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97-515Council File # �� • S � 5 QRI��A�_ Ordinance # Green Sheet# 3543� Preaented By Referred To 1 RESOLVED: That application. ID #38832, fot new Liquor On Sale-C, Sunday On Sale 2 Liquoz, Restaurant (C) Limited, Entertainment Class A and Cigarette 3 Licenses by A1ee, inc. DBA Bouzbon Bar (Cecilia J. Rendon - Mgr./Owner) 4 at 641 Dale St_ N., be and the same are hereby appraved with the 5 following condition: 1. Must obtain a current Certificate of Occupancy to occupy the building. 6 7 6 9 10 11 12 13 14 Adopted by Council: Date �j`� Adoption Certified by Council Secretary By: Approved By: Date Requested by Department of: • - -�-- �_•' '�= -.r•. - - - -'-- :,�-:_ - : BY: C�.,�..� �-,�� Form Approved by City Attorney �..I Approved by Mayor for Submission to Council By: RESOLUTION CITY OF SAINT PAUL, MINNESOTA 3� _.. °I�-SlS DEPARTMENT/OFFICE/COUNCIL DATEINRIATED GREEN SHEE N� 35437 LZEP - CONTACTPERSON&PHONE �DEPAqTMEMDIqECTOR �CffYCqUNGL �N�T�AU�ATE A�N CfiYATTORNEY CrtYCLERK Christine Rozek - 266-4108 M��p� � � MUST BE ON CqUNdL AGENDA BV (DAi� � ��N� � BUDGET DIflECfOq O FlN. 8 MCai SEfiVICES DIR. ORDFA O MAYOH (OR ASSISTANT) O 1 TOTAL # OA SIGNASURE P ES (CL1P ALL LOCA7fONS FOR SIGNATURE) ACf10N REQUESiED: Alee, Inc. DBA Bourbon Sar (Cecilia J. &endon - Mgr./Owner) requests Council approval of its application for a Liquor On Sa1e'- C, Sunday On Sa1e Liquor, Restaurant (C) Limited, Entertainment Class A and Gigarette Licenses located at 691 Da1e St. N. (ID �35832) RECOMMENDATIONS: Apprwe (A) w Reject (R) pERSONAL SERVICE CONTRACTS MUST ANSWER THE FOLLOWING QUESTIONS: __ PIANNtNG C�MM4SSI�N _ G�VI(, SERVIGE WMMfSS1�N �� Has this per5o�rtn ever worked under a ContraCt fOr this tlepertment? - _ CB CoMtdITTEE _ YES NO _ S7AFF 2. Has fhis person�rm ever been a city employee,? — YES NO _ OISTAICi COURT _ 3. Does this personttirm possess a skill not normai{y possessetl by any cuireM city emplqee? SUPPORfSWNICHCAUNC0.0&IECf1VE4 YES NO Explain all yas answers on saperate sheet antl attaeh to green sheet INITIATiNG PFiOBLEM. ISSUE. OPPORTUNITY (W1w. What, When. Wltere, Why): ' -a � �`k �: fty � M G �v: E+ 3 � : �< .,., i� �3 �:, � ��: �1V�� Ja�V i � I997 ��;2 4 - 199� ��°� :>> �� E�. JERRY BtAKEy ADVANTAGES IFAPPROVED: DISADVANTAGES IFAPPpOVE�: ��tCii1� �?��[Ch � R6�Y� Q � 4��% DISADVANTAGES 1F NOT APPpOVED: TOTAI, AMOUNT OF THANSACTION $ COST7REYENUE BUDGETED (CIRCLE ONE) YES NO FUNDIHG SOURCE ACTIVITY NUMBER FINANCfAL INWRMATION: (EXPLAIN) Greensneet # 35437 L.I.E.P. REVIEW CHECKLIST In Trackef? q�-s�s APP'n Received J App'n Processed Liquor On Sale - C, Sunday On Sale Liquor, Restaurant LicenselD # 38832 License Type: (C) Limited, Entertainment Class A& Cigarette Company Name_ Alee Inc. DBA: Bourbon Bar Susiness Addresss: 691 Dale St. N. Business Pfione: 489-8481 Contact NameJAddress: Cecilia J. Rendon - MRr. /Owner Home Phone: 489-8481 Date to Council Research: >/� PuMic Hearing Date:� � / % � Notice Sent to Applicant: _ r i9_l�A�� -�� Notice Sent to Department/ City Attomey Date Inspections zZ,9 � Environmental Heaith .22 � � Fire License Police Zoning 3.Z�.9� ��n � 35�ya3 ti doaS Labels Ordered:_T�`1f97 District Council #: �� Ward #: Comments n. ,� _ �. � • � ��, C`' �`."�`�' J '�'' � j � 7 V � �'.4'� » s — `�`� �-t� C.t�-� �t' � tk �'1 vv�a.� �C�cdi� �1eCt� �G�L�� •2�•9�- �• K • Site Pian Received:_ (8858 f�BCBIVBd: [ . 2 2 �� o. � . ° I�-S1�5 � U vu �� r v � Type of� G co��y n��: � if business is iQCC Doing Business As: Husiness Address: CLASS III LICENSE APPLICATION CITY OF SAIN1' pA UI, oSrce of Licease, �� and Fs�tironmrn W Pratation 73�5�. Paa h Srme 3pp 6 m � M�^a�au S51@ Y1 9090 fu(6I�S66-913< 77iIS APPLICATIO'.r IS SUBJEC7' 7'p RE� &y � pUBLIC YLEASE T7'PE OR P�T liy A�K O n Scc. l e^d-s�t,c. � t � u, � r � i U(� u �'` � Cocporation / Parmvship / SoSe Stra.[Address ,— Bem�een wba� �ross streets is the b ]ocated? Are the premises now o 12.5 Mai] To Address: N N' � n� n ., �� sva�aam�s Applicant Infor¢�auon: Y �'ame and 7'it1e: ��r � First _'_ZU" �C�J oe�c Z� Which side of the sveet? wP.S � Zip r ,. nvaaie f . _— � ,� t p Home Address: ��" • . �� / �d�� Jes- '�o.� �rlcf �oi. lL� i� ) r C�ir Strmt Ad Date of Birth: '� L cicy Suie Place of Binh: �_ � Z 'P ° �� T �---___ Home Phone: Have you ever been coovicted f any felony, criva or tiriolation of aoy c1ty ordinance ot6et than V��p y�! NO �� Date of arresr «'6ere? Charge: Conviction: List the names and residences of three persons of good moral chazacter,�ln �g within che Twin Cities Metro Area, not related to t6e aPPlkant or financially interested in t�e Premius or business, who may }� referred to as to the applicanPs chazacter: _-. �'�ME .,.......-- PHONE List $censes whicb you cuirendy bo]d, fomr_rIy 6e)d, or may bave ao interest in: Nave any of the above nazned licenses ever been revoked? __ yEg _�,O If yes, list the dates and reazons for revocation: � '� Yo� going to operate tbis business C l� � J�vst Name Midd 691 N. �(� �n� j Home Addrus. Streu Name �` being applied for. IIliUB� —� vIv'O If noG who�viil operau it? ��:�� .z. Ciry UIG � / "_'ll /O/,J-�/� Date of Binh �sir� u �7 �-r� � � P Phonc Numbcr T �going to have a manager or acsic�t ��s business? �� _�0 ,.nplc�e rhe foilowing in{ormation: If the manager is not the sazne ac the op�ry�or, ple�se �7�5'S Last u..,.,. e aw. Gry List all other officers of the corporation: OFFtCER 'tIIlE h0;� � T � ' � � � �` � '¢ [ � (Office Held) ADDRE< INl zL/ 1 ! 'O��Yw/J/1 .� ''� �/'fGL,fr� � If � sin�ss is a pazmership, please i�dude the following � Date Home Addras: S¢e�ame2. First Name Hoine qddteSS; Strut Nam. �Q� BUSINESS PHONE PHO\'E � ' n for e h parmer (use additionai pa es if nece�s G � � , � �1zi en) Lasc - . �-� � ym�. 5� C �ty State 7� �faiden) last Ciry s,�,. o:_ DATE OF B�� a �. z � _ Dam of F Phone of B'uth MIT'I�'ESOTA TAX IDEI�''IIF[Cq'I�ON I�°Ut,1ggZ _ p�y�y�t to the Iaws of J�+I'innesota, 1984, Chapter 502, Article 8, Sution 2(270.72) (T� Clearance; Issuance of Licenses), licensing authoriuea are required tp provide to tbe State of Mionesota Commissiooer of Revenue, il�a Minnesota business t,a�c ideotification number ynd the so,:�y� security number of each license applicant. Under the Minnesota Govemrrent Data Ptacums Act aod tbe Federal Peivacy qct of 1974, we are required to advise you of the following regarding t6e use of t6e Minnesota Tax Ickntification h'umSer: � m'S'°f°'n'ati°° �Y y� �sed a-deay the issuaoce or renewai of your liceose in the event you owe Minnesota sales, employer s witfiholding or motor vehic]e ezcise tazes; - Upon receiving this infor�ytioq the licensiog authoriry will suppiy it only to the Minnesota Deparm�ent of Revenue. However, under tbe Federal Exchange of Information Agreement, tbe Departn�ent of Kevenue may supp3y this information to the Intemal Revenue Ser�•ice, Minnesota Taz Identificadon I�umbets (Sales Br Use Taz \umber) may }� obtained fiom the State of Minnesota, Business Records �P�ment, 10 River Pazk Plaza (612-296-618I ), Social Security Number: �� —R 7 r 3 Minnesota Taz ldentification 1.'umber. 7 �( � ` /'. _____ If a Minnesou Taz Identi}ication lnmber is not requued fot the business being operated, (ndicate so b,v placing an "X" in the boz. __._ uP PSwneNumber P7ease list your employ�n� �stocy for thc precious five (7 }•ear period: Business/Emn�avmem Council File # �� • S � 5 QRI��A�_ Ordinance # Green Sheet# 3543� Preaented By Referred To 1 RESOLVED: That application. ID #38832, fot new Liquor On Sale-C, Sunday On Sale 2 Liquoz, Restaurant (C) Limited, Entertainment Class A and Cigarette 3 Licenses by A1ee, inc. DBA Bouzbon Bar (Cecilia J. Rendon - Mgr./Owner) 4 at 641 Dale St_ N., be and the same are hereby appraved with the 5 following condition: 1. Must obtain a current Certificate of Occupancy to occupy the building. 6 7 6 9 10 11 12 13 14 Adopted by Council: Date �j`� Adoption Certified by Council Secretary By: Approved By: Date Requested by Department of: • - -�-- �_•' '�= -.r•. - - - -'-- :,�-:_ - : BY: C�.,�..� �-,�� Form Approved by City Attorney �..I Approved by Mayor for Submission to Council By: RESOLUTION CITY OF SAINT PAUL, MINNESOTA 3� _.. °I�-SlS DEPARTMENT/OFFICE/COUNCIL DATEINRIATED GREEN SHEE N� 35437 LZEP - CONTACTPERSON&PHONE �DEPAqTMEMDIqECTOR �CffYCqUNGL �N�T�AU�ATE A�N CfiYATTORNEY CrtYCLERK Christine Rozek - 266-4108 M��p� � � MUST BE ON CqUNdL AGENDA BV (DAi� � ��N� � BUDGET DIflECfOq O FlN. 8 MCai SEfiVICES DIR. ORDFA O MAYOH (OR ASSISTANT) O 1 TOTAL # OA SIGNASURE P ES (CL1P ALL LOCA7fONS FOR SIGNATURE) ACf10N REQUESiED: Alee, Inc. DBA Bourbon Sar (Cecilia J. &endon - Mgr./Owner) requests Council approval of its application for a Liquor On Sa1e'- C, Sunday On Sa1e Liquor, Restaurant (C) Limited, Entertainment Class A and Gigarette Licenses located at 691 Da1e St. N. (ID �35832) RECOMMENDATIONS: Apprwe (A) w Reject (R) pERSONAL SERVICE CONTRACTS MUST ANSWER THE FOLLOWING QUESTIONS: __ PIANNtNG C�MM4SSI�N _ G�VI(, SERVIGE WMMfSS1�N �� Has this per5o�rtn ever worked under a ContraCt fOr this tlepertment? - _ CB CoMtdITTEE _ YES NO _ S7AFF 2. Has fhis person�rm ever been a city employee,? — YES NO _ OISTAICi COURT _ 3. Does this personttirm possess a skill not normai{y possessetl by any cuireM city emplqee? SUPPORfSWNICHCAUNC0.0&IECf1VE4 YES NO Explain all yas answers on saperate sheet antl attaeh to green sheet INITIATiNG PFiOBLEM. ISSUE. OPPORTUNITY (W1w. What, When. Wltere, Why): ' -a � �`k �: fty � M G �v: E+ 3 � : �< .,., i� �3 �:, � ��: �1V�� Ja�V i � I997 ��;2 4 - 199� ��°� :>> �� E�. JERRY BtAKEy ADVANTAGES IFAPPROVED: DISADVANTAGES IFAPPpOVE�: ��tCii1� �?��[Ch � R6�Y� Q � 4��% DISADVANTAGES 1F NOT APPpOVED: TOTAI, AMOUNT OF THANSACTION $ COST7REYENUE BUDGETED (CIRCLE ONE) YES NO FUNDIHG SOURCE ACTIVITY NUMBER FINANCfAL INWRMATION: (EXPLAIN) Greensneet # 35437 L.I.E.P. REVIEW CHECKLIST In Trackef? q�-s�s APP'n Received J App'n Processed Liquor On Sale - C, Sunday On Sale Liquor, Restaurant LicenselD # 38832 License Type: (C) Limited, Entertainment Class A& Cigarette Company Name_ Alee Inc. DBA: Bourbon Bar Susiness Addresss: 691 Dale St. N. Business Pfione: 489-8481 Contact NameJAddress: Cecilia J. Rendon - MRr. /Owner Home Phone: 489-8481 Date to Council Research: >/� PuMic Hearing Date:� � / % � Notice Sent to Applicant: _ r i9_l�A�� -�� Notice Sent to Department/ City Attomey Date Inspections zZ,9 � Environmental Heaith .22 � � Fire License Police Zoning 3.Z�.9� ��n � 35�ya3 ti doaS Labels Ordered:_T�`1f97 District Council #: �� Ward #: Comments n. ,� _ �. � • � ��, C`' �`."�`�' J '�'' � j � 7 V � �'.4'� » s — `�`� �-t� C.t�-� �t' � tk �'1 vv�a.� �C�cdi� �1eCt� �G�L�� •2�•9�- �• K • Site Pian Received:_ (8858 f�BCBIVBd: [ . 2 2 �� o. � . ° I�-S1�5 � U vu �� r v � Type of� G co��y n��: � if business is iQCC Doing Business As: Husiness Address: CLASS III LICENSE APPLICATION CITY OF SAIN1' pA UI, oSrce of Licease, �� and Fs�tironmrn W Pratation 73�5�. Paa h Srme 3pp 6 m � M�^a�au S51@ Y1 9090 fu(6I�S66-913< 77iIS APPLICATIO'.r IS SUBJEC7' 7'p RE� &y � pUBLIC YLEASE T7'PE OR P�T liy A�K O n Scc. l e^d-s�t,c. � t � u, � r � i U(� u �'` � Cocporation / Parmvship / SoSe Stra.[Address ,— Bem�een wba� �ross streets is the b ]ocated? Are the premises now o 12.5 Mai] To Address: N N' � n� n ., �� sva�aam�s Applicant Infor¢�auon: Y �'ame and 7'it1e: ��r � First _'_ZU" �C�J oe�c Z� Which side of the sveet? wP.S � Zip r ,. nvaaie f . _— � ,� t p Home Address: ��" • . �� / �d�� Jes- '�o.� �rlcf �oi. lL� i� ) r C�ir Strmt Ad Date of Birth: '� L cicy Suie Place of Binh: �_ � Z 'P ° �� T �---___ Home Phone: Have you ever been coovicted f any felony, criva or tiriolation of aoy c1ty ordinance ot6et than V��p y�! NO �� Date of arresr «'6ere? Charge: Conviction: List the names and residences of three persons of good moral chazacter,�ln �g within che Twin Cities Metro Area, not related to t6e aPPlkant or financially interested in t�e Premius or business, who may }� referred to as to the applicanPs chazacter: _-. �'�ME .,.......-- PHONE List $censes whicb you cuirendy bo]d, fomr_rIy 6e)d, or may bave ao interest in: Nave any of the above nazned licenses ever been revoked? __ yEg _�,O If yes, list the dates and reazons for revocation: � '� Yo� going to operate tbis business C l� � J�vst Name Midd 691 N. �(� �n� j Home Addrus. Streu Name �` being applied for. IIliUB� —� vIv'O If noG who�viil operau it? ��:�� .z. Ciry UIG � / "_'ll /O/,J-�/� Date of Binh �sir� u �7 �-r� � � P Phonc Numbcr T �going to have a manager or acsic�t ��s business? �� _�0 ,.nplc�e rhe foilowing in{ormation: If the manager is not the sazne ac the op�ry�or, ple�se �7�5'S Last u..,.,. e aw. Gry List all other officers of the corporation: OFFtCER 'tIIlE h0;� � T � ' � � � �` � '¢ [ � (Office Held) ADDRE< INl zL/ 1 ! 'O��Yw/J/1 .� ''� �/'fGL,fr� � If � sin�ss is a pazmership, please i�dude the following � Date Home Addras: S¢e�ame2. First Name Hoine qddteSS; Strut Nam. �Q� BUSINESS PHONE PHO\'E � ' n for e h parmer (use additionai pa es if nece�s G � � , � �1zi en) Lasc - . �-� � ym�. 5� C �ty State 7� �faiden) last Ciry s,�,. o:_ DATE OF B�� a �. z � _ Dam of F Phone of B'uth MIT'I�'ESOTA TAX IDEI�''IIF[Cq'I�ON I�°Ut,1ggZ _ p�y�y�t to the Iaws of J�+I'innesota, 1984, Chapter 502, Article 8, Sution 2(270.72) (T� Clearance; Issuance of Licenses), licensing authoriuea are required tp provide to tbe State of Mionesota Commissiooer of Revenue, il�a Minnesota business t,a�c ideotification number ynd the so,:�y� security number of each license applicant. Under the Minnesota Govemrrent Data Ptacums Act aod tbe Federal Peivacy qct of 1974, we are required to advise you of the following regarding t6e use of t6e Minnesota Tax Ickntification h'umSer: � m'S'°f°'n'ati°° �Y y� �sed a-deay the issuaoce or renewai of your liceose in the event you owe Minnesota sales, employer s witfiholding or motor vehic]e ezcise tazes; - Upon receiving this infor�ytioq the licensiog authoriry will suppiy it only to the Minnesota Deparm�ent of Revenue. However, under tbe Federal Exchange of Information Agreement, tbe Departn�ent of Kevenue may supp3y this information to the Intemal Revenue Ser�•ice, Minnesota Taz Identificadon I�umbets (Sales Br Use Taz \umber) may }� obtained fiom the State of Minnesota, Business Records �P�ment, 10 River Pazk Plaza (612-296-618I ), Social Security Number: �� —R 7 r 3 Minnesota Taz ldentification 1.'umber. 7 �( � ` /'. _____ If a Minnesou Taz Identi}ication lnmber is not requued fot the business being operated, (ndicate so b,v placing an "X" in the boz. __._ uP PSwneNumber P7ease list your employ�n� �stocy for thc precious five (7 }•ear period: Business/Emn�avmem Council File # �� • S � 5 QRI��A�_ Ordinance # Green Sheet# 3543� Preaented By Referred To 1 RESOLVED: That application. ID #38832, fot new Liquor On Sale-C, Sunday On Sale 2 Liquoz, Restaurant (C) Limited, Entertainment Class A and Cigarette 3 Licenses by A1ee, inc. DBA Bouzbon Bar (Cecilia J. Rendon - Mgr./Owner) 4 at 641 Dale St_ N., be and the same are hereby appraved with the 5 following condition: 1. Must obtain a current Certificate of Occupancy to occupy the building. 6 7 6 9 10 11 12 13 14 Adopted by Council: Date �j`� Adoption Certified by Council Secretary By: Approved By: Date Requested by Department of: • - -�-- �_•' '�= -.r•. - - - -'-- :,�-:_ - : BY: C�.,�..� �-,�� Form Approved by City Attorney �..I Approved by Mayor for Submission to Council By: RESOLUTION CITY OF SAINT PAUL, MINNESOTA 3� _.. °I�-SlS DEPARTMENT/OFFICE/COUNCIL DATEINRIATED GREEN SHEE N� 35437 LZEP - CONTACTPERSON&PHONE �DEPAqTMEMDIqECTOR �CffYCqUNGL �N�T�AU�ATE A�N CfiYATTORNEY CrtYCLERK Christine Rozek - 266-4108 M��p� � � MUST BE ON CqUNdL AGENDA BV (DAi� � ��N� � BUDGET DIflECfOq O FlN. 8 MCai SEfiVICES DIR. ORDFA O MAYOH (OR ASSISTANT) O 1 TOTAL # OA SIGNASURE P ES (CL1P ALL LOCA7fONS FOR SIGNATURE) ACf10N REQUESiED: Alee, Inc. DBA Bourbon Sar (Cecilia J. &endon - Mgr./Owner) requests Council approval of its application for a Liquor On Sa1e'- C, Sunday On Sa1e Liquor, Restaurant (C) Limited, Entertainment Class A and Gigarette Licenses located at 691 Da1e St. N. (ID �35832) RECOMMENDATIONS: Apprwe (A) w Reject (R) pERSONAL SERVICE CONTRACTS MUST ANSWER THE FOLLOWING QUESTIONS: __ PIANNtNG C�MM4SSI�N _ G�VI(, SERVIGE WMMfSS1�N �� Has this per5o�rtn ever worked under a ContraCt fOr this tlepertment? - _ CB CoMtdITTEE _ YES NO _ S7AFF 2. Has fhis person�rm ever been a city employee,? — YES NO _ OISTAICi COURT _ 3. Does this personttirm possess a skill not normai{y possessetl by any cuireM city emplqee? SUPPORfSWNICHCAUNC0.0&IECf1VE4 YES NO Explain all yas answers on saperate sheet antl attaeh to green sheet INITIATiNG PFiOBLEM. ISSUE. OPPORTUNITY (W1w. What, When. Wltere, Why): ' -a � �`k �: fty � M G �v: E+ 3 � : �< .,., i� �3 �:, � ��: �1V�� Ja�V i � I997 ��;2 4 - 199� ��°� :>> �� E�. JERRY BtAKEy ADVANTAGES IFAPPROVED: DISADVANTAGES IFAPPpOVE�: ��tCii1� �?��[Ch � R6�Y� Q � 4��% DISADVANTAGES 1F NOT APPpOVED: TOTAI, AMOUNT OF THANSACTION $ COST7REYENUE BUDGETED (CIRCLE ONE) YES NO FUNDIHG SOURCE ACTIVITY NUMBER FINANCfAL INWRMATION: (EXPLAIN) Greensneet # 35437 L.I.E.P. REVIEW CHECKLIST In Trackef? q�-s�s APP'n Received J App'n Processed Liquor On Sale - C, Sunday On Sale Liquor, Restaurant LicenselD # 38832 License Type: (C) Limited, Entertainment Class A& Cigarette Company Name_ Alee Inc. DBA: Bourbon Bar Susiness Addresss: 691 Dale St. N. Business Pfione: 489-8481 Contact NameJAddress: Cecilia J. Rendon - MRr. /Owner Home Phone: 489-8481 Date to Council Research: >/� PuMic Hearing Date:� � / % � Notice Sent to Applicant: _ r i9_l�A�� -�� Notice Sent to Department/ City Attomey Date Inspections zZ,9 � Environmental Heaith .22 � � Fire License Police Zoning 3.Z�.9� ��n � 35�ya3 ti doaS Labels Ordered:_T�`1f97 District Council #: �� Ward #: Comments n. ,� _ �. � • � ��, C`' �`."�`�' J '�'' � j � 7 V � �'.4'� » s — `�`� �-t� C.t�-� �t' � tk �'1 vv�a.� �C�cdi� �1eCt� �G�L�� •2�•9�- �• K • Site Pian Received:_ (8858 f�BCBIVBd: [ . 2 2 �� o. � . ° I�-S1�5 � U vu �� r v � Type of� G co��y n��: � if business is iQCC Doing Business As: Husiness Address: CLASS III LICENSE APPLICATION CITY OF SAIN1' pA UI, oSrce of Licease, �� and Fs�tironmrn W Pratation 73�5�. Paa h Srme 3pp 6 m � M�^a�au S51@ Y1 9090 fu(6I�S66-913< 77iIS APPLICATIO'.r IS SUBJEC7' 7'p RE� &y � pUBLIC YLEASE T7'PE OR P�T liy A�K O n Scc. l e^d-s�t,c. � t � u, � r � i U(� u �'` � Cocporation / Parmvship / SoSe Stra.[Address ,— Bem�een wba� �ross streets is the b ]ocated? Are the premises now o 12.5 Mai] To Address: N N' � n� n ., �� sva�aam�s Applicant Infor¢�auon: Y �'ame and 7'it1e: ��r � First _'_ZU" �C�J oe�c Z� Which side of the sveet? wP.S � Zip r ,. nvaaie f . _— � ,� t p Home Address: ��" • . �� / �d�� Jes- '�o.� �rlcf �oi. lL� i� ) r C�ir Strmt Ad Date of Birth: '� L cicy Suie Place of Binh: �_ � Z 'P ° �� T �---___ Home Phone: Have you ever been coovicted f any felony, criva or tiriolation of aoy c1ty ordinance ot6et than V��p y�! NO �� Date of arresr «'6ere? Charge: Conviction: List the names and residences of three persons of good moral chazacter,�ln �g within che Twin Cities Metro Area, not related to t6e aPPlkant or financially interested in t�e Premius or business, who may }� referred to as to the applicanPs chazacter: _-. �'�ME .,.......-- PHONE List $censes whicb you cuirendy bo]d, fomr_rIy 6e)d, or may bave ao interest in: Nave any of the above nazned licenses ever been revoked? __ yEg _�,O If yes, list the dates and reazons for revocation: � '� Yo� going to operate tbis business C l� � J�vst Name Midd 691 N. �(� �n� j Home Addrus. Streu Name �` being applied for. IIliUB� —� vIv'O If noG who�viil operau it? ��:�� .z. Ciry UIG � / "_'ll /O/,J-�/� Date of Binh �sir� u �7 �-r� � � P Phonc Numbcr T �going to have a manager or acsic�t ��s business? �� _�0 ,.nplc�e rhe foilowing in{ormation: If the manager is not the sazne ac the op�ry�or, ple�se �7�5'S Last u..,.,. e aw. Gry List all other officers of the corporation: OFFtCER 'tIIlE h0;� � T � ' � � � �` � '¢ [ � (Office Held) ADDRE< INl zL/ 1 ! 'O��Yw/J/1 .� ''� �/'fGL,fr� � If � sin�ss is a pazmership, please i�dude the following � Date Home Addras: S¢e�ame2. First Name Hoine qddteSS; Strut Nam. �Q� BUSINESS PHONE PHO\'E � ' n for e h parmer (use additionai pa es if nece�s G � � , � �1zi en) Lasc - . �-� � ym�. 5� C �ty State 7� �faiden) last Ciry s,�,. o:_ DATE OF B�� a �. z � _ Dam of F Phone of B'uth MIT'I�'ESOTA TAX IDEI�''IIF[Cq'I�ON I�°Ut,1ggZ _ p�y�y�t to the Iaws of J�+I'innesota, 1984, Chapter 502, Article 8, Sution 2(270.72) (T� Clearance; Issuance of Licenses), licensing authoriuea are required tp provide to tbe State of Mionesota Commissiooer of Revenue, il�a Minnesota business t,a�c ideotification number ynd the so,:�y� security number of each license applicant. Under the Minnesota Govemrrent Data Ptacums Act aod tbe Federal Peivacy qct of 1974, we are required to advise you of the following regarding t6e use of t6e Minnesota Tax Ickntification h'umSer: � m'S'°f°'n'ati°° �Y y� �sed a-deay the issuaoce or renewai of your liceose in the event you owe Minnesota sales, employer s witfiholding or motor vehic]e ezcise tazes; - Upon receiving this infor�ytioq the licensiog authoriry will suppiy it only to the Minnesota Deparm�ent of Revenue. However, under tbe Federal Exchange of Information Agreement, tbe Departn�ent of Kevenue may supp3y this information to the Intemal Revenue Ser�•ice, Minnesota Taz Identificadon I�umbets (Sales Br Use Taz \umber) may }� obtained fiom the State of Minnesota, Business Records �P�ment, 10 River Pazk Plaza (612-296-618I ), Social Security Number: �� —R 7 r 3 Minnesota Taz ldentification 1.'umber. 7 �( � ` /'. _____ If a Minnesou Taz Identi}ication lnmber is not requued fot the business being operated, (ndicate so b,v placing an "X" in the boz. __._ uP PSwneNumber P7ease list your employ�n� �stocy for thc precious five (7 }•ear period: Business/Emn�avmem