97-648Council File # —� t"��
Ordinance �
Green Sheet # ���✓�
Presented By �
RESOLUTION
CITY OF SAINT PAUL, MINNESOTA
Referred To
Committee: Date
�
1
2
3
RFSOLVED: That applicarion (ID #6425'� for a Gas Station, Restaurant-C, Grocery-C, and Cigaret#e License by
Super America Group Division of Asliland DBA SuperAmerica #4356 (Kevin Linn, Manager) at
56 Snelling Avenue North be and the same is hereby approved
4
`' Requested by Department of:
6 Yeas Navs Abse
7 Blak �
8 Bostrom __�,._ Office of License Ins and
9 Harr
10 Me a � EnvironMental Protection
11 :N
i� Morton
O
16 Adopted by Council: Date B y 0 �
17
18 Adoption Certified by Council Secretary
19 Form Approved by City Attorney
20
21 By: �` ---"— �-
22 By ' � '�'
23 Approved by Mayor: Date �'/�t 1
24 `�--
25 Approved by Mayor for Submiasion to
26 By: U Council
27
Y�
G'l-b�l�
DEPAflTMENTqFFlCE/COUNCIL DATE INITIATEO �/ � J J�
LIEP/Licensing GREEN SHEE
CONiA(.T PEflSON & PHONE INITIALlDATE WITIAVOATE
�DEPARTMENTDIRECTOR apTYCAUNCIL
Christine Rozek, 266-9108 A���N �CITYATfOqNEV �CT'CLERK
NUNBERFON
MUST BE ON COUNCIL AGENDA BY (DATE ROUiING � BUWET DIpECTOR O FIN. & MGT. SERVICES DIR.
For hearing: Z b �� OqDER �MpyOR{ORASSISTA!!n O
TOTAI # OF SIGNATURE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE)
ACTION REQUESTED:
The SuperAmerica Group Division of Ashland DBA SuperAmexica 464356 requests Council approval
of its application for a Gas Station, Restaurant-C, Grocery-C, and Cigarette License located
at 56 Snelling Avenue North (ID ��64257).
RECOMMENOpTiONS: Approve (A) or Re�ect (F) pERSONAL SERVICE CONTRACTS MUST ANSWER 7NE FOLLOWING DUESTIONS:
_ PIANNMG COMMISSION _ CIVIL SERVICE COMMISSION �� Has this perso�rm ever worked under a coMmct for this dePartment?
_ C�B COMMITiEE _ YES NO
_ STAFF 2. Has this personlfirm ever peen a city employee?
— YES N�
_ DISTqICTCOURT _ 3. DOesthiS fSOnRltm
pe possess e skill noi nwmally possessed by any current city employee?
SUPPORTSWHICHCAUNCILO&lECT1YE7 YES NO
Explatn all yas anawers on separete aheat anE attach to green shcet
INlT1ATING PROBLEM. ISSUE, OPP�RNNffY (Who, What, When, Whare, Why):
ADVANTAGESIFAPPROVED:
DISADVANTACaES IF APPROVE�:
�:du ,°,�$ . . ' ,�'; �" „�a..,-
. _ . . . a=-? e..4'.!
€;i�`i: 1 � E:��!
_ _ _. _....._ ..,��.:,��.?
DISADVANTA6ES IF NOTAPPROVED.
TO7AL AMOUNT OF TRANSACTION $ COST/REVENUE BUDGEiED (CIRCLE ONE) YES NO
FUNDIWG SOURCE ACTIVITY NUMBER
FINANCIAL INFORhiATION' (EXPLAIN)
Greensheet # 37931
In Tracker?
License 1D # 64257
L.I.E.P. REVIEW CHECKLIST Date: 3l27/97 /�� �
APP'n Received / APP'n Processed
LicenseType�as Station, Restaurant—C, Grocerv—C. and Cigarette i.;cen
COmpBny NBme: SuperAmerica Groun Division of Ashland DBA: SuperAmerica 4�4356
Business Addresss: 56 Snelling Avenue North Business Phone: 64�-07�0
Contact NamejAddress: Kevin Linn, 56 Snelling Ave N, 104 Home
Date to Councit Research:
Pubiic Hearing Date: � 2� q�- _
Notice SeM to Appficant:
3 J��' ��✓ ✓
Notice Sent to Pubtic: �
Labels Ordered: �
pistrict Council #: ,/_ �
Ward #:
Department/ Date Inspections Comments
City Attorney
�•Z���- �-� •
Environmentaf
Health
�•
Fire
�� � �
License siee alan Received:
�ease Received:
5 [���t� a,�
Police
5• Z • � �..' o ' � '
Zoning
Q.K -
MAR-19-1997 11�08 CITY OF ST PRUL LIEP
. . _ �� •
haVe mm iu�'Gt iu:
C�.ASS III CITI' OF SAINT PA=JI,
o�«�ru�r�e�;�
,,, �,IG�SEAPPiICAiION ,�a�,�„
�� 1 +flr ' � �,�P�,���
�� �t � q�a�, �0�3. �� 4r�3�, ��.��,�
�� (61712669D70 5z(EIt)166�91R6
2�s r�vFr rc��i§ r ' S �'r��'t�,� t f' r f'� r��$
PLEASE T'YPE OR FRTNT 7N II3K •
6.- :+`"�!RS[�r3A
.a �
,
compffi �?lti:tl�! li. R iYlt KI G�A
Gapor�tipp! Pertncr�kip! Selc Propriet�sAip
If business is incozgorated, give date of incoipora6on: _
Doing Busi:ress As: � Q � .� `
Husmess Address: 0� rA.•2 �� A
Strat Adbra. J
Betwan whai cross s�eers is the b�ness located?
An the premises now �upied? Whz�t Type of Bvsiuess?
� re.��: _L 0 B t�t t�UU S� Le
Applicanz
Naau mzd
612 266 9124 P,0'�2/06_�
BusinessPhone: �e1Z• Y(p�vU
CitY SWe Z3p
VJhich side of the stseet?
-- � •..._... ,...a.....,, ,.a., rsx
xo� Aaa��s; � ri u v�t�/U 0 d •
se�ana�. �s s,,,t z;�
Date of Birth: ��.. �e — V _ Place of $irtti Home Phone�a[S L 3 S7 ;� � 13
Have you ever been a�icted aZ'azi}r felotry, aime or v3ola$on of tt�y ary ordinance other than h�a�c? YES _ NO �_
Date of a�; ��p
Charge:
Coavic±iou: Sentcace:
List t�names �d tesidences oftbree persans of good moral chm•acter, Hving within the Twin Cities Metxo Area, not mlazed to �he appiicant
a� financia2ly iniensted "m the pzemisa ar business, who may be rcfcaed to as to the applicanYs charaeYer:
NAME ADDRESS PHONE
- B��d f�o�� S- ty 7� O-NaN D S7:S .,�►-�}�.� G,«-Y34s.�3 �
— �r
, f�m�ri�
Fiave �y'of the above n�ed
�
� A�Gw Rrt t wl_.I�v G t J.
2-
YES � NO If yes, list tiu daus and reasons for revocetioa:
�a.0 �J� v �
�-aa� -3b
.,�.e.,.,
s�Aae�. - �cuy .. �,.,� �
- --- - �
---- - - ,
t�e Addrm: sem �a�c �:�• �••.•
�
q�z roa � to �y�e a�w�2get oi ess,Saat ia ihis business? YES NO If tbe maaxg� is na tha s�me ts tbc operator,
aG
,�,..r� .�.
is a vumesshin. plex3e incFudeshz Yollpw�ing info:mation for each pazma (use additional pages if aecessary):
N�aeare� sero«��e cro sw4 z;� rn�?.mtxr
Feri\amc '.Y�d&e�isid �5�i�a) Laa Detcaf8ath
HomeMdrar. Sasa'..5�c Gty Suu Zip Phonc?.Smbet
MINt�TESOTA TAX IDENTTFICA?ION NUMSER - P�us�ant wtix Lea s of N'unnesota,1984, Chapter 502, ArticSe 8, Sxtioa 2 (170.72)
(fa� Clea�cC, IssUSnce ofLiccases). Taasiag authorines are required to pmvide to tbe Staie of Mmnesota Commissioner of Revmue, the
M'iaaaota busiatss tsx id�ntification rnrmba sad the socisl sccur'sry mnnber of ceck liccasc appHcant
Under tLe Mnaesota Govamneat Data Practices Aa sad the Fsderal Privacq Ad of i 974, we me:equircd to adviseyou of thc follow�ing
regar�rsgihe usc oftbe hSumaota TmcIdentificationNumber.
- rhis i�'amati� may be cBea so acny thc issvauce a reaewet of yrnu Iianu in thc cvem you owe a+�sota s�. emplcry� s
witbbolding as mo� ve�'iicle aca9e taxe�
- �P� ��'�8 tLis udamsao� tbe licensiag autbosiry w�t supply it �Iy to the Ni'uwesoQa AePanmmt of Revccnue. Aowever,
unda tho Federel Facchffitg� of 3nformatioa A�eement, ?lx DePartn'mt of Rrveaue maY �PPIY this iuf'orma8on to ttK Iaterasl
Rc�ue Scvix
Mmn�nra Taxldmfifiea�cmNumbas (sates &Ux TaxNtanbej msybe obtame� rrom tLe S�ate aiMinnaota, Busiaess Recor3s Dep�Smesu.
30 Ri�aPark Plaza (612-29b-6181} _ .. , . _.
Saial Secutiry Numbc ��`� d I��-aS U' NFmnesota Tax IdrntificaG� N�ber. : L� 7�C3 �S
_ If a i�aaesota Tax Idrntificarian Nwaba is aot requ�ed tor 4x businas be'sng apaatcd, indtcat� so by placing aa'X` ia � 6ox
,,, a�„
p]resolistyour eatplo;meni bistory forthe pre�§o.0 five (5}�e�sp�iod:
Lis� zlt other o�cers of the corp�tion:
pFFICER 1T'fI.E HO?�8 HOVE BUSL�rESS DAT£ OF
�.ex,rr rn�x�tirui ..4i)nRESS PHOVE PHOA°E BIftTH
Council File # —� t"��
Ordinance �
Green Sheet # ���✓�
Presented By �
RESOLUTION
CITY OF SAINT PAUL, MINNESOTA
Referred To
Committee: Date
�
1
2
3
RFSOLVED: That applicarion (ID #6425'� for a Gas Station, Restaurant-C, Grocery-C, and Cigaret#e License by
Super America Group Division of Asliland DBA SuperAmerica #4356 (Kevin Linn, Manager) at
56 Snelling Avenue North be and the same is hereby approved
4
`' Requested by Department of:
6 Yeas Navs Abse
7 Blak �
8 Bostrom __�,._ Office of License Ins and
9 Harr
10 Me a � EnvironMental Protection
11 :N
i� Morton
O
16 Adopted by Council: Date B y 0 �
17
18 Adoption Certified by Council Secretary
19 Form Approved by City Attorney
20
21 By: �` ---"— �-
22 By ' � '�'
23 Approved by Mayor: Date �'/�t 1
24 `�--
25 Approved by Mayor for Submiasion to
26 By: U Council
27
Y�
G'l-b�l�
DEPAflTMENTqFFlCE/COUNCIL DATE INITIATEO �/ � J J�
LIEP/Licensing GREEN SHEE
CONiA(.T PEflSON & PHONE INITIALlDATE WITIAVOATE
�DEPARTMENTDIRECTOR apTYCAUNCIL
Christine Rozek, 266-9108 A���N �CITYATfOqNEV �CT'CLERK
NUNBERFON
MUST BE ON COUNCIL AGENDA BY (DATE ROUiING � BUWET DIpECTOR O FIN. & MGT. SERVICES DIR.
For hearing: Z b �� OqDER �MpyOR{ORASSISTA!!n O
TOTAI # OF SIGNATURE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE)
ACTION REQUESTED:
The SuperAmerica Group Division of Ashland DBA SuperAmexica 464356 requests Council approval
of its application for a Gas Station, Restaurant-C, Grocery-C, and Cigarette License located
at 56 Snelling Avenue North (ID ��64257).
RECOMMENOpTiONS: Approve (A) or Re�ect (F) pERSONAL SERVICE CONTRACTS MUST ANSWER 7NE FOLLOWING DUESTIONS:
_ PIANNMG COMMISSION _ CIVIL SERVICE COMMISSION �� Has this perso�rm ever worked under a coMmct for this dePartment?
_ C�B COMMITiEE _ YES NO
_ STAFF 2. Has this personlfirm ever peen a city employee?
— YES N�
_ DISTqICTCOURT _ 3. DOesthiS fSOnRltm
pe possess e skill noi nwmally possessed by any current city employee?
SUPPORTSWHICHCAUNCILO&lECT1YE7 YES NO
Explatn all yas anawers on separete aheat anE attach to green shcet
INlT1ATING PROBLEM. ISSUE, OPP�RNNffY (Who, What, When, Whare, Why):
ADVANTAGESIFAPPROVED:
DISADVANTACaES IF APPROVE�:
�:du ,°,�$ . . ' ,�'; �" „�a..,-
. _ . . . a=-? e..4'.!
€;i�`i: 1 � E:��!
_ _ _. _....._ ..,��.:,��.?
DISADVANTA6ES IF NOTAPPROVED.
TO7AL AMOUNT OF TRANSACTION $ COST/REVENUE BUDGEiED (CIRCLE ONE) YES NO
FUNDIWG SOURCE ACTIVITY NUMBER
FINANCIAL INFORhiATION' (EXPLAIN)
Greensheet # 37931
In Tracker?
License 1D # 64257
L.I.E.P. REVIEW CHECKLIST Date: 3l27/97 /�� �
APP'n Received / APP'n Processed
LicenseType�as Station, Restaurant—C, Grocerv—C. and Cigarette i.;cen
COmpBny NBme: SuperAmerica Groun Division of Ashland DBA: SuperAmerica 4�4356
Business Addresss: 56 Snelling Avenue North Business Phone: 64�-07�0
Contact NamejAddress: Kevin Linn, 56 Snelling Ave N, 104 Home
Date to Councit Research:
Pubiic Hearing Date: � 2� q�- _
Notice SeM to Appficant:
3 J��' ��✓ ✓
Notice Sent to Pubtic: �
Labels Ordered: �
pistrict Council #: ,/_ �
Ward #:
Department/ Date Inspections Comments
City Attorney
�•Z���- �-� •
Environmentaf
Health
�•
Fire
�� � �
License siee alan Received:
�ease Received:
5 [���t� a,�
Police
5• Z • � �..' o ' � '
Zoning
Q.K -
MAR-19-1997 11�08 CITY OF ST PRUL LIEP
. . _ �� •
haVe mm iu�'Gt iu:
C�.ASS III CITI' OF SAINT PA=JI,
o�«�ru�r�e�;�
,,, �,IG�SEAPPiICAiION ,�a�,�„
�� 1 +flr ' � �,�P�,���
�� �t � q�a�, �0�3. �� 4r�3�, ��.��,�
�� (61712669D70 5z(EIt)166�91R6
2�s r�vFr rc��i§ r ' S �'r��'t�,� t f' r f'� r��$
PLEASE T'YPE OR FRTNT 7N II3K •
6.- :+`"�!RS[�r3A
.a �
,
compffi �?lti:tl�! li. R iYlt KI G�A
Gapor�tipp! Pertncr�kip! Selc Propriet�sAip
If business is incozgorated, give date of incoipora6on: _
Doing Busi:ress As: � Q � .� `
Husmess Address: 0� rA.•2 �� A
Strat Adbra. J
Betwan whai cross s�eers is the b�ness located?
An the premises now �upied? Whz�t Type of Bvsiuess?
� re.��: _L 0 B t�t t�UU S� Le
Applicanz
Naau mzd
612 266 9124 P,0'�2/06_�
BusinessPhone: �e1Z• Y(p�vU
CitY SWe Z3p
VJhich side of the stseet?
-- � •..._... ,...a.....,, ,.a., rsx
xo� Aaa��s; � ri u v�t�/U 0 d •
se�ana�. �s s,,,t z;�
Date of Birth: ��.. �e — V _ Place of $irtti Home Phone�a[S L 3 S7 ;� � 13
Have you ever been a�icted aZ'azi}r felotry, aime or v3ola$on of tt�y ary ordinance other than h�a�c? YES _ NO �_
Date of a�; ��p
Charge:
Coavic±iou: Sentcace:
List t�names �d tesidences oftbree persans of good moral chm•acter, Hving within the Twin Cities Metxo Area, not mlazed to �he appiicant
a� financia2ly iniensted "m the pzemisa ar business, who may be rcfcaed to as to the applicanYs charaeYer:
NAME ADDRESS PHONE
- B��d f�o�� S- ty 7� O-NaN D S7:S .,�►-�}�.� G,«-Y34s.�3 �
— �r
, f�m�ri�
Fiave �y'of the above n�ed
�
� A�Gw Rrt t wl_.I�v G t J.
2-
YES � NO If yes, list tiu daus and reasons for revocetioa:
�a.0 �J� v �
�-aa� -3b
.,�.e.,.,
s�Aae�. - �cuy .. �,.,� �
- --- - �
---- - - ,
t�e Addrm: sem �a�c �:�• �••.•
�
q�z roa � to �y�e a�w�2get oi ess,Saat ia ihis business? YES NO If tbe maaxg� is na tha s�me ts tbc operator,
aG
,�,..r� .�.
is a vumesshin. plex3e incFudeshz Yollpw�ing info:mation for each pazma (use additional pages if aecessary):
N�aeare� sero«��e cro sw4 z;� rn�?.mtxr
Feri\amc '.Y�d&e�isid �5�i�a) Laa Detcaf8ath
HomeMdrar. Sasa'..5�c Gty Suu Zip Phonc?.Smbet
MINt�TESOTA TAX IDENTTFICA?ION NUMSER - P�us�ant wtix Lea s of N'unnesota,1984, Chapter 502, ArticSe 8, Sxtioa 2 (170.72)
(fa� Clea�cC, IssUSnce ofLiccases). Taasiag authorines are required to pmvide to tbe Staie of Mmnesota Commissioner of Revmue, the
M'iaaaota busiatss tsx id�ntification rnrmba sad the socisl sccur'sry mnnber of ceck liccasc appHcant
Under tLe Mnaesota Govamneat Data Practices Aa sad the Fsderal Privacq Ad of i 974, we me:equircd to adviseyou of thc follow�ing
regar�rsgihe usc oftbe hSumaota TmcIdentificationNumber.
- rhis i�'amati� may be cBea so acny thc issvauce a reaewet of yrnu Iianu in thc cvem you owe a+�sota s�. emplcry� s
witbbolding as mo� ve�'iicle aca9e taxe�
- �P� ��'�8 tLis udamsao� tbe licensiag autbosiry w�t supply it �Iy to the Ni'uwesoQa AePanmmt of Revccnue. Aowever,
unda tho Federel Facchffitg� of 3nformatioa A�eement, ?lx DePartn'mt of Rrveaue maY �PPIY this iuf'orma8on to ttK Iaterasl
Rc�ue Scvix
Mmn�nra Taxldmfifiea�cmNumbas (sates &Ux TaxNtanbej msybe obtame� rrom tLe S�ate aiMinnaota, Busiaess Recor3s Dep�Smesu.
30 Ri�aPark Plaza (612-29b-6181} _ .. , . _.
Saial Secutiry Numbc ��`� d I��-aS U' NFmnesota Tax IdrntificaG� N�ber. : L� 7�C3 �S
_ If a i�aaesota Tax Idrntificarian Nwaba is aot requ�ed tor 4x businas be'sng apaatcd, indtcat� so by placing aa'X` ia � 6ox
,,, a�„
p]resolistyour eatplo;meni bistory forthe pre�§o.0 five (5}�e�sp�iod:
Lis� zlt other o�cers of the corp�tion:
pFFICER 1T'fI.E HO?�8 HOVE BUSL�rESS DAT£ OF
�.ex,rr rn�x�tirui ..4i)nRESS PHOVE PHOA°E BIftTH
Council File # —� t"��
Ordinance �
Green Sheet # ���✓�
Presented By �
RESOLUTION
CITY OF SAINT PAUL, MINNESOTA
Referred To
Committee: Date
�
1
2
3
RFSOLVED: That applicarion (ID #6425'� for a Gas Station, Restaurant-C, Grocery-C, and Cigaret#e License by
Super America Group Division of Asliland DBA SuperAmerica #4356 (Kevin Linn, Manager) at
56 Snelling Avenue North be and the same is hereby approved
4
`' Requested by Department of:
6 Yeas Navs Abse
7 Blak �
8 Bostrom __�,._ Office of License Ins and
9 Harr
10 Me a � EnvironMental Protection
11 :N
i� Morton
O
16 Adopted by Council: Date B y 0 �
17
18 Adoption Certified by Council Secretary
19 Form Approved by City Attorney
20
21 By: �` ---"— �-
22 By ' � '�'
23 Approved by Mayor: Date �'/�t 1
24 `�--
25 Approved by Mayor for Submiasion to
26 By: U Council
27
Y�
G'l-b�l�
DEPAflTMENTqFFlCE/COUNCIL DATE INITIATEO �/ � J J�
LIEP/Licensing GREEN SHEE
CONiA(.T PEflSON & PHONE INITIALlDATE WITIAVOATE
�DEPARTMENTDIRECTOR apTYCAUNCIL
Christine Rozek, 266-9108 A���N �CITYATfOqNEV �CT'CLERK
NUNBERFON
MUST BE ON COUNCIL AGENDA BY (DATE ROUiING � BUWET DIpECTOR O FIN. & MGT. SERVICES DIR.
For hearing: Z b �� OqDER �MpyOR{ORASSISTA!!n O
TOTAI # OF SIGNATURE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE)
ACTION REQUESTED:
The SuperAmerica Group Division of Ashland DBA SuperAmexica 464356 requests Council approval
of its application for a Gas Station, Restaurant-C, Grocery-C, and Cigarette License located
at 56 Snelling Avenue North (ID ��64257).
RECOMMENOpTiONS: Approve (A) or Re�ect (F) pERSONAL SERVICE CONTRACTS MUST ANSWER 7NE FOLLOWING DUESTIONS:
_ PIANNMG COMMISSION _ CIVIL SERVICE COMMISSION �� Has this perso�rm ever worked under a coMmct for this dePartment?
_ C�B COMMITiEE _ YES NO
_ STAFF 2. Has this personlfirm ever peen a city employee?
— YES N�
_ DISTqICTCOURT _ 3. DOesthiS fSOnRltm
pe possess e skill noi nwmally possessed by any current city employee?
SUPPORTSWHICHCAUNCILO&lECT1YE7 YES NO
Explatn all yas anawers on separete aheat anE attach to green shcet
INlT1ATING PROBLEM. ISSUE, OPP�RNNffY (Who, What, When, Whare, Why):
ADVANTAGESIFAPPROVED:
DISADVANTACaES IF APPROVE�:
�:du ,°,�$ . . ' ,�'; �" „�a..,-
. _ . . . a=-? e..4'.!
€;i�`i: 1 � E:��!
_ _ _. _....._ ..,��.:,��.?
DISADVANTA6ES IF NOTAPPROVED.
TO7AL AMOUNT OF TRANSACTION $ COST/REVENUE BUDGEiED (CIRCLE ONE) YES NO
FUNDIWG SOURCE ACTIVITY NUMBER
FINANCIAL INFORhiATION' (EXPLAIN)
Greensheet # 37931
In Tracker?
License 1D # 64257
L.I.E.P. REVIEW CHECKLIST Date: 3l27/97 /�� �
APP'n Received / APP'n Processed
LicenseType�as Station, Restaurant—C, Grocerv—C. and Cigarette i.;cen
COmpBny NBme: SuperAmerica Groun Division of Ashland DBA: SuperAmerica 4�4356
Business Addresss: 56 Snelling Avenue North Business Phone: 64�-07�0
Contact NamejAddress: Kevin Linn, 56 Snelling Ave N, 104 Home
Date to Councit Research:
Pubiic Hearing Date: � 2� q�- _
Notice SeM to Appficant:
3 J��' ��✓ ✓
Notice Sent to Pubtic: �
Labels Ordered: �
pistrict Council #: ,/_ �
Ward #:
Department/ Date Inspections Comments
City Attorney
�•Z���- �-� •
Environmentaf
Health
�•
Fire
�� � �
License siee alan Received:
�ease Received:
5 [���t� a,�
Police
5• Z • � �..' o ' � '
Zoning
Q.K -
MAR-19-1997 11�08 CITY OF ST PRUL LIEP
. . _ �� •
haVe mm iu�'Gt iu:
C�.ASS III CITI' OF SAINT PA=JI,
o�«�ru�r�e�;�
,,, �,IG�SEAPPiICAiION ,�a�,�„
�� 1 +flr ' � �,�P�,���
�� �t � q�a�, �0�3. �� 4r�3�, ��.��,�
�� (61712669D70 5z(EIt)166�91R6
2�s r�vFr rc��i§ r ' S �'r��'t�,� t f' r f'� r��$
PLEASE T'YPE OR FRTNT 7N II3K •
6.- :+`"�!RS[�r3A
.a �
,
compffi �?lti:tl�! li. R iYlt KI G�A
Gapor�tipp! Pertncr�kip! Selc Propriet�sAip
If business is incozgorated, give date of incoipora6on: _
Doing Busi:ress As: � Q � .� `
Husmess Address: 0� rA.•2 �� A
Strat Adbra. J
Betwan whai cross s�eers is the b�ness located?
An the premises now �upied? Whz�t Type of Bvsiuess?
� re.��: _L 0 B t�t t�UU S� Le
Applicanz
Naau mzd
612 266 9124 P,0'�2/06_�
BusinessPhone: �e1Z• Y(p�vU
CitY SWe Z3p
VJhich side of the stseet?
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se�ana�. �s s,,,t z;�
Date of Birth: ��.. �e — V _ Place of $irtti Home Phone�a[S L 3 S7 ;� � 13
Have you ever been a�icted aZ'azi}r felotry, aime or v3ola$on of tt�y ary ordinance other than h�a�c? YES _ NO �_
Date of a�; ��p
Charge:
Coavic±iou: Sentcace:
List t�names �d tesidences oftbree persans of good moral chm•acter, Hving within the Twin Cities Metxo Area, not mlazed to �he appiicant
a� financia2ly iniensted "m the pzemisa ar business, who may be rcfcaed to as to the applicanYs charaeYer:
NAME ADDRESS PHONE
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, f�m�ri�
Fiave �y'of the above n�ed
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YES � NO If yes, list tiu daus and reasons for revocetioa:
�a.0 �J� v �
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s�Aae�. - �cuy .. �,.,� �
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t�e Addrm: sem �a�c �:�• �••.•
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q�z roa � to �y�e a�w�2get oi ess,Saat ia ihis business? YES NO If tbe maaxg� is na tha s�me ts tbc operator,
aG
,�,..r� .�.
is a vumesshin. plex3e incFudeshz Yollpw�ing info:mation for each pazma (use additional pages if aecessary):
N�aeare� sero«��e cro sw4 z;� rn�?.mtxr
Feri\amc '.Y�d&e�isid �5�i�a) Laa Detcaf8ath
HomeMdrar. Sasa'..5�c Gty Suu Zip Phonc?.Smbet
MINt�TESOTA TAX IDENTTFICA?ION NUMSER - P�us�ant wtix Lea s of N'unnesota,1984, Chapter 502, ArticSe 8, Sxtioa 2 (170.72)
(fa� Clea�cC, IssUSnce ofLiccases). Taasiag authorines are required to pmvide to tbe Staie of Mmnesota Commissioner of Revmue, the
M'iaaaota busiatss tsx id�ntification rnrmba sad the socisl sccur'sry mnnber of ceck liccasc appHcant
Under tLe Mnaesota Govamneat Data Practices Aa sad the Fsderal Privacq Ad of i 974, we me:equircd to adviseyou of thc follow�ing
regar�rsgihe usc oftbe hSumaota TmcIdentificationNumber.
- rhis i�'amati� may be cBea so acny thc issvauce a reaewet of yrnu Iianu in thc cvem you owe a+�sota s�. emplcry� s
witbbolding as mo� ve�'iicle aca9e taxe�
- �P� ��'�8 tLis udamsao� tbe licensiag autbosiry w�t supply it �Iy to the Ni'uwesoQa AePanmmt of Revccnue. Aowever,
unda tho Federel Facchffitg� of 3nformatioa A�eement, ?lx DePartn'mt of Rrveaue maY �PPIY this iuf'orma8on to ttK Iaterasl
Rc�ue Scvix
Mmn�nra Taxldmfifiea�cmNumbas (sates &Ux TaxNtanbej msybe obtame� rrom tLe S�ate aiMinnaota, Busiaess Recor3s Dep�Smesu.
30 Ri�aPark Plaza (612-29b-6181} _ .. , . _.
Saial Secutiry Numbc ��`� d I��-aS U' NFmnesota Tax IdrntificaG� N�ber. : L� 7�C3 �S
_ If a i�aaesota Tax Idrntificarian Nwaba is aot requ�ed tor 4x businas be'sng apaatcd, indtcat� so by placing aa'X` ia � 6ox
,,, a�„
p]resolistyour eatplo;meni bistory forthe pre�§o.0 five (5}�e�sp�iod:
Lis� zlt other o�cers of the corp�tion:
pFFICER 1T'fI.E HO?�8 HOVE BUSL�rESS DAT£ OF
�.ex,rr rn�x�tirui ..4i)nRESS PHOVE PHOA°E BIftTH