97-568Council File # r � �
Ordinance #
7L� /�
Green Sheet # 3 �
�
`� si ( � rt k
`� � � �� ,�� �
t,
Presented By
Referred To
RESOLUTION
CITY OF SAiNT PAUL, MiNNESOTA
s.s
Committee: Date
a
2
3
RESOLVED: That application (ID #79079) for a Crrocery-C, Fireazms, Cigarette, and Restawant-B License by
Kmart Cor�wration DBA Kmart #4803 (7ames Milsow, Manager) at 1450 Universiry Avenue West
be and the same is hereby approved.
4
5 Requested by Department of:
6 Yea Navs Abaent
7 B a�e �
8 Bos r„ __m � t�` Office of License Yn$pections and
9 Harris
10 egar Env+rorL ental Protection
11 Mo o�
12 un� �
14 Co_�ns
15 � B \lJN-�P�1�'�� ��" �
16 Adopted by Council: Date �� y'
17
18 Adoption Certified by Counail Se tary
19 Form Approved by City Attorney
20 / \ �
21 By: a . p/ ` 7`'
22 � / ny: 9 f ����
23 Approved by Mayor: Date 'z�-! £l _`�
24
ZS � Approved by Mayor for Submission to
26 By. �� Council
27
Sy:
q'i-S�.Sr
DEPARTMENrAFFICElCOUNCIL DASE IN171ATED ..7 ( J "F �J
LIEP Licensin GREEN SHEE
GONTAGT PERSON 8 PHONE INITIAUDATE VNRIAUDATE
a DEPARTMENT DIRECTOR � GITY COUNCI�
Christine Rozek 266-91Q8 A���N �CITVATTORNEV aGITVCLERK
NUMBEHFOR
MUST BE ON CAUNCILAGENDA BY (DATE) qOUTING � BUDOET �IRECTOR Q FIN. 8 MGT. SERVICES Dlfl.
r' O hea ' n : lj �� OROEN � MAVOR (OR ASSISTANTj �
TOTAL # OF SIGNATURE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE)
ACTION flEQUESTED:
RMart Corporation DBA RMart /�4803 requests Council approval of its application for a
Grocery-C, Firearms, Cigarette, and Restaurant-B License located at 1450 University Ave W.
(ID 79079).
RECAMMENDATIONS: Approve (A) or Reject (a) pEPSONAL SEpViCE CONTRACTS MUST ANSW EA TNE FOLLOWING QUESTIONS:
_ PLANNING COMMISSION _ CIVIL SfRVICE CAMMISSION 1 Has iqis personlfinn eaer wwketl u�Wer a contrect for this depsrtment?
_ CIB CqMMI7TEE _ YES NO
_ siAFF 2. Has this parsaNfirm ever been a city employee?
— YES NO
_ D�STRICi COURT _ 3. Does this person/firm possess a skill not normally possessed by any current ciry employee7
SUPPORTS WHICH COUNCIL O&IECTIVE? YES NO
Explafn all yes answers on separate sheet entl attach to grcen sheet
INITIATING PflOBLEM, ISSUE, OPPORTUNITY (Wbo, What. When. Where. Why). �� t � �,�:, ��;; �� `
t��� �
�`�1AY fl 1 1997
��"� � ��
ADVANTAGES If APPRQVED�
DISA�VANTAGES IFAPPROVED:
Ahf�+t�4� fii� .Ag!
- ``a.°�:.. ,.. "_ �. -5 �'
tFt%� � � �.�i`��
DISAOVANTAGESIFNOTAPPROVEO: -- --�w-� � °�
70TAL AMOUNT OF TNANSACTION § COST/fiEVENUE BUDGETED (CIRCLE ONE) YES NO
FUNDIWG SOURCE ACTIVITY NUMBER
FINANCfAL INFORM'ATION: (EXPLAIN)
�reensheet # 37949 L.{.E.P. REVIEW CHECKLIST Date: 4f24/97 r q� �•S�
In TraCkef? App'n Aeceived / App'n ProcesseG
License lD # 79074 License Type: Grocery-C, Firearms, Ci�arette, and Restaurant-B
Company Name: �rt Corporation DBA: �rt 114803
Business Addresss: 1450 University Avenue West Business Phone:
Contact Name/Address: James Milsow, 9301 Colorado Rd, Home Phone: 831-3496
Date to Council Research: Bloomington 55438 ,L
Pubtic Nearing Date: � f 97 Labels Ordered: 7 /��
Notice Sent to Applicant: District Council #:
Notice Sent to Public:
Ward
DepartmentJ Date fnspections Comments
City Attomey � � � ( q � O �
�
Environmental
Heaith
��lo � � 7 � �
Fire � n "'
sr l� � � � tl�l,
License srte wan Received:_
Lease Received:
��j� � �'� a �--
Police
� �� �1�
Zoning
5��1���� bl�
`D
tNi
AUL
�
AAl1A
CLASS III
LICBNSE APPLICATIQN
THIS APPLICATION IS SUBJECT TO REVIEW BY THE PUBLIC
PLEASE TYPE OR PRINT IN RvX
being applied for: ��� t
CII'Y OF S�� PA'
03ice of License, In:pzctiont
xna Emiroml,rntil rrazction
35C S� ,� SL Suite i�
Si.�rt?a�_,� �!ncicsos 55103
(61ij2�W9� fc<(61l)355-
s 3! �.�°
s � 5. �'
s_,31'l. D
s o�4.
CompanyName: .f�Y/�c`.�✓� �O✓ /J�r'c '�i'�z�
Corpolation / Partnership / So]c Proprietnrship
If business is incorporated, give date of incorporation: �-�- ��'j'��
Doing Business As: �r�ixr� ���p Business Phone:
BusinessAddress: �`X'�� !�r>i�r�z°,✓fi"�� �l «J 7�-/.� f/ �i/� /�<�
Strect Addresa City 5'�afe Zip
Betneen what cross sheets is the btuiness located�
Which side of the street�
/fB� -s�`nn� c�rc�-..� �
Are the premises notir� occupied7.,? /5 Type of Business? /� ��ci'�
NaiiToAddress: _�/bp u> /� .��iy L��/ '�p�,/ �7/ /�/��,5/
S�Ad y�i - �GL J�' t��E.�o f' . crtY � stau zip
Applicani Infomation:
Name and Title:
Fust
y��.F{[�
(Maidrn)
�C�i
Last
'�'.�
Tide
Home Address: �%OL� c J �i /��i_z J f" ��l'p� `r�/ F
Stiut Address �
Cil3' $tatc Zip
Date of Birth: Place of Birth: Home Phone: �/��5��/
Have you ever bzzn com2cted of any felony, crime or ��iolation of any city ordinance other than tra�c? YES NO ��
Date of arrest:
Charge: _
Cont�iction:
Where?
Sentence:
Lisi the names and residences of three persons of good moral character, living within the Twin Cilies 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:
NAME
List licenses tuhich you
Have any of the above
' ',�.
� ..a ,
ADDRESS
PFiONE
i�� or may have an interest in:
revoked? YES ✓ NO If yes, list the dates and reasons for revocation:
2/18/97
�
,
Ar° yuu going to operaTe this business personally? YES ✓ NO"Ifnot, who will operate i?? ^ !� ��
`?"� � �,s � � i �so�..� `� �� /� 8
;
Fust 'smc �1iddlcLtitial (; (\faidrn) Ias[ - I � ofButh
��jC 1�-ot-c��ao KD �L� ��,eJ � N SS�(3�' s�-�i 3�F96
Home Addresw: Stmt `�amc City Stste Zip lfione tiumber
A*e you going to have a m�ag� o: assistant in this business? ✓ YES hs0 If the manzgzr is not the szsne as the operator,
please comp]ete the followting information:
First Nnme
�yaat� �;d�
(Vlniaca) Last
Date of Binh
HomeAddress: Street?�'nme
City ' State Zip
Please list your employment hi5�ory for the pre«ous five (5) }�eaz period:
�` 3t(o5
List all other officers of the corporation:
OFF'ICER TITLE HOME _
NAME (Office Held) ADDRESS
Address
P6one Number
HOME BUSJNESS DATE OF
PHONE PHONE BII2TH
5e� ( i St
If business is a parmership, please include the following information for each partner (use additional pages if necessary):
Firrt h*�e
Home Addisss: Strcet Name
Fi-s[!ticae
?vliddle Initinl
Home Addras: Street l�ame
(Visiden)
City
I.est
Stam Zip
I.a4
State Zip
Deu of Buth
Phone \umber
Date of Buth
Phone A��ber
MII�INESOTA TAX IDENTIFICATION NtTMBER - Pursuant to the Laws of Minnesota, ] 984, Chapter 502, Articie 8, Section 2(270.72)
(Tax Clesr�nce; Issuance of Licenses), licensing authorities are required to provide to the State of Minnesota Commissioner of Revenue, the
Minnesota business ta�c identi5cation number and the social security number of each license applicant
Under tLe Minnesota Government Data Practices Act and the Federal Privacy Act of 1974, we are required to advise you of the fallowing
regarding the use of the Minvesota Tax Identificalion Number:
- This information may be used to deny the issuance or renewal of your licetsse in the event you owe Minnesofa sales, employer's
withhalding or motor vehicle excise taxes; ,
= Upon receiving this information, the licensing authority will supply it oniy to the Mumesota Depafinent of Revenue. However,
under the Federal Exchange of Information Ageemrnt, the Department of Revrnue may supply this information to the Intemal
Revenue Service.
Mmne�ota Ta� Identification Niunbers (Sales & Use Tax Numba) may be obtained from the State of Minnesota, Business F2ecords Departmrnt,
10 River Park Plaza (612-296-6181).
��o � o �/ �6��5""`��a?
Sesial-Secuaty Number: �J b o�a 9�'�O Mimiesota Tax Identification Number:
! If a Minnesota Tax Identificalion Number is not required for the business being operated, indicate so by placing an"X" in the box.
2/78/97
Council File # r � �
Ordinance #
7L� /�
Green Sheet # 3 �
�
`� si ( � rt k
`� � � �� ,�� �
t,
Presented By
Referred To
RESOLUTION
CITY OF SAiNT PAUL, MiNNESOTA
s.s
Committee: Date
a
2
3
RESOLVED: That application (ID #79079) for a Crrocery-C, Fireazms, Cigarette, and Restawant-B License by
Kmart Cor�wration DBA Kmart #4803 (7ames Milsow, Manager) at 1450 Universiry Avenue West
be and the same is hereby approved.
4
5 Requested by Department of:
6 Yea Navs Abaent
7 B a�e �
8 Bos r„ __m � t�` Office of License Yn$pections and
9 Harris
10 egar Env+rorL ental Protection
11 Mo o�
12 un� �
14 Co_�ns
15 � B \lJN-�P�1�'�� ��" �
16 Adopted by Council: Date �� y'
17
18 Adoption Certified by Counail Se tary
19 Form Approved by City Attorney
20 / \ �
21 By: a . p/ ` 7`'
22 � / ny: 9 f ����
23 Approved by Mayor: Date 'z�-! £l _`�
24
ZS � Approved by Mayor for Submission to
26 By. �� Council
27
Sy:
q'i-S�.Sr
DEPARTMENrAFFICElCOUNCIL DASE IN171ATED ..7 ( J "F �J
LIEP Licensin GREEN SHEE
GONTAGT PERSON 8 PHONE INITIAUDATE VNRIAUDATE
a DEPARTMENT DIRECTOR � GITY COUNCI�
Christine Rozek 266-91Q8 A���N �CITVATTORNEV aGITVCLERK
NUMBEHFOR
MUST BE ON CAUNCILAGENDA BY (DATE) qOUTING � BUDOET �IRECTOR Q FIN. 8 MGT. SERVICES Dlfl.
r' O hea ' n : lj �� OROEN � MAVOR (OR ASSISTANTj �
TOTAL # OF SIGNATURE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE)
ACTION flEQUESTED:
RMart Corporation DBA RMart /�4803 requests Council approval of its application for a
Grocery-C, Firearms, Cigarette, and Restaurant-B License located at 1450 University Ave W.
(ID 79079).
RECAMMENDATIONS: Approve (A) or Reject (a) pEPSONAL SEpViCE CONTRACTS MUST ANSW EA TNE FOLLOWING QUESTIONS:
_ PLANNING COMMISSION _ CIVIL SfRVICE CAMMISSION 1 Has iqis personlfinn eaer wwketl u�Wer a contrect for this depsrtment?
_ CIB CqMMI7TEE _ YES NO
_ siAFF 2. Has this parsaNfirm ever been a city employee?
— YES NO
_ D�STRICi COURT _ 3. Does this person/firm possess a skill not normally possessed by any current ciry employee7
SUPPORTS WHICH COUNCIL O&IECTIVE? YES NO
Explafn all yes answers on separate sheet entl attach to grcen sheet
INITIATING PflOBLEM, ISSUE, OPPORTUNITY (Wbo, What. When. Where. Why). �� t � �,�:, ��;; �� `
t��� �
�`�1AY fl 1 1997
��"� � ��
ADVANTAGES If APPRQVED�
DISA�VANTAGES IFAPPROVED:
Ahf�+t�4� fii� .Ag!
- ``a.°�:.. ,.. "_ �. -5 �'
tFt%� � � �.�i`��
DISAOVANTAGESIFNOTAPPROVEO: -- --�w-� � °�
70TAL AMOUNT OF TNANSACTION § COST/fiEVENUE BUDGETED (CIRCLE ONE) YES NO
FUNDIWG SOURCE ACTIVITY NUMBER
FINANCfAL INFORM'ATION: (EXPLAIN)
�reensheet # 37949 L.{.E.P. REVIEW CHECKLIST Date: 4f24/97 r q� �•S�
In TraCkef? App'n Aeceived / App'n ProcesseG
License lD # 79074 License Type: Grocery-C, Firearms, Ci�arette, and Restaurant-B
Company Name: �rt Corporation DBA: �rt 114803
Business Addresss: 1450 University Avenue West Business Phone:
Contact Name/Address: James Milsow, 9301 Colorado Rd, Home Phone: 831-3496
Date to Council Research: Bloomington 55438 ,L
Pubtic Nearing Date: � f 97 Labels Ordered: 7 /��
Notice Sent to Applicant: District Council #:
Notice Sent to Public:
Ward
DepartmentJ Date fnspections Comments
City Attomey � � � ( q � O �
�
Environmental
Heaith
��lo � � 7 � �
Fire � n "'
sr l� � � � tl�l,
License srte wan Received:_
Lease Received:
��j� � �'� a �--
Police
� �� �1�
Zoning
5��1���� bl�
`D
tNi
AUL
�
AAl1A
CLASS III
LICBNSE APPLICATIQN
THIS APPLICATION IS SUBJECT TO REVIEW BY THE PUBLIC
PLEASE TYPE OR PRINT IN RvX
being applied for: ��� t
CII'Y OF S�� PA'
03ice of License, In:pzctiont
xna Emiroml,rntil rrazction
35C S� ,� SL Suite i�
Si.�rt?a�_,� �!ncicsos 55103
(61ij2�W9� fc<(61l)355-
s 3! �.�°
s � 5. �'
s_,31'l. D
s o�4.
CompanyName: .f�Y/�c`.�✓� �O✓ /J�r'c '�i'�z�
Corpolation / Partnership / So]c Proprietnrship
If business is incorporated, give date of incorporation: �-�- ��'j'��
Doing Business As: �r�ixr� ���p Business Phone:
BusinessAddress: �`X'�� !�r>i�r�z°,✓fi"�� �l «J 7�-/.� f/ �i/� /�<�
Strect Addresa City 5'�afe Zip
Betneen what cross sheets is the btuiness located�
Which side of the street�
/fB� -s�`nn� c�rc�-..� �
Are the premises notir� occupied7.,? /5 Type of Business? /� ��ci'�
NaiiToAddress: _�/bp u> /� .��iy L��/ '�p�,/ �7/ /�/��,5/
S�Ad y�i - �GL J�' t��E.�o f' . crtY � stau zip
Applicani Infomation:
Name and Title:
Fust
y��.F{[�
(Maidrn)
�C�i
Last
'�'.�
Tide
Home Address: �%OL� c J �i /��i_z J f" ��l'p� `r�/ F
Stiut Address �
Cil3' $tatc Zip
Date of Birth: Place of Birth: Home Phone: �/��5��/
Have you ever bzzn com2cted of any felony, crime or ��iolation of any city ordinance other than tra�c? YES NO ��
Date of arrest:
Charge: _
Cont�iction:
Where?
Sentence:
Lisi the names and residences of three persons of good moral character, living within the Twin Cilies 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:
NAME
List licenses tuhich you
Have any of the above
' ',�.
� ..a ,
ADDRESS
PFiONE
i�� or may have an interest in:
revoked? YES ✓ NO If yes, list the dates and reasons for revocation:
2/18/97
�
,
Ar° yuu going to operaTe this business personally? YES ✓ NO"Ifnot, who will operate i?? ^ !� ��
`?"� � �,s � � i �so�..� `� �� /� 8
;
Fust 'smc �1iddlcLtitial (; (\faidrn) Ias[ - I � ofButh
��jC 1�-ot-c��ao KD �L� ��,eJ � N SS�(3�' s�-�i 3�F96
Home Addresw: Stmt `�amc City Stste Zip lfione tiumber
A*e you going to have a m�ag� o: assistant in this business? ✓ YES hs0 If the manzgzr is not the szsne as the operator,
please comp]ete the followting information:
First Nnme
�yaat� �;d�
(Vlniaca) Last
Date of Binh
HomeAddress: Street?�'nme
City ' State Zip
Please list your employment hi5�ory for the pre«ous five (5) }�eaz period:
�` 3t(o5
List all other officers of the corporation:
OFF'ICER TITLE HOME _
NAME (Office Held) ADDRESS
Address
P6one Number
HOME BUSJNESS DATE OF
PHONE PHONE BII2TH
5e� ( i St
If business is a parmership, please include the following information for each partner (use additional pages if necessary):
Firrt h*�e
Home Addisss: Strcet Name
Fi-s[!ticae
?vliddle Initinl
Home Addras: Street l�ame
(Visiden)
City
I.est
Stam Zip
I.a4
State Zip
Deu of Buth
Phone \umber
Date of Buth
Phone A��ber
MII�INESOTA TAX IDENTIFICATION NtTMBER - Pursuant to the Laws of Minnesota, ] 984, Chapter 502, Articie 8, Section 2(270.72)
(Tax Clesr�nce; Issuance of Licenses), licensing authorities are required to provide to the State of Minnesota Commissioner of Revenue, the
Minnesota business ta�c identi5cation number and the social security number of each license applicant
Under tLe Minnesota Government Data Practices Act and the Federal Privacy Act of 1974, we are required to advise you of the fallowing
regarding the use of the Minvesota Tax Identificalion Number:
- This information may be used to deny the issuance or renewal of your licetsse in the event you owe Minnesofa sales, employer's
withhalding or motor vehicle excise taxes; ,
= Upon receiving this information, the licensing authority will supply it oniy to the Mumesota Depafinent of Revenue. However,
under the Federal Exchange of Information Ageemrnt, the Department of Revrnue may supply this information to the Intemal
Revenue Service.
Mmne�ota Ta� Identification Niunbers (Sales & Use Tax Numba) may be obtained from the State of Minnesota, Business F2ecords Departmrnt,
10 River Park Plaza (612-296-6181).
��o � o �/ �6��5""`��a?
Sesial-Secuaty Number: �J b o�a 9�'�O Mimiesota Tax Identification Number:
! If a Minnesota Tax Identificalion Number is not required for the business being operated, indicate so by placing an"X" in the box.
2/78/97
Council File # r � �
Ordinance #
7L� /�
Green Sheet # 3 �
�
`� si ( � rt k
`� � � �� ,�� �
t,
Presented By
Referred To
RESOLUTION
CITY OF SAiNT PAUL, MiNNESOTA
s.s
Committee: Date
a
2
3
RESOLVED: That application (ID #79079) for a Crrocery-C, Fireazms, Cigarette, and Restawant-B License by
Kmart Cor�wration DBA Kmart #4803 (7ames Milsow, Manager) at 1450 Universiry Avenue West
be and the same is hereby approved.
4
5 Requested by Department of:
6 Yea Navs Abaent
7 B a�e �
8 Bos r„ __m � t�` Office of License Yn$pections and
9 Harris
10 egar Env+rorL ental Protection
11 Mo o�
12 un� �
14 Co_�ns
15 � B \lJN-�P�1�'�� ��" �
16 Adopted by Council: Date �� y'
17
18 Adoption Certified by Counail Se tary
19 Form Approved by City Attorney
20 / \ �
21 By: a . p/ ` 7`'
22 � / ny: 9 f ����
23 Approved by Mayor: Date 'z�-! £l _`�
24
ZS � Approved by Mayor for Submission to
26 By. �� Council
27
Sy:
q'i-S�.Sr
DEPARTMENrAFFICElCOUNCIL DASE IN171ATED ..7 ( J "F �J
LIEP Licensin GREEN SHEE
GONTAGT PERSON 8 PHONE INITIAUDATE VNRIAUDATE
a DEPARTMENT DIRECTOR � GITY COUNCI�
Christine Rozek 266-91Q8 A���N �CITVATTORNEV aGITVCLERK
NUMBEHFOR
MUST BE ON CAUNCILAGENDA BY (DATE) qOUTING � BUDOET �IRECTOR Q FIN. 8 MGT. SERVICES Dlfl.
r' O hea ' n : lj �� OROEN � MAVOR (OR ASSISTANTj �
TOTAL # OF SIGNATURE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE)
ACTION flEQUESTED:
RMart Corporation DBA RMart /�4803 requests Council approval of its application for a
Grocery-C, Firearms, Cigarette, and Restaurant-B License located at 1450 University Ave W.
(ID 79079).
RECAMMENDATIONS: Approve (A) or Reject (a) pEPSONAL SEpViCE CONTRACTS MUST ANSW EA TNE FOLLOWING QUESTIONS:
_ PLANNING COMMISSION _ CIVIL SfRVICE CAMMISSION 1 Has iqis personlfinn eaer wwketl u�Wer a contrect for this depsrtment?
_ CIB CqMMI7TEE _ YES NO
_ siAFF 2. Has this parsaNfirm ever been a city employee?
— YES NO
_ D�STRICi COURT _ 3. Does this person/firm possess a skill not normally possessed by any current ciry employee7
SUPPORTS WHICH COUNCIL O&IECTIVE? YES NO
Explafn all yes answers on separate sheet entl attach to grcen sheet
INITIATING PflOBLEM, ISSUE, OPPORTUNITY (Wbo, What. When. Where. Why). �� t � �,�:, ��;; �� `
t��� �
�`�1AY fl 1 1997
��"� � ��
ADVANTAGES If APPRQVED�
DISA�VANTAGES IFAPPROVED:
Ahf�+t�4� fii� .Ag!
- ``a.°�:.. ,.. "_ �. -5 �'
tFt%� � � �.�i`��
DISAOVANTAGESIFNOTAPPROVEO: -- --�w-� � °�
70TAL AMOUNT OF TNANSACTION § COST/fiEVENUE BUDGETED (CIRCLE ONE) YES NO
FUNDIWG SOURCE ACTIVITY NUMBER
FINANCfAL INFORM'ATION: (EXPLAIN)
�reensheet # 37949 L.{.E.P. REVIEW CHECKLIST Date: 4f24/97 r q� �•S�
In TraCkef? App'n Aeceived / App'n ProcesseG
License lD # 79074 License Type: Grocery-C, Firearms, Ci�arette, and Restaurant-B
Company Name: �rt Corporation DBA: �rt 114803
Business Addresss: 1450 University Avenue West Business Phone:
Contact Name/Address: James Milsow, 9301 Colorado Rd, Home Phone: 831-3496
Date to Council Research: Bloomington 55438 ,L
Pubtic Nearing Date: � f 97 Labels Ordered: 7 /��
Notice Sent to Applicant: District Council #:
Notice Sent to Public:
Ward
DepartmentJ Date fnspections Comments
City Attomey � � � ( q � O �
�
Environmental
Heaith
��lo � � 7 � �
Fire � n "'
sr l� � � � tl�l,
License srte wan Received:_
Lease Received:
��j� � �'� a �--
Police
� �� �1�
Zoning
5��1���� bl�
`D
tNi
AUL
�
AAl1A
CLASS III
LICBNSE APPLICATIQN
THIS APPLICATION IS SUBJECT TO REVIEW BY THE PUBLIC
PLEASE TYPE OR PRINT IN RvX
being applied for: ��� t
CII'Y OF S�� PA'
03ice of License, In:pzctiont
xna Emiroml,rntil rrazction
35C S� ,� SL Suite i�
Si.�rt?a�_,� �!ncicsos 55103
(61ij2�W9� fc<(61l)355-
s 3! �.�°
s � 5. �'
s_,31'l. D
s o�4.
CompanyName: .f�Y/�c`.�✓� �O✓ /J�r'c '�i'�z�
Corpolation / Partnership / So]c Proprietnrship
If business is incorporated, give date of incorporation: �-�- ��'j'��
Doing Business As: �r�ixr� ���p Business Phone:
BusinessAddress: �`X'�� !�r>i�r�z°,✓fi"�� �l «J 7�-/.� f/ �i/� /�<�
Strect Addresa City 5'�afe Zip
Betneen what cross sheets is the btuiness located�
Which side of the street�
/fB� -s�`nn� c�rc�-..� �
Are the premises notir� occupied7.,? /5 Type of Business? /� ��ci'�
NaiiToAddress: _�/bp u> /� .��iy L��/ '�p�,/ �7/ /�/��,5/
S�Ad y�i - �GL J�' t��E.�o f' . crtY � stau zip
Applicani Infomation:
Name and Title:
Fust
y��.F{[�
(Maidrn)
�C�i
Last
'�'.�
Tide
Home Address: �%OL� c J �i /��i_z J f" ��l'p� `r�/ F
Stiut Address �
Cil3' $tatc Zip
Date of Birth: Place of Birth: Home Phone: �/��5��/
Have you ever bzzn com2cted of any felony, crime or ��iolation of any city ordinance other than tra�c? YES NO ��
Date of arrest:
Charge: _
Cont�iction:
Where?
Sentence:
Lisi the names and residences of three persons of good moral character, living within the Twin Cilies 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:
NAME
List licenses tuhich you
Have any of the above
' ',�.
� ..a ,
ADDRESS
PFiONE
i�� or may have an interest in:
revoked? YES ✓ NO If yes, list the dates and reasons for revocation:
2/18/97
�
,
Ar° yuu going to operaTe this business personally? YES ✓ NO"Ifnot, who will operate i?? ^ !� ��
`?"� � �,s � � i �so�..� `� �� /� 8
;
Fust 'smc �1iddlcLtitial (; (\faidrn) Ias[ - I � ofButh
��jC 1�-ot-c��ao KD �L� ��,eJ � N SS�(3�' s�-�i 3�F96
Home Addresw: Stmt `�amc City Stste Zip lfione tiumber
A*e you going to have a m�ag� o: assistant in this business? ✓ YES hs0 If the manzgzr is not the szsne as the operator,
please comp]ete the followting information:
First Nnme
�yaat� �;d�
(Vlniaca) Last
Date of Binh
HomeAddress: Street?�'nme
City ' State Zip
Please list your employment hi5�ory for the pre«ous five (5) }�eaz period:
�` 3t(o5
List all other officers of the corporation:
OFF'ICER TITLE HOME _
NAME (Office Held) ADDRESS
Address
P6one Number
HOME BUSJNESS DATE OF
PHONE PHONE BII2TH
5e� ( i St
If business is a parmership, please include the following information for each partner (use additional pages if necessary):
Firrt h*�e
Home Addisss: Strcet Name
Fi-s[!ticae
?vliddle Initinl
Home Addras: Street l�ame
(Visiden)
City
I.est
Stam Zip
I.a4
State Zip
Deu of Buth
Phone \umber
Date of Buth
Phone A��ber
MII�INESOTA TAX IDENTIFICATION NtTMBER - Pursuant to the Laws of Minnesota, ] 984, Chapter 502, Articie 8, Section 2(270.72)
(Tax Clesr�nce; Issuance of Licenses), licensing authorities are required to provide to the State of Minnesota Commissioner of Revenue, the
Minnesota business ta�c identi5cation number and the social security number of each license applicant
Under tLe Minnesota Government Data Practices Act and the Federal Privacy Act of 1974, we are required to advise you of the fallowing
regarding the use of the Minvesota Tax Identificalion Number:
- This information may be used to deny the issuance or renewal of your licetsse in the event you owe Minnesofa sales, employer's
withhalding or motor vehicle excise taxes; ,
= Upon receiving this information, the licensing authority will supply it oniy to the Mumesota Depafinent of Revenue. However,
under the Federal Exchange of Information Ageemrnt, the Department of Revrnue may supply this information to the Intemal
Revenue Service.
Mmne�ota Ta� Identification Niunbers (Sales & Use Tax Numba) may be obtained from the State of Minnesota, Business F2ecords Departmrnt,
10 River Park Plaza (612-296-6181).
��o � o �/ �6��5""`��a?
Sesial-Secuaty Number: �J b o�a 9�'�O Mimiesota Tax Identification Number:
! If a Minnesota Tax Identificalion Number is not required for the business being operated, indicate so by placing an"X" in the box.
2/78/97