97-639Council File # C� ` bJ�
Ordinance #
Green Sheet # � 7 ���
Presented By
Referred To
57
Committee: Date
i
2
3
RESOLVED: That application (ID #18760) for a Gas Statlon, Restaurant-C, Grocery-C, and Cigarette License by
Super America Group Division of Asliland DBA SuperAmerica #4425 (Alan Stewart, Manager) at
275 McKnight Road South be and ffie same is hereby approved.
4
5 Requested by Department of:
6 Yeas a a se
7 B a e�Tc y
S Bostrom
9 Harris —�-
10 P e a ==
11 _�
14 T ort��n
15 �
16 Adopted by Council: Date �\ 5� �q�'�
17 ��..
18 Adoption Certified by Council Secretary
19 "
20
21 By: � � �
22 `' _ /
23 Approved by Mayor: Date �/ 'a-
24 �-
25 �1 (
26 By: �^-�"' �
27
RESOLUTION
CITY OF SAINT PAUL, MINNESOTA
• - -�-- - - •�-
4 •,n - •,
By: 17 .t.t �
Form Approved by City Attorney
�� _
By: �
Approved by Mayor for Submission to
Council
By:
���3�
A � 6
�,�,���N��� DATE INRIATED GREEN SHEE s � ��� '
LIEP(Licensin INRIAVDATE INmAWATE
CONTACT PERSON & PMONE O OEPApTMENT �IRECTOF � CITY GOUNCIL
Christine Rozek 266-9108 ''�'�" � cmnrroaNer O CITYCLERK
MUST BE ON GOUNCIL AGENDA BV (DAT� NUYBEN GOA O gUDGET DIRECTOF � FIN. & MGT. SERVICES DIR.
POUTING
�] � OROEA � MpypR (OR ASSISTANn �
For hearin : D
TOTAL # OF SIGNATURE PAGES (CLIP ALL LOCATIONS FOR SICaNATURE)
ACTION RE�UESTED:
The SuperAmerica Group Division o£ Ashland DBA SuperAmerica ��4425 requests Council approval
o£ its application for a Gas Station, Restauran[-C, Grocery-C, and Cigarette License
located at 275 McKnight Road South (ID Ik18760).
RECOMMENOA71�N5: Approve (A) or RejeG (R) PEHSONAL SERVICE CONiRACTS MUST ANSWER THE FOLIOWING QUEST�ONS:
_ PLANN W G COMMISSION _ CIVIL SERVICE CAMMISSION �� Has this person�rm ever worked u�der a carrtrac[ for Mis departmanY?
_ CIB COMMITfEE _ YES NO
_ SrAFF 2. Has this person�rm ever been a ciry employee?
— YES NO
_ DIS7ta1CT COUR7 _ 3. Does this person/tirm possess a skill not no�ma�ly pos5essetl by any currern city employee?
SUPPORTS WHICN COUNCIL OBJECfIVE? YES NO
Explafn all yes answers on seperate sheet ana atteeh to green ahcet
INITIATING PROBLEM, ISSUE, OPPpRTUNITY (Who, What, When. Where, Why):
ADVANTAGES IFAPPROVED:
DISADVANTAGES IF APPROVED'
�.91».�..�,._ .-_,__, .d.. �`:,,_.A..
i�i,�: s i `'� i:J�f
� ,.
-- -_ . __ _._ .�„w.��.=�
DISADVANTAGES IF NOT APPRQVED'
TOTAL AMOUTIT OF TRANSACTION $ COSTIREVEICUE BUDGETED (CiRCLE ONE) YES NO
FUNDIfiG SOUACE ACTIVITY NUMeER
FiNANqAL WFORFlA710N: (EXPLAIN)
G�eensneet# 37934 L.I.E.P. REVIEW CHECKLIST Date: 3/27/97 /
In Trackef? App'n Received J App'n Processed
q�b3�t
LicenselD # 18760 L�cense Type�as Station Restaurant-C, Gxocexv-C, and CiQarette Licen
CAmpany Name:SuperAmerica Group Division of Ashland DBA:SuverAmerica �/4425
Business Addresss: 275 McKnight Road South Business Phone: 739-5012
Contact Name/Address: L�7-an Stewart, 275 McKni�ht Road So Home Phone:
Date ta Council Research: 55119
Public Hearing Date: �i �Z� � Labeis Ordered: /✓�
Notice Sent to Appiicant: District Council #: �
a�� a..�
Notice Sent to Public: � �` �� Ward #: f
( Departmentf Date Inspections Comments
City Attorney
�'2�'l�-
Environmental
Heaith
N•
�► •
License
� �� c �� � � 1 E.i
Police
�:�r.r��
Site Plan Received:_
Lease Received:
Zoning
._ MFlR-19-1997 11�08 CITY �F ST PRUL LIEP
(4.
(olJ � b3�
�,(.�$S �j CITY OF SAINT PAUT.
�± LICENSE APPLICATI4N �"��
1 -YDr' ��P�ssa�zo
��.� ��
�' � �i ao, Wrz3. � i � �, ��� �<���z6
�rv�ccYikz , �° .
s �r c r ' �°�. �sr �S
PLEASE TYPE OR PR1NT IN 7rIIC ��
Tcge of Licease(S) ban�
CompsnyName: � �cli�9'��.«•�G`�
Cafpoc.ti� � PuG�a+hip � Sole Proprivarship
Sf ��uiness is incoiparated, 8re aste of incoiporat;on: _
17oia8 Business As: � 4�..]�{ �. �N4�1 R! GQ
sc«s aaa��,. „
Bmvaa what cross streers is the bv9ness located? ,_
Are the preAises now :edT tA' What T
Msi1 To .9ddress: _�� U X! t� V V�
F'r��r.r.�
Applicant Infom
Nmx and Titic:
�—as-
F'mc '.11'idA< �/ (Maidn) Last Tuk '
HoIDG.dl�7CS5: ��1 a G� f�� (/ O �
S1sctAdd�ca City Stuc yip
Date of Birtfi: I I�. (/ � V'� Place of $irth: Hame Pbone�.Ia61. 3 S7 �� 13
Ha�e }rov ever baen comicted of sup fciony, aime or violadon of anp ciry ozdinance other than trafftc? YES _ NO,�_
Date of azrest: Wherep
��8�
Contiction: $eute�cc;
Lut d�c nam�s and resideno�s of t2uce pers�ns of good motal characts, 6ving within the Twin Cities Me�o Area, not related to rhe appiicani
or 5nmacia!]y interested m fhe premiss or business, who may ix refazed W as to tbe applicam's ch�acter:
NAME ADDRESS pHp�
B A�[� ���,4L� S— lY7�b—yaND S'y:S .�1�}�.s. G/�.�13�.53�7
�Iave
:�wi��.�r�r
. ♦
., ...
�►.a..�. t
,�������
..
have an interesc in:
612 265
s '�df�'l
... i
sum z�
Witich side of the sh�eet? __
S/Z
h°+. zi
.`.L-Iw t r J ,
YES � NO ffyes, list ttu data mmd reasons fos revocavoa:
2/t8N1
MqR-19-1997 11�08 CITY QF gT�CIL LIEP 612 266 9124 P.04/05
. / �1.`l'�p`�j`�
�oa-ous�€�oo��r�+t�sbus��s�°�`' i'�s �L.�'•'io �fnot,.ihou-ivaparaeJ'f1PERAMERICt1GROii�73
Z-
+ mess/Etq I�o�ment �i
each parma (use additional psges if necessary):
�.�
xoxAddm+� scas�anse chy .3aw z;p � •'�ba
F'rx\amc '-.fiddSoEoiti.l (-4t++des3 La Datcof8't3
HoseAd�xt� Srea:�e Ciry Sau Zip Zrnoae\`acbtt
MNI�TES07A TAX IDENTIFICATiObi NFJNIBEfL - P�usuant to the La�zs of NGuaesota, i984, Chaptcr 502,Articic 8, Section Z(270.72)
(Ta� C}ea�ce; Issusaoc of Licenses). &xnsiag siuhorities are requaed ta pmvidc to the State of bKuneso�a Commi.ssioaet of Revmue, the
Mwnaosa busiaess tax ideatification numba sAd the socisl srcuriry nvmber of cech S�caue appHcant
UudeY the k&aaesote Gwetnment Data Yraciices Aa �d sbe Feda�sl Pricacy Act of I974, we sre requir�d to ad�ise you of thc foIlow�ing
regard'mg the use of tFse MIImcsota T�c Ideatificatiou NumSa:
-?bis infaimation msy be usd to dmp tfie �tas... � reaewat of yoiu ficauc in the evmt you owe Mumesors ssles, employds
witbboldv�g � motorvchicic exase t�e�
- TJP°n mceis'm8 this udorms¢on. ttic liceosiag autbairy w�t suppIy it oaly to the M'innesota De.Pazaveat of Revcnuc. Iiowever,
uada tha Fedasl Exc3�ge of 7nfarnation Agreemcn; the Depmtmcat of Revenue maY �PP1S this information tn 4u IMeraal
Revenue Scvix .
Mum�ta TaxI�tificffiiasNumbecs Csates & Use TaxDfiaubc) may be obramed from tLe state ofMnnaota, Susincss R�rds Departmau.
lORivaParkPlazx(612-296-b181}. �.. .. /_.
�oc:iat Securily Ncm�brr. ,� I � �l � �� � ' _ NFumcsota Ta�tic�ti5�aiioa N�ba: �i� �%Y.� t�S _
_ If a 2�auesota Tax Idcnrifica6on 2Vumbes is aot requi:ed fac the business bcing operated. indicatc so by ptacmg an'X' ia r}x �wx
enctfo
Arecw�g�to�ta�smzg�oress,�tiathisburiness? YES :dOI€thcmaazgaisnotthesxtne€srbeoperator,
Plczse listyour emplo;ment history fot tLe prc«o•.0 fxve (5) reuperiod:
List zII othes o�cus of t8e cospa. ztion:
p�� T'tY7.E HOME HOV,$ BUSATESS DATEOF
;�p�,� (O�aHayd) � AAT�SS T'HO\'E Pi-IO2�'E BIltTH
Council File # C� ` bJ�
Ordinance #
Green Sheet # � 7 ���
Presented By
Referred To
57
Committee: Date
i
2
3
RESOLVED: That application (ID #18760) for a Gas Statlon, Restaurant-C, Grocery-C, and Cigarette License by
Super America Group Division of Asliland DBA SuperAmerica #4425 (Alan Stewart, Manager) at
275 McKnight Road South be and ffie same is hereby approved.
4
5 Requested by Department of:
6 Yeas a a se
7 B a e�Tc y
S Bostrom
9 Harris —�-
10 P e a ==
11 _�
14 T ort��n
15 �
16 Adopted by Council: Date �\ 5� �q�'�
17 ��..
18 Adoption Certified by Council Secretary
19 "
20 ����
21 By: ��
22 _/
23 Approved by Mayor: Date �/ 'a-
24
25 �
26 By: �'
27
RESOLUTION
CITY OF SAINT PAUL, MINNESOTA
• - -�-- - - •�-
4 •,n - •,
By: 17 .t.t �
Form Approved by City Attorney
�� _
By: �
Approved by Mayor for Submission to
Council
By:
���3�
A � 6
�,�,���N��� DATE INRIATED GREEN SHEE s � ��� '
LIEP(Licensin INRIAVDATE INmAWATE
CONTACT PERSON & PMONE O OEPApTMENT �IRECTOF � CITY GOUNCIL
Christine Rozek 266-9108 ''�'�" � cmnrroaNer O CITYCLERK
MUST BE ON GOUNCIL AGENDA BV (DAT� NUYBEN GOA O gUDGET DIRECTOF � FIN. & MGT. SERVICES DIR.
POUTING
�] � OROEA � MpypR (OR ASSISTANn �
For hearin : D
TOTAL # OF SIGNATURE PAGES (CLIP ALL LOCATIONS FOR SICaNATURE)
ACTION RE�UESTED:
The SuperAmerica Group Division o£ Ashland DBA SuperAmerica ��4425 requests Council approval
o£ its application for a Gas Station, Restauran[-C, Grocery-C, and Cigarette License
located at 275 McKnight Road South (ID Ik18760).
RECOMMENOA71�N5: Approve (A) or RejeG (R) PEHSONAL SERVICE CONiRACTS MUST ANSWER THE FOLIOWING QUEST�ONS:
_ PLANN W G COMMISSION _ CIVIL SERVICE CAMMISSION �� Has this person�rm ever worked u�der a carrtrac[ for Mis departmanY?
_ CIB COMMITfEE _ YES NO
_ SrAFF 2. Has this person�rm ever been a ciry employee?
— YES NO
_ DIS7ta1CT COUR7 _ 3. Does this person/tirm possess a skill not no�ma�ly pos5essetl by any currern city employee?
SUPPORTS WHICN COUNCIL OBJECfIVE? YES NO
Explafn all yes answers on seperate sheet ana atteeh to green ahcet
INITIATING PROBLEM, ISSUE, OPPpRTUNITY (Who, What, When. Where, Why):
ADVANTAGES IFAPPROVED:
DISADVANTAGES IF APPROVED'
�.91».�..�,._ .-_,__, .d.. �`:,,_.A..
i�i,�: s i `'� i:J�f
� ,.
-- -_ . __ _._ .�„w.��.=�
DISADVANTAGES IF NOT APPRQVED'
TOTAL AMOUTIT OF TRANSACTION $ COSTIREVEICUE BUDGETED (CiRCLE ONE) YES NO
FUNDIfiG SOUACE ACTIVITY NUMeER
FiNANqAL WFORFlA710N: (EXPLAIN)
G�eensneet# 37934 L.I.E.P. REVIEW CHECKLIST Date: 3/27/97 /
In Trackef? App'n Received J App'n Processed
q�b3�t
LicenselD # 18760 L�cense Type�as Station Restaurant-C, Gxocexv-C, and CiQarette Licen
CAmpany Name:SuperAmerica Group Division of Ashland DBA:SuverAmerica �/4425
Business Addresss: 275 McKnight Road South Business Phone: 739-5012
Contact Name/Address: L�7-an Stewart, 275 McKni�ht Road So Home Phone:
Date ta Council Research: 55119
Public Hearing Date: �i �Z� � Labeis Ordered: /✓�
Notice Sent to Appiicant: District Council #: �
a�� a..�
Notice Sent to Public: � �` �� Ward #: f
( Departmentf Date Inspections Comments
City Attorney
�'2�'l�-
Environmental
Heaith
N•
�► •
License
� �� c �� � � 1 E.i
Police
�:�r.r��
Site Plan Received:_
Lease Received:
Zoning
._ MFlR-19-1997 11�08 CITY �F ST PRUL LIEP
(4.
(olJ � b3�
�,(.�$S �j CITY OF SAINT PAUT.
�± LICENSE APPLICATI4N �"��
1 -YDr' ��P�ssa�zo
��.� ��
�' � �i ao, Wrz3. � i � �, ��� �<���z6
�rv�ccYikz , �° .
s �r c r ' �°�. �sr �S
PLEASE TYPE OR PR1NT IN 7rIIC ��
Tcge of Licease(S) ban�
CompsnyName: � �cli�9'��.«•�G`�
Cafpoc.ti� � PuG�a+hip � Sole Proprivarship
Sf ��uiness is incoiparated, 8re aste of incoiporat;on: _
17oia8 Business As: � 4�..]�{ �. �N4�1 R! GQ
sc«s aaa��,. „
Bmvaa what cross streers is the bv9ness located? ,_
Are the preAises now :edT tA' What T
Msi1 To .9ddress: _�� U X! t� V V�
F'r��r.r.�
Applicant Infom
Nmx and Titic:
�—as-
F'mc '.11'idA< �/ (Maidn) Last Tuk '
HoIDG.dl�7CS5: ��1 a G� f�� (/ O �
S1sctAdd�ca City Stuc yip
Date of Birtfi: I I�. (/ � V'� Place of $irth: Hame Pbone�.Ia61. 3 S7 �� 13
Ha�e }rov ever baen comicted of sup fciony, aime or violadon of anp ciry ozdinance other than trafftc? YES _ NO,�_
Date of azrest: Wherep
��8�
Contiction: $eute�cc;
Lut d�c nam�s and resideno�s of t2uce pers�ns of good motal characts, 6ving within the Twin Cities Me�o Area, not related to rhe appiicani
or 5nmacia!]y interested m fhe premiss or business, who may ix refazed W as to tbe applicam's ch�acter:
NAME ADDRESS pHp�
B A�[� ���,4L� S— lY7�b—yaND S'y:S .�1�}�.s. G/�.�13�.53�7
�Iave
:�wi��.�r�r
. ♦
., ...
�►.a..�. t
,�������
..
have an interesc in:
612 265
s '�df�'l
... i
sum z�
Witich side of the sh�eet? __
S/Z
h°+. zi
.`.L-Iw t r J ,
YES � NO ffyes, list ttu data mmd reasons fos revocavoa:
2/t8N1
MqR-19-1997 11�08 CITY QF gT�CIL LIEP 612 266 9124 P.04/05
. / �1.`l'�p`�j`�
�oa-ous�€�oo��r�+t�sbus��s�°�`' i'�s �L.�'•'io �fnot,.ihou-ivaparaeJ'f1PERAMERICt1GROii�73
Z-
+ mess/Etq I�o�ment �i
each parma (use additional psges if necessary):
�.�
xoxAddm+� scas�anse chy .3aw z;p � •'�ba
F'rx\amc '-.fiddSoEoiti.l (-4t++des3 La Datcof8't3
HoseAd�xt� Srea:�e Ciry Sau Zip Zrnoae\`acbtt
MNI�TES07A TAX IDENTIFICATiObi NFJNIBEfL - P�usuant to the La�zs of NGuaesota, i984, Chaptcr 502,Articic 8, Section Z(270.72)
(Ta� C}ea�ce; Issusaoc of Licenses). &xnsiag siuhorities are requaed ta pmvidc to the State of bKuneso�a Commi.ssioaet of Revmue, the
Mwnaosa busiaess tax ideatification numba sAd the socisl srcuriry nvmber of cech S�caue appHcant
UudeY the k&aaesote Gwetnment Data Yraciices Aa �d sbe Feda�sl Pricacy Act of I974, we sre requir�d to ad�ise you of thc foIlow�ing
regard'mg the use of tFse MIImcsota T�c Ideatificatiou NumSa:
-?bis infaimation msy be usd to dmp tfie �tas... � reaewat of yoiu ficauc in the evmt you owe Mumesors ssles, employds
witbboldv�g � motorvchicic exase t�e�
- TJP°n mceis'm8 this udorms¢on. ttic liceosiag autbairy w�t suppIy it oaly to the M'innesota De.Pazaveat of Revcnuc. Iiowever,
uada tha Fedasl Exc3�ge of 7nfarnation Agreemcn; the Depmtmcat of Revenue maY �PP1S this information tn 4u IMeraal
Revenue Scvix .
Mum�ta TaxI�tificffiiasNumbecs Csates & Use TaxDfiaubc) may be obramed from tLe state ofMnnaota, Susincss R�rds Departmau.
lORivaParkPlazx(612-296-b181}. �.. .. /_.
�oc:iat Securily Ncm�brr. ,� I � �l � �� � ' _ NFumcsota Ta�tic�ti5�aiioa N�ba: �i� �%Y.� t�S _
_ If a 2�auesota Tax Idcnrifica6on 2Vumbes is aot requi:ed fac the business bcing operated. indicatc so by ptacmg an'X' ia r}x �wx
enctfo
Arecw�g�to�ta�smzg�oress,�tiathisburiness? YES :dOI€thcmaazgaisnotthesxtne€srbeoperator,
Plczse listyour emplo;ment history fot tLe prc«o•.0 fxve (5) reuperiod:
List zII othes o�cus of t8e cospa. ztion:
p�� T'tY7.E HOME HOV,$ BUSATESS DATEOF
;�p�,� (O�aHayd) � AAT�SS T'HO\'E Pi-IO2�'E BIltTH
Council File # C� ` bJ�
Ordinance #
Green Sheet # � 7 ���
Presented By
Referred To
57
Committee: Date
i
2
3
RESOLVED: That application (ID #18760) for a Gas Statlon, Restaurant-C, Grocery-C, and Cigarette License by
Super America Group Division of Asliland DBA SuperAmerica #4425 (Alan Stewart, Manager) at
275 McKnight Road South be and ffie same is hereby approved.
4
5 Requested by Department of:
6 Yeas a a se
7 B a e�Tc y
S Bostrom
9 Harris —�-
10 P e a ==
11 _�
14 T ort��n
15 �
16 Adopted by Council: Date �\ 5� �q�'�
17 ��..
18 Adoption Certified by Council Secretary
19 "
20 ����
21 By: ��
22 _/
23 Approved by Mayor: Date �/ 'a-
24
25 �
26 By: �'
27
RESOLUTION
CITY OF SAINT PAUL, MINNESOTA
• - -�-- - - •�-
4 •,n - •,
By: 17 .t.t �
Form Approved by City Attorney
�� _
By: �
Approved by Mayor for Submission to
Council
By:
���3�
A � 6
�,�,���N��� DATE INRIATED GREEN SHEE s � ��� '
LIEP(Licensin INRIAVDATE INmAWATE
CONTACT PERSON & PMONE O OEPApTMENT �IRECTOF � CITY GOUNCIL
Christine Rozek 266-9108 ''�'�" � cmnrroaNer O CITYCLERK
MUST BE ON GOUNCIL AGENDA BV (DAT� NUYBEN GOA O gUDGET DIRECTOF � FIN. & MGT. SERVICES DIR.
POUTING
�] � OROEA � MpypR (OR ASSISTANn �
For hearin : D
TOTAL # OF SIGNATURE PAGES (CLIP ALL LOCATIONS FOR SICaNATURE)
ACTION RE�UESTED:
The SuperAmerica Group Division o£ Ashland DBA SuperAmerica ��4425 requests Council approval
o£ its application for a Gas Station, Restauran[-C, Grocery-C, and Cigarette License
located at 275 McKnight Road South (ID Ik18760).
RECOMMENOA71�N5: Approve (A) or RejeG (R) PEHSONAL SERVICE CONiRACTS MUST ANSWER THE FOLIOWING QUEST�ONS:
_ PLANN W G COMMISSION _ CIVIL SERVICE CAMMISSION �� Has this person�rm ever worked u�der a carrtrac[ for Mis departmanY?
_ CIB COMMITfEE _ YES NO
_ SrAFF 2. Has this person�rm ever been a ciry employee?
— YES NO
_ DIS7ta1CT COUR7 _ 3. Does this person/tirm possess a skill not no�ma�ly pos5essetl by any currern city employee?
SUPPORTS WHICN COUNCIL OBJECfIVE? YES NO
Explafn all yes answers on seperate sheet ana atteeh to green ahcet
INITIATING PROBLEM, ISSUE, OPPpRTUNITY (Who, What, When. Where, Why):
ADVANTAGES IFAPPROVED:
DISADVANTAGES IF APPROVED'
�.91».�..�,._ .-_,__, .d.. �`:,,_.A..
i�i,�: s i `'� i:J�f
� ,.
-- -_ . __ _._ .�„w.��.=�
DISADVANTAGES IF NOT APPRQVED'
TOTAL AMOUTIT OF TRANSACTION $ COSTIREVEICUE BUDGETED (CiRCLE ONE) YES NO
FUNDIfiG SOUACE ACTIVITY NUMeER
FiNANqAL WFORFlA710N: (EXPLAIN)
G�eensneet# 37934 L.I.E.P. REVIEW CHECKLIST Date: 3/27/97 /
In Trackef? App'n Received J App'n Processed
q�b3�t
LicenselD # 18760 L�cense Type�as Station Restaurant-C, Gxocexv-C, and CiQarette Licen
CAmpany Name:SuperAmerica Group Division of Ashland DBA:SuverAmerica �/4425
Business Addresss: 275 McKnight Road South Business Phone: 739-5012
Contact Name/Address: L�7-an Stewart, 275 McKni�ht Road So Home Phone:
Date ta Council Research: 55119
Public Hearing Date: �i �Z� � Labeis Ordered: /✓�
Notice Sent to Appiicant: District Council #: �
a�� a..�
Notice Sent to Public: � �` �� Ward #: f
( Departmentf Date Inspections Comments
City Attorney
�'2�'l�-
Environmental
Heaith
N•
�► •
License
� �� c �� � � 1 E.i
Police
�:�r.r��
Site Plan Received:_
Lease Received:
Zoning
._ MFlR-19-1997 11�08 CITY �F ST PRUL LIEP
(4.
(olJ � b3�
�,(.�$S �j CITY OF SAINT PAUT.
�± LICENSE APPLICATI4N �"��
1 -YDr' ��P�ssa�zo
��.� ��
�' � �i ao, Wrz3. � i � �, ��� �<���z6
�rv�ccYikz , �° .
s �r c r ' �°�. �sr �S
PLEASE TYPE OR PR1NT IN 7rIIC ��
Tcge of Licease(S) ban�
CompsnyName: � �cli�9'��.«•�G`�
Cafpoc.ti� � PuG�a+hip � Sole Proprivarship
Sf ��uiness is incoiparated, 8re aste of incoiporat;on: _
17oia8 Business As: � 4�..]�{ �. �N4�1 R! GQ
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Bmvaa what cross streers is the bv9ness located? ,_
Are the preAises now :edT tA' What T
Msi1 To .9ddress: _�� U X! t� V V�
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Applicant Infom
Nmx and Titic:
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F'mc '.11'idA< �/ (Maidn) Last Tuk '
HoIDG.dl�7CS5: ��1 a G� f�� (/ O �
S1sctAdd�ca City Stuc yip
Date of Birtfi: I I�. (/ � V'� Place of $irth: Hame Pbone�.Ia61. 3 S7 �� 13
Ha�e }rov ever baen comicted of sup fciony, aime or violadon of anp ciry ozdinance other than trafftc? YES _ NO,�_
Date of azrest: Wherep
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Contiction: $eute�cc;
Lut d�c nam�s and resideno�s of t2uce pers�ns of good motal characts, 6ving within the Twin Cities Me�o Area, not related to rhe appiicani
or 5nmacia!]y interested m fhe premiss or business, who may ix refazed W as to tbe applicam's ch�acter:
NAME ADDRESS pHp�
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612 265
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Witich side of the sh�eet? __
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YES � NO ffyes, list ttu data mmd reasons fos revocavoa:
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MqR-19-1997 11�08 CITY QF gT�CIL LIEP 612 266 9124 P.04/05
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+ mess/Etq I�o�ment �i
each parma (use additional psges if necessary):
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xoxAddm+� scas�anse chy .3aw z;p � •'�ba
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MNI�TES07A TAX IDENTIFICATiObi NFJNIBEfL - P�usuant to the La�zs of NGuaesota, i984, Chaptcr 502,Articic 8, Section Z(270.72)
(Ta� C}ea�ce; Issusaoc of Licenses). &xnsiag siuhorities are requaed ta pmvidc to the State of bKuneso�a Commi.ssioaet of Revmue, the
Mwnaosa busiaess tax ideatification numba sAd the socisl srcuriry nvmber of cech S�caue appHcant
UudeY the k&aaesote Gwetnment Data Yraciices Aa �d sbe Feda�sl Pricacy Act of I974, we sre requir�d to ad�ise you of thc foIlow�ing
regard'mg the use of tFse MIImcsota T�c Ideatificatiou NumSa:
-?bis infaimation msy be usd to dmp tfie �tas... � reaewat of yoiu ficauc in the evmt you owe Mumesors ssles, employds
witbboldv�g � motorvchicic exase t�e�
- TJP°n mceis'm8 this udorms¢on. ttic liceosiag autbairy w�t suppIy it oaly to the M'innesota De.Pazaveat of Revcnuc. Iiowever,
uada tha Fedasl Exc3�ge of 7nfarnation Agreemcn; the Depmtmcat of Revenue maY �PP1S this information tn 4u IMeraal
Revenue Scvix .
Mum�ta TaxI�tificffiiasNumbecs Csates & Use TaxDfiaubc) may be obramed from tLe state ofMnnaota, Susincss R�rds Departmau.
lORivaParkPlazx(612-296-b181}. �.. .. /_.
�oc:iat Securily Ncm�brr. ,� I � �l � �� � ' _ NFumcsota Ta�tic�ti5�aiioa N�ba: �i� �%Y.� t�S _
_ If a 2�auesota Tax Idcnrifica6on 2Vumbes is aot requi:ed fac the business bcing operated. indicatc so by ptacmg an'X' ia r}x �wx
enctfo
Arecw�g�to�ta�smzg�oress,�tiathisburiness? YES :dOI€thcmaazgaisnotthesxtne€srbeoperator,
Plczse listyour emplo;ment history fot tLe prc«o•.0 fxve (5) reuperiod:
List zII othes o�cus of t8e cospa. ztion:
p�� T'tY7.E HOME HOV,$ BUSATESS DATEOF
;�p�,� (O�aHayd) � AAT�SS T'HO\'E Pi-IO2�'E BIltTH