi5cation Number is not required for the business being operated, indicate so by placing an "X" in the box.
� 2/18/97
Q � -155°�
CERTIFICATION OF WORKERS' COMPENSATION CO VERAGE PURSUfv'vT TO MIATNESOTA STANTE 176.182
I hereby certify that I, or m}' company, azn in compliznce «ith the u orkers' compensauon insurance cocerage requirements of Minnesota Statu?e
176.182, subclivision 2. I a1� understand that provision of false infotmation in this certification constitutes sufficient grounds for adverse action
agauist 2111icenses held, including revocation and suspension of szid licznses.
Name of Insurance Compzny:
Policy Nu.*nber: Coverage from to
I hace no emplopees cocered under wo,kers' compensation insurance (L\iTIALS)
eL�VY FALSIFICATION OF Al\SWERS GIVEN OR �IATERIAL SUBMPI'ZED
WILL RESTTLT IN DEl�'IAL OF THIS APPLTCATION
I hereby state that I hace znsu all of Tl�e preceding questions, and that the informalion contained herein is true and conect to the best of
my knowledge and belief. I hereby state further that I have receiaed no money or other consideration, by way of loan, gift, contributioq or
othen��ise, othe: than alread;� clisclos�l in the applicarion w�hich I herewith submitted. I also understand this premise ma}� bz inspected by police,
fire, health and other cit}� o�cizls at any and all times w�hen tl�e business is in operation.
/°-1' Y7
for all applications)
We eill accept gayment by cash, check {made payabie to City of Saint Paul) or credit card (M/C or Visa).
Date
IFPAYINGBYCREDITCARDPLEASECOMPLETETHEFOLLOiVINGINFORb1ATION: �MasterCard � Visa
EXPIRATION DATE:
❑oio❑
of
for all
'' *Note: If this application is FoodlLiquar related, please contact a City of Saint Paul Health Inspector, Steve Olson (266-9139), to re�riew
plans.
if any substantial changes to structure are anticipated, please contact a CiTy of Saint Paul Plan Examiner at 266-9007 to apply for
buiTdingpermiu.
If there aze ury changes to the parking lot, floor space, or for new opetations, please contact a City of Saint Paul Zoning Inspector at
266-9008.
AS1 applications mquire the folloe�ing documeats. Please attach these documents e•hen submitfing your application:
I. A detailed 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 I 4" paper):
- Name, address, and phone number.
- The scale sbould be stated such as 1" = 20'. ^N should he indicated toward the top.
- Placement of all pertinent features of the interior of the licensed facility sttcl� as seating areas, icitchens, offices, zepau azea,
pazking rest rooms, ete.
- 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 ]ease agreement or proof of ownership of the properiy.
SPECIFIC LICENSE APPLICATIONS REQi7IItE ADDTTIONAL �ORMATION.
PLEASE SEE REVERSE FOR DETAILS >>>>
ACCOUNf NUMBER:
i■s■ ■■■■ ■■■■ ■■■■
. �� 2/18/97
CLASS III
LICENSE APPLICATION
THIS APPLICATION IS SuBJECT TO REVIEW BY THE PUBLIC
Type o£License(s) being applied for:
11°t�A � P1�/1;�t�e
��i� I� r ,
4 L t?V
`Gtf[�y��.1/t e �
�C�'GC.vt - f' � �� �
Coiporation 1 PeRneiship 1 Sote
PLEASE TYPE OR PRINT IN IIvK
If business is incorporated, a�•e date of incoiporation:
Doing Business As: � 1 t5�, �,�.A a� .��i�-jf�
Business Address:
SCUtAddrcss
Between what cross streeu is the business located?
Are the premises now occupied? � VJhaY Type of Business?
'I"vlail To Address: �� 9 1s� `'i �' vY- .
s� nemzv
Name and Title: � �� f '�
b�i
?vtiddle
�
_
�
�
'� i �
� • �
�
_� , _�.
CI'IY OF SAlNT PAUL
�ce of L�cense, Lsspections
zna &nirovmrntal Protect;on
350 5:7� SC Stiic 3A
�`.?'+.�y' .�S6c�esota 5510]
(6l2)2oS9094 fuC612)26b912<
g�� I.�
�
S �,�„.
s -� ��7,�'
s ��E <T
c ;? 1'� �
Business Phone: � �.,'� — �3'j Z
1�"i r1�
State Zip
Wluch side of the street?
� �
s� z;P
�#� �. 1 � �
, Titic
Home Address: � `� �'�_ � �, ?�I�1 I`f'S a'T �%�f.t.� ��� �]���
s�n nae,<.� c;ry s�w ztp �
Date of Birrh: � o�- �, Place of Birth: �� �� �� � Home Phone: �`' , o� �'
Have you ever been comlcted of any felony, crime or ti�iolation of any city ordinance other than haffic? YES NO �
Date of arrest:
Chazge: _
Conviction:
VJhere?
List the names and residences of three persons of good moral character, living within the Twin Cities Metro Area, not related to the applicant
or financially interested in the premises or busines, who may be referred to as to tl�e applicant's character:
2�TAME
ADDRESS
Sentence:
� PHONE
'c�� �F;��rSO�r �a�7 I�EI}JE2 a��-ry, �t� �aan,v 11��r to�3
�s !� rz tJ a 2 s t o�.-� 1 h f� O t.� �s-f-s ft.r�3 {}c z 4�� i L�� /h � �$�' U i 9
-� f} il� p" h£ �� e r� � L(� t.�r�o�� �.2� 5�- Q,v f S�t.r�n ti �, r� �<fK � 5 i�'
,
List licenses which you cwrently hold, formerly held, or may ha`�e an interest in:
Have auy of the above named licenses ever
�%:
revoked7 YES /� 2�30 If yes, list the dates aad reasons for revocation:
2718197
Are you going to operate this business personally? _�`1 YES NO If not, �lfio will operate it?
���
$tmt?��emc
M;aa�� ���t
HOME
P.DDRESS
Are you going to have a aanagzs or assistant in this business? YES
plexse conp3ete the follo�xing informztion:
Fixst?:ame
Home Address: Stxcet \ame
I�Tiddic Initial
List all other officers of the coiporation:
OFFICER TI1I.E
NAME , � (Office Held)
N
�
Ci:c
(�kidcn)
Cirv
Detc of Birth
Stat� Zip Phone 1Jumber
� NO If the manager is not the sasne as the onerator,
I.ast
Stzte
HOME
PHO;�'E
�.3 �
a-
a�•�ss9
Zip
Datr of Birth
Phone Numbcr
DATE OF
BIItTH , 9 �
� -
v
�
If business is a partnetship, piease inc]ude tbe following informalion for each partner (use additional pages if necessary):
First\�c ?vfiddlcIititial (.Maidcn) Last DateofBirth
Home Addross: Streel
Finti:ame
Middle 3nitial
HomcAddxsse: Sh�ctN�e
City
BUSINESS
PHOA'E
�4R• c�o
fete Zip
I.ast
State Zip
Phone ISumbet
Phone Nnmber
MINf�'ESOTA TAX SDENTIFICATION NUMBER - Pursuant to the I,aws of Minnesotz, 1984, Chapter 502, Article 8, Section 2(270.72)
(TaY Cleazance; Issuance of Licenses), licensing authorities are required to provide to the State of Minnesota Commissioner of Revrnue, the
Minnesota business tar idrntification number and the social secunTy number of each license applicant.
Under the Minnesota Crovemment Data Practices 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 drny the issuance or renewal of your license in the event you owe Minnesota sales, employer s
withholding or motor vehicle excise taYes;
- Upon receiving this information, the licensing authoriry' will supply it oaly to the Minnesota Department of Revenue. However,
under the Federal Exchange of Information Agreement, the Depar[ment of Recenue may supply tlus information to the Intemal
Revenue Serc7ce.
Minnesota Tax Identi5cation Numbers (Sales & Use TaY Niunber) may be obtained from the State of Minnesota, Business Records Department,
10 River Park Plaza (612-246-6181).
Social Security Number. 7 7/- � c�- -�� �� Minnesota Tax IdentiScation Number: ,�� �o a` � a.
_ If a Minnesota Tax Identification Number is not required for the business being operated, indicate so by placing an°X" in the bok.
�,�!r
2/18/97
Ciry
(.Vfeidrn)
Please lisi your employment history for tlie pre��ious five (5) czar period:
CER cL ICATIQN OF WORKERS' CO2�/iPENSATION COVERAGE PURSUA\�T TO MINNESOTA STATUTE 176.182 �? �� S S�
I herehy certify that I, or my company, am in compliance nith the iaa:l:ers' compensation insurance coverage requirements of Minnesot2 Statute
17G.182, subdivision 2, I also understand that p;o��ision of iaise information in ihis certi5calion constitutes s�cient grounds for adverse action
against all licenses held, including revocation and suspension of said licenses.
I�'azne of Insurance Company:
Policy Numbzr: Co��erage from to
I have no emplo}'ees covered under n•orkers' compensation insurance (L�'ITIALS)
ANY FALSIFICATION OR AI�*SWERS GIVEN OR MATER3AL SUBNII'iTED
Vr'ILL RESULT IN pEI�'L�L OF THIS APPLICATION
I hereby state that I have ansu�ered all of the preceding questions, and that the information contzined herein is true and correct to the best of
my lmowledge and belief. I hereby state further that I have recei��ed no money or other consideratioq by k�ay of loan, gift, con�ihution, or
othetwise, other than already disclosed in the �plicalion wfiich I hereuith su6mitte�. I also understand this premise may be inspected by police,
fue, health and other city officials at any �zd all times when thz business is in operarion.
7
We will accept pa?�ment by cash, check (made payable to City of Saipt Paun or credit card (M/C or Visa).
(F PAYINC BY CREDIT CARD PLEASE COMPLETE THE FOLLON'ING INFORMATION: � MasterCard � Visa
�XPII2ATION DATE: ACCOUNI' NL7MBER:
C70iC7❑ ❑OC7❑ ❑C]�❑ ❑C70❑ ❑C7�❑
*�� of
Cazd
**Note: If this application is Food/Liquor related, p]ease contact a Ciry of Saint Paul Health Inspector, Steve Olson (266-9139), to re��iew
plans.
If any substantial changes to shvcture are anticipated, please contact a City of Saint Pau1 Plan Examiner at 256-9007 to apply for
building permits.
If there are any changes to the paricing }ot, floor space, or for new operations, please contact a Ciry of Saint Paul Zoning Inspector at
266-9008.
All applicarions requim ihe folloRing documents. Please attach these documents wfien submitting your application:
1. A detailed description of the design, location and square footage of the premises to be licensed (site plan).
The foIlowing data should be on the site plan (preferably on an 8 1/2" x I 1" or 8 1/2" x 14" paper):
- Nazne, address, and phone number.
- The scale should be stated such as I" = 20'. ^N should be indicated towazd the top.
- Placement of all pertinent features of the interior of the ]icensed facility such as seating ueas, kitchens, offices, repair area,
parking, rest rooms, efe.
- If a request is for an addifion or expansion of ffie licensed facility, indicate both the cturent azea and the proposed ehpansion.
2. A copy of your lease agreement or proof of ownership of the property.
SPECIkTC LICENSE APPLICATIONS REQUII2E ADDTTIONAL IiV�'ORMATION.
PLEA3E SEE REVERSE FOR DETAII,S >>>>
�:,
u:
2/IS/97
Council File # 1 /� q
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
2$
29
flRIGINAL
RESOLUTION
Green Sheet $ 50237
�
Presented
Referred To
Committee: Date
�
RESOLVED: That application, ID #33570, for a Restaurant (B), Entertainment - Class A,
Sunday On-Sa1e Liquor, Liquor-On-Sale C, Gambling Location (Class C) and
Cigarette Licenses by JRR, Inc. DBA Joe and Stan's (Revin J. ICelly), located
at 949 7th Street West, be and the same is hereby approved.
Requested by Department of:
Adoption Certified by Council Secretary
$Y� ��—� e�- . �
Approved by Mayor: Date 'L4 �
By: !-G
Office of License Insoections and
nv+ o m ntal Protection
BY� <C���<S!�'� l�I� �
Form Approved by City Attorne
BY: (/ �w�GZ� � h
Approved by yor for Submission to
Council
By:
Adopted by Council: Date fl, a..a ��q*�
LIEPfLicense
Christine A. Rozek - 266-9108
Hearing:
TOTAL # OF SIGNATURE PAGES
N�
IGREEN SHEET
� D£PARTMENT DIRECTOR
� GIN ATCORNEY
FOk ❑BUDGETO�tiECTOR
. O MAYOF (OR ASSISTANT�
(CLIP ALL �OCATIONS FOR SIGNATURE)
O CITY COUNCIL
O CITY CIERK
O FIN- & MG7. SE
�
50237
q�-�SSq
INITIAUDATE
�"""""`°"° 3RR, Inc. DBA Joe and Stan's (Kevin J. Re11y), ID �E33570, requests Council
approval o£ their application for a Restaurant (B), Enteztainment - Class A, Sunday On-Sale
Liquor, Liquor-On-Sale.C, Gambling Location (Class C), and Cigarette licenses at
949 7th Street W.
OMMENDATIONS: npo�we IA) w Aeject IA) pERSONAL SERVICE GONTpACTS MUST ANSWEB THE FOLLOWING QUESTIONS:
. PLANNING COMMISSION _ CIVIL SERVICE COMMISSION �� Ha5 thi5 personttifm ¢ver worked Under a Contract fo� thi5 tlBpartment?
_ CIB COMMITTEE _ YES NO
2. Has fhis personffi�m ever been a ciry employee�
. STAFf
— VES NO
_ DISiRiCT CoVar _ 3. Does this personNirm possess a skill not norma�ly possassed by any current city employea�
PORTS WHICH fAUNCIL OBJEGTIVE? YES NO
Explein a11 yes answers on separate shaet and ettach to green sheet
IFAPPROVED: .
IF
NOV 10 1997
AMOUNT OF TFiAN5ACT10N
FUNp11dG SOURCE
F�NANCIAL INFOqfuSATIpN. (EXPLAIN)
�,. `.
COSTBEVENUE BUDGETED�CIACIE ONE) YES NO
ACTIVITY NUMBER
� �
CLASS III
LICENSE APPLICATION
THIS APPLICATION IS SLBJECT TO REVTEW BY THE pUBLIC
PLEASE TYPE OR PRIN"T IN INK
Type ofLicense(s) being applie3 for:
Company Nazne:
Corporation / Partnrnhip / $ole Proprietorship
CITY OF SAINT PA�
06ce of License, I�spettions
and En�vonmmial Prottction
350 St Pnc St Svi¢ 3C0
Sx:.it na•.Q Nv��tz 55103
(6]])]669pgp (�(612)26S9134
If business is incorporated, give date of i �i � i J'��
Doing Business As: �O� r�- tJ c� � q- J � Susiness Phone: � 7, ���`j (
BusinessAddress: Q� C� {� `j`� � �,�- -�p�,�,� rn pJ ss l� c�
Street Address . City State Zip
Beh��een what cross �ireets is the basiness located?
Are the premises now
Mail To Address: �
Applicant InfomiaGon:
Name and Title: _ '"�
��� VJhat Type of Business?
� ` 4,�. <
Stmt Addreas
�
Which side of the street?
'01�
'� ��rv� ,� S S f � �
Citl' Sta�e yip
F� �tiddlc � (*daidrn) S.ari f � Title
Home Address � � q � � � � � )� j,� ,�'�q� rn � C rl
s��caaa�, , csry suu zia
Date of Birth: d3 I� 1 J�' Place of Birth: S�' Pfk(,L Homa Phone; �E573 R.2 z�'
Have you ever been convicted of any felony, cnme or esolation of any city ordinance other than traffic? YES NO �
Date of arrest:
Chazge: _
Conviction:
Sentence:
List the names and residences of ihree 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 referted to as to the applicant's chazacter:
NAME ADDR� , /� PHONE
i � _ ��v7"� ('S D •'v ''F (� ck � .Pi9 Ft, � c n ^!-�A,� p � Fn �, rt _ t - / _ ci� v. , � : 1
r.-�
List licenses uhich you currrntly hold formerly heId, or
-- �/�`�C�"t �
have aninterestin:
�{ �63 j
Have any of the above named licenses ever been revoked? YES
Wherz?
_.,�_ NO If yes, list the dates and reasons for revocation:
2/IS/97
�se you going to operaTe this business personally? `Z YES NO If not, who u7ll operate it?
°1�1 �55�
Fis[\ame :Jud8lclxuUet (,bia�dcn) Last DatcofHirth
Home Addreu: Strcet \nme City Sfatc Zip Phone \umber
Are you going to have a manager or assistant in this business� YES �_ NO If the man2ger is not the seme as the operator,
piease comQlete the following informxtion:
Fust N�e
Home Addresx: Strect \�eme
csTy
Please list your employment history for the previous five (5) } ear period:
BusinessJEir�3ovment Address
List all other officers of the corporation:
OFFICER TITLE HOME
N� (Office Held) ADDI2ESS
Iast
sr�m
HOME SUSTNESS
PHONE PHONE
a°�a �ia� �-4 -,
�c�� 73a—�s—r9 ��
Zip
- � e. r
If business is a partnership, please include the foltowing information for each paztner (use additional pages if necessary):
Date of Birth
Phone N�ba
DATE OF
F'vstNamc Middlclnitial (Maiden) Lazt
Datc of Bir(h
Home Addms: 54ut Name - .
.. __ ._h , ,,,,��..,,_ _.�.,._.
. . ..._ _ _., . -
Fustl�*ame ... MiddicInitisl - �
Home Addmss: - Streetl3ame -' - _ ..
CiTy
��)
C;Ty
State yip
I.est
slatc zip.
Phone Numba
FI��i1
Phone Nirmber
MII�INESOTA TAX IDENTIFICATIOI3 NIIMBER - Pursuanf to the Iaws of Minnesota, 1984, Chapter 502, Article 8, Section 2(270.72)
(TaY Cleazance; Issuance of Licenses), licensing authorities are required to provide to the State of Minnesota Commissioner of Revenue, the
Minnesota business taY identification number and the social security munber of each licetvse applicant
Under the Minnesota Government Data Practices Act and the Federal Privacy Act of I 974, we are required to advise you of the following
regarding the use of the Minnesota Tas Identification Number:
- This information may be used to deuy the issuance or renewal of your license in the event you owe Mumesota sales, employer's
wittrholding or motor vehicle �cise tases;
- Upon receiving this infoimation, the licensing authority will supply it only to the Minnesota Department of Revenue. However,
under the Federal Exchange of Infotmation Agreemrnt, the Department of Revenue may supply this information to the Intemai
Revenue Service.
Minnesota Tax Identification Ntunbe� (Sa]es & Use Tax Number) may be obtained &om the State of Minnesota, Business Records Department,
I 0 River Park Plaza (612-296-6 ]$1).
Social Secuxity I3umber Minnesota Ta�c Identi&cation Number:
If a Minnesota Tax Identification Number is pot required for the business being operated, indicate so by placing an"X" in the box.
L�4
;�'fiddlc Snitial (!daidcn)
_- ... 2/18/97
Lc agplyi�g for,
Cabaret adutt, p]ease attach written proof that each employee is at ]east 18 }'ears old.
q�1 �SS9
Conversation/Itap parlor adult, please attach tz�ritten proof that each emplo}�ee is at least 18 yeazs old.
Entertainzvent, please sp�u`y class 1� B, or C]icense; obtzin asid attach si�atues of approval from 90% oi }'ou neighbors tx�ithin 350
feet of the estab]isbment Tlus licznse must be applied for in conjunc5on with a Liqnor, Wine, Malt On Sale or RrntaUDance Hall license.
Firearms, please aftach a letter �;ith the following infomiation: state if selling or only repauing, Federal Fireazms License Number, t}pe
of ATmed Services discharge (Honorable, Generai, Bad Conduct, Undesirabie, Dishonorable, or no military seclice. (NOIE:
Establisbment must be commercially zoned.)
Game room, please provide ihe foliotving infoimalion: name of machine and list price. (NOTE: A Poo1 Ha11 license is required if there
ue any pool tables in the establishment.)
HealthlSports dub adult, please attach written proof that each employee is at le2st 18 years old.
Liquor off/on sate, refer to attached liquor application.
I.ock oQening senices, please attach a list of all employees (with homz adchess and te]ephane number) who wi11 be doing the 3ock opening
service; attach $10,000 Surety Bond.
Massa;e center, please attach a detailed description of the sere�ices being pro��ided.
Massage center adult, please attach written proof that each employee is at least 18 yeazs old,
Massage practitioner, please submit proof of successfiil comp7etion of written and practical esams from the City of Saint Paul authorized
e��amin inswance certificate showing coverage of S 1,000,000.00 each general liability and professional liability k2th the City of Szint
Pau1 named as an additional insuree� and a 30 day notice of cancellation; proof of affiliation from a licensed City of Saint Paul therapeutic
massage center or state licensed health facility ,
Matomycle dea3er, please include State of Minnesota Dealer Number.
New motor ��ehide dealer, please include State of Minnesota Dealer Number.
Parldng bUramp, glease include the number ofparking spaces, and attach plans containing a genzral descriplion of the securify provided
at the lot/ramp, a site plan showing driven�a}'s of the pmpos�l lot and the lega] description of the property (this requirement necessary only
if no site plan is cunently on file). Attach a cover letter dexribing your plans to comply with the lighting and pzinting requirements.
PaRV6roker, please attach $5,000.00 Surety Bond.
Second hand dealer-motor vehicie, please include State of Minnesota Deala Nwnbet.
Second hand deaEer-motor vehicle parts, please attach $5,000.00 Surety Bond.
Steam room/bath house adutt, please attach written proof that each employee is at least 18 years oid.
Tf�eater adult, please attach written proof that each empioyee is at least 18 yeus old
2/1 s/97
CLASS III
LICENSE APPLICATION
TF3IS APPLICATION IS SUBJECT TO REVIEW BY Tfic PUBLIC
PLEASE TYPE OR PRINT IN Ii�TK
�t't -t.
CITX OF SAINT PAUL
�ce ofLicrnse, Lupec�ou
end Er.vironmrnial Protetion
3X+Ston� St 51'm� ]00
Sz:.it?ev7�Macvws 55:0]
�s�a7assso90 �(s�z7los�
�p2t '/ �
T}peofLicense(s)beingapplie3for:o`2�SS'C� �1�.�� _sRF}N iaS`t 9j'S 5 °��.5.�d
° o�-�k2. �n7�''r2y"y�-iev171GN'i- C1.�4�1� � S �t �.60
s ,��_vv
�1 �Y� . c� r�
s . cs �
�.i�-
Cmporation / Partnmk�ip / Sole Proprietonk�ip �'�T��� � �G
If business is incotporated, give date of iucorporation: R'� ��` p �� 3 ��'��
Doing Business As: _.� c`� �- t9 ti%C1 �1 C Business Phone: � `1S - 7 /
,. � � - �—,-
Business Address:
3trcctAdd=rss City State Zip
Behveen what cross streets is the business located�
Are the premises now occupied? _� Wfiat Type of Business?
Mail To Address: �^�I' -�v 1� `2�' S�`" >`
Stre� AadRss
�Applicant Infoimation:
Name and Title: _ _
c�ry
Statc Zip
+ �F�t ?.s;aai� ��a�) �t r,n�
Home Address: 1�PJ � � ft`� l4 O a4 �l p��� �cA L� �"1 � ��( a-�/
StreQ Addttss CiTy Statc Zip
Date of Birth: 1� .� (n .�� � Place of Birth: nl.� �rj Home Phone: '7 .3Z� � d� 11
Have you ever been com-icted of any felcny, crime or �riolatioa of any city ordinance other than+*affic? YES NO �_
Date of azrest:
Charge: _
Conviction:
Sentence:
W�T�7
Lisc ffie names and tesidences of tl�ree 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 applicanYs character:
�
e��;_
Which side of the street?
`�' � ) !�
E
Have any of the above named licenses ever been
33
PHONE
YES _�_ NO If }'es, list the dates and reasons for revocation:
� �: :
4 2/18N7
List licenses u�hich you curtentiy hold, formerly held, or may have an interest in:
��?,0 �'( �' ��R.-
�� ,
Are you going to operate chis business personally? �_ YES
Fint \*amc
Struttiemc
M;aai� 1rit,�t
c:�;�>
Cin�
NO If not, vrho titill operate it?
I.aR
Statc
g � —15.5�
nam oea;ccl,
Zip Phonc Number
Are you going to have a manager or zssistant in this business?
ptease compiete the foltowing information:
Fixst tirmc
Home Adt�ices: Strect'.�ame
Ci:y
Please list yosr employment his[ory for the previous five (5) }'eu period:
Business/Emp]otiment Address
List a11 other officers of the corporation:
OFFICER TITLE
NAME (Office Held)
HOME
ADDRESS
Last
State
HOME BiJSINESS
PHONE PHOI�TE
-5'a,
DATE OF
BII2TH
If business is a partnership, please include the fdlowing infarmation for each partner (use additianal pages if neczssary):
Fustl�*ame Middlelnitial (Maidcn) Last DateofBirth
Homc Addiess: SGeet Name
FirstN�e
fIamtAddrese: StmtNmmc
YES �._ NO If the manager is not ihe same as ihe operator,
?�fiddle initisl (�qai�-n)
ciTy
Middlc Tnitisl
.(Viaidrn)
ciTy
State Zip
S.aS.
Siate Zip
Phone Number
IIetc
Phone N�ber
MINNESOTA TAX IDENTIFICATION NUMBER - Pursuant to the Laws of Muu�esota, 1984, Chapter 502, Articie 8, Seclion 2(270.72)
(Ta�c Cleazznce; Issuance of Licenses), licensing authorities are required to provide to the State of Minnesota Couunissioner of Revenue, the
Minnesota business ta�c idemification number and the social security number of each license applicant.
Under the t�iinnesota Govemment Data Practices Act and the Federal Privacy Act of 1974, we are required to ade�ise you of the folloa�ing
regazding the use of the Minnesota Tax Identification Number:
- This information may be used to deiry the issuance or renewai of your license in the evrnt you owe Miimesota sales, employer's
withholding or motor vehicle excise taxes;
- Upon receiving this infomiation, the licensing authority will supply it only to the Minnesota Department of Revenue. However,
under the Federal Exchange of Information Agreement, the Departrnent of Revenue may supply this information to ihe Intemal
Revenue Service.
Minnes�ta Tax Identificarion Numbees (Sales & Use Tau Numher) may be obtained from the State of Minnesota, Business Records Departrnent,
16 River Park Plaza (612-296-6181).
Social Security Number:
Minnesota Tax Identification Number:
Date of Buth
Zip Phonc \'�bcr
�5J
�.s"
`3)
_ If a Nunnesota Tax Identi5cation Number is not required for the business being operated, indicate so by placing an "X" in the box.
� 2/18/97
Q � -155°�
CERTIFICATION OF WORKERS' COMPENSATION CO VERAGE PURSUfv'vT TO MIATNESOTA STANTE 176.182
I hereby certify that I, or m}' company, azn in compliznce «ith the u orkers' compensauon insurance cocerage requirements of Minnesota Statu?e
176.182, subclivision 2. I a1� understand that provision of false infotmation in this certification constitutes sufficient grounds for adverse action
agauist 2111icenses held, including revocation and suspension of szid licznses.
Name of Insurance Compzny:
Policy Nu.*nber: Coverage from to
I hace no emplopees cocered under wo,kers' compensation insurance (L\iTIALS)
eL�VY FALSIFICATION OF Al\SWERS GIVEN OR �IATERIAL SUBMPI'ZED
WILL RESTTLT IN DEl�'IAL OF THIS APPLTCATION
I hereby state that I hace znsu all of Tl�e preceding questions, and that the informalion contained herein is true and conect to the best of
my knowledge and belief. I hereby state further that I have receiaed no money or other consideration, by way of loan, gift, contributioq or
othen��ise, othe: than alread;� clisclos�l in the applicarion w�hich I herewith submitted. I also understand this premise ma}� bz inspected by police,
fire, health and other cit}� o�cizls at any and all times w�hen tl�e business is in operation.
/°-1' Y7
for all applications)
We eill accept gayment by cash, check {made payabie to City of Saint Paul) or credit card (M/C or Visa).
Date
IFPAYINGBYCREDITCARDPLEASECOMPLETETHEFOLLOiVINGINFORb1ATION: �MasterCard � Visa
EXPIRATION DATE:
❑oio❑
of
for all
'' *Note: If this application is FoodlLiquar related, please contact a City of Saint Paul Health Inspector, Steve Olson (266-9139), to re�riew
plans.
if any substantial changes to structure are anticipated, please contact a CiTy of Saint Paul Plan Examiner at 266-9007 to apply for
buiTdingpermiu.
If there aze ury changes to the parking lot, floor space, or for new opetations, please contact a City of Saint Paul Zoning Inspector at
266-9008.
AS1 applications mquire the folloe�ing documeats. Please attach these documents e•hen submitfing your application:
I. A detailed 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 I 4" paper):
- Name, address, and phone number.
- The scale sbould be stated such as 1" = 20'. ^N should he indicated toward the top.
- Placement of all pertinent features of the interior of the licensed facility sttcl� as seating areas, icitchens, offices, zepau azea,
pazking rest rooms, ete.
- 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 ]ease agreement or proof of ownership of the properiy.
SPECIFIC LICENSE APPLICATIONS REQi7IItE ADDTTIONAL �ORMATION.
PLEASE SEE REVERSE FOR DETAILS >>>>
ACCOUNf NUMBER:
i■s■ ■■■■ ■■■■ ■■■■
. �� 2/18/97
CLASS III
LICENSE APPLICATION
THIS APPLICATION IS SuBJECT TO REVIEW BY THE PUBLIC
Type o£License(s) being applied for:
11°t�A � P1�/1;�t�e
��i� I� r ,
4 L t?V
`Gtf[�y��.1/t e �
�C�'GC.vt - f' � �� �
Coiporation 1 PeRneiship 1 Sote
PLEASE TYPE OR PRINT IN IIvK
If business is incorporated, a�•e date of incoiporation:
Doing Business As: � 1 t5�, �,�.A a� .��i�-jf�
Business Address:
SCUtAddrcss
Between what cross streeu is the business located?
Are the premises now occupied? � VJhaY Type of Business?
'I"vlail To Address: �� 9 1s� `'i �' vY- .
s� nemzv
Name and Title: � �� f '�
b�i
?vtiddle
�
_
�
�
'� i �
� • �
�
_� , _�.
CI'IY OF SAlNT PAUL
�ce of L�cense, Lsspections
zna &nirovmrntal Protect;on
350 5:7� SC Stiic 3A
�`.?'+.�y' .�S6c�esota 5510]
(6l2)2oS9094 fuC612)26b912<
g�� I.�
�
S �,�„.
s -� ��7,�'
s ��E <T
c ;? 1'� �
Business Phone: � �.,'� — �3'j Z
1�"i r1�
State Zip
Wluch side of the street?
� �
s� z;P
�#� �. 1 � �
, Titic
Home Address: � `� �'�_ � �, ?�I�1 I`f'S a'T �%�f.t.� ��� �]���
s�n nae,<.� c;ry s�w ztp �
Date of Birrh: � o�- �, Place of Birth: �� �� �� � Home Phone: �`' , o� �'
Have you ever been comlcted of any felony, crime or ti�iolation of any city ordinance other than haffic? YES NO �
Date of arrest:
Chazge: _
Conviction:
VJhere?
List the names and residences of three persons of good moral character, living within the Twin Cities Metro Area, not related to the applicant
or financially interested in the premises or busines, who may be referred to as to tl�e applicant's character:
2�TAME
ADDRESS
Sentence:
� PHONE
'c�� �F;��rSO�r �a�7 I�EI}JE2 a��-ry, �t� �aan,v 11��r to�3
�s !� rz tJ a 2 s t o�.-� 1 h f� O t.� �s-f-s ft.r�3 {}c z 4�� i L�� /h � �$�' U i 9
-� f} il� p" h£ �� e r� � L(� t.�r�o�� �.2� 5�- Q,v f S�t.r�n ti �, r� �<fK � 5 i�'
,
List licenses which you cwrently hold, formerly held, or may ha`�e an interest in:
Have auy of the above named licenses ever
�%:
revoked7 YES /� 2�30 If yes, list the dates aad reasons for revocation:
2718197
Are you going to operate this business personally? _�`1 YES NO If not, �lfio will operate it?
���
$tmt?��emc
M;aa�� ���t
HOME
P.DDRESS
Are you going to have a aanagzs or assistant in this business? YES
plexse conp3ete the follo�xing informztion:
Fixst?:ame
Home Address: Stxcet \ame
I�Tiddic Initial
List all other officers of the coiporation:
OFFICER TI1I.E
NAME , � (Office Held)
N
�
Ci:c
(�kidcn)
Cirv
Detc of Birth
Stat� Zip Phone 1Jumber
� NO If the manager is not the sasne as the onerator,
I.ast
Stzte
HOME
PHO;�'E
�.3 �
a-
a�•�ss9
Zip
Datr of Birth
Phone Numbcr
DATE OF
BIItTH , 9 �
� -
v
�
If business is a partnetship, piease inc]ude tbe following informalion for each partner (use additional pages if necessary):
First\�c ?vfiddlcIititial (.Maidcn) Last DateofBirth
Home Addross: Streel
Finti:ame
Middle 3nitial
HomcAddxsse: Sh�ctN�e
City
BUSINESS
PHOA'E
�4R• c�o
fete Zip
I.ast
State Zip
Phone ISumbet
Phone Nnmber
MINf�'ESOTA TAX SDENTIFICATION NUMBER - Pursuant to the I,aws of Minnesotz, 1984, Chapter 502, Article 8, Section 2(270.72)
(TaY Cleazance; Issuance of Licenses), licensing authorities are required to provide to the State of Minnesota Commissioner of Revrnue, the
Minnesota business tar idrntification number and the social secunTy number of each license applicant.
Under the Minnesota Crovemment Data Practices 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 drny the issuance or renewal of your license in the event you owe Minnesota sales, employer s
withholding or motor vehicle excise taYes;
- Upon receiving this information, the licensing authoriry' will supply it oaly to the Minnesota Department of Revenue. However,
under the Federal Exchange of Information Agreement, the Depar[ment of Recenue may supply tlus information to the Intemal
Revenue Serc7ce.
Minnesota Tax Identi5cation Numbers (Sales & Use TaY Niunber) may be obtained from the State of Minnesota, Business Records Department,
10 River Park Plaza (612-246-6181).
Social Security Number. 7 7/- � c�- -�� �� Minnesota Tax IdentiScation Number: ,�� �o a` � a.
_ If a Minnesota Tax Identification Number is not required for the business being operated, indicate so by placing an°X" in the bok.
�,�!r
2/18/97
Ciry
(.Vfeidrn)
Please lisi your employment history for tlie pre��ious five (5) czar period:
CER cL ICATIQN OF WORKERS' CO2�/iPENSATION COVERAGE PURSUA\�T TO MINNESOTA STATUTE 176.182 �? �� S S�
I herehy certify that I, or my company, am in compliance nith the iaa:l:ers' compensation insurance coverage requirements of Minnesot2 Statute
17G.182, subdivision 2, I also understand that p;o��ision of iaise information in ihis certi5calion constitutes s�cient grounds for adverse action
against all licenses held, including revocation and suspension of said licenses.
I�'azne of Insurance Company:
Policy Numbzr: Co��erage from to
I have no emplo}'ees covered under n•orkers' compensation insurance (L�'ITIALS)
ANY FALSIFICATION OR AI�*SWERS GIVEN OR MATER3AL SUBNII'iTED
Vr'ILL RESULT IN pEI�'L�L OF THIS APPLICATION
I hereby state that I have ansu�ered all of the preceding questions, and that the information contzined herein is true and correct to the best of
my lmowledge and belief. I hereby state further that I have recei��ed no money or other consideratioq by k�ay of loan, gift, con�ihution, or
othetwise, other than already disclosed in the �plicalion wfiich I hereuith su6mitte�. I also understand this premise may be inspected by police,
fue, health and other city officials at any �zd all times when thz business is in operarion.
7
We will accept pa?�ment by cash, check (made payable to City of Saipt Paun or credit card (M/C or Visa).
(F PAYINC BY CREDIT CARD PLEASE COMPLETE THE FOLLON'ING INFORMATION: � MasterCard � Visa
�XPII2ATION DATE: ACCOUNI' NL7MBER:
C70iC7❑ ❑OC7❑ ❑C]�❑ ❑C70❑ ❑C7�❑
*�� of
Cazd
**Note: If this application is Food/Liquor related, p]ease contact a Ciry of Saint Paul Health Inspector, Steve Olson (266-9139), to re��iew
plans.
If any substantial changes to shvcture are anticipated, please contact a City of Saint Pau1 Plan Examiner at 256-9007 to apply for
building permits.
If there are any changes to the paricing }ot, floor space, or for new operations, please contact a Ciry of Saint Paul Zoning Inspector at
266-9008.
All applicarions requim ihe folloRing documents. Please attach these documents wfien submitting your application:
1. A detailed description of the design, location and square footage of the premises to be licensed (site plan).
The foIlowing data should be on the site plan (preferably on an 8 1/2" x I 1" or 8 1/2" x 14" paper):
- Nazne, address, and phone number.
- The scale should be stated such as I" = 20'. ^N should be indicated towazd the top.
- Placement of all pertinent features of the interior of the ]icensed facility such as seating ueas, kitchens, offices, repair area,
parking, rest rooms, efe.
- If a request is for an addifion or expansion of ffie licensed facility, indicate both the cturent azea and the proposed ehpansion.
2. A copy of your lease agreement or proof of ownership of the property.
SPECIkTC LICENSE APPLICATIONS REQUII2E ADDTTIONAL IiV�'ORMATION.
PLEA3E SEE REVERSE FOR DETAII,S >>>>
�:,
u:
2/IS/97
Council File # 1 /� q
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
2$
29
flRIGINAL
RESOLUTION
Green Sheet $ 50237
�
Presented
Referred To
Committee: Date
�
RESOLVED: That application, ID #33570, for a Restaurant (B), Entertainment - Class A,
Sunday On-Sa1e Liquor, Liquor-On-Sale C, Gambling Location (Class C) and
Cigarette Licenses by JRR, Inc. DBA Joe and Stan's (Revin J. ICelly), located
at 949 7th Street West, be and the same is hereby approved.
Requested by Department of:
Adoption Certified by Council Secretary
$Y� ��—� e�- . �
Approved by Mayor: Date 'L4 �
By: !-G
Office of License Insoections and
nv+ o m ntal Protection
BY� <C���<S!�'� l�I� �
Form Approved by City Attorne
BY: (/ �w�GZ� � h
Approved by yor for Submission to
Council
By:
Adopted by Council: Date fl, a..a ��q*�
LIEPfLicense
Christine A. Rozek - 266-9108
Hearing:
TOTAL # OF SIGNATURE PAGES
N�
IGREEN SHEET
� D£PARTMENT DIRECTOR
� GIN ATCORNEY
FOk ❑BUDGETO�tiECTOR
. O MAYOF (OR ASSISTANT�
(CLIP ALL �OCATIONS FOR SIGNATURE)
O CITY COUNCIL
O CITY CIERK
O FIN- & MG7. SE
�
50237
q�-�SSq
INITIAUDATE
�"""""`°"° 3RR, Inc. DBA Joe and Stan's (Kevin J. Re11y), ID �E33570, requests Council
approval o£ their application for a Restaurant (B), Enteztainment - Class A, Sunday On-Sale
Liquor, Liquor-On-Sale.C, Gambling Location (Class C), and Cigarette licenses at
949 7th Street W.
OMMENDATIONS: npo�we IA) w Aeject IA) pERSONAL SERVICE GONTpACTS MUST ANSWEB THE FOLLOWING QUESTIONS:
. PLANNING COMMISSION _ CIVIL SERVICE COMMISSION �� Ha5 thi5 personttifm ¢ver worked Under a Contract fo� thi5 tlBpartment?
_ CIB COMMITTEE _ YES NO
2. Has fhis personffi�m ever been a ciry employee�
. STAFf
— VES NO
_ DISiRiCT CoVar _ 3. Does this personNirm possess a skill not norma�ly possassed by any current city employea�
PORTS WHICH fAUNCIL OBJEGTIVE? YES NO
Explein a11 yes answers on separate shaet and ettach to green sheet
IFAPPROVED: .
IF
NOV 10 1997
AMOUNT OF TFiAN5ACT10N
FUNp11dG SOURCE
F�NANCIAL INFOqfuSATIpN. (EXPLAIN)
�,. `.
COSTBEVENUE BUDGETED�CIACIE ONE) YES NO
ACTIVITY NUMBER
� �
CLASS III
LICENSE APPLICATION
THIS APPLICATION IS SLBJECT TO REVTEW BY THE pUBLIC
PLEASE TYPE OR PRIN"T IN INK
Type ofLicense(s) being applie3 for:
Company Nazne:
Corporation / Partnrnhip / $ole Proprietorship
CITY OF SAINT PA�
06ce of License, I�spettions
and En�vonmmial Prottction
350 St Pnc St Svi¢ 3C0
Sx:.it na•.Q Nv��tz 55103
(6]])]669pgp (�(612)26S9134
If business is incorporated, give date of i �i � i J'��
Doing Business As: �O� r�- tJ c� � q- J � Susiness Phone: � 7, ���`j (
BusinessAddress: Q� C� {� `j`� � �,�- -�p�,�,� rn pJ ss l� c�
Street Address . City State Zip
Beh��een what cross �ireets is the basiness located?
Are the premises now
Mail To Address: �
Applicant InfomiaGon:
Name and Title: _ '"�
��� VJhat Type of Business?
� ` 4,�. <
Stmt Addreas
�
Which side of the street?
'01�
'� ��rv� ,� S S f � �
Citl' Sta�e yip
F� �tiddlc � (*daidrn) S.ari f � Title
Home Address � � q � � � � � )� j,� ,�'�q� rn � C rl
s��caaa�, , csry suu zia
Date of Birth: d3 I� 1 J�' Place of Birth: S�' Pfk(,L Homa Phone; �E573 R.2 z�'
Have you ever been convicted of any felony, cnme or esolation of any city ordinance other than traffic? YES NO �
Date of arrest:
Chazge: _
Conviction:
Sentence:
List the names and residences of ihree 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 referted to as to the applicant's chazacter:
NAME ADDR� , /� PHONE
i � _ ��v7"� ('S D •'v ''F (� ck � .Pi9 Ft, � c n ^!-�A,� p � Fn �, rt _ t - / _ ci� v. , � : 1
r.-�
List licenses uhich you currrntly hold formerly heId, or
-- �/�`�C�"t �
have aninterestin:
�{ �63 j
Have any of the above named licenses ever been revoked? YES
Wherz?
_.,�_ NO If yes, list the dates and reasons for revocation:
2/IS/97
�se you going to operaTe this business personally? `Z YES NO If not, who u7ll operate it?
°1�1 �55�
Fis[\ame :Jud8lclxuUet (,bia�dcn) Last DatcofHirth
Home Addreu: Strcet \nme City Sfatc Zip Phone \umber
Are you going to have a manager or assistant in this business� YES �_ NO If the man2ger is not the seme as the operator,
piease comQlete the following informxtion:
Fust N�e
Home Addresx: Strect \�eme
csTy
Please list your employment history for the previous five (5) } ear period:
BusinessJEir�3ovment Address
List all other officers of the corporation:
OFFICER TITLE HOME
N� (Office Held) ADDI2ESS
Iast
sr�m
HOME SUSTNESS
PHONE PHONE
a°�a �ia� �-4 -,
�c�� 73a—�s—r9 ��
Zip
- � e. r
If business is a partnership, please include the foltowing information for each paztner (use additional pages if necessary):
Date of Birth
Phone N�ba
DATE OF
F'vstNamc Middlclnitial (Maiden) Lazt
Datc of Bir(h
Home Addms: 54ut Name - .
.. __ ._h , ,,,,��..,,_ _.�.,._.
. . ..._ _ _., . -
Fustl�*ame ... MiddicInitisl - �
Home Addmss: - Streetl3ame -' - _ ..
CiTy
��)
C;Ty
State yip
I.est
slatc zip.
Phone Numba
FI��i1
Phone Nirmber
MII�INESOTA TAX IDENTIFICATIOI3 NIIMBER - Pursuanf to the Iaws of Minnesota, 1984, Chapter 502, Article 8, Section 2(270.72)
(TaY Cleazance; Issuance of Licenses), licensing authorities are required to provide to the State of Minnesota Commissioner of Revenue, the
Minnesota business taY identification number and the social security munber of each licetvse applicant
Under the Minnesota Government Data Practices Act and the Federal Privacy Act of I 974, we are required to advise you of the following
regarding the use of the Minnesota Tas Identification Number:
- This information may be used to deuy the issuance or renewal of your license in the event you owe Mumesota sales, employer's
wittrholding or motor vehicle �cise tases;
- Upon receiving this infoimation, the licensing authority will supply it only to the Minnesota Department of Revenue. However,
under the Federal Exchange of Infotmation Agreemrnt, the Department of Revenue may supply this information to the Intemai
Revenue Service.
Minnesota Tax Identification Ntunbe� (Sa]es & Use Tax Number) may be obtained &om the State of Minnesota, Business Records Department,
I 0 River Park Plaza (612-296-6 ]$1).
Social Secuxity I3umber Minnesota Ta�c Identi&cation Number:
If a Minnesota Tax Identification Number is pot required for the business being operated, indicate so by placing an"X" in the box.
L�4
;�'fiddlc Snitial (!daidcn)
_- ... 2/18/97
Lc agplyi�g for,
Cabaret adutt, p]ease attach written proof that each employee is at ]east 18 }'ears old.
q�1 �SS9
Conversation/Itap parlor adult, please attach tz�ritten proof that each emplo}�ee is at least 18 yeazs old.
Entertainzvent, please sp�u`y class 1� B, or C]icense; obtzin asid attach si�atues of approval from 90% oi }'ou neighbors tx�ithin 350
feet of the estab]isbment Tlus licznse must be applied for in conjunc5on with a Liqnor, Wine, Malt On Sale or RrntaUDance Hall license.
Firearms, please aftach a letter �;ith the following infomiation: state if selling or only repauing, Federal Fireazms License Number, t}pe
of ATmed Services discharge (Honorable, Generai, Bad Conduct, Undesirabie, Dishonorable, or no military seclice. (NOIE:
Establisbment must be commercially zoned.)
Game room, please provide ihe foliotving infoimalion: name of machine and list price. (NOTE: A Poo1 Ha11 license is required if there
ue any pool tables in the establishment.)
HealthlSports dub adult, please attach written proof that each employee is at le2st 18 years old.
Liquor off/on sate, refer to attached liquor application.
I.ock oQening senices, please attach a list of all employees (with homz adchess and te]ephane number) who wi11 be doing the 3ock opening
service; attach $10,000 Surety Bond.
Massa;e center, please attach a detailed description of the sere�ices being pro��ided.
Massage center adult, please attach written proof that each employee is at least 18 yeazs old,
Massage practitioner, please submit proof of successfiil comp7etion of written and practical esams from the City of Saint Paul authorized
e��amin inswance certificate showing coverage of S 1,000,000.00 each general liability and professional liability k2th the City of Szint
Pau1 named as an additional insuree� and a 30 day notice of cancellation; proof of affiliation from a licensed City of Saint Paul therapeutic
massage center or state licensed health facility ,
Matomycle dea3er, please include State of Minnesota Dealer Number.
New motor ��ehide dealer, please include State of Minnesota Dealer Number.
Parldng bUramp, glease include the number ofparking spaces, and attach plans containing a genzral descriplion of the securify provided
at the lot/ramp, a site plan showing driven�a}'s of the pmpos�l lot and the lega] description of the property (this requirement necessary only
if no site plan is cunently on file). Attach a cover letter dexribing your plans to comply with the lighting and pzinting requirements.
PaRV6roker, please attach $5,000.00 Surety Bond.
Second hand dealer-motor vehicie, please include State of Minnesota Deala Nwnbet.
Second hand deaEer-motor vehicle parts, please attach $5,000.00 Surety Bond.
Steam room/bath house adutt, please attach written proof that each employee is at least 18 years oid.
Tf�eater adult, please attach written proof that each empioyee is at least 18 yeus old
2/1 s/97
CLASS III
LICENSE APPLICATION
TF3IS APPLICATION IS SUBJECT TO REVIEW BY Tfic PUBLIC
PLEASE TYPE OR PRINT IN Ii�TK
�t't -t.
CITX OF SAINT PAUL
�ce ofLicrnse, Lupec�ou
end Er.vironmrnial Protetion
3X+Ston� St 51'm� ]00
Sz:.it?ev7�Macvws 55:0]
�s�a7assso90 �(s�z7los�
�p2t '/ �
T}peofLicense(s)beingapplie3for:o`2�SS'C� �1�.�� _sRF}N iaS`t 9j'S 5 °��.5.�d
° o�-�k2. �n7�''r2y"y�-iev171GN'i- C1.�4�1� � S �t �.60
s ,��_vv
�1 �Y� . c� r�
s . cs �
�.i�-
Cmporation / Partnmk�ip / Sole Proprietonk�ip �'�T��� � �G
If business is incotporated, give date of iucorporation: R'� ��` p �� 3 ��'��
Doing Business As: _.� c`� �- t9 ti%C1 �1 C Business Phone: � `1S - 7 /
,. � � - �—,-
Business Address:
3trcctAdd=rss City State Zip
Behveen what cross streets is the business located�
Are the premises now occupied? _� Wfiat Type of Business?
Mail To Address: �^�I' -�v 1� `2�' S�`" >`
Stre� AadRss
�Applicant Infoimation:
Name and Title: _ _
c�ry
Statc Zip
+ �F�t ?.s;aai� ��a�) �t r,n�
Home Address: 1�PJ � � ft`� l4 O a4 �l p��� �cA L� �"1 � ��( a-�/
StreQ Addttss CiTy Statc Zip
Date of Birth: 1� .� (n .�� � Place of Birth: nl.� �rj Home Phone: '7 .3Z� � d� 11
Have you ever been com-icted of any felcny, crime or �riolatioa of any city ordinance other than+*affic? YES NO �_
Date of azrest:
Charge: _
Conviction:
Sentence:
W�T�7
Lisc ffie names and tesidences of tl�ree 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 applicanYs character:
�
e��;_
Which side of the street?
`�' � ) !�
E
Have any of the above named licenses ever been
33
PHONE
YES _�_ NO If }'es, list the dates and reasons for revocation:
� �: :
4 2/18N7
List licenses u�hich you curtentiy hold, formerly held, or may have an interest in:
��?,0 �'( �' ��R.-
�� ,
Are you going to operate chis business personally? �_ YES
Fint \*amc
Struttiemc
M;aai� 1rit,�t
c:�;�>
Cin�
NO If not, vrho titill operate it?
I.aR
Statc
g � —15.5�
nam oea;ccl,
Zip Phonc Number
Are you going to have a manager or zssistant in this business?
ptease compiete the foltowing information:
Fixst tirmc
Home Adt�ices: Strect'.�ame
Ci:y
Please list yosr employment his[ory for the previous five (5) }'eu period:
Business/Emp]otiment Address
List a11 other officers of the corporation:
OFFICER TITLE
NAME (Office Held)
HOME
ADDRESS
Last
State
HOME BiJSINESS
PHONE PHOI�TE
-5'a,
DATE OF
BII2TH
If business is a partnership, please include the fdlowing infarmation for each partner (use additianal pages if neczssary):
Fustl�*ame Middlelnitial (Maidcn) Last DateofBirth
Homc Addiess: SGeet Name
FirstN�e
fIamtAddrese: StmtNmmc
YES �._ NO If the manager is not ihe same as ihe operator,
?�fiddle initisl (�qai�-n)
ciTy
Middlc Tnitisl
.(Viaidrn)
ciTy
State Zip
S.aS.
Siate Zip
Phone Number
IIetc
Phone N�ber
MINNESOTA TAX IDENTIFICATION NUMBER - Pursuant to the Laws of Muu�esota, 1984, Chapter 502, Articie 8, Seclion 2(270.72)
(Ta�c Cleazznce; Issuance of Licenses), licensing authorities are required to provide to the State of Minnesota Couunissioner of Revenue, the
Minnesota business ta�c idemification number and the social security number of each license applicant.
Under the t�iinnesota Govemment Data Practices Act and the Federal Privacy Act of 1974, we are required to ade�ise you of the folloa�ing
regazding the use of the Minnesota Tax Identification Number:
- This information may be used to deiry the issuance or renewai of your license in the evrnt you owe Miimesota sales, employer's
withholding or motor vehicle excise taxes;
- Upon receiving this infomiation, the licensing authority will supply it only to the Minnesota Department of Revenue. However,
under the Federal Exchange of Information Agreement, the Departrnent of Revenue may supply this information to ihe Intemal
Revenue Service.
Minnes�ta Tax Identificarion Numbees (Sales & Use Tau Numher) may be obtained from the State of Minnesota, Business Records Departrnent,
16 River Park Plaza (612-296-6181).
Social Security Number:
Minnesota Tax Identification Number:
Date of Buth
Zip Phonc \'�bcr
�5J
�.s"
`3)
_ If a Nunnesota Tax Identi5cation Number is not required for the business being operated, indicate so by placing an "X" in the box.
� 2/18/97
Q � -155°�
CERTIFICATION OF WORKERS' COMPENSATION CO VERAGE PURSUfv'vT TO MIATNESOTA STANTE 176.182
I hereby certify that I, or m}' company, azn in compliznce «ith the u orkers' compensauon insurance cocerage requirements of Minnesota Statu?e
176.182, subclivision 2. I a1� understand that provision of false infotmation in this certification constitutes sufficient grounds for adverse action
agauist 2111icenses held, including revocation and suspension of szid licznses.
Name of Insurance Compzny:
Policy Nu.*nber: Coverage from to
I hace no emplopees cocered under wo,kers' compensation insurance (L\iTIALS)
eL�VY FALSIFICATION OF Al\SWERS GIVEN OR �IATERIAL SUBMPI'ZED
WILL RESTTLT IN DEl�'IAL OF THIS APPLTCATION
I hereby state that I hace znsu all of Tl�e preceding questions, and that the informalion contained herein is true and conect to the best of
my knowledge and belief. I hereby state further that I have receiaed no money or other consideration, by way of loan, gift, contributioq or
othen��ise, othe: than alread;� clisclos�l in the applicarion w�hich I herewith submitted. I also understand this premise ma}� bz inspected by police,
fire, health and other cit}� o�cizls at any and all times w�hen tl�e business is in operation.
/°-1' Y7
for all applications)
We eill accept gayment by cash, check {made payabie to City of Saint Paul) or credit card (M/C or Visa).
Date
IFPAYINGBYCREDITCARDPLEASECOMPLETETHEFOLLOiVINGINFORb1ATION: �MasterCard � Visa
EXPIRATION DATE:
❑oio❑
of
for all
'' *Note: If this application is FoodlLiquar related, please contact a City of Saint Paul Health Inspector, Steve Olson (266-9139), to re�riew
plans.
if any substantial changes to structure are anticipated, please contact a CiTy of Saint Paul Plan Examiner at 266-9007 to apply for
buiTdingpermiu.
If there aze ury changes to the parking lot, floor space, or for new opetations, please contact a City of Saint Paul Zoning Inspector at
266-9008.
AS1 applications mquire the folloe�ing documeats. Please attach these documents e•hen submitfing your application:
I. A detailed 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 I 4" paper):
- Name, address, and phone number.
- The scale sbould be stated such as 1" = 20'. ^N should he indicated toward the top.
- Placement of all pertinent features of the interior of the licensed facility sttcl� as seating areas, icitchens, offices, zepau azea,
pazking rest rooms, ete.
- 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 ]ease agreement or proof of ownership of the properiy.
SPECIFIC LICENSE APPLICATIONS REQi7IItE ADDTTIONAL �ORMATION.
PLEASE SEE REVERSE FOR DETAILS >>>>
ACCOUNf NUMBER:
i■s■ ■■■■ ■■■■ ■■■■
. �� 2/18/97
CLASS III
LICENSE APPLICATION
THIS APPLICATION IS SuBJECT TO REVIEW BY THE PUBLIC
Type o£License(s) being applied for:
11°t�A � P1�/1;�t�e
��i� I� r ,
4 L t?V
`Gtf[�y��.1/t e �
�C�'GC.vt - f' � �� �
Coiporation 1 PeRneiship 1 Sote
PLEASE TYPE OR PRINT IN IIvK
If business is incorporated, a�•e date of incoiporation:
Doing Business As: � 1 t5�, �,�.A a� .��i�-jf�
Business Address:
SCUtAddrcss
Between what cross streeu is the business located?
Are the premises now occupied? � VJhaY Type of Business?
'I"vlail To Address: �� 9 1s� `'i �' vY- .
s� nemzv
Name and Title: � �� f '�
b�i
?vtiddle
�
_
�
�
'� i �
� • �
�
_� , _�.
CI'IY OF SAlNT PAUL
�ce of L�cense, Lsspections
zna &nirovmrntal Protect;on
350 5:7� SC Stiic 3A
�`.?'+.�y' .�S6c�esota 5510]
(6l2)2oS9094 fuC612)26b912<
g�� I.�
�
S �,�„.
s -� ��7,�'
s ��E <T
c ;? 1'� �
Business Phone: � �.,'� — �3'j Z
1�"i r1�
State Zip
Wluch side of the street?
� �
s� z;P
�#� �. 1 � �
, Titic
Home Address: � `� �'�_ � �, ?�I�1 I`f'S a'T �%�f.t.� ��� �]���
s�n nae,<.� c;ry s�w ztp �
Date of Birrh: � o�- �, Place of Birth: �� �� �� � Home Phone: �`' , o� �'
Have you ever been comlcted of any felony, crime or ti�iolation of any city ordinance other than haffic? YES NO �
Date of arrest:
Chazge: _
Conviction:
VJhere?
List the names and residences of three persons of good moral character, living within the Twin Cities Metro Area, not related to the applicant
or financially interested in the premises or busines, who may be referred to as to tl�e applicant's character:
2�TAME
ADDRESS
Sentence:
� PHONE
'c�� �F;��rSO�r �a�7 I�EI}JE2 a��-ry, �t� �aan,v 11��r to�3
�s !� rz tJ a 2 s t o�.-� 1 h f� O t.� �s-f-s ft.r�3 {}c z 4�� i L�� /h � �$�' U i 9
-� f} il� p" h£ �� e r� � L(� t.�r�o�� �.2� 5�- Q,v f S�t.r�n ti �, r� �<fK � 5 i�'
,
List licenses which you cwrently hold, formerly held, or may ha`�e an interest in:
Have auy of the above named licenses ever
�%:
revoked7 YES /� 2�30 If yes, list the dates aad reasons for revocation:
2718197
Are you going to operate this business personally? _�`1 YES NO If not, �lfio will operate it?
���
$tmt?��emc
M;aa�� ���t
HOME
P.DDRESS
Are you going to have a aanagzs or assistant in this business? YES
plexse conp3ete the follo�xing informztion:
Fixst?:ame
Home Address: Stxcet \ame
I�Tiddic Initial
List all other officers of the coiporation:
OFFICER TI1I.E
NAME , � (Office Held)
N
�
Ci:c
(�kidcn)
Cirv
Detc of Birth
Stat� Zip Phone 1Jumber
� NO If the manager is not the sasne as the onerator,
I.ast
Stzte
HOME
PHO;�'E
�.3 �
a-
a�•�ss9
Zip
Datr of Birth
Phone Numbcr
DATE OF
BIItTH , 9 �
� -
v
�
If business is a partnetship, piease inc]ude tbe following informalion for each partner (use additional pages if necessary):
First\�c ?vfiddlcIititial (.Maidcn) Last DateofBirth
Home Addross: Streel
Finti:ame
Middle 3nitial
HomcAddxsse: Sh�ctN�e
City
BUSINESS
PHOA'E
�4R• c�o
fete Zip
I.ast
State Zip
Phone ISumbet
Phone Nnmber
MINf�'ESOTA TAX SDENTIFICATION NUMBER - Pursuant to the I,aws of Minnesotz, 1984, Chapter 502, Article 8, Section 2(270.72)
(TaY Cleazance; Issuance of Licenses), licensing authorities are required to provide to the State of Minnesota Commissioner of Revrnue, the
Minnesota business tar idrntification number and the social secunTy number of each license applicant.
Under the Minnesota Crovemment Data Practices 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 drny the issuance or renewal of your license in the event you owe Minnesota sales, employer s
withholding or motor vehicle excise taYes;
- Upon receiving this information, the licensing authoriry' will supply it oaly to the Minnesota Department of Revenue. However,
under the Federal Exchange of Information Agreement, the Depar[ment of Recenue may supply tlus information to the Intemal
Revenue Serc7ce.
Minnesota Tax Identi5cation Numbers (Sales & Use TaY Niunber) may be obtained from the State of Minnesota, Business Records Department,
10 River Park Plaza (612-246-6181).
Social Security Number. 7 7/- � c�- -�� �� Minnesota Tax IdentiScation Number: ,�� �o a` � a.
_ If a Minnesota Tax Identification Number is not required for the business being operated, indicate so by placing an°X" in the bok.
�,�!r
2/18/97
Ciry
(.Vfeidrn)
Please lisi your employment history for tlie pre��ious five (5) czar period:
CER cL ICATIQN OF WORKERS' CO2�/iPENSATION COVERAGE PURSUA\�T TO MINNESOTA STATUTE 176.182 �? �� S S�
I herehy certify that I, or my company, am in compliance nith the iaa:l:ers' compensation insurance coverage requirements of Minnesot2 Statute
17G.182, subdivision 2, I also understand that p;o��ision of iaise information in ihis certi5calion constitutes s�cient grounds for adverse action
against all licenses held, including revocation and suspension of said licenses.
I�'azne of Insurance Company:
Policy Numbzr: Co��erage from to
I have no emplo}'ees covered under n•orkers' compensation insurance (L�'ITIALS)
ANY FALSIFICATION OR AI�*SWERS GIVEN OR MATER3AL SUBNII'iTED
Vr'ILL RESULT IN pEI�'L�L OF THIS APPLICATION
I hereby state that I have ansu�ered all of the preceding questions, and that the information contzined herein is true and correct to the best of
my lmowledge and belief. I hereby state further that I have recei��ed no money or other consideratioq by k�ay of loan, gift, con�ihution, or
othetwise, other than already disclosed in the �plicalion wfiich I hereuith su6mitte�. I also understand this premise may be inspected by police,
fue, health and other city officials at any �zd all times when thz business is in operarion.
7
We will accept pa?�ment by cash, check (made payable to City of Saipt Paun or credit card (M/C or Visa).
(F PAYINC BY CREDIT CARD PLEASE COMPLETE THE FOLLON'ING INFORMATION: � MasterCard � Visa
�XPII2ATION DATE: ACCOUNI' NL7MBER:
C70iC7❑ ❑OC7❑ ❑C]�❑ ❑C70❑ ❑C7�❑
*�� of
Cazd
**Note: If this application is Food/Liquor related, p]ease contact a Ciry of Saint Paul Health Inspector, Steve Olson (266-9139), to re��iew
plans.
If any substantial changes to shvcture are anticipated, please contact a City of Saint Pau1 Plan Examiner at 256-9007 to apply for
building permits.
If there are any changes to the paricing }ot, floor space, or for new operations, please contact a Ciry of Saint Paul Zoning Inspector at
266-9008.
All applicarions requim ihe folloRing documents. Please attach these documents wfien submitting your application:
1. A detailed description of the design, location and square footage of the premises to be licensed (site plan).
The foIlowing data should be on the site plan (preferably on an 8 1/2" x I 1" or 8 1/2" x 14" paper):
- Nazne, address, and phone number.
- The scale should be stated such as I" = 20'. ^N should be indicated towazd the top.
- Placement of all pertinent features of the interior of the ]icensed facility such as seating ueas, kitchens, offices, repair area,
parking, rest rooms, efe.
- If a request is for an addifion or expansion of ffie licensed facility, indicate both the cturent azea and the proposed ehpansion.
2. A copy of your lease agreement or proof of ownership of the property.
SPECIkTC LICENSE APPLICATIONS REQUII2E ADDTTIONAL IiV�'ORMATION.
PLEA3E SEE REVERSE FOR DETAII,S >>>>
�:,
u:
2/IS/97