The URL can be used to link to this page

97-842Council File # � O �14` ordinance # Green Sheet # `-' ��'" ; -. �-, . Presented By Referred To RESOLUTION CITY OF SAINT PAUL, MINNESOTA Com[nittee: Date � 1 z 3 RESOLVED: That application (ID #44204) for a New Motor Velricle Dealer and Second Hand Dealer-Motor Vehicie License by Healffi East Transportation DBA Health East Transportation (William Juergens, Manager) at 481 Front Avenue be and the same is heteby approved 4 5 Requested by Department ofe 6 Yeas Navs Absen 7 s a�ev 8 Bostr�om '�- Of£ice of L�cenae Inapections and 9 Hasris --�` i 0 e a� � �� Enoironmental Protection 12 �� 13 Morton � 15 t � .�,,(�,_�, � 16 Adopted by Council: Date �,\q q� $ Y° r�^`�" """`� � ,�— i� •tis--� V 18 Adoption Certified by Council Secretary 19 Form Approved by City Attorney 20 � 21 By: �- , g . `-�� -f 22 y 23 Approved by r: Date 7 � 24 � 25 Approved by Mayor for Submissioa ta Z6 $ye Council 2? By: �'-a�- !�a r�ri� �/a197 °t'? - 8 y'�. DEP�FTMENTAFFICEDOUNCIL DATE INITIATED 3 7 9 4 5 LIEP Licensin GREEN SHEE CON7ACT PERSON & PHONE INITIAVDATE INITIAVDATE � DEPARIMENT DfRECTOR O CfSY COUNCit ASSIGN G�TYAITORNEY GTVCLEqK hristine Rozek 266-9108 NUTABEPFOR 0 � MUST BE ON UN ILAGENDA BY (�ATE) pOUTING � BUDGET DIRECTO � FIN. & MGT. SERVICES DIR. i � � OFDEfl � MAYOP (OR ASSISTAN� O TOTAL # OF SIGNATURE PAGES (CLIP ALL LOCATIONS AOR SIGNATIlAE) ACTION REQUESTED: Health East Transportation DBA Health East Transportation requests Council approval of its application for a New Metor Vehicle Dealer and Second Hand Dealer-Motor Vehicle License located at 4S1 Front Avenue (ID //44204). RECOMMENDATIONS: Approve (A� or Raiect (R) PERSONAL SERVICE CONTRACTS MUST ANSWER THE FOLLOWING QUESTIONS: _ PLANNING COMMISSION _ QIVIL SERVICE COMMISSION �� Ha5 Nis pefS00/fifm BVef WOfkOd Undef a CAntfdCt fOf thiS department? _ CIB COMMITTEE _ YES �NO _� - 2. Has Ihis personflirm ever been a ciry employee? — YES NO _ DISTRICTCOURT _ 3. DOeSthis personRirm possess a skill noi normafty possessed by any curtent city empbyee? SUPPOqTS WHICH COUNCIL O&IECTIVE? YES NO Explaln a�l yes answers on separate sheet and attech to green aheet INITIATING PROBLEM. ISSUE, OPPORTUNITV (Who. What. WheP. WhCre, Wtly): ��k,o;�� K��tY .. A�� 2s �s9� C��`� �i � ADVANTACaESIFAPPROVED: DISADVANTAGESIFAPPFOVED: � � �@_'�� . r:^��,^. �3u,�IXgnay`� ] .�� ,; �'�,'�� Ci. .�; __.,_� _�� .. <.� '° DISADVANTAGES IF NOTAPPROVED: � � � �t��,±�l��fl i �AY 2'7 1997 J�E CC?��ii�S TOTAL AMOUNT OF TRANSAC710N $ COS7/REVENUE BUDGE7ED (CIRCLE ONE) YES NO FUNOIidG SOUHCE ACTIYITY NUMBER FINANCIAL INFORhfATION. (EXPL4IN) Greensheet # 37945 L.I.E.P. REVIEW CHECKLIST Date: 4/23/97 �� `�� 1 In Tracke�? App'n Received / App'n Processetl License ID # 4 �' Z ��' license 7ype: New Motor Vehicle Dealer and Second Hand Dealer— Health East Transnortation Motor ��icle HPalrh F��r T,- � ortat;�n Company Name: an:.� Business Addresss: �+sl FRont Avenue Business Phone: 232-1700 ContaCt Name/Address: William Juer�ens, 7165 Sunfish Court, Home Phone: �83-8246 Lino Lakes, MN 55014 Date to Council Research: Public Hearing Date: -� Labels Ordered: � ✓1 flotice Sent to App{icant: !/ District Council #: Notice Sent to Department f City Attorney �i7��1 i Date Inspections Comments �• Environmental Health N .i� Fire •a-•��--I D•K License Police 5-ZZ.-�� 5 •�- � �- Zoning � • 2 I •q�- Ward #: _ _� Site Plan Received:_ taase aeceivea: �� D• � � �� U � y��/ THIS APPLICATION IS SUBJECT TO REVIEW BY Tf� PUBLIC PLEASE TYPE OR PRINT IN INK CLASS III LICENSE APPLICATION CITY OF SAINT PAUL oe;ce atli�a+se. I,specfimss and Emvonmenlal Protettion 3t� St Ppv St S�vl<300 Sa'vR Pu�,.Kvmaom SSIOI (617)1669D90fu(67�2659174 �w a� -� r S � � �d S .�� CompanyName: �"�'9�ay9�iss� ��sifi�>.�r.o� a� Partnership / Sole Proprietorship If business is inwcporated, give date of incorporation: Doing Business As: ��c �F ��f�s! '��°r'Si'c-c n3r�✓ B�iness Phane: �.�� /7d C= Business Address: ��` �` -�!'��/ f �L =' S•� �.4c� � r'in/ 5.5//� Strea Md�esS � CiTy Statc Zip Between what cross streets is the business located? 11?A +LYtr.e:.J/ •4�c..1 nc-z_ Which side of the sveet� �o /� � Are the premises now occupied7 y.�'� What Type ofBusiness9 /�c!�it 5+-t.- ""�%t�'�xs `+-a•>.?':'. -� Mail To Address: Dn! f C�ry stnfe Z;p +�tr,�sfr•^?! Applicant Infomation: �-� Name and Tide: /i1_��-r�i�n2 .� � ��-S /j�'.yN9Lc�2� F'vst .tif'iddlc (1vleidrn) Lst Title / Home Address: J�� —Si✓c''S.� L, � ii✓r"i �4.�'G� �.� SS ��7 Sirat Addrees City Slate Zip Date of Birth: � L"-S� Place of Birth: r.�✓.�lF�t��-/S Home Phone: �''`"�� Have you ever been com�icted of any felony, crime or ��iolation of any city ordinance other than traffic? YES NO � Date of azrest: Charge: _ Com�ction: Where7 Srntence: List ihe names and residences of ttvee persons of good moral character, living within the Twin Cities Metro Area, not retated to the applicant or financially interested in the premises or business, who ma}' be referred to as to the applicant's chazacter: NAMF AnnRFCC PF-TnNR Have any of the above named Iicenses ever been revokedl YES _��F10 If yes, list the dates and reasons for revocation: 2/18/97 List licenses which you currenily ho1d, formerly held, or may ha<<e an interest in: /ve you going to operate ilris business personally? � YES Fust Vame Ttiddlc Initisl (!4laidrn) Ham<Addrae: Street:�ame Cin� Are you going to have a manager orassistant in ttus business? _� YES please complete the follou�ing informalion: I�TO If not, w�ho v.ill operate it? LRI SWe q�_��a � Da�c orsinh Zip Phone Number 4' �o� G 2C�' , �"� � .� NO If the manager is not the sazne as the operator, FitstKnme M�iddleIaitisl (�iaiden) I.ast DateofHuth Homc Add`rn: Siroet �ame Please listyour emplo}mrnt his[ory fa the pre�ROUS five (5) }'eaz period: S�nte Zip Phone I�umbcr BusinesslEmplo�ment Ad ess �G�-�>-f��; � �f�l '"/'c•-✓y �:- �. Sr ��Ll�� s:S"I/�7 List all other officers of the corporalion: OFFICER TITLE HOME NAME (Office Held) ADDRESS HOME BUSINESS PHONE PHONE If business is a parmership, please include the following infotmation for each partner (use additional pages if necessary): Furt I�ame HomeAddreae: Sireetl�ame Middle Initial (Meidrn) �Y I,ast State Zip DATE OF BIIZTH �rm Phwe 1:wnbcr Firat I�ame bLddle )nitiil (.'Neidrn) LaA Dau of B'vth Home Add`ev; Street I�ame City Stnle Zip Phone Numbcr MINNES07A TAX IDENTIFICATION NUMBER - Pursuant to the Laws of Minnesota, S 984, Chapter 502, Article 8, Section 2(270.72) (Tax Clearaz�ce; Issuance of Licenses), licensing authorities are required to pto�4de to the State of Minnesota Commissioner of Revenue, the Minnesota business tax adentification number and the social security number of each license applicant. i3nder tLe Minnesota Government Data Praclices Act and ttie Federal Privacy Act of 1974, we aze required to advise you of tt�e foltowing regazding the use of the Minnesota Tax Identification Num6er: - This information may be used to drny the issuance or renewal of your license in the event you owe Minnesotz sales, employer s w�thholding or motor vehicle excise taYes; - Upon receiving this information, the licensing authoriry wili supply it only to the Minnesota Department of Revenue. I3owever, under the Federa] fixchange of Information Agreement, the Department of Revenue may supply this info�ation to the Intemal Revenue Service. Ivfinnesota Tax Identi5cation Ntmibers (Sales & Use Tax Nutnber) may be obtained from the State of Minnesota, Business Records Department, 10 River Park Plaza (612-296-6181). Social Security Number: .5 i i S�i � S Mumesota Tax tdrntification Number: �� •SG3 _ If a Minnesota Tax Identification Number is not required for ihe business being operated, indicate so by placing an "X" in the box. 2/18,'97 ,. Council File # � O �14` ordinance # Green Sheet # `-' ��'" ; -. �-, . Presented By Referred To RESOLUTION CITY OF SAINT PAUL, MINNESOTA Com[nittee: Date � 1 z 3 RESOLVED: That application (ID #44204) for a New Motor Velricle Dealer and Second Hand Dealer-Motor Vehicie License by Healffi East Transportation DBA Health East Transportation (William Juergens, Manager) at 481 Front Avenue be and the same is heteby approved 4 5 Requested by Department ofe 6 Yeas Navs Absen 7 s a�ev 8 Bostr�om '�- Of£ice of L�cenae Inapections and 9 Hasris --�` i 0 e a� � �� Enoironmental Protection 12 �� 13 Morton � 15 t � .�,,(�,_�, � 16 Adopted by Council: Date �,\q q� $ Y° r�^`�" """`� � ,�— i� •tis--� V 18 Adoption Certified by Council Secretary 19 Form Approved by City Attorney 20 � 21 By: �- , g . `-�� -f 22 y 23 Approved by r: Date 7 � 24 � 25 Approved by Mayor for Submissioa ta Z6 $ye Council 2? By: �'-a�- !�a r�ri� �/a197 °t'? - 8 y'�. DEP�FTMENTAFFICEDOUNCIL DATE INITIATED 3 7 9 4 5 LIEP Licensin GREEN SHEE CON7ACT PERSON & PHONE INITIAVDATE INITIAVDATE � DEPARIMENT DfRECTOR O CfSY COUNCit ASSIGN G�TYAITORNEY GTVCLEqK hristine Rozek 266-9108 NUTABEPFOR 0 � MUST BE ON UN ILAGENDA BY (�ATE) pOUTING � BUDGET DIRECTO � FIN. & MGT. SERVICES DIR. i � � OFDEfl � MAYOP (OR ASSISTAN� O TOTAL # OF SIGNATURE PAGES (CLIP ALL LOCATIONS AOR SIGNATIlAE) ACTION REQUESTED: Health East Transportation DBA Health East Transportation requests Council approval of its application for a New Metor Vehicle Dealer and Second Hand Dealer-Motor Vehicle License located at 4S1 Front Avenue (ID //44204). RECOMMENDATIONS: Approve (A� or Raiect (R) PERSONAL SERVICE CONTRACTS MUST ANSWER THE FOLLOWING QUESTIONS: _ PLANNING COMMISSION _ QIVIL SERVICE COMMISSION �� Ha5 Nis pefS00/fifm BVef WOfkOd Undef a CAntfdCt fOf thiS department? _ CIB COMMITTEE _ YES �NO _� - 2. Has Ihis personflirm ever been a ciry employee? — YES NO _ DISTRICTCOURT _ 3. DOeSthis personRirm possess a skill noi normafty possessed by any curtent city empbyee? SUPPOqTS WHICH COUNCIL O&IECTIVE? YES NO Explaln a�l yes answers on separate sheet and attech to green aheet INITIATING PROBLEM. ISSUE, OPPORTUNITV (Who. What. WheP. WhCre, Wtly): ��k,o;�� K��tY .. A�� 2s �s9� C��`� �i � ADVANTACaESIFAPPROVED: DISADVANTAGESIFAPPFOVED: � � �@_'�� . r:^��,^. �3u,�IXgnay`� ] .�� ,; �'�,'�� Ci. .�; __.,_� _�� .. <.� '° DISADVANTAGES IF NOTAPPROVED: � � � �t��,±�l��fl i �AY 2'7 1997 J�E CC?��ii�S TOTAL AMOUNT OF TRANSAC710N $ COS7/REVENUE BUDGE7ED (CIRCLE ONE) YES NO FUNOIidG SOUHCE ACTIYITY NUMBER FINANCIAL INFORhfATION. (EXPL4IN) Greensheet # 37945 L.I.E.P. REVIEW CHECKLIST Date: 4/23/97 �� `�� 1 In Tracke�? App'n Received / App'n Processetl License ID # 4 �' Z ��' license 7ype: New Motor Vehicle Dealer and Second Hand Dealer— Health East Transnortation Motor ��icle HPalrh F��r T,- � ortat;�n Company Name: an:.� Business Addresss: �+sl FRont Avenue Business Phone: 232-1700 ContaCt Name/Address: William Juer�ens, 7165 Sunfish Court, Home Phone: �83-8246 Lino Lakes, MN 55014 Date to Council Research: Public Hearing Date: -� Labels Ordered: � ✓1 flotice Sent to App{icant: !/ District Council #: Notice Sent to Department f City Attorney �i7��1 i Date Inspections Comments �• Environmental Health N .i� Fire •a-•��--I D•K License Police 5-ZZ.-�� 5 •�- � �- Zoning � • 2 I •q�- Ward #: _ _� Site Plan Received:_ taase aeceivea: �� D• � � �� U � y��/ THIS APPLICATION IS SUBJECT TO REVIEW BY Tf� PUBLIC PLEASE TYPE OR PRINT IN INK CLASS III LICENSE APPLICATION CITY OF SAINT PAUL oe;ce atli�a+se. I,specfimss and Emvonmenlal Protettion 3t� St Ppv St S�vl<300 Sa'vR Pu�,.Kvmaom SSIOI (617)1669D90fu(67�2659174 �w a� -� r S � � �d S .�� CompanyName: �"�'9�ay9�iss� ��sifi�>.�r.o� a� Partnership / Sole Proprietorship If business is inwcporated, give date of incorporation: Doing Business As: ��c �F ��f�s! '��°r'Si'c-c n3r�✓ B�iness Phane: �.�� /7d C= Business Address: ��` �` -�!'��/ f �L =' S•� �.4c� � r'in/ 5.5//� Strea Md�esS � CiTy Statc Zip Between what cross streets is the business located? 11?A +LYtr.e:.J/ •4�c..1 nc-z_ Which side of the sveet� �o /� � Are the premises now occupied7 y.�'� What Type ofBusiness9 /�c!�it 5+-t.- ""�%t�'�xs `+-a•>.?':'. -� Mail To Address: Dn! f C�ry stnfe Z;p +�tr,�sfr•^?! Applicant Infomation: �-� Name and Tide: /i1_��-r�i�n2 .� � ��-S /j�'.yN9Lc�2� F'vst .tif'iddlc (1vleidrn) Lst Title / Home Address: J�� —Si✓c''S.� L, � ii✓r"i �4.�'G� �.� SS ��7 Sirat Addrees City Slate Zip Date of Birth: � L"-S� Place of Birth: r.�✓.�lF�t��-/S Home Phone: �''`"�� Have you ever been com�icted of any felony, crime or ��iolation of any city ordinance other than traffic? YES NO � Date of azrest: Charge: _ Com�ction: Where7 Srntence: List ihe names and residences of ttvee persons of good moral character, living within the Twin Cities Metro Area, not retated to the applicant or financially interested in the premises or business, who ma}' be referred to as to the applicant's chazacter: NAMF AnnRFCC PF-TnNR Have any of the above named Iicenses ever been revokedl YES _��F10 If yes, list the dates and reasons for revocation: 2/18/97 List licenses which you currenily ho1d, formerly held, or may ha<<e an interest in: /ve you going to operate ilris business personally? � YES Fust Vame Ttiddlc Initisl (!4laidrn) Ham<Addrae: Street:�ame Cin� Are you going to have a manager orassistant in ttus business? _� YES please complete the follou�ing informalion: I�TO If not, w�ho v.ill operate it? LRI SWe q�_��a � Da�c orsinh Zip Phone Number 4' �o� G 2C�' , �"� � .� NO If the manager is not the sazne as the operator, FitstKnme M�iddleIaitisl (�iaiden) I.ast DateofHuth Homc Add`rn: Siroet �ame Please listyour emplo}mrnt his[ory fa the pre�ROUS five (5) }'eaz period: S�nte Zip Phone I�umbcr BusinesslEmplo�ment Ad ess �G�-�>-f��; � �f�l '"/'c•-✓y �:- �. Sr ��Ll�� s:S"I/�7 List all other officers of the corporalion: OFFICER TITLE HOME NAME (Office Held) ADDRESS HOME BUSINESS PHONE PHONE If business is a parmership, please include the following infotmation for each partner (use additional pages if necessary): Furt I�ame HomeAddreae: Sireetl�ame Middle Initial (Meidrn) �Y I,ast State Zip DATE OF BIIZTH �rm Phwe 1:wnbcr Firat I�ame bLddle )nitiil (.'Neidrn) LaA Dau of B'vth Home Add`ev; Street I�ame City Stnle Zip Phone Numbcr MINNES07A TAX IDENTIFICATION NUMBER - Pursuant to the Laws of Minnesota, S 984, Chapter 502, Article 8, Section 2(270.72) (Tax Clearaz�ce; Issuance of Licenses), licensing authorities are required to pto�4de to the State of Minnesota Commissioner of Revenue, the Minnesota business tax adentification number and the social security number of each license applicant. i3nder tLe Minnesota Government Data Praclices Act and ttie Federal Privacy Act of 1974, we aze required to advise you of tt�e foltowing regazding the use of the Minnesota Tax Identification Num6er: - This information may be used to drny the issuance or renewal of your license in the event you owe Minnesotz sales, employer s w�thholding or motor vehicle excise taYes; - Upon receiving this information, the licensing authoriry wili supply it only to the Minnesota Department of Revenue. I3owever, under the Federa] fixchange of Information Agreement, the Department of Revenue may supply this info�ation to the Intemal Revenue Service. Ivfinnesota Tax Identi5cation Ntmibers (Sales & Use Tax Nutnber) may be obtained from the State of Minnesota, Business Records Department, 10 River Park Plaza (612-296-6181). Social Security Number: .5 i i S�i � S Mumesota Tax tdrntification Number: �� •SG3 _ If a Minnesota Tax Identification Number is not required for ihe business being operated, indicate so by placing an "X" in the box. 2/18,'97 ,. Council File # � O �14` ordinance # Green Sheet # `-' ��'" ; -. �-, . Presented By Referred To RESOLUTION CITY OF SAINT PAUL, MINNESOTA Com[nittee: Date � 1 z 3 RESOLVED: That application (ID #44204) for a New Motor Velricle Dealer and Second Hand Dealer-Motor Vehicie License by Healffi East Transportation DBA Health East Transportation (William Juergens, Manager) at 481 Front Avenue be and the same is heteby approved 4 5 Requested by Department ofe 6 Yeas Navs Absen 7 s a�ev 8 Bostr�om '�- Of£ice of L�cenae Inapections and 9 Hasris --�` i 0 e a� � �� Enoironmental Protection 12 �� 13 Morton � 15 t � .�,,(�,_�, � 16 Adopted by Council: Date �,\q q� $ Y° r�^`�" """`� � ,�— i� •tis--� V 18 Adoption Certified by Council Secretary 19 Form Approved by City Attorney 20 � 21 By: �- , g . `-�� -f 22 y 23 Approved by r: Date 7 � 24 � 25 Approved by Mayor for Submissioa ta Z6 $ye Council 2? By: �'-a�- !�a r�ri� �/a197 °t'? - 8 y'�. DEP�FTMENTAFFICEDOUNCIL DATE INITIATED 3 7 9 4 5 LIEP Licensin GREEN SHEE CON7ACT PERSON & PHONE INITIAVDATE INITIAVDATE � DEPARIMENT DfRECTOR O CfSY COUNCit ASSIGN G�TYAITORNEY GTVCLEqK hristine Rozek 266-9108 NUTABEPFOR 0 � MUST BE ON UN ILAGENDA BY (�ATE) pOUTING � BUDGET DIRECTO � FIN. & MGT. SERVICES DIR. i � � OFDEfl � MAYOP (OR ASSISTAN� O TOTAL # OF SIGNATURE PAGES (CLIP ALL LOCATIONS AOR SIGNATIlAE) ACTION REQUESTED: Health East Transportation DBA Health East Transportation requests Council approval of its application for a New Metor Vehicle Dealer and Second Hand Dealer-Motor Vehicle License located at 4S1 Front Avenue (ID //44204). RECOMMENDATIONS: Approve (A� or Raiect (R) PERSONAL SERVICE CONTRACTS MUST ANSWER THE FOLLOWING QUESTIONS: _ PLANNING COMMISSION _ QIVIL SERVICE COMMISSION �� Ha5 Nis pefS00/fifm BVef WOfkOd Undef a CAntfdCt fOf thiS department? _ CIB COMMITTEE _ YES �NO _� - 2. Has Ihis personflirm ever been a ciry employee? — YES NO _ DISTRICTCOURT _ 3. DOeSthis personRirm possess a skill noi normafty possessed by any curtent city empbyee? SUPPOqTS WHICH COUNCIL O&IECTIVE? YES NO Explaln a�l yes answers on separate sheet and attech to green aheet INITIATING PROBLEM. ISSUE, OPPORTUNITV (Who. What. WheP. WhCre, Wtly): ��k,o;�� K��tY .. A�� 2s �s9� C��`� �i � ADVANTACaESIFAPPROVED: DISADVANTAGESIFAPPFOVED: � � �@_'�� . r:^��,^. �3u,�IXgnay`� ] .�� ,; �'�,'�� Ci. .�; __.,_� _�� .. <.� '° DISADVANTAGES IF NOTAPPROVED: � � � �t��,±�l��fl i �AY 2'7 1997 J�E CC?��ii�S TOTAL AMOUNT OF TRANSAC710N $ COS7/REVENUE BUDGE7ED (CIRCLE ONE) YES NO FUNOIidG SOUHCE ACTIYITY NUMBER FINANCIAL INFORhfATION. (EXPL4IN) Greensheet # 37945 L.I.E.P. REVIEW CHECKLIST Date: 4/23/97 �� `�� 1 In Tracke�? App'n Received / App'n Processetl License ID # 4 �' Z ��' license 7ype: New Motor Vehicle Dealer and Second Hand Dealer— Health East Transnortation Motor ��icle HPalrh F��r T,- � ortat;�n Company Name: an:.� Business Addresss: �+sl FRont Avenue Business Phone: 232-1700 ContaCt Name/Address: William Juer�ens, 7165 Sunfish Court, Home Phone: �83-8246 Lino Lakes, MN 55014 Date to Council Research: Public Hearing Date: -� Labels Ordered: � ✓1 flotice Sent to App{icant: !/ District Council #: Notice Sent to Department f City Attorney �i7��1 i Date Inspections Comments �• Environmental Health N .i� Fire •a-•��--I D•K License Police 5-ZZ.-�� 5 •�- � �- Zoning � • 2 I •q�- Ward #: _ _� Site Plan Received:_ taase aeceivea: �� D• � � �� U � y��/ THIS APPLICATION IS SUBJECT TO REVIEW BY Tf� PUBLIC PLEASE TYPE OR PRINT IN INK CLASS III LICENSE APPLICATION CITY OF SAINT PAUL oe;ce atli�a+se. I,specfimss and Emvonmenlal Protettion 3t� St Ppv St S�vl<300 Sa'vR Pu�,.Kvmaom SSIOI (617)1669D90fu(67�2659174 �w a� -� r S � � �d S .�� CompanyName: �"�'9�ay9�iss� ��sifi�>.�r.o� a� Partnership / Sole Proprietorship If business is inwcporated, give date of incorporation: Doing Business As: ��c �F ��f�s! '��°r'Si'c-c n3r�✓ B�iness Phane: �.�� /7d C= Business Address: ��` �` -�!'��/ f �L =' S•� �.4c� � r'in/ 5.5//� Strea Md�esS � CiTy Statc Zip Between what cross streets is the business located? 11?A +LYtr.e:.J/ •4�c..1 nc-z_ Which side of the sveet� �o /� � Are the premises now occupied7 y.�'� What Type ofBusiness9 /�c!�it 5+-t.- ""�%t�'�xs `+-a•>.?':'. -� Mail To Address: Dn! f C�ry stnfe Z;p +�tr,�sfr•^?! Applicant Infomation: �-� Name and Tide: /i1_��-r�i�n2 .� � ��-S /j�'.yN9Lc�2� F'vst .tif'iddlc (1vleidrn) Lst Title / Home Address: J�� —Si✓c''S.� L, � ii✓r"i �4.�'G� �.� SS ��7 Sirat Addrees City Slate Zip Date of Birth: � L"-S� Place of Birth: r.�✓.�lF�t��-/S Home Phone: �''`"�� Have you ever been com�icted of any felony, crime or ��iolation of any city ordinance other than traffic? YES NO � Date of azrest: Charge: _ Com�ction: Where7 Srntence: List ihe names and residences of ttvee persons of good moral character, living within the Twin Cities Metro Area, not retated to the applicant or financially interested in the premises or business, who ma}' be referred to as to the applicant's chazacter: NAMF AnnRFCC PF-TnNR Have any of the above named Iicenses ever been revokedl YES _��F10 If yes, list the dates and reasons for revocation: 2/18/97 List licenses which you currenily ho1d, formerly held, or may ha<<e an interest in: /ve you going to operate ilris business personally? � YES Fust Vame Ttiddlc Initisl (!4laidrn) Ham<Addrae: Street:�ame Cin� Are you going to have a manager orassistant in ttus business? _� YES please complete the follou�ing informalion: I�TO If not, w�ho v.ill operate it? LRI SWe q�_��a � Da�c orsinh Zip Phone Number 4' �o� G 2C�' , �"� � .� NO If the manager is not the sazne as the operator, FitstKnme M�iddleIaitisl (�iaiden) I.ast DateofHuth Homc Add`rn: Siroet �ame Please listyour emplo}mrnt his[ory fa the pre�ROUS five (5) }'eaz period: S�nte Zip Phone I�umbcr BusinesslEmplo�ment Ad ess �G�-�>-f��; � �f�l '"/'c•-✓y �:- �. Sr ��Ll�� s:S"I/�7 List all other officers of the corporalion: OFFICER TITLE HOME NAME (Office Held) ADDRESS HOME BUSINESS PHONE PHONE If business is a parmership, please include the following infotmation for each partner (use additional pages if necessary): Furt I�ame HomeAddreae: Sireetl�ame Middle Initial (Meidrn) �Y I,ast State Zip DATE OF BIIZTH �rm Phwe 1:wnbcr Firat I�ame bLddle )nitiil (.'Neidrn) LaA Dau of B'vth Home Add`ev; Street I�ame City Stnle Zip Phone Numbcr MINNES07A TAX IDENTIFICATION NUMBER - Pursuant to the Laws of Minnesota, S 984, Chapter 502, Article 8, Section 2(270.72) (Tax Clearaz�ce; Issuance of Licenses), licensing authorities are required to pto�4de to the State of Minnesota Commissioner of Revenue, the Minnesota business tax adentification number and the social security number of each license applicant. i3nder tLe Minnesota Government Data Praclices Act and ttie Federal Privacy Act of 1974, we aze required to advise you of tt�e foltowing regazding the use of the Minnesota Tax Identification Num6er: - This information may be used to drny the issuance or renewal of your license in the event you owe Minnesotz sales, employer s w�thholding or motor vehicle excise taYes; - Upon receiving this information, the licensing authoriry wili supply it only to the Minnesota Department of Revenue. I3owever, under the Federa] fixchange of Information Agreement, the Department of Revenue may supply this info�ation to the Intemal Revenue Service. Ivfinnesota Tax Identi5cation Ntmibers (Sales & Use Tax Nutnber) may be obtained from the State of Minnesota, Business Records Department, 10 River Park Plaza (612-296-6181). Social Security Number: .5 i i S�i � S Mumesota Tax tdrntification Number: �� •SG3 _ If a Minnesota Tax Identification Number is not required for ihe business being operated, indicate so by placing an "X" in the box. 2/18,'97 ,.