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97-517g- � � �' � �'1 �� `.� � a � :`°l � < Council File # �� ordinance # Green Sheet # `1s�'O� Presented By Referred To RESOLUTION SA1NT PAUL, MINNESOTA Committee: Date 3� i 2 3 RESOLVED: That application (ID #31405) for an Off 5ale Malt, Cigazette, and Grocery-C License by Hidden Falls Food Mazket DBA Hidden Falls Food Mazket (Reem Wadi, co-owner) aY 1040 Cleveland Avenue South be and the same is hereby approved. 4 5 6 � Navs — 7 B a — — 8 Bostrom 9 � H a r r is — 10 e rd — 11 — 13 vne �,. _ 14 � — 15 16 Adopted by Council: Date � 17 18 Adoption Certified by Council Sec � 19 20 � 21 By. ,. �a\� 22 � c � 23 Approved by� r: Date �/✓ j 24 `C��i`� ",6�- 25 26 By; 27 Requested by Department of: • - -,-- �-!- -e- ,�e �. - - -� - -�--- �s�-i. ;� By: � � � �� Form Approved by City Attorney Approved by Mayor for Submission to Council By: � DEPAFiTMENT/OFFICFJCOUNCIL DATEINffiATEO GREEN SHEE N_ 35309 I,IEPJI,icensin - -- COMACT PFA$ON 8 PHONE INRIAUDATE INITIAUDATE � DEPApTMENT DIAECTOR � C1TY COUNCII Christine Rozek, 266-9108 ^�G+ �cmarroaNev �cmc�nK MUST BE ON COUNqL AGENOA BY (DA'fE) /� p�jm�� BUDGET DIRECTOR O FIN. & MGT. SEAYICES �IR. r'OL hearin : S'� Z? OqDEB ❑�y��OR�n�A� � TOTAL # OF SIGNATURE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE) AC{iWl R£WES7ED: Hidden Falls Food MaYket DBA Hidden Fa11s Food Market requests Council approval of its application £or an Off Sale Malt, Cigaxetta, and Grocery-C License located at 1040 Cleveland Avenue South (ID Ii31405). RECOMMENDATONS: Approve (A} or Rajeq (R) pERSONAL SERViCE CONTRACSS MUSS ANSWER TXE FOLLOWING QUESTIONS: _ PLANNING COMMISSION _ CNIL SEfiY�CE COMMISSION �� Has ihis perSONFittn ever worked untler a contract For this depertment? � _ CIB COMMIrtEE _ YES NO —�� _ 2. Has this person/firm ever been a city emplqree? YES NO _ otSTRICi CoUR7 _ 3. Dces this persoMirm possess a skill not normally possessed by arry current city employee? SUPPOqTS WHICH COUNCIL O&IECi1VET YES NO Explain all yes answero on separate sheet and attech to green sheet INITATING PROBLEM. iSSUE, OPPORTUNI'fY (Wlq. Whet, When, Where, Why): ADVANTAGES IFAPPROVED: DISADVANTAGES IFAPPROVED: is11�.�,�"e�� e*�``�`��4..'�',�1 4.+�Rit� RF� Q 4 ��7 ��., DISAOVMITAGES lF N�7 APPRQYED: - TOTAL AMOUNT OF TNANSACTION S COST/qEVENUE BUDGETED (CIHCLE ONE) YES NO FUNDIHG SOURCE ACTIVI7Y NUMHER FINANCIAL INFORMATION: (EXPLAIN) Greensheet # 35309 L.I.E.P. REVIEW CHECKUST Date: 3/4/97 � 9'�-5 j'T !n Tracker? apP'n aece�ved / aPp'n arxessed license 1D # 31405 License Type: Off Sale Malt C� garPrte ana rr or�_r CompaRy Name: Hidden Falls Food M?rket DBA: same Business Addresss: 1040 Cleveland Averna Cnnth Business Phone: gs9-4349 Contact NamejAddress: Reem Wadi, 802 W Co Rd D��119 Home Phone: 639-1156 ew rig ton> Date to Councii Research: PubliC Hearing Date: � Notice Sent to Appficant: � Notice Serd to Public: �� !� 7! �� Labels Ordered: �/// � � Disirict Council #: / � Ward � Department/ Date Inspections Comments City Attomey 3•bf •`t� . �. . Environmental Heaith �.2g•�� - K � Fire .�y.9 �� . License Site Plan Recaived:_ Lease Received: 1��'��37 ��.. Potice 3•{1•9� o.�K • Zoning 3•l1-9�- p�' � �(�o�' CLASS III CITY OF SAIN �?UL �� LICENSE APPLICATION �"� `""�`,''�""�"� �a �.;�o,�,�i r�o��n;� 330 SL Ptla Sc Svh 300 $avVyui,\{��plp 55101 (61l)166909p !u(6i3)366911d THIS APPLICATION IS SUBJECT TO REVIEW BY THE PUBLIC Type of License(s) being applied for: S G•�� s 3 j�� $ ��b� $ $ Company I�Tazne: S O� � r'� Q•{ i E'�O✓ 51-n � Corporation / Partnaship / Sole Proprietorship If business is incorporated, p� e date of incorporation: N�/� Doing Business As: HLD�E� F�1��- S �oofl N1 1c i Business Phone: Business Address: _/� yo S <_ �a� €1 �.N.� A�ie S�'. (�� M�J � j 1�� svicet Aadrcss city smte zip Beh��een what cross meets is the business ]ocated? __ _ R'lrich side of the street? Are the premises nou� occupied? � R�hat T}Pe of Business? MailToAddress: �°�(o S C�evtXa�r.� hJQ �SU6 � SVeel Addrae City Sfate Zip Applicant Informati Nameand7iile: lC�E/� � � W{�� pW`^n�� First :.Sddle (Maidut7 1,s4 Trtle Home Address: �oz- � C� iQ� � y�. �\y �✓ew (3t.��k�*n ,��✓ J i 112 � S}JCC(.4ddIC53 CITy' SIBIC ZIP Date of Birth: / o-2� - 66 Place of Buth: �v��.l� Home Phone: 63°� i 1 j(� Have you eva been com�icted of any felony, crime or vioIalion of any city ordinance othet than traffic? YES NO _S(_ Date of arresC Chazge: _ Com•iction: Where? Senience: List ihe names and residences of three persons of good mozal character, Iiving w'ithin ihe TN�in Cilies Metro Area, not related to the applicant or financiall}' interested in the premises or basiness, who ma}' be referred to as to the applicanYs chazacter: Ha�•e any of the abo��e named licenses e�•er been rcvoked? YES NO Ifyes, list the dates and reasons for re��ocation 2; } 8%97 PLEASE TYPE OR PRINT IN INK List licenses �chich }�ou currentlp hold, fonnerly held, or ma}' ha��e an interest in: ,,. Are }•ou going to operate ilvs business personally? �_ YES NO If not, �cho will operate it? Q� �,S �� First�ame Home Addrev: Sircct \ame /ve }�ou going to hace a manager or assistant in ttus business7 p3ease complete the follon�ing informalion: Fvst ��e HomeAddress: S4cct\ame Please list your emplo}ment tristory for the pre�hous five (5) } ear period: Business/Emploc�nent Address t,sst Stete Zip Phone\�ber I,est Slate Zip Dace of airlh Phonc \�ber �Oti($ p Lu i � �4 List all other officers of the corporation: OFFICER TITLE HOME NAME (Office Held) ADDRESS HOME BUSINESS DATE OF PHONE PH023E BII2TH If business is a partnership, please include the following information for each partner (use additional pages if necessaz}�): n% �� Middlc Iniliel \fiddle Initial Middle Initid Cin' YES ,�c_ NO If the manager is not the sazne u the operator, Cih' (�laidrn) Home Add'sss: SUeet \eme Fint�ame �iti� (�iaidrn) Nome Add'es+: Strttt I�ame City Last State I.est Sinte Date of Birth Zip Phone \umber Date of Binh Zip P6one\umbcr MINNESOTA TAX IDENTIFICATIO23 NUMBER - Pursuant to the Iaa�s of Minnesota, 1984, Chapter 502, Ariicle 8, Section 2(270.72) (Ta� Clearance; Issuance of Licenses), licensing authorities are required to pro�'ide to the State of Minnesota Commissioner of Revenue, the Minnesota business ta� identification number and the social security number of each license applicant. Under the Minnesota Crovemment Data Practices Act and the Federal Privacy Act of 1974, we aze requued to ad�7se you of the following regarding the use of ihe Minnesota Tax Identification Number: - This information may be used to deny the issuance or renewal of }'our license in the event }'ou o�re Miiuiesota sales, employer s atithholding or motor vehicle escise tazes; - Upon recei��ing this information, ihe licensing authoriry H�ill supply it only to ihe Minnesota Department of Re�•enue. Hon�ever, under the Federal Erchange of Information Agreemrnt, the Department of Re�•enue may supply this information to the Intemal Revenue Senice. 1�tinnesots Ta� Identi5cation Numbers (Sales & Use Ta� Number) may be obttined from the State of Minnesota, Business Records Departmrnt, 10 Ricer Pazk Plaza (612-296-618 ] ). Socia3 Secwity Numher: !�. ��— f �/-- 7odd Minnesota TalIdentification Number: 2.�0 ��, _ lf a Minnesota Tax Ident�cation Number is not required for the business being operated, indicate so b}� placing an "X" in the bo�. 2!18 97 g- � � �' � �'1 �� `.� � a � :`°l � < Council File # �� ordinance # Green Sheet # `1s�'O� Presented By Referred To RESOLUTION SA1NT PAUL, MINNESOTA Committee: Date 3� i 2 3 RESOLVED: That application (ID #31405) for an Off 5ale Malt, Cigazette, and Grocery-C License by Hidden Falls Food Mazket DBA Hidden Falls Food Mazket (Reem Wadi, co-owner) aY 1040 Cleveland Avenue South be and the same is hereby approved. 4 5 6 � Navs — 7 B a — — 8 Bostrom 9 � H a r r is — 10 e rd — 11 — 13 vne �,. _ 14 � — 15 16 Adopted by Council: Date � 17 18 Adoption Certified by Council Sec � 19 20 � 21 By. ,. �a\� 22 � c � 23 Approved by� r: Date �/✓ j 24 `C��i`� ",6�- 25 26 By; 27 Requested by Department of: • - -,-- �-!- -e- ,�e �. - - -� - -�--- �s�-i. ;� By: � � � �� Form Approved by City Attorney Approved by Mayor for Submission to Council By: � DEPAFiTMENT/OFFICFJCOUNCIL DATEINffiATEO GREEN SHEE N_ 35309 I,IEPJI,icensin - -- COMACT PFA$ON 8 PHONE INRIAUDATE INITIAUDATE � DEPApTMENT DIAECTOR � C1TY COUNCII Christine Rozek, 266-9108 ^�G+ �cmarroaNev �cmc�nK MUST BE ON COUNqL AGENOA BY (DA'fE) /� p�jm�� BUDGET DIRECTOR O FIN. & MGT. SEAYICES �IR. r'OL hearin : S'� Z? OqDEB ❑�y��OR�n�A� � TOTAL # OF SIGNATURE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE) AC{iWl R£WES7ED: Hidden Falls Food MaYket DBA Hidden Fa11s Food Market requests Council approval of its application £or an Off Sale Malt, Cigaxetta, and Grocery-C License located at 1040 Cleveland Avenue South (ID Ii31405). RECOMMENDATONS: Approve (A} or Rajeq (R) pERSONAL SERViCE CONTRACSS MUSS ANSWER TXE FOLLOWING QUESTIONS: _ PLANNING COMMISSION _ CNIL SEfiY�CE COMMISSION �� Has ihis perSONFittn ever worked untler a contract For this depertment? � _ CIB COMMIrtEE _ YES NO —�� _ 2. Has this person/firm ever been a city emplqree? YES NO _ otSTRICi CoUR7 _ 3. Dces this persoMirm possess a skill not normally possessed by arry current city employee? SUPPOqTS WHICH COUNCIL O&IECi1VET YES NO Explain all yes answero on separate sheet and attech to green sheet INITATING PROBLEM. iSSUE, OPPORTUNI'fY (Wlq. Whet, When, Where, Why): ADVANTAGES IFAPPROVED: DISADVANTAGES IFAPPROVED: is11�.�,�"e�� e*�``�`��4..'�',�1 4.+�Rit� RF� Q 4 ��7 ��., DISAOVMITAGES lF N�7 APPRQYED: - TOTAL AMOUNT OF TNANSACTION S COST/qEVENUE BUDGETED (CIHCLE ONE) YES NO FUNDIHG SOURCE ACTIVI7Y NUMHER FINANCIAL INFORMATION: (EXPLAIN) Greensheet # 35309 L.I.E.P. REVIEW CHECKUST Date: 3/4/97 � 9'�-5 j'T !n Tracker? apP'n aece�ved / aPp'n arxessed license 1D # 31405 License Type: Off Sale Malt C� garPrte ana rr or�_r CompaRy Name: Hidden Falls Food M?rket DBA: same Business Addresss: 1040 Cleveland Averna Cnnth Business Phone: gs9-4349 Contact NamejAddress: Reem Wadi, 802 W Co Rd D��119 Home Phone: 639-1156 ew rig ton> Date to Councii Research: PubliC Hearing Date: � Notice Sent to Appficant: � Notice Serd to Public: �� !� 7! �� Labels Ordered: �/// � � Disirict Council #: / � Ward � Department/ Date Inspections Comments City Attomey 3•bf •`t� . �. . Environmental Heaith �.2g•�� - K � Fire .�y.9 �� . License Site Plan Recaived:_ Lease Received: 1��'��37 ��.. Potice 3•{1•9� o.�K • Zoning 3•l1-9�- p�' � �(�o�' CLASS III CITY OF SAIN �?UL �� LICENSE APPLICATION �"� `""�`,''�""�"� �a �.;�o,�,�i r�o��n;� 330 SL Ptla Sc Svh 300 $avVyui,\{��plp 55101 (61l)166909p !u(6i3)366911d THIS APPLICATION IS SUBJECT TO REVIEW BY THE PUBLIC Type of License(s) being applied for: S G•�� s 3 j�� $ ��b� $ $ Company I�Tazne: S O� � r'� Q•{ i E'�O✓ 51-n � Corporation / Partnaship / Sole Proprietorship If business is incorporated, p� e date of incorporation: N�/� Doing Business As: HLD�E� F�1��- S �oofl N1 1c i Business Phone: Business Address: _/� yo S <_ �a� €1 �.N.� A�ie S�'. (�� M�J � j 1�� svicet Aadrcss city smte zip Beh��een what cross meets is the business ]ocated? __ _ R'lrich side of the street? Are the premises nou� occupied? � R�hat T}Pe of Business? MailToAddress: �°�(o S C�evtXa�r.� hJQ �SU6 � SVeel Addrae City Sfate Zip Applicant Informati Nameand7iile: lC�E/� � � W{�� pW`^n�� First :.Sddle (Maidut7 1,s4 Trtle Home Address: �oz- � C� iQ� � y�. �\y �✓ew (3t.��k�*n ,��✓ J i 112 � S}JCC(.4ddIC53 CITy' SIBIC ZIP Date of Birth: / o-2� - 66 Place of Buth: �v��.l� Home Phone: 63°� i 1 j(� Have you eva been com�icted of any felony, crime or vioIalion of any city ordinance othet than traffic? YES NO _S(_ Date of arresC Chazge: _ Com•iction: Where? Senience: List ihe names and residences of three persons of good mozal character, Iiving w'ithin ihe TN�in Cilies Metro Area, not related to the applicant or financiall}' interested in the premises or basiness, who ma}' be referred to as to the applicanYs chazacter: Ha�•e any of the abo��e named licenses e�•er been rcvoked? YES NO Ifyes, list the dates and reasons for re��ocation 2; } 8%97 PLEASE TYPE OR PRINT IN INK List licenses �chich }�ou currentlp hold, fonnerly held, or ma}' ha��e an interest in: ,,. Are }•ou going to operate ilvs business personally? �_ YES NO If not, �cho will operate it? Q� �,S �� First�ame Home Addrev: Sircct \ame /ve }�ou going to hace a manager or assistant in ttus business7 p3ease complete the follon�ing informalion: Fvst ��e HomeAddress: S4cct\ame Please list your emplo}ment tristory for the pre�hous five (5) } ear period: Business/Emploc�nent Address t,sst Stete Zip Phone\�ber I,est Slate Zip Dace of airlh Phonc \�ber �Oti($ p Lu i � �4 List all other officers of the corporation: OFFICER TITLE HOME NAME (Office Held) ADDRESS HOME BUSINESS DATE OF PHONE PH023E BII2TH If business is a partnership, please include the following information for each partner (use additional pages if necessaz}�): n% �� Middlc Iniliel \fiddle Initial Middle Initid Cin' YES ,�c_ NO If the manager is not the sazne u the operator, Cih' (�laidrn) Home Add'sss: SUeet \eme Fint�ame �iti� (�iaidrn) Nome Add'es+: Strttt I�ame City Last State I.est Sinte Date of Birth Zip Phone \umber Date of Binh Zip P6one\umbcr MINNESOTA TAX IDENTIFICATIO23 NUMBER - Pursuant to the Iaa�s of Minnesota, 1984, Chapter 502, Ariicle 8, Section 2(270.72) (Ta� Clearance; Issuance of Licenses), licensing authorities are required to pro�'ide to the State of Minnesota Commissioner of Revenue, the Minnesota business ta� identification number and the social security number of each license applicant. Under the Minnesota Crovemment Data Practices Act and the Federal Privacy Act of 1974, we aze requued to ad�7se you of the following regarding the use of ihe Minnesota Tax Identification Number: - This information may be used to deny the issuance or renewal of }'our license in the event }'ou o�re Miiuiesota sales, employer s atithholding or motor vehicle escise tazes; - Upon recei��ing this information, ihe licensing authoriry H�ill supply it only to ihe Minnesota Department of Re�•enue. Hon�ever, under the Federal Erchange of Information Agreemrnt, the Department of Re�•enue may supply this information to the Intemal Revenue Senice. 1�tinnesots Ta� Identi5cation Numbers (Sales & Use Ta� Number) may be obttined from the State of Minnesota, Business Records Departmrnt, 10 Ricer Pazk Plaza (612-296-618 ] ). Socia3 Secwity Numher: !�. ��— f �/-- 7odd Minnesota TalIdentification Number: 2.�0 ��, _ lf a Minnesota Tax Ident�cation Number is not required for the business being operated, indicate so b}� placing an "X" in the bo�. 2!18 97 g- � � �' � �'1 �� `.� � a � :`°l � < Council File # �� ordinance # Green Sheet # `1s�'O� Presented By Referred To RESOLUTION SA1NT PAUL, MINNESOTA Committee: Date 3� i 2 3 RESOLVED: That application (ID #31405) for an Off 5ale Malt, Cigazette, and Grocery-C License by Hidden Falls Food Mazket DBA Hidden Falls Food Mazket (Reem Wadi, co-owner) aY 1040 Cleveland Avenue South be and the same is hereby approved. 4 5 6 � Navs — 7 B a — — 8 Bostrom 9 � H a r r is — 10 e rd — 11 — 13 vne �,. _ 14 � — 15 16 Adopted by Council: Date � 17 18 Adoption Certified by Council Sec � 19 20 � 21 By. ,. �a\� 22 � c � 23 Approved by� r: Date �/✓ j 24 `C��i`� ",6�- 25 26 By; 27 Requested by Department of: • - -,-- �-!- -e- ,�e �. - - -� - -�--- �s�-i. ;� By: � � � �� Form Approved by City Attorney Approved by Mayor for Submission to Council By: � DEPAFiTMENT/OFFICFJCOUNCIL DATEINffiATEO GREEN SHEE N_ 35309 I,IEPJI,icensin - -- COMACT PFA$ON 8 PHONE INRIAUDATE INITIAUDATE � DEPApTMENT DIAECTOR � C1TY COUNCII Christine Rozek, 266-9108 ^�G+ �cmarroaNev �cmc�nK MUST BE ON COUNqL AGENOA BY (DA'fE) /� p�jm�� BUDGET DIRECTOR O FIN. & MGT. SEAYICES �IR. r'OL hearin : S'� Z? OqDEB ❑�y��OR�n�A� � TOTAL # OF SIGNATURE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE) AC{iWl R£WES7ED: Hidden Falls Food MaYket DBA Hidden Fa11s Food Market requests Council approval of its application £or an Off Sale Malt, Cigaxetta, and Grocery-C License located at 1040 Cleveland Avenue South (ID Ii31405). RECOMMENDATONS: Approve (A} or Rajeq (R) pERSONAL SERViCE CONTRACSS MUSS ANSWER TXE FOLLOWING QUESTIONS: _ PLANNING COMMISSION _ CNIL SEfiY�CE COMMISSION �� Has ihis perSONFittn ever worked untler a contract For this depertment? � _ CIB COMMIrtEE _ YES NO —�� _ 2. Has this person/firm ever been a city emplqree? YES NO _ otSTRICi CoUR7 _ 3. Dces this persoMirm possess a skill not normally possessed by arry current city employee? SUPPOqTS WHICH COUNCIL O&IECi1VET YES NO Explain all yes answero on separate sheet and attech to green sheet INITATING PROBLEM. iSSUE, OPPORTUNI'fY (Wlq. Whet, When, Where, Why): ADVANTAGES IFAPPROVED: DISADVANTAGES IFAPPROVED: is11�.�,�"e�� e*�``�`��4..'�',�1 4.+�Rit� RF� Q 4 ��7 ��., DISAOVMITAGES lF N�7 APPRQYED: - TOTAL AMOUNT OF TNANSACTION S COST/qEVENUE BUDGETED (CIHCLE ONE) YES NO FUNDIHG SOURCE ACTIVI7Y NUMHER FINANCIAL INFORMATION: (EXPLAIN) Greensheet # 35309 L.I.E.P. REVIEW CHECKUST Date: 3/4/97 � 9'�-5 j'T !n Tracker? apP'n aece�ved / aPp'n arxessed license 1D # 31405 License Type: Off Sale Malt C� garPrte ana rr or�_r CompaRy Name: Hidden Falls Food M?rket DBA: same Business Addresss: 1040 Cleveland Averna Cnnth Business Phone: gs9-4349 Contact NamejAddress: Reem Wadi, 802 W Co Rd D��119 Home Phone: 639-1156 ew rig ton> Date to Councii Research: PubliC Hearing Date: � Notice Sent to Appficant: � Notice Serd to Public: �� !� 7! �� Labels Ordered: �/// � � Disirict Council #: / � Ward � Department/ Date Inspections Comments City Attomey 3•bf •`t� . �. . Environmental Heaith �.2g•�� - K � Fire .�y.9 �� . License Site Plan Recaived:_ Lease Received: 1��'��37 ��.. Potice 3•{1•9� o.�K • Zoning 3•l1-9�- p�' � �(�o�' CLASS III CITY OF SAIN �?UL �� LICENSE APPLICATION �"� `""�`,''�""�"� �a �.;�o,�,�i r�o��n;� 330 SL Ptla Sc Svh 300 $avVyui,\{��plp 55101 (61l)166909p !u(6i3)366911d THIS APPLICATION IS SUBJECT TO REVIEW BY THE PUBLIC Type of License(s) being applied for: S G•�� s 3 j�� $ ��b� $ $ Company I�Tazne: S O� � r'� Q•{ i E'�O✓ 51-n � Corporation / Partnaship / Sole Proprietorship If business is incorporated, p� e date of incorporation: N�/� Doing Business As: HLD�E� F�1��- S �oofl N1 1c i Business Phone: Business Address: _/� yo S <_ �a� €1 �.N.� A�ie S�'. (�� M�J � j 1�� svicet Aadrcss city smte zip Beh��een what cross meets is the business ]ocated? __ _ R'lrich side of the street? Are the premises nou� occupied? � R�hat T}Pe of Business? MailToAddress: �°�(o S C�evtXa�r.� hJQ �SU6 � SVeel Addrae City Sfate Zip Applicant Informati Nameand7iile: lC�E/� � � W{�� pW`^n�� First :.Sddle (Maidut7 1,s4 Trtle Home Address: �oz- � C� iQ� � y�. �\y �✓ew (3t.��k�*n ,��✓ J i 112 � S}JCC(.4ddIC53 CITy' SIBIC ZIP Date of Birth: / o-2� - 66 Place of Buth: �v��.l� Home Phone: 63°� i 1 j(� Have you eva been com�icted of any felony, crime or vioIalion of any city ordinance othet than traffic? YES NO _S(_ Date of arresC Chazge: _ Com•iction: Where? Senience: List ihe names and residences of three persons of good mozal character, Iiving w'ithin ihe TN�in Cilies Metro Area, not related to the applicant or financiall}' interested in the premises or basiness, who ma}' be referred to as to the applicanYs chazacter: Ha�•e any of the abo��e named licenses e�•er been rcvoked? YES NO Ifyes, list the dates and reasons for re��ocation 2; } 8%97 PLEASE TYPE OR PRINT IN INK List licenses �chich }�ou currentlp hold, fonnerly held, or ma}' ha��e an interest in: ,,. Are }•ou going to operate ilvs business personally? �_ YES NO If not, �cho will operate it? Q� �,S �� First�ame Home Addrev: Sircct \ame /ve }�ou going to hace a manager or assistant in ttus business7 p3ease complete the follon�ing informalion: Fvst ��e HomeAddress: S4cct\ame Please list your emplo}ment tristory for the pre�hous five (5) } ear period: Business/Emploc�nent Address t,sst Stete Zip Phone\�ber I,est Slate Zip Dace of airlh Phonc \�ber �Oti($ p Lu i � �4 List all other officers of the corporation: OFFICER TITLE HOME NAME (Office Held) ADDRESS HOME BUSINESS DATE OF PHONE PH023E BII2TH If business is a partnership, please include the following information for each partner (use additional pages if necessaz}�): n% �� Middlc Iniliel \fiddle Initial Middle Initid Cin' YES ,�c_ NO If the manager is not the sazne u the operator, Cih' (�laidrn) Home Add'sss: SUeet \eme Fint�ame �iti� (�iaidrn) Nome Add'es+: Strttt I�ame City Last State I.est Sinte Date of Birth Zip Phone \umber Date of Binh Zip P6one\umbcr MINNESOTA TAX IDENTIFICATIO23 NUMBER - Pursuant to the Iaa�s of Minnesota, 1984, Chapter 502, Ariicle 8, Section 2(270.72) (Ta� Clearance; Issuance of Licenses), licensing authorities are required to pro�'ide to the State of Minnesota Commissioner of Revenue, the Minnesota business ta� identification number and the social security number of each license applicant. Under the Minnesota Crovemment Data Practices Act and the Federal Privacy Act of 1974, we aze requued to ad�7se you of the following regarding the use of ihe Minnesota Tax Identification Number: - This information may be used to deny the issuance or renewal of }'our license in the event }'ou o�re Miiuiesota sales, employer s atithholding or motor vehicle escise tazes; - Upon recei��ing this information, ihe licensing authoriry H�ill supply it only to ihe Minnesota Department of Re�•enue. Hon�ever, under the Federal Erchange of Information Agreemrnt, the Department of Re�•enue may supply this information to the Intemal Revenue Senice. 1�tinnesots Ta� Identi5cation Numbers (Sales & Use Ta� Number) may be obttined from the State of Minnesota, Business Records Departmrnt, 10 Ricer Pazk Plaza (612-296-618 ] ). Socia3 Secwity Numher: !�. ��— f �/-- 7odd Minnesota TalIdentification Number: 2.�0 ��, _ lf a Minnesota Tax Ident�cation Number is not required for the business being operated, indicate so b}� placing an "X" in the bo�. 2!18 97