97-77Council File � � — � �
Ordinance �
creen Sheet ¥ 35399
RESOLUTION
OF INT PAUL, MINNESOTA
Presented By
Referred To
Committee: Date
i RESOLVED: That application (ID #21678) for a Restaurant-A, Entertainment-B, Sunday On Sale
z Liquor and Liquor On Sale-B License by 7ackson Venture, Inc. DBA Artists Quarter
s (Ken Horst, Owner) at 366 7ackson Street be and the same is hereby approved ;
with the following conditions:
1) This license becomes invalid if a lease cannot be
negotiated.
2) Food cannot be served without approval by Environmental Health.
4
5 Requested by Department of:
6 Yeas Navs Absent
7 BSake,y �
8 oa�r;
9 Harris
1� Re�tman �
12 Thune �
13 Bostrom
15 � �
16 Adopted by Council: Date �
17
18 Adoption certified by Council Secretary
19 �
20 �� 21 By:" Z— ��
22 � �
23 Approved by Mayor: Date
24
25
26 By: ���_
27
Office of License, Inspections and
Environmental Protection
By:
Form Approved by City Attorney
$Y� �lLY,� \ �. �.,.,.�
Approved by Mayor for Submission to
Council
By:
`t'Z -`t`1
DEPARTMENT/OFFICE/COUNCII DATEINITIATED GREEN SHEE N� 35399
LIEP/Licensin -- `-
CpNTACTPERSON&PHONE �DEPAqTMENTDIPECTOR �C(IYCOUNCIL �NITIAUDATE
Christine Rozek 266-9108 "�'�" QCITYATTORNEV �CrtYCLERK
NUYBERFOR
MUST BE ON CAUNCIL AGENOA BY (DAT R��S�NG � BUDGEf DIRECfOfi O PIN. & MGT. SERVICES OIR.
For hearin : Z 2 41 OROEfl O MAYOR (ORASSISTANf) �
TOTAL # OF SIGNATUR PAGES (CLIP ALL LOCATIONS POR SIGNATURE)
AGTION FEDUESSED:
Jackson Venture, Inc. DBA Artists Quarter requests Council approval of its application for
a Restaurant-A, Entertainment-B, Sunday On-Sale I.iquor and Liquor On Sale-B License
at 366 Jackson Street (ID �121678).
RECAMMENDA710N5: Approve (A) or Reject (R) pERSONAL SEFiVICE CONTRACTS MUST ANSWER THE FOLLOWING �UESTION3:
_ PLANNINO CAMMISSION _ CIVIL SEflVICE COMMISSION �� Has this perso�rtn ever worked untler a conVact for Mis department? -
_ � ���� _ YES - NO
' � A � 2. Has this personffrm ever been a ciry employee?
— YES NO
_ DISinICT COUiti _ 3. Does this personrfirm possess a skill not normall
y possessed by any curteM ciry employee?
SUPPORTSWHICNCOUNCILOBJECTIVE7 YES NO
Explain all yes anawers on separate sheet anE ettaeh to green Sheet
INITIATING PROBLEM, ISSUE, OPPORTUNITY �Nho. What, When, Where. Why)�
ADVANTAGESIFAPPROVED:
DISADYANTAGES IF APPROVED'
DISApVANTAGES If NOTAPPFiOVED:
TOTAL AMOUNT OF THANSACT�ON $ COST/REVENUE BUDGETED (CIRCLE ONE) YES NO
FUNDING SOURCE ACTIVITY NUMBER
FiNANC1AL INFOHMATION: (EXPWN�
Greensneet � 35445 L.I.E.P. REVIEW CHECKLIST �ate: /��—��
In TrackeR app�n Received / App'n Processed
Restaurant (C) Limited, Entertainment Class B, Sunday
License ID # 21678 License Type: On—Sale and Liauor On—Sale (B)
COmp2ny Name: Jackson Venture Inc. DBA: Artists Quarter
Business Addresss: 175 Sth St. E. 55101 Business Phone: 292-1359
Contact Name/Address: Ken Horst Home Phone: 292-1519
Date to Council Research: 673 Humboldt Ave. 55107
Public Hearing Date: 1 ���'. G� Labels Ordered:
Notice Sent to
Notice Sent to Public:
District Council
Ward #:
Department/ Date Inspections Comments
City Attorney
i � Z� � �'� � 1L.
Environmental i_ �•�.� ,
Health �U� �U� /�,Cts �h'�
Fire (� ` f� " Y� 5 n p c� G:1 e�+ �`� �
!—
LiC8tlS6 Site Plan Received:_
Lease Received:
i a��
Police
) ��� i� ��
Zoning
{ l ��,� l( C> l�s.
S
Are you going to operate this business personally? YES �_ NO If not, who will operate it? q''i —'Z '�
I�enneth Hor t
F1xst Nnme Middic Iuitial (,Nudcn) Lnst Date oFBirih
673 Humbolt Aveneue St. Paul MN 55107
HomeAddeexs; ShcctNamc City Statc Zip PhoncNumbez
Are you going to have amanager or assistant in tlus business? x YES NO If the manager is not thz same as the opera?or,
please complete the following infoimation:
Gama_ac nnarat�r -
� Fust Name Middlc Initial (Ufaiden) Lart Dete ofBirth
Home Address: Shett Neme
ciry
Please list your employment history for the previous five (5) year period:
Business/Emplovmrnt Address
State Zip
3hf zNt �.,rer 22� �23- -P 1. rma s���
List all other officers of the cotporation:
OFFICER TITLE HOME
NAME �/' (Office Held) ADARESS
HOME BUSINESS DATE OF
PHONE PHONE BII2TH
Y�en Horst Vice PresirlPnt fi7"i Si h 1t �� ?92 1519 �q7 14�„q �����Li
St. Pau1, PIl3 55107
Wilfred B�vne PYPCIljPT1YJTYPA , 7FR F �t�a��oi iioi 292--1�59 5/4�'�7
St Paul, MN 551p1
If business is a partnership, please include the following information for each parhier (use additional pages if necessary):
Fiss[ Name
Homc Address: Strect Nemc
Fust Nnmc
Home Addirss: Sheet Name
Middle Tnitiai
Middle Initial
(Ma�drn)
c[Ty
City
Last
Sta[e Zip
Last
Siate Zip
Da[e of BuiS
Phone Numba
Date of Buth
Phone Number
MQSNESOTA TAX IDENTTFICATION NUMBER - Pursuant Yo the Laws of Minnesota,1984, Chapter 502, Article 8, Section 2(270.72)
(TaY Clearance; Issuance of Licenses), licensing authoriUes ue required to provide to the State of Minnesota Commissioner of Revenue, the
Minnesota business tax identification number and the social security number of each license applicant.
Under the Minnesota Govenunent Data Practices Act and the Federal Privacy Act of 1974, we are required to advise you of the foilowing
regazding the use of the Minnesota Tax Iden�cation Number:
- This information may be used to deny the issuance or renewal of your license in the event you owe Minnesota sales, employer's
withholding or motor vehicle excise texes;
- Upon receiving this information, the licensing authoriry wilt supply it only to the Minnesota Depamnent of Revenue. Howe�er,
under the Federal Exchange of Information Agreement, the Department of Revenue may supply t}us infoimation to the Intemal
Revenue Service.
Muuiesota TaY Identification Numbers (5ales & Use Tax Niunber) znay be obtained from ihe State of Minnesota, Business Records Departrnent,
10 River Park Plaza (612-296-6181).
Social Security Number: 41-1819256 Minnesota Tax IdentificaUOn Number: �94414�
_ If a Minnesota TaY Identification Number is not required for the business being operated, indicate so by placing an"X" in the box.
12/18/96
�i�l-`�`�t
CERTIFICATION OF WORKERS' COMPENSATION COVERAGE FURSUAN'P TO MINNESOTA STATUTE 176.182
I herehy certify that I, or my comp�y, azn in cotnpliance with the workers` compensation insurance coverage requirements of Minnesota Statute
176.182, subdivision 2. I also undasrtand fl�at provision of faLse iaformation in this certification constitutes sufficient grounds for adverse action
against all licenses held, including revocation and suspension of said licenses.
Name of Insurance Company:
Poliey Number: Coverage from
I have no employees covered under workers' compensation insurance (INITIALS)
A1VX FALS4TCATION OF ANSWERS GIVEN OR MAT`ERIAL SUBbIITTED
WILL RESULT IN DEI�TIAL OF TffiS APPLICATION
I hereby state that I have answered all of Yhe preceding questions, and that the information contained herein is true and correct to the best of
my Imowledge and belief I hereby state fiuther that I have received no money or othet consideratioq by way of loan, gift, contribution, or
othenvise, other than already disolosed in the application which I herewith submitted, I also understand t2ris premise may be inspected by police,
fire, health and other city officials at any and all times when the business is in operation.
We will accept payment by cash, check (made payable to City of 5aint Paul) or eredit card (M/C or Visa).
IFPAXINGBYCREDITCARDPLEASECOMPLETETHEFOLLOWINGINFORMATION: �MasterCazd � Visa
EXPIRATION DATE:
� � � �
Name of Cacdhotder
for all
x*Note: If this application is Food/Liquor related, please contact a City of Saint Paul Health Inspector, Steve Olson (266-9139), to revie�v
plans.
If any substantial changes w structure are anticipated, please contact a City of Saint Paul Plan Exanuner at 266-900'I to apply fox
building permits.
If there are any ct�anges to the parking lot, floor space, or for new operations, please contact a City of Saint Paul Zoning Inspector at
266-9008.
All applications require the following documents. Please attach fheae documents when submitting your application:
1. A detailed descripuon of the design, locaUon and square footage of the premises to be licensed (site plan).
The following data should be on the site pIan (preferably on an 8 1/2" x I 1" or 8 1/2" x 14" paper):
- Name, address, and phone number.
- The scale should be stated such as 1" = 20'. ^N should 6e indicated towazd the top.
- Placement of all peRinent features of the interior of the licensed facility such as seating azeas, kitchens, offices, repair azea,
pazking, rest rooms, etc. '
- 3f a request is for an addilion or expansion of the licensed faciliry, indicate both the current area and the proposed expansion.
2. A copy of your lease agreemrnt or proof of ownership of the properry.
SPECIFIC LICENSE APPLICATIONS REQCJIRE ADDTTIONAL INFORMATION.
PLEA5E SEE RE VERSE FOR DETAII,S >>>>
ACCOUNT NL3MBER:
�1-■� � �_�_�_�_�_�_�_�_�_�_�_��
12718196
Council File � � — � �
Ordinance �
creen Sheet ¥ 35399
RESOLUTION
OF INT PAUL, MINNESOTA
Presented By
Referred To
Committee: Date
i RESOLVED: That application (ID #21678) for a Restaurant-A, Entertainment-B, Sunday On Sale
z Liquor and Liquor On Sale-B License by 7ackson Venture, Inc. DBA Artists Quarter
s (Ken Horst, Owner) at 366 7ackson Street be and the same is hereby approved ;
with the following conditions:
1) This license becomes invalid if a lease cannot be
negotiated.
2) Food cannot be served without approval by Environmental Health.
4
5 Requested by Department of:
6 Yeas Navs Absent
7 BSake,y �
8 oa�r;
9 Harris
1� Re�tman �
12 Thune �
13 Bostrom
15 � �
16 Adopted by Council: Date �
17
18 Adoption certified by Council Secretary
19 �
20 �� 21 By:" Z— ��
22 � �
23 Approved by Mayor: Date
24
25
26 By: ���_
27
Office of License, Inspections and
Environmental Protection
By:
Form Approved by City Attorney
$Y� �lLY,� \ �. �.,.,.�
Approved by Mayor for Submission to
Council
By:
`t'Z -`t`1
DEPARTMENT/OFFICE/COUNCII DATEINITIATED GREEN SHEE N� 35399
LIEP/Licensin -- `-
CpNTACTPERSON&PHONE �DEPAqTMENTDIPECTOR �C(IYCOUNCIL �NITIAUDATE
Christine Rozek 266-9108 "�'�" QCITYATTORNEV �CrtYCLERK
NUYBERFOR
MUST BE ON CAUNCIL AGENOA BY (DAT R��S�NG � BUDGEf DIRECfOfi O PIN. & MGT. SERVICES OIR.
For hearin : Z 2 41 OROEfl O MAYOR (ORASSISTANf) �
TOTAL # OF SIGNATUR PAGES (CLIP ALL LOCATIONS POR SIGNATURE)
AGTION FEDUESSED:
Jackson Venture, Inc. DBA Artists Quarter requests Council approval of its application for
a Restaurant-A, Entertainment-B, Sunday On-Sale I.iquor and Liquor On Sale-B License
at 366 Jackson Street (ID �121678).
RECAMMENDA710N5: Approve (A) or Reject (R) pERSONAL SEFiVICE CONTRACTS MUST ANSWER THE FOLLOWING �UESTION3:
_ PLANNINO CAMMISSION _ CIVIL SEflVICE COMMISSION �� Has this perso�rtn ever worked untler a conVact for Mis department? -
_ � ���� _ YES - NO
' � A � 2. Has this personffrm ever been a ciry employee?
— YES NO
_ DISinICT COUiti _ 3. Does this personrfirm possess a skill not normall
y possessed by any curteM ciry employee?
SUPPORTSWHICNCOUNCILOBJECTIVE7 YES NO
Explain all yes anawers on separate sheet anE ettaeh to green Sheet
INITIATING PROBLEM, ISSUE, OPPORTUNITY �Nho. What, When, Where. Why)�
ADVANTAGESIFAPPROVED:
DISADYANTAGES IF APPROVED'
DISApVANTAGES If NOTAPPFiOVED:
TOTAL AMOUNT OF THANSACT�ON $ COST/REVENUE BUDGETED (CIRCLE ONE) YES NO
FUNDING SOURCE ACTIVITY NUMBER
FiNANC1AL INFOHMATION: (EXPWN�
Greensneet � 35445 L.I.E.P. REVIEW CHECKLIST �ate: /��—��
In TrackeR app�n Received / App'n Processed
Restaurant (C) Limited, Entertainment Class B, Sunday
License ID # 21678 License Type: On—Sale and Liauor On—Sale (B)
COmp2ny Name: Jackson Venture Inc. DBA: Artists Quarter
Business Addresss: 175 Sth St. E. 55101 Business Phone: 292-1359
Contact Name/Address: Ken Horst Home Phone: 292-1519
Date to Council Research: 673 Humboldt Ave. 55107
Public Hearing Date: 1 ���'. G� Labels Ordered:
Notice Sent to
Notice Sent to Public:
District Council
Ward #:
Department/ Date Inspections Comments
City Attorney
i � Z� � �'� � 1L.
Environmental i_ �•�.� ,
Health �U� �U� /�,Cts �h'�
Fire (� ` f� " Y� 5 n p c� G:1 e�+ �`� �
!—
LiC8tlS6 Site Plan Received:_
Lease Received:
i a��
Police
) ��� i� ��
Zoning
{ l ��,� l( C> l�s.
S
Are you going to operate this business personally? YES �_ NO If not, who will operate it? q''i —'Z '�
I�enneth Hor t
F1xst Nnme Middic Iuitial (,Nudcn) Lnst Date oFBirih
673 Humbolt Aveneue St. Paul MN 55107
HomeAddeexs; ShcctNamc City Statc Zip PhoncNumbez
Are you going to have amanager or assistant in tlus business? x YES NO If the manager is not thz same as the opera?or,
please complete the following infoimation:
Gama_ac nnarat�r -
� Fust Name Middlc Initial (Ufaiden) Lart Dete ofBirth
Home Address: Shett Neme
ciry
Please list your employment history for the previous five (5) year period:
Business/Emplovmrnt Address
State Zip
3hf zNt �.,rer 22� �23- -P 1. rma s���
List all other officers of the cotporation:
OFFICER TITLE HOME
NAME �/' (Office Held) ADARESS
HOME BUSINESS DATE OF
PHONE PHONE BII2TH
Y�en Horst Vice PresirlPnt fi7"i Si h 1t �� ?92 1519 �q7 14�„q �����Li
St. Pau1, PIl3 55107
Wilfred B�vne PYPCIljPT1YJTYPA , 7FR F �t�a��oi iioi 292--1�59 5/4�'�7
St Paul, MN 551p1
If business is a partnership, please include the following information for each parhier (use additional pages if necessary):
Fiss[ Name
Homc Address: Strect Nemc
Fust Nnmc
Home Addirss: Sheet Name
Middle Tnitiai
Middle Initial
(Ma�drn)
c[Ty
City
Last
Sta[e Zip
Last
Siate Zip
Da[e of BuiS
Phone Numba
Date of Buth
Phone Number
MQSNESOTA TAX IDENTTFICATION NUMBER - Pursuant Yo the Laws of Minnesota,1984, Chapter 502, Article 8, Section 2(270.72)
(TaY Clearance; Issuance of Licenses), licensing authoriUes ue required to provide to the State of Minnesota Commissioner of Revenue, the
Minnesota business tax identification number and the social security number of each license applicant.
Under the Minnesota Govenunent Data Practices Act and the Federal Privacy Act of 1974, we are required to advise you of the foilowing
regazding the use of the Minnesota Tax Iden�cation Number:
- This information may be used to deny the issuance or renewal of your license in the event you owe Minnesota sales, employer's
withholding or motor vehicle excise texes;
- Upon receiving this information, the licensing authoriry wilt supply it only to the Minnesota Depamnent of Revenue. Howe�er,
under the Federal Exchange of Information Agreement, the Department of Revenue may supply t}us infoimation to the Intemal
Revenue Service.
Muuiesota TaY Identification Numbers (5ales & Use Tax Niunber) znay be obtained from ihe State of Minnesota, Business Records Departrnent,
10 River Park Plaza (612-296-6181).
Social Security Number: 41-1819256 Minnesota Tax IdentificaUOn Number: �94414�
_ If a Minnesota TaY Identification Number is not required for the business being operated, indicate so by placing an"X" in the box.
12/18/96
�i�l-`�`�t
CERTIFICATION OF WORKERS' COMPENSATION COVERAGE FURSUAN'P TO MINNESOTA STATUTE 176.182
I herehy certify that I, or my comp�y, azn in cotnpliance with the workers` compensation insurance coverage requirements of Minnesota Statute
176.182, subdivision 2. I also undasrtand fl�at provision of faLse iaformation in this certification constitutes sufficient grounds for adverse action
against all licenses held, including revocation and suspension of said licenses.
Name of Insurance Company:
Poliey Number: Coverage from
I have no employees covered under workers' compensation insurance (INITIALS)
A1VX FALS4TCATION OF ANSWERS GIVEN OR MAT`ERIAL SUBbIITTED
WILL RESULT IN DEI�TIAL OF TffiS APPLICATION
I hereby state that I have answered all of Yhe preceding questions, and that the information contained herein is true and correct to the best of
my Imowledge and belief I hereby state fiuther that I have received no money or othet consideratioq by way of loan, gift, contribution, or
othenvise, other than already disolosed in the application which I herewith submitted, I also understand t2ris premise may be inspected by police,
fire, health and other city officials at any and all times when the business is in operation.
We will accept payment by cash, check (made payable to City of 5aint Paul) or eredit card (M/C or Visa).
IFPAXINGBYCREDITCARDPLEASECOMPLETETHEFOLLOWINGINFORMATION: �MasterCazd � Visa
EXPIRATION DATE:
� � � �
Name of Cacdhotder
for all
x*Note: If this application is Food/Liquor related, please contact a City of Saint Paul Health Inspector, Steve Olson (266-9139), to revie�v
plans.
If any substantial changes w structure are anticipated, please contact a City of Saint Paul Plan Exanuner at 266-900'I to apply fox
building permits.
If there are any ct�anges to the parking lot, floor space, or for new operations, please contact a City of Saint Paul Zoning Inspector at
266-9008.
All applications require the following documents. Please attach fheae documents when submitting your application:
1. A detailed descripuon of the design, locaUon and square footage of the premises to be licensed (site plan).
The following data should be on the site pIan (preferably on an 8 1/2" x I 1" or 8 1/2" x 14" paper):
- Name, address, and phone number.
- The scale should be stated such as 1" = 20'. ^N should 6e indicated towazd the top.
- Placement of all peRinent features of the interior of the licensed facility such as seating azeas, kitchens, offices, repair azea,
pazking, rest rooms, etc. '
- 3f a request is for an addilion or expansion of the licensed faciliry, indicate both the current area and the proposed expansion.
2. A copy of your lease agreemrnt or proof of ownership of the properry.
SPECIFIC LICENSE APPLICATIONS REQCJIRE ADDTTIONAL INFORMATION.
PLEA5E SEE RE VERSE FOR DETAII,S >>>>
ACCOUNT NL3MBER:
�1-■� � �_�_�_�_�_�_�_�_�_�_�_��
12718196
Council File � � — � �
Ordinance �
creen Sheet ¥ 35399
RESOLUTION
OF INT PAUL, MINNESOTA
Presented By
Referred To
Committee: Date
i RESOLVED: That application (ID #21678) for a Restaurant-A, Entertainment-B, Sunday On Sale
z Liquor and Liquor On Sale-B License by 7ackson Venture, Inc. DBA Artists Quarter
s (Ken Horst, Owner) at 366 7ackson Street be and the same is hereby approved ;
with the following conditions:
1) This license becomes invalid if a lease cannot be
negotiated.
2) Food cannot be served without approval by Environmental Health.
4
5 Requested by Department of:
6 Yeas Navs Absent
7 BSake,y �
8 oa�r;
9 Harris
1� Re�tman �
12 Thune �
13 Bostrom
15 � �
16 Adopted by Council: Date �
17
18 Adoption certified by Council Secretary
19 �
20 �� 21 By:" Z— ��
22 � �
23 Approved by Mayor: Date
24
25
26 By: ���_
27
Office of License, Inspections and
Environmental Protection
By:
Form Approved by City Attorney
$Y� �lLY,� \ �. �.,.,.�
Approved by Mayor for Submission to
Council
By:
`t'Z -`t`1
DEPARTMENT/OFFICE/COUNCII DATEINITIATED GREEN SHEE N� 35399
LIEP/Licensin -- `-
CpNTACTPERSON&PHONE �DEPAqTMENTDIPECTOR �C(IYCOUNCIL �NITIAUDATE
Christine Rozek 266-9108 "�'�" QCITYATTORNEV �CrtYCLERK
NUYBERFOR
MUST BE ON CAUNCIL AGENOA BY (DAT R��S�NG � BUDGEf DIRECfOfi O PIN. & MGT. SERVICES OIR.
For hearin : Z 2 41 OROEfl O MAYOR (ORASSISTANf) �
TOTAL # OF SIGNATUR PAGES (CLIP ALL LOCATIONS POR SIGNATURE)
AGTION FEDUESSED:
Jackson Venture, Inc. DBA Artists Quarter requests Council approval of its application for
a Restaurant-A, Entertainment-B, Sunday On-Sale I.iquor and Liquor On Sale-B License
at 366 Jackson Street (ID �121678).
RECAMMENDA710N5: Approve (A) or Reject (R) pERSONAL SEFiVICE CONTRACTS MUST ANSWER THE FOLLOWING �UESTION3:
_ PLANNINO CAMMISSION _ CIVIL SEflVICE COMMISSION �� Has this perso�rtn ever worked untler a conVact for Mis department? -
_ � ���� _ YES - NO
' � A � 2. Has this personffrm ever been a ciry employee?
— YES NO
_ DISinICT COUiti _ 3. Does this personrfirm possess a skill not normall
y possessed by any curteM ciry employee?
SUPPORTSWHICNCOUNCILOBJECTIVE7 YES NO
Explain all yes anawers on separate sheet anE ettaeh to green Sheet
INITIATING PROBLEM, ISSUE, OPPORTUNITY �Nho. What, When, Where. Why)�
ADVANTAGESIFAPPROVED:
DISADYANTAGES IF APPROVED'
DISApVANTAGES If NOTAPPFiOVED:
TOTAL AMOUNT OF THANSACT�ON $ COST/REVENUE BUDGETED (CIRCLE ONE) YES NO
FUNDING SOURCE ACTIVITY NUMBER
FiNANC1AL INFOHMATION: (EXPWN�
Greensneet � 35445 L.I.E.P. REVIEW CHECKLIST �ate: /��—��
In TrackeR app�n Received / App'n Processed
Restaurant (C) Limited, Entertainment Class B, Sunday
License ID # 21678 License Type: On—Sale and Liauor On—Sale (B)
COmp2ny Name: Jackson Venture Inc. DBA: Artists Quarter
Business Addresss: 175 Sth St. E. 55101 Business Phone: 292-1359
Contact Name/Address: Ken Horst Home Phone: 292-1519
Date to Council Research: 673 Humboldt Ave. 55107
Public Hearing Date: 1 ���'. G� Labels Ordered:
Notice Sent to
Notice Sent to Public:
District Council
Ward #:
Department/ Date Inspections Comments
City Attorney
i � Z� � �'� � 1L.
Environmental i_ �•�.� ,
Health �U� �U� /�,Cts �h'�
Fire (� ` f� " Y� 5 n p c� G:1 e�+ �`� �
!—
LiC8tlS6 Site Plan Received:_
Lease Received:
i a��
Police
) ��� i� ��
Zoning
{ l ��,� l( C> l�s.
S
Are you going to operate this business personally? YES �_ NO If not, who will operate it? q''i —'Z '�
I�enneth Hor t
F1xst Nnme Middic Iuitial (,Nudcn) Lnst Date oFBirih
673 Humbolt Aveneue St. Paul MN 55107
HomeAddeexs; ShcctNamc City Statc Zip PhoncNumbez
Are you going to have amanager or assistant in tlus business? x YES NO If the manager is not thz same as the opera?or,
please complete the following infoimation:
Gama_ac nnarat�r -
� Fust Name Middlc Initial (Ufaiden) Lart Dete ofBirth
Home Address: Shett Neme
ciry
Please list your employment history for the previous five (5) year period:
Business/Emplovmrnt Address
State Zip
3hf zNt �.,rer 22� �23- -P 1. rma s���
List all other officers of the cotporation:
OFFICER TITLE HOME
NAME �/' (Office Held) ADARESS
HOME BUSINESS DATE OF
PHONE PHONE BII2TH
Y�en Horst Vice PresirlPnt fi7"i Si h 1t �� ?92 1519 �q7 14�„q �����Li
St. Pau1, PIl3 55107
Wilfred B�vne PYPCIljPT1YJTYPA , 7FR F �t�a��oi iioi 292--1�59 5/4�'�7
St Paul, MN 551p1
If business is a partnership, please include the following information for each parhier (use additional pages if necessary):
Fiss[ Name
Homc Address: Strect Nemc
Fust Nnmc
Home Addirss: Sheet Name
Middle Tnitiai
Middle Initial
(Ma�drn)
c[Ty
City
Last
Sta[e Zip
Last
Siate Zip
Da[e of BuiS
Phone Numba
Date of Buth
Phone Number
MQSNESOTA TAX IDENTTFICATION NUMBER - Pursuant Yo the Laws of Minnesota,1984, Chapter 502, Article 8, Section 2(270.72)
(TaY Clearance; Issuance of Licenses), licensing authoriUes ue required to provide to the State of Minnesota Commissioner of Revenue, the
Minnesota business tax identification number and the social security number of each license applicant.
Under the Minnesota Govenunent Data Practices Act and the Federal Privacy Act of 1974, we are required to advise you of the foilowing
regazding the use of the Minnesota Tax Iden�cation Number:
- This information may be used to deny the issuance or renewal of your license in the event you owe Minnesota sales, employer's
withholding or motor vehicle excise texes;
- Upon receiving this information, the licensing authoriry wilt supply it only to the Minnesota Depamnent of Revenue. Howe�er,
under the Federal Exchange of Information Agreement, the Department of Revenue may supply t}us infoimation to the Intemal
Revenue Service.
Muuiesota TaY Identification Numbers (5ales & Use Tax Niunber) znay be obtained from ihe State of Minnesota, Business Records Departrnent,
10 River Park Plaza (612-296-6181).
Social Security Number: 41-1819256 Minnesota Tax IdentificaUOn Number: �94414�
_ If a Minnesota TaY Identification Number is not required for the business being operated, indicate so by placing an"X" in the box.
12/18/96
�i�l-`�`�t
CERTIFICATION OF WORKERS' COMPENSATION COVERAGE FURSUAN'P TO MINNESOTA STATUTE 176.182
I herehy certify that I, or my comp�y, azn in cotnpliance with the workers` compensation insurance coverage requirements of Minnesota Statute
176.182, subdivision 2. I also undasrtand fl�at provision of faLse iaformation in this certification constitutes sufficient grounds for adverse action
against all licenses held, including revocation and suspension of said licenses.
Name of Insurance Company:
Poliey Number: Coverage from
I have no employees covered under workers' compensation insurance (INITIALS)
A1VX FALS4TCATION OF ANSWERS GIVEN OR MAT`ERIAL SUBbIITTED
WILL RESULT IN DEI�TIAL OF TffiS APPLICATION
I hereby state that I have answered all of Yhe preceding questions, and that the information contained herein is true and correct to the best of
my Imowledge and belief I hereby state fiuther that I have received no money or othet consideratioq by way of loan, gift, contribution, or
othenvise, other than already disolosed in the application which I herewith submitted, I also understand t2ris premise may be inspected by police,
fire, health and other city officials at any and all times when the business is in operation.
We will accept payment by cash, check (made payable to City of 5aint Paul) or eredit card (M/C or Visa).
IFPAXINGBYCREDITCARDPLEASECOMPLETETHEFOLLOWINGINFORMATION: �MasterCazd � Visa
EXPIRATION DATE:
� � � �
Name of Cacdhotder
for all
x*Note: If this application is Food/Liquor related, please contact a City of Saint Paul Health Inspector, Steve Olson (266-9139), to revie�v
plans.
If any substantial changes w structure are anticipated, please contact a City of Saint Paul Plan Exanuner at 266-900'I to apply fox
building permits.
If there are any ct�anges to the parking lot, floor space, or for new operations, please contact a City of Saint Paul Zoning Inspector at
266-9008.
All applications require the following documents. Please attach fheae documents when submitting your application:
1. A detailed descripuon of the design, locaUon and square footage of the premises to be licensed (site plan).
The following data should be on the site pIan (preferably on an 8 1/2" x I 1" or 8 1/2" x 14" paper):
- Name, address, and phone number.
- The scale should be stated such as 1" = 20'. ^N should 6e indicated towazd the top.
- Placement of all peRinent features of the interior of the licensed facility such as seating azeas, kitchens, offices, repair azea,
pazking, rest rooms, etc. '
- 3f a request is for an addilion or expansion of the licensed faciliry, indicate both the current area and the proposed expansion.
2. A copy of your lease agreemrnt or proof of ownership of the properry.
SPECIFIC LICENSE APPLICATIONS REQCJIRE ADDTTIONAL INFORMATION.
PLEA5E SEE RE VERSE FOR DETAII,S >>>>
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