97-635Council File $ _\���
Ordinance #
Green Sheet # �✓ �
Presented By
Referred To
RESOLUTION
GlTY OF SAlNT PAUL, MINNESOTA
�
Committee: Date
��
1
2
3
RESOLVED: T'hat application (ID #34699) for a Gas Statioq Restaurant-C, Grocery-C, and Cigazette License by
Super America Group Division of Asliland DBA SuperAmerica #4430 (James Hanson, Manager)
at 846 3ohnson Pazkway be and the same is hereby approved
4
5 Requested by Department of:
6 Yeas Navs en
7 B a�key —
8 Bostrom Otfice of License zngpections and
9 Harris
10 Me a� Environmental Protection _
11 ran
12 T une
13 Morton n
14 � � _ � ^'"1,`�v
15
16 Adopted by Council: Date $ �"7 B Y'
17 �
18 Adoption Certified by Council Secretary
19 Form Approved by City Attorney
20 / �
21 By: �- .
22 — �— '�°
23 Approved by Mayor: Date ,£�
24
25 Approved by Mayor £or Submiasion to
Council
26 By: r v
27
Bye
Greensheet# 35320 L.I.E.P. REVIEW CHECKLIST Date: 3/27/97 /`�� b3
In Trackel? APP'n �� / APP'� P���
LicenSelD # 34699 LicenSE TypeGas Station Restaurant-C, Grocerv-C, and Ciearette Licen
Company Name:SuperAmerica Group Division o£ Ashland DBA:SuperAmerica ��4430
BusinesS Addresss: $46 Johnson Parkway Business Phone: 778-9193
ContaCt Name/Address: James Hanson, 846 Johnson Parkway Home Phone:
Date to Counc7 s s i n�
Public Hearing i
Notice Sent to P
Notice Se to F
DepartmernJ
Ciry Attomey
Environmental
Heaith
Fire
License
Poiice
Labefs Ordered: f�+�
District Council #:
`
Date fnspections
��� �� �
Ward #: !
Comments
5 1� a �-- o .� .
S� �i`�� at `'
�/�
Zoning
�1����
�"JL//t
D� �
o. �
Site Plan Received:_
tease aece��ed:
c.
oE��roFF������ DATEINrtfATEO GREEN SHEE N_ 35320
LIEPjLicensin --- —
CONTACT PEfi30N 8 PHONE INITIAVDAiE INRIAUDATE
O DEPAHTMENT DIREGTOfl � CfTV CAUNGIL
Christine Rozek, 266-9108 "��N �cmnTror+Ner �cmc�aK
MUST BE ON CAUNqL AGENDA BY (DAT� q��� O BUDGET OIPECTO O FIN. $ MGT. SERVICES DIR.
For hearin : S ri � ���" �" 1nVOR � �
TOTAL # OF SIGNANRE PAGES (CLIP ALL LOCATIONS'FOR SIGNA'NRE)
ACTION RC-0UESTED:
The SuperAmerica Group Division of Ashland DBA SuperAmerica 1�4430 requests Council approval
of its applicatin for a Gas Station, Restaurant-C; �rocery-C, and Cigarette License at
846 Johnson Parkway (ID 9l34699).
RECOMMENOA7lONS: Appave (n) «Reject (R) pERSONAL SERVICE CONTRACTS MUSTANSWER TNE POLLOWINfi QUESTIONS:
_ PLANNWG COMM�SS�ON _ CIVII SERVICE COMMISSION �� Has this persoNfirtn ever worketl under a contract for this departmeM? �
_ � _ YES �NO
2. Has this person/Firm ever been a ciry employee?
_ STAFF — YES NO
_ ni57alci COUA7 _ 3. Does this perso�rm possess a skill not normalty possessetl by any current ciry employee?
SUPPORTS WH1CN COUNCIL 0&IECf1VE7 YES NO
Esplain ell yas answers on sepa�ate sheet and attaeh to green sheet
INI71A71NG PROBLEM, ISSUE, OPPORTUNITY (Who, Whet, VJhen. W�ere. NTy):
ADVANTACaES IFAPPROVED:
D15ADVANTAGES IFAPPROVED:
A�a'�.,n:',�mn :,,:.."_.� 4�3'�sS€�`i
xi` i . :
id`@�a� 12 �997
�... ��.
DISAOVANTAGES IF NOT APPROYED:
TOTAL AMOUNT OF TRANSACTION $ COST/REVENUE BUDGETED (CIRCLE OfiE) YES MO
FUNDINCa SOURCE ACTIVITV NUMBER
FINANCIAL INFORMATION: (EXPLAIN)
MRR-19-1997 11�08 CITY OF .°.T PRUL LIEP 612 266
��b"35
C�.ASS III CITY OF SAINT PAUI.
o$x ofLiocxsq tm� eaioK
l � ; LICENSE APPLICATION � �� �,
A ������
/ � j � / � �����
� / ,�m��'{, '��l � �Qa�� ���r f ""- i `fv�� imz�aws�orstau)zesr�x�
TF�S LIC��8N1�� r � S �P�I�� e �'� t' � 7 �
PLFASE T'YPE ORPRINT IN II �b
T�pe of License(s} be;�
CompanyName: .�lA l}� �( WlL lLi(.yq
Corp�u�'�tionlPatnenlap / Sole Pmpriqarstrip
If business is iacorparated, give date of inwiporation: _
17oia8 B�siness As: ,�,J ���'til�l R 1 G�
Susinas Addsess: �'�����a=���SQ�/�-
-a�: -3
sa«s n4a,en c;cy
BCINGCS WJ781 C705S S�CeLS 15 fllE b[L4IICS5 ]OCfl1PQ�
Are thc premises now occ ted? Wttaf Type of$vsiness?
�70.��: p 0 g(!1� t�lt30 �[ Le,c; N�t
SY�aL Ad�etl �7
N8IllC 812� T1tIC:
S Tlf�i�'�
s T 6st! e o
susinessPhonr.�rYL.•77�—I/ q�
�y S.Sid L
Statn Zip
�CTS S1dC OftltG SIlYlt�
� t/OSl'L
7 ' h�e� �
I• ♦ � _• .
F�rR AYidAe y (Maidq) 7.est Tit1e
�IOIDC At1{�7CSS: � l� v�! �� G D �
StrK Addian CSty Stnte Zip
Date vf Birth: 1�+�e � l� ? Place of $irtli Home Phone�aO f. 3 57-1� � 1�
FIaveyou ever baen comictcd of aag fciotry, crime ps violation of any ary ordin�ce otber th� traffic? YES _ NO�
Date of a�resk Wl�ere7
Ctsat'&e:
Conviction: Scntcna:
Listth�nsm�s �td�esidences of three ge�sons of good maral cliazactec, fiviug within the Twin Cities Me�o Area, not nlated co the apglicani
or financially interested ia ifie premises ar business, who may be refcred tA as to �c applicanYs chazaeter.
NAME - n ADDRESS PHONE
�A��► I�►Q�.�t.1 S 14 7„2 0—y� D S7.'S • i9���- �I�-Y36-S,33T
�AN CH �P A�� M- IbRI� i9�{�. S-} iv W N,�W Bn; �LrF� L��-�N��1
fonnrRy hala oz
Have �'of the above named
baen nwoked7
iuterest in:
YES � NO If yes, list tfie data avd reasons foz revocsvoa:
��t8�97
MAR-19-1997 11�0B CI7Y OF �,T LIEP 612 266 9124 P.94i06
. . S'1-b35
Are yrou going .o operzu ilas business pasonally? ��S .�{�, *IO ffnot, �rho w7A o p er2te s'iIPER AMEIilCAC1pOCIl�
/aL � �2. _�78'-5i93
s� z� rnn,:::,�
Pl�zse listyouc emplo,ment hinory for tbe pre�za:LS $�e (5) ce� pmod:
BLrness/E�rnme� Address
iafo:mation for eaeh parmet (use addihonal pages if necessmy):
HvxAddren: 50-ea\emc C'.ry Stde ZiP Yhona?�mmbcr
Fru� '.�fiddScIaiiwl G�Sa+dca) Lea Dateef$ath
HaxRdSut: Saash'�c Cq State Zip T�nouh`waber
MIDIh'ESOTAtAX IDENIIFICATION NIIMBER - P�us�ant to the Lav.s of Mmsesota,1984, Chapta 502, Ar6cle 8, Section 2(270.72)
(t�c Clesr�mce: Iswance of Licenxs), &censing authotiries are req�al to provi& to tbe State of Msanesota CAmmissiona of Rt�eaue. ffie
h�ota bvsiaesstsx idcnrification nwnba aad the sociat sxuriry numbec of ach Iianse spplicent
Under the �ota Gavamncnt Data Yractices Aet sud sbe Fedasl Pricacp Ad of t 97C, we are required to ad� is� you ofth� fallawing
regzrdiag t�e use of the Mumtsota T�c Identification Numba:
- Zhis iafamati� maq bc used to dcaq rLe ��3...+� or renewaF of yoiu liccusc za the evmt you owe Mumesota sales. emPlos'a s
withholdmg or motor vehicle exase ta�e,
'�P� �S tbis infom�sfion, tfie lice¢siag authasiry w�t supplS it aaly ta tLe N{inz�esoaa AtParme¢t of Revcnue. Aowe�er.
wda ihe Federal Excbm�gt of Tnfa�mation Agreement, the Pepmtmcnt of Rcveaue maY ?�PP�9 this inioraia6on to 4K Sataaal
Revreue Seiv;cc "
lvf�ara I'�cIdm65�asianNumbas (Sates & LFSe Tmc N�aba') maY be obrained from t�e Stau of M���, Business Rccords DeParfma�t.
10 Riva Park Plaza (622-296-6181} . . . ... . . ' -
s�;� s�e r�vQ:1�_�3 / �-a-a-S O __ �� r�x ra�,�s� �z�: : !� �.� �.s
, If a M'ianssosa Taz IdrntiScation Numba u aot require3 for tfie businas being operaud, indicau sa hy placiag aa'X` ia �fx box
,,, e �,
pst c� gouw to �zcx a L)mz$a c�ess:S�� in this bvsiness? YES :�O If the mmaga is not the same as the operafor,
p7ezse complee tbe follrncing uu`amateoa:
Lis2 zIl other o�ic�ts of tbe ccupa. zvon:
p�iC� T1'!'LE HO!v�E HOV� BUSL*lESS DATEOF
;�*A2,2� (O�aHe}d) � ADJ�SS PHOVE PHOA'E BIRTFi
Council File $ _\���
Ordinance #
Green Sheet # �✓ �
Presented By
Referred To
RESOLUTION
GlTY OF SAlNT PAUL, MINNESOTA
�
Committee: Date
��
1
2
3
RESOLVED: T'hat application (ID #34699) for a Gas Statioq Restaurant-C, Grocery-C, and Cigazette License by
Super America Group Division of Asliland DBA SuperAmerica #4430 (James Hanson, Manager)
at 846 3ohnson Pazkway be and the same is hereby approved
4
5 Requested by Department of:
6 Yeas Navs en
7 B a�key —
8 Bostrom Otfice of License zngpections and
9 Harris
10 Me a� Environmental Protection _
11 ran
12 T une
13 Morton n
14 � � _ � ^'"1,`�v
15
16 Adopted by Council: Date $ �"7 B Y'
17 �
18 Adoption Certified by Council Secretary
19 Form Approved by City Attorney
20 / �
21 By: �- .
22 — �— '�°
23 Approved by Mayor: Date ,£�
24
25 Approved by Mayor £or Submiasion to
Council
26 By: r v
27
Bye
Greensheet# 35320 L.I.E.P. REVIEW CHECKLIST Date: 3/27/97 /`�� b3
In Trackel? APP'n �� / APP'� P���
LicenSelD # 34699 LicenSE TypeGas Station Restaurant-C, Grocerv-C, and Ciearette Licen
Company Name:SuperAmerica Group Division o£ Ashland DBA:SuperAmerica ��4430
BusinesS Addresss: $46 Johnson Parkway Business Phone: 778-9193
ContaCt Name/Address: James Hanson, 846 Johnson Parkway Home Phone:
Date to Counc7 s s i n�
Public Hearing i
Notice Sent to P
Notice Se to F
DepartmernJ
Ciry Attomey
Environmental
Heaith
Fire
License
Poiice
Labefs Ordered: f�+�
District Council #:
`
Date fnspections
��� �� �
Ward #: !
Comments
5 1� a �-- o .� .
S� �i`�� at `'
�/�
Zoning
�1����
�"JL//t
D� �
o. �
Site Plan Received:_
tease aece��ed:
c.
oE��roFF������ DATEINrtfATEO GREEN SHEE N_ 35320
LIEPjLicensin --- —
CONTACT PEfi30N 8 PHONE INITIAVDAiE INRIAUDATE
O DEPAHTMENT DIREGTOfl � CfTV CAUNGIL
Christine Rozek, 266-9108 "��N �cmnTror+Ner �cmc�aK
MUST BE ON CAUNqL AGENDA BY (DAT� q��� O BUDGET OIPECTO O FIN. $ MGT. SERVICES DIR.
For hearin : S ri � ���" �" 1nVOR � �
TOTAL # OF SIGNANRE PAGES (CLIP ALL LOCATIONS'FOR SIGNA'NRE)
ACTION RC-0UESTED:
The SuperAmerica Group Division of Ashland DBA SuperAmerica 1�4430 requests Council approval
of its applicatin for a Gas Station, Restaurant-C; �rocery-C, and Cigarette License at
846 Johnson Parkway (ID 9l34699).
RECOMMENOA7lONS: Appave (n) «Reject (R) pERSONAL SERVICE CONTRACTS MUSTANSWER TNE POLLOWINfi QUESTIONS:
_ PLANNWG COMM�SS�ON _ CIVII SERVICE COMMISSION �� Has this persoNfirtn ever worketl under a contract for this departmeM? �
_ � _ YES �NO
2. Has this person/Firm ever been a ciry employee?
_ STAFF — YES NO
_ ni57alci COUA7 _ 3. Does this perso�rm possess a skill not normalty possessetl by any current ciry employee?
SUPPORTS WH1CN COUNCIL 0&IECf1VE7 YES NO
Esplain ell yas answers on sepa�ate sheet and attaeh to green sheet
INI71A71NG PROBLEM, ISSUE, OPPORTUNITY (Who, Whet, VJhen. W�ere. NTy):
ADVANTACaES IFAPPROVED:
D15ADVANTAGES IFAPPROVED:
A�a'�.,n:',�mn :,,:.."_.� 4�3'�sS€�`i
xi` i . :
id`@�a� 12 �997
�... ��.
DISAOVANTAGES IF NOT APPROYED:
TOTAL AMOUNT OF TRANSACTION $ COST/REVENUE BUDGETED (CIRCLE OfiE) YES MO
FUNDINCa SOURCE ACTIVITV NUMBER
FINANCIAL INFORMATION: (EXPLAIN)
MRR-19-1997 11�08 CITY OF .°.T PRUL LIEP 612 266
��b"35
C�.ASS III CITY OF SAINT PAUI.
o$x ofLiocxsq tm� eaioK
l � ; LICENSE APPLICATION � �� �,
A ������
/ � j � / � �����
� / ,�m��'{, '��l � �Qa�� ���r f ""- i `fv�� imz�aws�orstau)zesr�x�
TF�S LIC��8N1�� r � S �P�I�� e �'� t' � 7 �
PLFASE T'YPE ORPRINT IN II �b
T�pe of License(s} be;�
CompanyName: .�lA l}� �( WlL lLi(.yq
Corp�u�'�tionlPatnenlap / Sole Pmpriqarstrip
If business is iacorparated, give date of inwiporation: _
17oia8 B�siness As: ,�,J ���'til�l R 1 G�
Susinas Addsess: �'�����a=���SQ�/�-
-a�: -3
sa«s n4a,en c;cy
BCINGCS WJ781 C705S S�CeLS 15 fllE b[L4IICS5 ]OCfl1PQ�
Are thc premises now occ ted? Wttaf Type of$vsiness?
�70.��: p 0 g(!1� t�lt30 �[ Le,c; N�t
SY�aL Ad�etl �7
N8IllC 812� T1tIC:
S Tlf�i�'�
s T 6st! e o
susinessPhonr.�rYL.•77�—I/ q�
�y S.Sid L
Statn Zip
�CTS S1dC OftltG SIlYlt�
� t/OSl'L
7 ' h�e� �
I• ♦ � _• .
F�rR AYidAe y (Maidq) 7.est Tit1e
�IOIDC At1{�7CSS: � l� v�! �� G D �
StrK Addian CSty Stnte Zip
Date vf Birth: 1�+�e � l� ? Place of $irtli Home Phone�aO f. 3 57-1� � 1�
FIaveyou ever baen comictcd of aag fciotry, crime ps violation of any ary ordin�ce otber th� traffic? YES _ NO�
Date of a�resk Wl�ere7
Ctsat'&e:
Conviction: Scntcna:
Listth�nsm�s �td�esidences of three ge�sons of good maral cliazactec, fiviug within the Twin Cities Me�o Area, not nlated co the apglicani
or financially interested ia ifie premises ar business, who may be refcred tA as to �c applicanYs chazaeter.
NAME - n ADDRESS PHONE
�A��► I�►Q�.�t.1 S 14 7„2 0—y� D S7.'S • i9���- �I�-Y36-S,33T
�AN CH �P A�� M- IbRI� i9�{�. S-} iv W N,�W Bn; �LrF� L��-�N��1
fonnrRy hala oz
Have �'of the above named
baen nwoked7
iuterest in:
YES � NO If yes, list tfie data avd reasons foz revocsvoa:
��t8�97
MAR-19-1997 11�0B CI7Y OF �,T LIEP 612 266 9124 P.94i06
. . S'1-b35
Are yrou going .o operzu ilas business pasonally? ��S .�{�, *IO ffnot, �rho w7A o p er2te s'iIPER AMEIilCAC1pOCIl�
/aL � �2. _�78'-5i93
s� z� rnn,:::,�
Pl�zse listyouc emplo,ment hinory for tbe pre�za:LS $�e (5) ce� pmod:
BLrness/E�rnme� Address
iafo:mation for eaeh parmet (use addihonal pages if necessmy):
HvxAddren: 50-ea\emc C'.ry Stde ZiP Yhona?�mmbcr
Fru� '.�fiddScIaiiwl G�Sa+dca) Lea Dateef$ath
HaxRdSut: Saash'�c Cq State Zip T�nouh`waber
MIDIh'ESOTAtAX IDENIIFICATION NIIMBER - P�us�ant to the Lav.s of Mmsesota,1984, Chapta 502, Ar6cle 8, Section 2(270.72)
(t�c Clesr�mce: Iswance of Licenxs), &censing authotiries are req�al to provi& to tbe State of Msanesota CAmmissiona of Rt�eaue. ffie
h�ota bvsiaesstsx idcnrification nwnba aad the sociat sxuriry numbec of ach Iianse spplicent
Under the �ota Gavamncnt Data Yractices Aet sud sbe Fedasl Pricacp Ad of t 97C, we are required to ad� is� you ofth� fallawing
regzrdiag t�e use of the Mumtsota T�c Identification Numba:
- Zhis iafamati� maq bc used to dcaq rLe ��3...+� or renewaF of yoiu liccusc za the evmt you owe Mumesota sales. emPlos'a s
withholdmg or motor vehicle exase ta�e,
'�P� �S tbis infom�sfion, tfie lice¢siag authasiry w�t supplS it aaly ta tLe N{inz�esoaa AtParme¢t of Revcnue. Aowe�er.
wda ihe Federal Excbm�gt of Tnfa�mation Agreement, the Pepmtmcnt of Rcveaue maY ?�PP�9 this inioraia6on to 4K Sataaal
Revreue Seiv;cc "
lvf�ara I'�cIdm65�asianNumbas (Sates & LFSe Tmc N�aba') maY be obrained from t�e Stau of M���, Business Rccords DeParfma�t.
10 Riva Park Plaza (622-296-6181} . . . ... . . ' -
s�;� s�e r�vQ:1�_�3 / �-a-a-S O __ �� r�x ra�,�s� �z�: : !� �.� �.s
, If a M'ianssosa Taz IdrntiScation Numba u aot require3 for tfie businas being operaud, indicau sa hy placiag aa'X` ia �fx box
,,, e �,
pst c� gouw to �zcx a L)mz$a c�ess:S�� in this bvsiness? YES :�O If the mmaga is not the same as the operafor,
p7ezse complee tbe follrncing uu`amateoa:
Lis2 zIl other o�ic�ts of tbe ccupa. zvon:
p�iC� T1'!'LE HO!v�E HOV� BUSL*lESS DATEOF
;�*A2,2� (O�aHe}d) � ADJ�SS PHOVE PHOA'E BIRTFi
Council File $ _\���
Ordinance #
Green Sheet # �✓ �
Presented By
Referred To
RESOLUTION
GlTY OF SAlNT PAUL, MINNESOTA
�
Committee: Date
��
1
2
3
RESOLVED: T'hat application (ID #34699) for a Gas Statioq Restaurant-C, Grocery-C, and Cigazette License by
Super America Group Division of Asliland DBA SuperAmerica #4430 (James Hanson, Manager)
at 846 3ohnson Pazkway be and the same is hereby approved
4
5 Requested by Department of:
6 Yeas Navs en
7 B a�key —
8 Bostrom Otfice of License zngpections and
9 Harris
10 Me a� Environmental Protection _
11 ran
12 T une
13 Morton n
14 � � _ � ^'"1,`�v
15
16 Adopted by Council: Date $ �"7 B Y'
17 �
18 Adoption Certified by Council Secretary
19 Form Approved by City Attorney
20 / �
21 By: �- .
22 — �— '�°
23 Approved by Mayor: Date ,£�
24
25 Approved by Mayor £or Submiasion to
Council
26 By: r v
27
Bye
Greensheet# 35320 L.I.E.P. REVIEW CHECKLIST Date: 3/27/97 /`�� b3
In Trackel? APP'n �� / APP'� P���
LicenSelD # 34699 LicenSE TypeGas Station Restaurant-C, Grocerv-C, and Ciearette Licen
Company Name:SuperAmerica Group Division o£ Ashland DBA:SuperAmerica ��4430
BusinesS Addresss: $46 Johnson Parkway Business Phone: 778-9193
ContaCt Name/Address: James Hanson, 846 Johnson Parkway Home Phone:
Date to Counc7 s s i n�
Public Hearing i
Notice Sent to P
Notice Se to F
DepartmernJ
Ciry Attomey
Environmental
Heaith
Fire
License
Poiice
Labefs Ordered: f�+�
District Council #:
`
Date fnspections
��� �� �
Ward #: !
Comments
5 1� a �-- o .� .
S� �i`�� at `'
�/�
Zoning
�1����
�"JL//t
D� �
o. �
Site Plan Received:_
tease aece��ed:
c.
oE��roFF������ DATEINrtfATEO GREEN SHEE N_ 35320
LIEPjLicensin --- —
CONTACT PEfi30N 8 PHONE INITIAVDAiE INRIAUDATE
O DEPAHTMENT DIREGTOfl � CfTV CAUNGIL
Christine Rozek, 266-9108 "��N �cmnTror+Ner �cmc�aK
MUST BE ON CAUNqL AGENDA BY (DAT� q��� O BUDGET OIPECTO O FIN. $ MGT. SERVICES DIR.
For hearin : S ri � ���" �" 1nVOR � �
TOTAL # OF SIGNANRE PAGES (CLIP ALL LOCATIONS'FOR SIGNA'NRE)
ACTION RC-0UESTED:
The SuperAmerica Group Division of Ashland DBA SuperAmerica 1�4430 requests Council approval
of its applicatin for a Gas Station, Restaurant-C; �rocery-C, and Cigarette License at
846 Johnson Parkway (ID 9l34699).
RECOMMENOA7lONS: Appave (n) «Reject (R) pERSONAL SERVICE CONTRACTS MUSTANSWER TNE POLLOWINfi QUESTIONS:
_ PLANNWG COMM�SS�ON _ CIVII SERVICE COMMISSION �� Has this persoNfirtn ever worketl under a contract for this departmeM? �
_ � _ YES �NO
2. Has this person/Firm ever been a ciry employee?
_ STAFF — YES NO
_ ni57alci COUA7 _ 3. Does this perso�rm possess a skill not normalty possessetl by any current ciry employee?
SUPPORTS WH1CN COUNCIL 0&IECf1VE7 YES NO
Esplain ell yas answers on sepa�ate sheet and attaeh to green sheet
INI71A71NG PROBLEM, ISSUE, OPPORTUNITY (Who, Whet, VJhen. W�ere. NTy):
ADVANTACaES IFAPPROVED:
D15ADVANTAGES IFAPPROVED:
A�a'�.,n:',�mn :,,:.."_.� 4�3'�sS€�`i
xi` i . :
id`@�a� 12 �997
�... ��.
DISAOVANTAGES IF NOT APPROYED:
TOTAL AMOUNT OF TRANSACTION $ COST/REVENUE BUDGETED (CIRCLE OfiE) YES MO
FUNDINCa SOURCE ACTIVITV NUMBER
FINANCIAL INFORMATION: (EXPLAIN)
MRR-19-1997 11�08 CITY OF .°.T PRUL LIEP 612 266
��b"35
C�.ASS III CITY OF SAINT PAUI.
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l � ; LICENSE APPLICATION � �� �,
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TF�S LIC��8N1�� r � S �P�I�� e �'� t' � 7 �
PLFASE T'YPE ORPRINT IN II �b
T�pe of License(s} be;�
CompanyName: .�lA l}� �( WlL lLi(.yq
Corp�u�'�tionlPatnenlap / Sole Pmpriqarstrip
If business is iacorparated, give date of inwiporation: _
17oia8 B�siness As: ,�,J ���'til�l R 1 G�
Susinas Addsess: �'�����a=���SQ�/�-
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sa«s n4a,en c;cy
BCINGCS WJ781 C705S S�CeLS 15 fllE b[L4IICS5 ]OCfl1PQ�
Are thc premises now occ ted? Wttaf Type of$vsiness?
�70.��: p 0 g(!1� t�lt30 �[ Le,c; N�t
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Statn Zip
�CTS S1dC OftltG SIlYlt�
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F�rR AYidAe y (Maidq) 7.est Tit1e
�IOIDC At1{�7CSS: � l� v�! �� G D �
StrK Addian CSty Stnte Zip
Date vf Birth: 1�+�e � l� ? Place of $irtli Home Phone�aO f. 3 57-1� � 1�
FIaveyou ever baen comictcd of aag fciotry, crime ps violation of any ary ordin�ce otber th� traffic? YES _ NO�
Date of a�resk Wl�ere7
Ctsat'&e:
Conviction: Scntcna:
Listth�nsm�s �td�esidences of three ge�sons of good maral cliazactec, fiviug within the Twin Cities Me�o Area, not nlated co the apglicani
or financially interested ia ifie premises ar business, who may be refcred tA as to �c applicanYs chazaeter.
NAME - n ADDRESS PHONE
�A��► I�►Q�.�t.1 S 14 7„2 0—y� D S7.'S • i9���- �I�-Y36-S,33T
�AN CH �P A�� M- IbRI� i9�{�. S-} iv W N,�W Bn; �LrF� L��-�N��1
fonnrRy hala oz
Have �'of the above named
baen nwoked7
iuterest in:
YES � NO If yes, list tfie data avd reasons foz revocsvoa:
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MAR-19-1997 11�0B CI7Y OF �,T LIEP 612 266 9124 P.94i06
. . S'1-b35
Are yrou going .o operzu ilas business pasonally? ��S .�{�, *IO ffnot, �rho w7A o p er2te s'iIPER AMEIilCAC1pOCIl�
/aL � �2. _�78'-5i93
s� z� rnn,:::,�
Pl�zse listyouc emplo,ment hinory for tbe pre�za:LS $�e (5) ce� pmod:
BLrness/E�rnme� Address
iafo:mation for eaeh parmet (use addihonal pages if necessmy):
HvxAddren: 50-ea\emc C'.ry Stde ZiP Yhona?�mmbcr
Fru� '.�fiddScIaiiwl G�Sa+dca) Lea Dateef$ath
HaxRdSut: Saash'�c Cq State Zip T�nouh`waber
MIDIh'ESOTAtAX IDENIIFICATION NIIMBER - P�us�ant to the Lav.s of Mmsesota,1984, Chapta 502, Ar6cle 8, Section 2(270.72)
(t�c Clesr�mce: Iswance of Licenxs), &censing authotiries are req�al to provi& to tbe State of Msanesota CAmmissiona of Rt�eaue. ffie
h�ota bvsiaesstsx idcnrification nwnba aad the sociat sxuriry numbec of ach Iianse spplicent
Under the �ota Gavamncnt Data Yractices Aet sud sbe Fedasl Pricacp Ad of t 97C, we are required to ad� is� you ofth� fallawing
regzrdiag t�e use of the Mumtsota T�c Identification Numba:
- Zhis iafamati� maq bc used to dcaq rLe ��3...+� or renewaF of yoiu liccusc za the evmt you owe Mumesota sales. emPlos'a s
withholdmg or motor vehicle exase ta�e,
'�P� �S tbis infom�sfion, tfie lice¢siag authasiry w�t supplS it aaly ta tLe N{inz�esoaa AtParme¢t of Revcnue. Aowe�er.
wda ihe Federal Excbm�gt of Tnfa�mation Agreement, the Pepmtmcnt of Rcveaue maY ?�PP�9 this inioraia6on to 4K Sataaal
Revreue Seiv;cc "
lvf�ara I'�cIdm65�asianNumbas (Sates & LFSe Tmc N�aba') maY be obrained from t�e Stau of M���, Business Rccords DeParfma�t.
10 Riva Park Plaza (622-296-6181} . . . ... . . ' -
s�;� s�e r�vQ:1�_�3 / �-a-a-S O __ �� r�x ra�,�s� �z�: : !� �.� �.s
, If a M'ianssosa Taz IdrntiScation Numba u aot require3 for tfie businas being operaud, indicau sa hy placiag aa'X` ia �fx box
,,, e �,
pst c� gouw to �zcx a L)mz$a c�ess:S�� in this bvsiness? YES :�O If the mmaga is not the same as the operafor,
p7ezse complee tbe follrncing uu`amateoa:
Lis2 zIl other o�ic�ts of tbe ccupa. zvon:
p�iC� T1'!'LE HO!v�E HOV� BUSL*lESS DATEOF
;�*A2,2� (O�aHe}d) � ADJ�SS PHOVE PHOA'E BIRTFi