97-636council File � – \�b�v
ordinance #
Green Sheet # J �`�
Presented By
Referred To
RESOLUTION
1 RESOLVED: That application (ID #22493) for a Gas Station, Restaurant-C, Grocery-C, and Cigarette License by
2 Super America Crraup Division of Ashland DBA SuperAmerica #4020 (Bryan Raines, Manager) at
3 399 Lea7ngton Parkway North be and the same is hereby approved.
4
`' Requested by Department of:
6 Yeas Nays s
9 B a ec y �
8 Bostrom � Off'ce of License Insgections and
9 Ha ris =_�
11 Me a�mran_ nv' o menta7 P o eCt�on
12 une
13 Morton
14 , i n ,/I �
15 jf(' /�
16 Adopted hy Council: Date B Y 0
17
1S Adoption Certi£ied by Council Secretary
19 Form Approved by City Attorney
20
21 By: a �
22
23 Approved by Mayor: Date
24
25 Approved by Mayor for Submisaion to
26 By:
� � Council
27
By:
q�bSb
„�..�.�
DEPMNTMEM�OFFICE/COUNCIL �ATEINITIATED GREEN SHEE � I � L�
LIEP/Licensing
CONiACT PERSON & PHONE � DEFARTMENT DIRECTOR�rt�AL/DATE � CRV CAUNGIL �NITIAVOATE
Christine Rozek, 266-9108 AS'��N �CR1'ATTORNEY OCffYCLERK
NUYeERFOR
MUST BE ON CAUNCIL AGENDA BY (OA ) ROI/i1NG � BUDGET DIRECTO � FIN. & MC�L SERVICES ��R.
For hearin : j`t, �� OADER � MAYOF (ORASSISTANn �
TOTAL # OF SIGNATURE PAGES (GLIP ALL LOCATIONS FOR SIGNATUREj
ACTION RE�UESTEO:
The SuperAmerica Group Division of Ashland DBA SuperAmerica Ii4020 requests Council approval
of its application for a Gas Station, Restaurant-C, Grocery-C, and Cigarette License located
at 399 Lexington Parkway North (ID 4122493).
RECOMMENDnTIONS: npprove (A) or Reject (F) PERSONAL SERVICE CONTRACTS MUST ANSWER THE FOLLOWING QUESTIONS:
_ PLANNING COMMISSION _ CIVIL SERVICE COMMISSION �� Has this person/firm ever worked under a contrect for this department?
_ CIB COMMITTEE _ YES NO
_ STarF _ 2. Has this personffirm ever been a ciry employee?
YES NO
_ DISTRICT CAURi _ 3. Does this per5on/Firm po55e55 a sklll no[ normall oSSeSSed
y p by any cunent c"Ry employee?
SUPPoRTS WHICH COUNCIL O&IECTIVE? YES NO
Explain all yes answers on separate sheet antl attach to green sheet
INITIATING PROBLEM, ISSUE. OPPORTUNITV (Who, What, When, Where, Why):
AOVANTAGES IF APPftOVEO:
RECElV�D
DISADVANTAGES IFAPPROVED.
1ERRY BLAK�f ,_a_. ; _ ��; ��. ,.-_°._.;
i.:r;� 3� i��a
.--- .�, _, h_��__���.
DISA�VANTAGES IF NOTAPPROVED'
707AL AMOUNT OF TRANSACTION $ COSi/REVENUE BUDGETED (CIRCLE ONE) YES NO
FUNDIHG SOURCE ACTIVI7Y NUMBER
PINANCIALINFORRfATION'(EXPLAIN)
Greensheet # 37929 L.I.E.P. REVIEW CHECKLIST �ate: 3lz7/97 [
ln Tracket? npp'n aecetved / aap'n Processed
��b3b
License ID # ZZk93 License Type�as Station Restaurant-C, Grocerv-C, and Ciearette Licen:
Comp2ny Name: SuperAmerica Group Div3sion of Ashland DBA: SuverAmerica �k4020
Business Addresss: 399 LexinQton Parkway North Business Phone: 646-1611
ContaCt Name/Address: Brvan Raines, 399 Lexin�ton Pkwy No _ Home Phone:
Date to Council Research: 55104
Public Hearing Date: 5 �-- Labels Ordered: i4��
Notice Sent to Applicant: District Councif #: � 3
Notice Sent to Pubtic: ���� L'"' Ward #: 1
Department/ Date lnspections Comme�ts
City Attorney
� •2 •�} O�� .
Environmental
Health
N -I�
Fire
Q•�'
License �� �� �����—
Lease Received:
5�g���
Police
�•2•9� �. .
Zoning
�� .
MRR-19-1997 11�08
Y
�
CITY OF ST PRUL LIEP
r�
f4.
. � '�
C�,ASS III CI?Y flF SAIIVT PAUI.
LiCENSE APP�,ICATION °$" `�'� ��
Ap � �_��;�
� 1 r ��p��.��
r�eN �w+�rxiax � �i � �oao, �t��. � � ��, ��� ����
�S i TC.L'RI°i't�i� 1 r � � � ���sh�O�, �t �7s+-a
PLEASE 11'PE OR PRINT IN II�fIC �d
2ype of Lue�sets) b�g aPPHed for:
Compffig Name:
corye»tionf Pettnenh;p l sok Yropipam6;p
I€busiaess is inwtpozated, 8Eve date ofiacorporation: _
�� s�,� as:?!`�it q___yh•t R� i�A
B�� ��: _ 9 9 e�.A. �,. . _ -
Betwan what cross s4eets is the busness located?
Are the P�ises now occ ied7 W�t
�ro��: __ P d ��. t Vc
��
Applieant Infa=mation: f, �
Name ead Tifle: .r�/�-$7/7.Q, SU 7
�� (� �
Home Address: _� C� L] �/ L/�1
G--��. -
612 266 912q p, g2�6
^--•— �
s_ ?
S_ L rL_dG
� � s�si� Ph�nr bl,�.
��.I.s� �c.SJ� U�
c;ty sw�
Which side of the snctit?
(bfni8c+)
�
�... �
r f.'4,..;.�
� rak
3b
so-asnaaea � �,
Scaw y�
77ate ofBirtfi; II •�I - L'7 Piace of $itth:
Home Phone:�[t 6 5� % 3
Have you ever been comicted of saq fclrnry, aime or violation of any ary ordinance other than tcaffc?
Dateofaires�; �� � NO .t'
Chargc
Convicfion;
Seuteace;
��'�"$ ��sidences o�'three persons of good moral characta; li wrth�n the Twiu Cities Metro Az no[ rdatod to the
�t fin�cislly interesta3 m ihe ptemises or bissiness, who may Ix rcfared to as to tbe applicanYs characler. � BPFlicant
Q �� _A O �� ADDRESS
F� n 1 I S ���I 7 O TRi� � J/ S PHONE
��.,...._. ,�_ . ��}�.s- �l�•Y3L.s�:�
- N�w 8rt: wL-F.a t � � .
�:
�
XES � NO ffYa, list t7u dates sad reaso�xs for revocarion:
2/t&9?
I � '
�
612 266 9124 P.&1/06
J = =."� . �1 b3b
_.�.ness pcsonatiy? 1'ES � NO ffnot, �x$o w5A operxte.�.1PER E1M�*$IL'� (�s�Q��
�
ad�rm� sceecWe
c�
Areraig�3to�n�eanm?;ecaess.�vintbisbusiaess? YES
v7ezsetomvle�e che follo� iw�ormEtioa:
srm
4�
Pkase list your emplo}ment histoiy for tbe pre�io:ts five (5j c•ea.r period:
B �u' �A ess!E�qplo�ment Address
n.,� z�
:v0 If the msn2ger is noc the szme Es the operata,
7,.t{ Deu ofBir.7e
.,�, ssiGS� � .t- [si6-
s� z;� rn«���+�x,
infa�mation for eaeh partner (use addiflonal paga if naxssazy):
xzx ��3�C+.: saen.emc Ciir statc z,r �c?.4xiba
Fcu.\vx '.fidd(e�isiJ (-�Lidea) Lau Deteof$cd+
HomeACSdtae' Sua1'.:+�c C'rty Stau ZiP YLone;.'umba
MINI�TESOTA TAX IDENTffICATION NiJMBER - P�usuaat w the Lau•s of NGaaesota,1984, Chapcer 502, Artfcic 8, Scctian 2(270.72)
(Tae Cleazanca, Lssvance of Liceas�s). &crosing authotiries are rec��ed to provide to the State of Mmnesota Commissioner ofRcvean4 the
kfinnosotabus�ness sax id�ntificaUon rnttnba a�i tha soeiat secariry number of carh8ceuse applicsnL
%
Uuder the Mmaesota Gwermneat Data Yractias Aa aad tbe Fedasl Pricary Act of S 974, we ffie requircd to advise yau ofthc foIlovciag
regard'mg tht use oftbe 2vfmnesossTaxIdenti8cationNumba:
- Ihis inf�marion may be useJ to deaq ehe '�+.s...� � reaewet of yo�u Iiccuse ia th� eveat you owe Mmnesota sa7es. emPlogd's
withholdmg a motor �e excise teoce�
'�P°II �8 ��� the licensiag avthasity w�! supply it ontp to the lvf�nesoaa Deparmxat of IZtvcnue. However,
undcr tbe Fedual ExcL�sge of informatioa Agrcement, the DePmtc°art of Revenue maY �PPil` this infora�afion m the 7�eraa3
Reve�t�e SSetvi�
Mm�s Faxldmti6ca6aaNumbets (sales &7Js�T�xNuu�cjmsybe oFnained fra� tl,e Stste oiM�ota, Bus;ness Rxor3s Deparimen�
I O Ri�a Park Plaza (612-296-6181} _. .. . _
��, ���:?�C�..� a-�-as � _ ��T�������:1� 9�1:��5
` tf a Miaaesosa Tax Idcntificarioa AIwaba u not requize3 for the business being operatad, indicau so by ptaciag aa'X` iu rLe box
nnen�
List zII ot�er o5cas of the c�pa:ztioa:
p�� TT� gp?vI� HOV,E 8U5L'QESS DAT£ OF
?.�AL2F_ tOfftcxHeSd) . ADA�.55 PH01'£ PH02� BIRTH
council File � – \�b�v
ordinance #
Green Sheet # J �`�
Presented By
Referred To
RESOLUTION
1 RESOLVED: That application (ID #22493) for a Gas Station, Restaurant-C, Grocery-C, and Cigarette License by
2 Super America Crraup Division of Ashland DBA SuperAmerica #4020 (Bryan Raines, Manager) at
3 399 Lea7ngton Parkway North be and the same is hereby approved.
4
`' Requested by Department of:
6 Yeas Nays s
9 B a ec y �
8 Bostrom � Off'ce of License Insgections and
9 Ha ris =_�
11 Me a�mran_ nv' o menta7 P o eCt�on
12 une
13 Morton
14 , i n ,/I �
15 jf(' /�
16 Adopted hy Council: Date B Y 0
17
1S Adoption Certi£ied by Council Secretary
19 Form Approved by City Attorney
20
21 By: a �
22
23 Approved by Mayor: Date
24
25 Approved by Mayor for Submisaion to
26 By:
� � Council
27
By:
q�bSb
„�..�.�
DEPMNTMEM�OFFICE/COUNCIL �ATEINITIATED GREEN SHEE � I � L�
LIEP/Licensing
CONiACT PERSON & PHONE � DEFARTMENT DIRECTOR�rt�AL/DATE � CRV CAUNGIL �NITIAVOATE
Christine Rozek, 266-9108 AS'��N �CR1'ATTORNEY OCffYCLERK
NUYeERFOR
MUST BE ON CAUNCIL AGENDA BY (OA ) ROI/i1NG � BUDGET DIRECTO � FIN. & MC�L SERVICES ��R.
For hearin : j`t, �� OADER � MAYOF (ORASSISTANn �
TOTAL # OF SIGNATURE PAGES (GLIP ALL LOCATIONS FOR SIGNATUREj
ACTION RE�UESTEO:
The SuperAmerica Group Division of Ashland DBA SuperAmerica Ii4020 requests Council approval
of its application for a Gas Station, Restaurant-C, Grocery-C, and Cigarette License located
at 399 Lexington Parkway North (ID 4122493).
RECOMMENDnTIONS: npprove (A) or Reject (F) PERSONAL SERVICE CONTRACTS MUST ANSWER THE FOLLOWING QUESTIONS:
_ PLANNING COMMISSION _ CIVIL SERVICE COMMISSION �� Has this person/firm ever worked under a contrect for this department?
_ CIB COMMITTEE _ YES NO
_ STarF _ 2. Has this personffirm ever been a ciry employee?
YES NO
_ DISTRICT CAURi _ 3. Does this per5on/Firm po55e55 a sklll no[ normall oSSeSSed
y p by any cunent c"Ry employee?
SUPPoRTS WHICH COUNCIL O&IECTIVE? YES NO
Explain all yes answers on separate sheet antl attach to green sheet
INITIATING PROBLEM, ISSUE. OPPORTUNITV (Who, What, When, Where, Why):
AOVANTAGES IF APPftOVEO:
RECElV�D
DISADVANTAGES IFAPPROVED.
1ERRY BLAK�f ,_a_. ; _ ��; ��. ,.-_°._.;
i.:r;� 3� i��a
.--- .�, _, h_��__���.
DISA�VANTAGES IF NOTAPPROVED'
707AL AMOUNT OF TRANSACTION $ COSi/REVENUE BUDGETED (CIRCLE ONE) YES NO
FUNDIHG SOURCE ACTIVI7Y NUMBER
PINANCIALINFORRfATION'(EXPLAIN)
Greensheet # 37929 L.I.E.P. REVIEW CHECKLIST �ate: 3lz7/97 [
ln Tracket? npp'n aecetved / aap'n Processed
��b3b
License ID # ZZk93 License Type�as Station Restaurant-C, Grocerv-C, and Ciearette Licen:
Comp2ny Name: SuperAmerica Group Div3sion of Ashland DBA: SuverAmerica �k4020
Business Addresss: 399 LexinQton Parkway North Business Phone: 646-1611
ContaCt Name/Address: Brvan Raines, 399 Lexin�ton Pkwy No _ Home Phone:
Date to Council Research: 55104
Public Hearing Date: 5 �-- Labels Ordered: i4��
Notice Sent to Applicant: District Councif #: � 3
Notice Sent to Pubtic: ���� L'"' Ward #: 1
Department/ Date lnspections Comme�ts
City Attorney
� •2 •�} O�� .
Environmental
Health
N -I�
Fire
Q•�'
License �� �� �����—
Lease Received:
5�g���
Police
�•2•9� �. .
Zoning
�� .
MRR-19-1997 11�08
Y
�
CITY OF ST PRUL LIEP
r�
f4.
. � '�
C�,ASS III CI?Y flF SAIIVT PAUI.
LiCENSE APP�,ICATION °$" `�'� ��
Ap � �_��;�
� 1 r ��p��.��
r�eN �w+�rxiax � �i � �oao, �t��. � � ��, ��� ����
�S i TC.L'RI°i't�i� 1 r � � � ���sh�O�, �t �7s+-a
PLEASE 11'PE OR PRINT IN II�fIC �d
2ype of Lue�sets) b�g aPPHed for:
Compffig Name:
corye»tionf Pettnenh;p l sok Yropipam6;p
I€busiaess is inwtpozated, 8Eve date ofiacorporation: _
�� s�,� as:?!`�it q___yh•t R� i�A
B�� ��: _ 9 9 e�.A. �,. . _ -
Betwan what cross s4eets is the busness located?
Are the P�ises now occ ied7 W�t
�ro��: __ P d ��. t Vc
��
Applieant Infa=mation: f, �
Name ead Tifle: .r�/�-$7/7.Q, SU 7
�� (� �
Home Address: _� C� L] �/ L/�1
G--��. -
612 266 912q p, g2�6
^--•— �
s_ ?
S_ L rL_dG
� � s�si� Ph�nr bl,�.
��.I.s� �c.SJ� U�
c;ty sw�
Which side of the snctit?
(bfni8c+)
�
�... �
r f.'4,..;.�
� rak
3b
so-asnaaea � �,
Scaw y�
77ate ofBirtfi; II •�I - L'7 Piace of $itth:
Home Phone:�[t 6 5� % 3
Have you ever been comicted of saq fclrnry, aime or violation of any ary ordinance other than tcaffc?
Dateofaires�; �� � NO .t'
Chargc
Convicfion;
Seuteace;
��'�"$ ��sidences o�'three persons of good moral characta; li wrth�n the Twiu Cities Metro Az no[ rdatod to the
�t fin�cislly interesta3 m ihe ptemises or bissiness, who may Ix rcfared to as to tbe applicanYs characler. � BPFlicant
Q �� _A O �� ADDRESS
F� n 1 I S ���I 7 O TRi� � J/ S PHONE
��.,...._. ,�_ . ��}�.s- �l�•Y3L.s�:�
- N�w 8rt: wL-F.a t � � .
�:
�
XES � NO ffYa, list t7u dates sad reaso�xs for revocarion:
2/t&9?
I � '
�
612 266 9124 P.&1/06
J = =."� . �1 b3b
_.�.ness pcsonatiy? 1'ES � NO ffnot, �x$o w5A operxte.�.1PER E1M�*$IL'� (�s�Q��
�
ad�rm� sceecWe
c�
Areraig�3to�n�eanm?;ecaess.�vintbisbusiaess? YES
v7ezsetomvle�e che follo� iw�ormEtioa:
srm
4�
Pkase list your emplo}ment histoiy for tbe pre�io:ts five (5j c•ea.r period:
B �u' �A ess!E�qplo�ment Address
n.,� z�
:v0 If the msn2ger is noc the szme Es the operata,
7,.t{ Deu ofBir.7e
.,�, ssiGS� � .t- [si6-
s� z;� rn«���+�x,
infa�mation for eaeh partner (use addiflonal paga if naxssazy):
xzx ��3�C+.: saen.emc Ciir statc z,r �c?.4xiba
Fcu.\vx '.fidd(e�isiJ (-�Lidea) Lau Deteof$cd+
HomeACSdtae' Sua1'.:+�c C'rty Stau ZiP YLone;.'umba
MINI�TESOTA TAX IDENTffICATION NiJMBER - P�usuaat w the Lau•s of NGaaesota,1984, Chapcer 502, Artfcic 8, Scctian 2(270.72)
(Tae Cleazanca, Lssvance of Liceas�s). &crosing authotiries are rec��ed to provide to the State of Mmnesota Commissioner ofRcvean4 the
kfinnosotabus�ness sax id�ntificaUon rnttnba a�i tha soeiat secariry number of carh8ceuse applicsnL
%
Uuder the Mmaesota Gwermneat Data Yractias Aa aad tbe Fedasl Pricary Act of S 974, we ffie requircd to advise yau ofthc foIlovciag
regard'mg tht use oftbe 2vfmnesossTaxIdenti8cationNumba:
- Ihis inf�marion may be useJ to deaq ehe '�+.s...� � reaewet of yo�u Iiccuse ia th� eveat you owe Mmnesota sa7es. emPlogd's
withholdmg a motor �e excise teoce�
'�P°II �8 ��� the licensiag avthasity w�! supply it ontp to the lvf�nesoaa Deparmxat of IZtvcnue. However,
undcr tbe Fedual ExcL�sge of informatioa Agrcement, the DePmtc°art of Revenue maY �PPil` this infora�afion m the 7�eraa3
Reve�t�e SSetvi�
Mm�s Faxldmti6ca6aaNumbets (sales &7Js�T�xNuu�cjmsybe oFnained fra� tl,e Stste oiM�ota, Bus;ness Rxor3s Deparimen�
I O Ri�a Park Plaza (612-296-6181} _. .. . _
��, ���:?�C�..� a-�-as � _ ��T�������:1� 9�1:��5
` tf a Miaaesosa Tax Idcntificarioa AIwaba u not requize3 for the business being operatad, indicau so by ptaciag aa'X` iu rLe box
nnen�
List zII ot�er o5cas of the c�pa:ztioa:
p�� TT� gp?vI� HOV,E 8U5L'QESS DAT£ OF
?.�AL2F_ tOfftcxHeSd) . ADA�.55 PH01'£ PH02� BIRTH
council File � – \�b�v
ordinance #
Green Sheet # J �`�
Presented By
Referred To
RESOLUTION
1 RESOLVED: That application (ID #22493) for a Gas Station, Restaurant-C, Grocery-C, and Cigarette License by
2 Super America Crraup Division of Ashland DBA SuperAmerica #4020 (Bryan Raines, Manager) at
3 399 Lea7ngton Parkway North be and the same is hereby approved.
4
`' Requested by Department of:
6 Yeas Nays s
9 B a ec y �
8 Bostrom � Off'ce of License Insgections and
9 Ha ris =_�
11 Me a�mran_ nv' o menta7 P o eCt�on
12 une
13 Morton
14 , i n ,/I �
15 jf(' /�
16 Adopted hy Council: Date B Y 0
17
1S Adoption Certi£ied by Council Secretary
19 Form Approved by City Attorney
20
21 By: a �
22
23 Approved by Mayor: Date
24
25 Approved by Mayor for Submisaion to
26 By:
� � Council
27
By:
q�bSb
„�..�.�
DEPMNTMEM�OFFICE/COUNCIL �ATEINITIATED GREEN SHEE � I � L�
LIEP/Licensing
CONiACT PERSON & PHONE � DEFARTMENT DIRECTOR�rt�AL/DATE � CRV CAUNGIL �NITIAVOATE
Christine Rozek, 266-9108 AS'��N �CR1'ATTORNEY OCffYCLERK
NUYeERFOR
MUST BE ON CAUNCIL AGENDA BY (OA ) ROI/i1NG � BUDGET DIRECTO � FIN. & MC�L SERVICES ��R.
For hearin : j`t, �� OADER � MAYOF (ORASSISTANn �
TOTAL # OF SIGNATURE PAGES (GLIP ALL LOCATIONS FOR SIGNATUREj
ACTION RE�UESTEO:
The SuperAmerica Group Division of Ashland DBA SuperAmerica Ii4020 requests Council approval
of its application for a Gas Station, Restaurant-C, Grocery-C, and Cigarette License located
at 399 Lexington Parkway North (ID 4122493).
RECOMMENDnTIONS: npprove (A) or Reject (F) PERSONAL SERVICE CONTRACTS MUST ANSWER THE FOLLOWING QUESTIONS:
_ PLANNING COMMISSION _ CIVIL SERVICE COMMISSION �� Has this person/firm ever worked under a contrect for this department?
_ CIB COMMITTEE _ YES NO
_ STarF _ 2. Has this personffirm ever been a ciry employee?
YES NO
_ DISTRICT CAURi _ 3. Does this per5on/Firm po55e55 a sklll no[ normall oSSeSSed
y p by any cunent c"Ry employee?
SUPPoRTS WHICH COUNCIL O&IECTIVE? YES NO
Explain all yes answers on separate sheet antl attach to green sheet
INITIATING PROBLEM, ISSUE. OPPORTUNITV (Who, What, When, Where, Why):
AOVANTAGES IF APPftOVEO:
RECElV�D
DISADVANTAGES IFAPPROVED.
1ERRY BLAK�f ,_a_. ; _ ��; ��. ,.-_°._.;
i.:r;� 3� i��a
.--- .�, _, h_��__���.
DISA�VANTAGES IF NOTAPPROVED'
707AL AMOUNT OF TRANSACTION $ COSi/REVENUE BUDGETED (CIRCLE ONE) YES NO
FUNDIHG SOURCE ACTIVI7Y NUMBER
PINANCIALINFORRfATION'(EXPLAIN)
Greensheet # 37929 L.I.E.P. REVIEW CHECKLIST �ate: 3lz7/97 [
ln Tracket? npp'n aecetved / aap'n Processed
��b3b
License ID # ZZk93 License Type�as Station Restaurant-C, Grocerv-C, and Ciearette Licen:
Comp2ny Name: SuperAmerica Group Div3sion of Ashland DBA: SuverAmerica �k4020
Business Addresss: 399 LexinQton Parkway North Business Phone: 646-1611
ContaCt Name/Address: Brvan Raines, 399 Lexin�ton Pkwy No _ Home Phone:
Date to Council Research: 55104
Public Hearing Date: 5 �-- Labels Ordered: i4��
Notice Sent to Applicant: District Councif #: � 3
Notice Sent to Pubtic: ���� L'"' Ward #: 1
Department/ Date lnspections Comme�ts
City Attorney
� •2 •�} O�� .
Environmental
Health
N -I�
Fire
Q•�'
License �� �� �����—
Lease Received:
5�g���
Police
�•2•9� �. .
Zoning
�� .
MRR-19-1997 11�08
Y
�
CITY OF ST PRUL LIEP
r�
f4.
. � '�
C�,ASS III CI?Y flF SAIIVT PAUI.
LiCENSE APP�,ICATION °$" `�'� ��
Ap � �_��;�
� 1 r ��p��.��
r�eN �w+�rxiax � �i � �oao, �t��. � � ��, ��� ����
�S i TC.L'RI°i't�i� 1 r � � � ���sh�O�, �t �7s+-a
PLEASE 11'PE OR PRINT IN II�fIC �d
2ype of Lue�sets) b�g aPPHed for:
Compffig Name:
corye»tionf Pettnenh;p l sok Yropipam6;p
I€busiaess is inwtpozated, 8Eve date ofiacorporation: _
�� s�,� as:?!`�it q___yh•t R� i�A
B�� ��: _ 9 9 e�.A. �,. . _ -
Betwan what cross s4eets is the busness located?
Are the P�ises now occ ied7 W�t
�ro��: __ P d ��. t Vc
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Applieant Infa=mation: f, �
Name ead Tifle: .r�/�-$7/7.Q, SU 7
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Home Address: _� C� L] �/ L/�1
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612 266 912q p, g2�6
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c;ty sw�
Which side of the snctit?
(bfni8c+)
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so-asnaaea � �,
Scaw y�
77ate ofBirtfi; II •�I - L'7 Piace of $itth:
Home Phone:�[t 6 5� % 3
Have you ever been comicted of saq fclrnry, aime or violation of any ary ordinance other than tcaffc?
Dateofaires�; �� � NO .t'
Chargc
Convicfion;
Seuteace;
��'�"$ ��sidences o�'three persons of good moral characta; li wrth�n the Twiu Cities Metro Az no[ rdatod to the
�t fin�cislly interesta3 m ihe ptemises or bissiness, who may Ix rcfared to as to tbe applicanYs characler. � BPFlicant
Q �� _A O �� ADDRESS
F� n 1 I S ���I 7 O TRi� � J/ S PHONE
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XES � NO ffYa, list t7u dates sad reaso�xs for revocarion:
2/t&9?
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612 266 9124 P.&1/06
J = =."� . �1 b3b
_.�.ness pcsonatiy? 1'ES � NO ffnot, �x$o w5A operxte.�.1PER E1M�*$IL'� (�s�Q��
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ad�rm� sceecWe
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Areraig�3to�n�eanm?;ecaess.�vintbisbusiaess? YES
v7ezsetomvle�e che follo� iw�ormEtioa:
srm
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Pkase list your emplo}ment histoiy for tbe pre�io:ts five (5j c•ea.r period:
B �u' �A ess!E�qplo�ment Address
n.,� z�
:v0 If the msn2ger is noc the szme Es the operata,
7,.t{ Deu ofBir.7e
.,�, ssiGS� � .t- [si6-
s� z;� rn«���+�x,
infa�mation for eaeh partner (use addiflonal paga if naxssazy):
xzx ��3�C+.: saen.emc Ciir statc z,r �c?.4xiba
Fcu.\vx '.fidd(e�isiJ (-�Lidea) Lau Deteof$cd+
HomeACSdtae' Sua1'.:+�c C'rty Stau ZiP YLone;.'umba
MINI�TESOTA TAX IDENTffICATION NiJMBER - P�usuaat w the Lau•s of NGaaesota,1984, Chapcer 502, Artfcic 8, Scctian 2(270.72)
(Tae Cleazanca, Lssvance of Liceas�s). &crosing authotiries are rec��ed to provide to the State of Mmnesota Commissioner ofRcvean4 the
kfinnosotabus�ness sax id�ntificaUon rnttnba a�i tha soeiat secariry number of carh8ceuse applicsnL
%
Uuder the Mmaesota Gwermneat Data Yractias Aa aad tbe Fedasl Pricary Act of S 974, we ffie requircd to advise yau ofthc foIlovciag
regard'mg tht use oftbe 2vfmnesossTaxIdenti8cationNumba:
- Ihis inf�marion may be useJ to deaq ehe '�+.s...� � reaewet of yo�u Iiccuse ia th� eveat you owe Mmnesota sa7es. emPlogd's
withholdmg a motor �e excise teoce�
'�P°II �8 ��� the licensiag avthasity w�! supply it ontp to the lvf�nesoaa Deparmxat of IZtvcnue. However,
undcr tbe Fedual ExcL�sge of informatioa Agrcement, the DePmtc°art of Revenue maY �PPil` this infora�afion m the 7�eraa3
Reve�t�e SSetvi�
Mm�s Faxldmti6ca6aaNumbets (sales &7Js�T�xNuu�cjmsybe oFnained fra� tl,e Stste oiM�ota, Bus;ness Rxor3s Deparimen�
I O Ri�a Park Plaza (612-296-6181} _. .. . _
��, ���:?�C�..� a-�-as � _ ��T�������:1� 9�1:��5
` tf a Miaaesosa Tax Idcntificarioa AIwaba u not requize3 for the business being operatad, indicau so by ptaciag aa'X` iu rLe box
nnen�
List zII ot�er o5cas of the c�pa:ztioa:
p�� TT� gp?vI� HOV,E 8U5L'QESS DAT£ OF
?.�AL2F_ tOfftcxHeSd) . ADA�.55 PH01'£ PH02� BIRTH