97-843Council File $ ��
Ordinance #
Green Sheet $ � ���
QRIGI{�!A�.
Presented By
Referred To
RESOlUT10N
CfTY OF SAiNT PAUL, MINNESOTA
7�
Committee: Date
1
2
3
RESOLVED: That application (ID #77741) for a Wine On Sale, On Sale Mait (3.2), and Restaurant-B License by
Knns Inc. DBA Korean Restaurant Shilla (Namld Kim, Owner) at 694 Snelling Avenue North be
and the same is hereby approved.
4
5
6 Yeas Navs Absent Requested by Department of:
7 B a ev �
8 Bastrom O� of License. Inspgqtions and
9 Harrzs
10 Me ar Env;ronmenta� protection
11 ==37�� �
14 Morton O By: `�, f i�' `�'�'--� l
15
16 Adopted by Council: Date ��_ � —
17
18 Adoption Certified by Council Secretary
19 Form Approved by city Attorney
20 \
21 By: �- . /\ _ >
22 By: �J w/
23 Approved y or: Date Q q
24
25 Approved by Mayor for Submission to
26 $y: Council
27
By:
`t�1- �43
�,��T,���N��� OATE INITIATED GREEN SHEE 3 7 5 4 3
LIEP fLicens in INITIAL/DATE INITIAL/DATE
CONTAGTPERSON&PHONE �OEPARTMENTDIqECTOR �CfiYCAUNCIL
A$$IGN CENATTORNEV CITYCLERK
Christine Rozek 266-9108 NUMBEPFOp � �
MUSTBE ON CAUNCIL AGENDA BY DAT/E)� ROUTING � BUDGET �IRECTOR � FIN. 8 MfaT. SERVICES DIR.
For hearin : 7 �] � ORDER O MAYOR (ORASSISTANn �
TOTAL # OP SIGNATURE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE)
ACTION AE�UESTED:
Kims Inc. DBA Rorean Restaurant Shilla requests Council approval of its application for a
Wine On Sale, On Sale Malt (3.2), and Restaurant-B License located at b94 Snelling Ave N.
(ID 1�77741).
FiECAMMENDATIONS: Appmve (A) or Re�ect (R) pERSONAL SERVICE CONTHACTS MUST ANSWER THE FOLLOWING DUESTIONS:
_ PLANNING COMMISSION _ CIVIL SEqVIGE COMMISSION �� Has this personflrtm eve� worKed under a con[ract for this department?
_ CIB COMMITTEE _ YES NO
_ S7AfF 2- Has this personNirm ever been a ciry employee?
— YES NO
_ DISTRIC7 CoURT — 3. Does this person/firm pOSSess a skill not normally po5sessed by any curtent city emplqee?
SUPPORT$ WHIGH COUNCI� OBJEGTIVE? YES NO
Explain ell yes answers on separate sheet and ettech to green sheet
INRIATING PROBLEM, ISSUE. OPP�RTUNIN (Who. Wnet. WhBn. Where, Why):
� i �a,��
'u�. ix � da � � �m
APR 29 1997
����� ������ ��
A�VANTAGESIFAPPROVED:
DISADVANTAGES IF APPROVEO:
v'� �6w.!
�` �.ak,;°��; � �
��3� .l � 1J`r7
_LL.�
DISADVANTAGES IF NOTAPPROVED:
TOTAL AMOUNT OF TRANSACTION $ COSTlREVENUE BUDGETED (CIRCLE ONE) YES ti0
FUNDIfBG SOURCE ACTIVITY NUMBER
FINANCIALINFORFnATION.(EXPLAIN)
Greensheet # 37943 L.I.E.P. REVIEW CHECKLIST Date: 4/25J97 /
In Tracker? P,pp'n Received J App'n Processed
�� - d t-l3
LicenselD # 77741 License Type: Wine On Sale, On Sale Malt (3.2), Restaurant-B
Company Name: �ims Inc. DBA: Rorean Restaurant Shilla
Business Addresss: 694 Snelling Avenue North Business Phone: 645-0�06
Contact Name/Address: Namki Rim, 8212 Lyndale Ave So Home Phone: 884-8357
Date to Council Researoh: $loomington, NIN 55420
Public Hearing Date:
Notice Sent to Applicant; � %
Labels Ordered: �+� I ��i �
oistrict Councif #: �{
Notice Sent to Public: `�� �ull 0 �� /� Ward #: �
Department/ Date Inspections Comments
City Attorney
�. �- .�j�.. �, .
Environmental
Health
�•�.•`��- D.IC .
Fire
� � '��- a � .
License Site Plan Received:_
Lease Received:
� � 2� ��� �� ��
� j<<[��
� �,..� ���-�.� a'�—
Poiice
�•� •°!�' �`j•�. •
2oning
�: 21 �� �- o. � -
-----�.
Type of License(s)
THIS APPLICATION 3S SL3SJECT TO RE W BY P IC
PLEASE TYPE OR PRINT IN INK
Company Name:
Coryoration / Partnrnhip / Sote Proprietorship
If business is incorporated, gi��e date of incorporation:
Doing Business As:
Business Address:
Betueen
Are the premises nou� occupiedl �e i
Mail To Address:
G
Strcet AdcSress
Where7
CITY OF SAINT PAUL
office oPtuaue, inspectimu
and En.vommrntai Proteclion
3WSCPetaSLS�vk3W •J , w
Sc.tRUl'Hnmaoh51101 ��
(51:j:56o?u i<:`-"'::'.E.c:: • .
• i
CiTy
Home Address: _ _pe2� �
Business Phone:�� `a —(- � —onr> �
Applicant Infomation: , / �/
Name and Title: _�� � 1 '�4�t� �l 1 ��� �.1 v i� i yyl ��,�} 1�P�
Fint >2iddte (\Saidcn} 1,mt Title
Date of Bvth: .3 P3ace of Birih: ot. C�
Have you ever been comicted of any felony, crime or ��olation of any city ordinance other than tra$ic7
Date of errest:
Chazge: _
Con�icfion:
Sentrnce:
S�stt Zip
Home Phone: � � 2— �L�. 8��
YES NO _�
List the naznes and residences of three persons of good moral character, living within the Twin Cities Metro Area, not related to the applicant
or financially interested in the premises or business, who may be referred to as to the applicanf s chazacter:
CLASS III
LICENSE APPLICATION
�3
ADDRESS
PHONE
Sttiso-n �lo� .��oo w. �p� s�. � taZ ��na M�l 5�3G, SZ�l�oG79
k e'2 (� f� t' IM � g h � 3 Yd f��/ ' h� {� � t�'lltin4'4 H �✓1 1�) 7 J�t�Y 't"��F?I 1.�,
—b��un_ T� �� 5. 6 �h S�-. C-ti to y,,� t�,nl � 33 -8 2G
Li licenses u�hich you currenIly hold, formerly held, or may have an interest in: �
1 \� �
Ha��e sny of the above named Iicenses e�'er been revoked7 YES _� NO Ifyes, list the dates and reasons for re��ocation:
2/18/97
---p
Are you going to operaie this business personally7 _� YES
NO If not, who will operate it?
��
__,�_ w � � �
V H �
a'1-�43
First\amc 1.tiddlelcntinl (!Jwiben) Last DateofB'utA
HomeAddrn+: Strcet'.�ame Cin� Stete Zip PhoneN�ber
Are you going to ha��e a manager orassisiant in this business7 _� YES NO If the manager is not the same as the operator,
please complete the following infonnation:
Firs[ A`ame ALddlc Ltitial Q.faidrn) Last Date of Birth
HomeAddreSS: Sfrcct:�ame
City
Please lis[ your emplo}ment hisiory for the previous five (5) }'ear period:
Businccs/EmQlo�7nent Address
��
List all other officers of the corporation:
OFFICER TITLE HOME
NAME (Office Held) ADDRESS
2
HOME
PHOI�IE
-5 a
Stau Zip Phone Nomber
�1U - S 1
BUSINESS
DATE OF
BIl2TH
If business is a partnership, please include the following information for each partner (use additional pages if necessary):
Fitat\nme
!Niddle Initisl
(!�-0siden)
ier.t
Date of Hirth
Home Addras: Strxt 2:ame City S�a4 Zip Phone Number
F'valldame Middlelnilid (�kidm) Lasl DaieofBirth
HomeAddresa: Stm[I�ame City Sute Zip
MI13NESOTA TAX IDENTiFICATION NUMBER - Pursuant to tFie Laws of Minnesota, 798A, Chapter 502, Article 8, Seclion 2(276.72)
(Tax Clearance; Issuance of Licenses), licensing authorities ase required to provide to the State of Minnesota Commissioner of Revenue, the
Minnesota business tax identificalion number and the social security number of each license applicant.
Under the Minnesota Govemment Data Practice Act and the Federat Privacy Act of 1974, we are required to advise you of the following
regarding the use of the Minnesota Ta�t Identification Number:
- This information may be used to deny the issuance or renewal of your license in the eveni you o�ue Mim�esota sales, employer s
withholding or motor vehicle excise taaces;
- Upon receiving this information, the licensing authority w111 supply it on]y to the Mumesota Depaftment of Itevenue. However,
under the Federal Exchange of Infomiation Agreement, the Department of Revenue may supply tivs information to the Intemal
Revenue Service.
Minnesota Tax Ideotification N�be� (Sales & Use Tax Number) may be obtained from the State of Minnesota, Business Records Department,
10 Rives Pazk Plaza (612-246-6181).
Social Security Ntunber: �� I g `it'o Minnesota Tax Identification Number: �j 1 T�� 8S�
_ IS a Minnesota Tax Idrnlificalion I3umber is not required for the business being operated, indicate so by placing an"X" in the box.
2/18'97
Council File $ ��
Ordinance #
Green Sheet $ � ���
QRIGI{�!A�.
Presented By
Referred To
RESOlUT10N
CfTY OF SAiNT PAUL, MINNESOTA
7�
Committee: Date
1
2
3
RESOLVED: That application (ID #77741) for a Wine On Sale, On Sale Mait (3.2), and Restaurant-B License by
Knns Inc. DBA Korean Restaurant Shilla (Namld Kim, Owner) at 694 Snelling Avenue North be
and the same is hereby approved.
4
5
6 Yeas Navs Absent Requested by Department of:
7 B a ev �
8 Bastrom O� of License. Inspgqtions and
9 Harrzs
10 Me ar Env;ronmenta� protection
11 ==37�� �
14 Morton O By: `�, f i�' `�'�'--� l
15
16 Adopted by Council: Date ��_ � —
17
18 Adoption Certified by Council Secretary
19 Form Approved by city Attorney
20 \
21 By: �- . /\ _ >
22 By: �J w/
23 Approved y or: Date Q q
24
25 Approved by Mayor for Submission to
26 $y: Council
27
By:
`t�1- �43
�,��T,���N��� OATE INITIATED GREEN SHEE 3 7 5 4 3
LIEP fLicens in INITIAL/DATE INITIAL/DATE
CONTAGTPERSON&PHONE �OEPARTMENTDIqECTOR �CfiYCAUNCIL
A$$IGN CENATTORNEV CITYCLERK
Christine Rozek 266-9108 NUMBEPFOp � �
MUSTBE ON CAUNCIL AGENDA BY DAT/E)� ROUTING � BUDGET �IRECTOR � FIN. 8 MfaT. SERVICES DIR.
For hearin : 7 �] � ORDER O MAYOR (ORASSISTANn �
TOTAL # OP SIGNATURE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE)
ACTION AE�UESTED:
Kims Inc. DBA Rorean Restaurant Shilla requests Council approval of its application for a
Wine On Sale, On Sale Malt (3.2), and Restaurant-B License located at b94 Snelling Ave N.
(ID 1�77741).
FiECAMMENDATIONS: Appmve (A) or Re�ect (R) pERSONAL SERVICE CONTHACTS MUST ANSWER THE FOLLOWING DUESTIONS:
_ PLANNING COMMISSION _ CIVIL SEqVIGE COMMISSION �� Has this personflrtm eve� worKed under a con[ract for this department?
_ CIB COMMITTEE _ YES NO
_ S7AfF 2- Has this personNirm ever been a ciry employee?
— YES NO
_ DISTRIC7 CoURT — 3. Does this person/firm pOSSess a skill not normally po5sessed by any curtent city emplqee?
SUPPORT$ WHIGH COUNCI� OBJEGTIVE? YES NO
Explain ell yes answers on separate sheet and ettech to green sheet
INRIATING PROBLEM, ISSUE. OPP�RTUNIN (Who. Wnet. WhBn. Where, Why):
� i �a,��
'u�. ix � da � � �m
APR 29 1997
����� ������ ��
A�VANTAGESIFAPPROVED:
DISADVANTAGES IF APPROVEO:
v'� �6w.!
�` �.ak,;°��; � �
��3� .l � 1J`r7
_LL.�
DISADVANTAGES IF NOTAPPROVED:
TOTAL AMOUNT OF TRANSACTION $ COSTlREVENUE BUDGETED (CIRCLE ONE) YES ti0
FUNDIfBG SOURCE ACTIVITY NUMBER
FINANCIALINFORFnATION.(EXPLAIN)
Greensheet # 37943 L.I.E.P. REVIEW CHECKLIST Date: 4/25J97 /
In Tracker? P,pp'n Received J App'n Processed
�� - d t-l3
LicenselD # 77741 License Type: Wine On Sale, On Sale Malt (3.2), Restaurant-B
Company Name: �ims Inc. DBA: Rorean Restaurant Shilla
Business Addresss: 694 Snelling Avenue North Business Phone: 645-0�06
Contact Name/Address: Namki Rim, 8212 Lyndale Ave So Home Phone: 884-8357
Date to Council Researoh: $loomington, NIN 55420
Public Hearing Date:
Notice Sent to Applicant; � %
Labels Ordered: �+� I ��i �
oistrict Councif #: �{
Notice Sent to Public: `�� �ull 0 �� /� Ward #: �
Department/ Date Inspections Comments
City Attorney
�. �- .�j�.. �, .
Environmental
Health
�•�.•`��- D.IC .
Fire
� � '��- a � .
License Site Plan Received:_
Lease Received:
� � 2� ��� �� ��
� j<<[��
� �,..� ���-�.� a'�—
Poiice
�•� •°!�' �`j•�. •
2oning
�: 21 �� �- o. � -
-----�.
Type of License(s)
THIS APPLICATION 3S SL3SJECT TO RE W BY P IC
PLEASE TYPE OR PRINT IN INK
Company Name:
Coryoration / Partnrnhip / Sote Proprietorship
If business is incorporated, gi��e date of incorporation:
Doing Business As:
Business Address:
Betueen
Are the premises nou� occupiedl �e i
Mail To Address:
G
Strcet AdcSress
Where7
CITY OF SAINT PAUL
office oPtuaue, inspectimu
and En.vommrntai Proteclion
3WSCPetaSLS�vk3W •J , w
Sc.tRUl'Hnmaoh51101 ��
(51:j:56o?u i<:`-"'::'.E.c:: • .
• i
CiTy
Home Address: _ _pe2� �
Business Phone:�� `a —(- � —onr> �
Applicant Infomation: , / �/
Name and Title: _�� � 1 '�4�t� �l 1 ��� �.1 v i� i yyl ��,�} 1�P�
Fint >2iddte (\Saidcn} 1,mt Title
Date of Bvth: .3 P3ace of Birih: ot. C�
Have you ever been comicted of any felony, crime or ��olation of any city ordinance other than tra$ic7
Date of errest:
Chazge: _
Con�icfion:
Sentrnce:
S�stt Zip
Home Phone: � � 2— �L�. 8��
YES NO _�
List the naznes and residences of three persons of good moral character, living within the Twin Cities Metro Area, not related to the applicant
or financially interested in the premises or business, who may be referred to as to the applicanf s chazacter:
CLASS III
LICENSE APPLICATION
�3
ADDRESS
PHONE
Sttiso-n �lo� .��oo w. �p� s�. � taZ ��na M�l 5�3G, SZ�l�oG79
k e'2 (� f� t' IM � g h � 3 Yd f��/ ' h� {� � t�'lltin4'4 H �✓1 1�) 7 J�t�Y 't"��F?I 1.�,
—b��un_ T� �� 5. 6 �h S�-. C-ti to y,,� t�,nl � 33 -8 2G
Li licenses u�hich you currenIly hold, formerly held, or may have an interest in: �
1 \� �
Ha��e sny of the above named Iicenses e�'er been revoked7 YES _� NO Ifyes, list the dates and reasons for re��ocation:
2/18/97
---p
Are you going to operaie this business personally7 _� YES
NO If not, who will operate it?
��
__,�_ w � � �
V H �
a'1-�43
First\amc 1.tiddlelcntinl (!Jwiben) Last DateofB'utA
HomeAddrn+: Strcet'.�ame Cin� Stete Zip PhoneN�ber
Are you going to ha��e a manager orassisiant in this business7 _� YES NO If the manager is not the same as the operator,
please complete the following infonnation:
Firs[ A`ame ALddlc Ltitial Q.faidrn) Last Date of Birth
HomeAddreSS: Sfrcct:�ame
City
Please lis[ your emplo}ment hisiory for the previous five (5) }'ear period:
Businccs/EmQlo�7nent Address
��
List all other officers of the corporation:
OFFICER TITLE HOME
NAME (Office Held) ADDRESS
2
HOME
PHOI�IE
-5 a
Stau Zip Phone Nomber
�1U - S 1
BUSINESS
DATE OF
BIl2TH
If business is a partnership, please include the following information for each partner (use additional pages if necessary):
Fitat\nme
!Niddle Initisl
(!�-0siden)
ier.t
Date of Hirth
Home Addras: Strxt 2:ame City S�a4 Zip Phone Number
F'valldame Middlelnilid (�kidm) Lasl DaieofBirth
HomeAddresa: Stm[I�ame City Sute Zip
MI13NESOTA TAX IDENTiFICATION NUMBER - Pursuant to tFie Laws of Minnesota, 798A, Chapter 502, Article 8, Seclion 2(276.72)
(Tax Clearance; Issuance of Licenses), licensing authorities ase required to provide to the State of Minnesota Commissioner of Revenue, the
Minnesota business tax identificalion number and the social security number of each license applicant.
Under the Minnesota Govemment Data Practice Act and the Federat Privacy Act of 1974, we are required to advise you of the following
regarding the use of the Minnesota Ta�t Identification Number:
- This information may be used to deny the issuance or renewal of your license in the eveni you o�ue Mim�esota sales, employer s
withholding or motor vehicle excise taaces;
- Upon receiving this information, the licensing authority w111 supply it on]y to the Mumesota Depaftment of Itevenue. However,
under the Federal Exchange of Infomiation Agreement, the Department of Revenue may supply tivs information to the Intemal
Revenue Service.
Minnesota Tax Ideotification N�be� (Sales & Use Tax Number) may be obtained from the State of Minnesota, Business Records Department,
10 Rives Pazk Plaza (612-246-6181).
Social Security Ntunber: �� I g `it'o Minnesota Tax Identification Number: �j 1 T�� 8S�
_ IS a Minnesota Tax Idrnlificalion I3umber is not required for the business being operated, indicate so by placing an"X" in the box.
2/18'97
Council File $ ��
Ordinance #
Green Sheet $ � ���
QRIGI{�!A�.
Presented By
Referred To
RESOlUT10N
CfTY OF SAiNT PAUL, MINNESOTA
7�
Committee: Date
1
2
3
RESOLVED: That application (ID #77741) for a Wine On Sale, On Sale Mait (3.2), and Restaurant-B License by
Knns Inc. DBA Korean Restaurant Shilla (Namld Kim, Owner) at 694 Snelling Avenue North be
and the same is hereby approved.
4
5
6 Yeas Navs Absent Requested by Department of:
7 B a ev �
8 Bastrom O� of License. Inspgqtions and
9 Harrzs
10 Me ar Env;ronmenta� protection
11 ==37�� �
14 Morton O By: `�, f i�' `�'�'--� l
15
16 Adopted by Council: Date ��_ � —
17
18 Adoption Certified by Council Secretary
19 Form Approved by city Attorney
20 \
21 By: �- . /\ _ >
22 By: �J w/
23 Approved y or: Date Q q
24
25 Approved by Mayor for Submission to
26 $y: Council
27
By:
`t�1- �43
�,��T,���N��� OATE INITIATED GREEN SHEE 3 7 5 4 3
LIEP fLicens in INITIAL/DATE INITIAL/DATE
CONTAGTPERSON&PHONE �OEPARTMENTDIqECTOR �CfiYCAUNCIL
A$$IGN CENATTORNEV CITYCLERK
Christine Rozek 266-9108 NUMBEPFOp � �
MUSTBE ON CAUNCIL AGENDA BY DAT/E)� ROUTING � BUDGET �IRECTOR � FIN. 8 MfaT. SERVICES DIR.
For hearin : 7 �] � ORDER O MAYOR (ORASSISTANn �
TOTAL # OP SIGNATURE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE)
ACTION AE�UESTED:
Kims Inc. DBA Rorean Restaurant Shilla requests Council approval of its application for a
Wine On Sale, On Sale Malt (3.2), and Restaurant-B License located at b94 Snelling Ave N.
(ID 1�77741).
FiECAMMENDATIONS: Appmve (A) or Re�ect (R) pERSONAL SERVICE CONTHACTS MUST ANSWER THE FOLLOWING DUESTIONS:
_ PLANNING COMMISSION _ CIVIL SEqVIGE COMMISSION �� Has this personflrtm eve� worKed under a con[ract for this department?
_ CIB COMMITTEE _ YES NO
_ S7AfF 2- Has this personNirm ever been a ciry employee?
— YES NO
_ DISTRIC7 CoURT — 3. Does this person/firm pOSSess a skill not normally po5sessed by any curtent city emplqee?
SUPPORT$ WHIGH COUNCI� OBJEGTIVE? YES NO
Explain ell yes answers on separate sheet and ettech to green sheet
INRIATING PROBLEM, ISSUE. OPP�RTUNIN (Who. Wnet. WhBn. Where, Why):
� i �a,��
'u�. ix � da � � �m
APR 29 1997
����� ������ ��
A�VANTAGESIFAPPROVED:
DISADVANTAGES IF APPROVEO:
v'� �6w.!
�` �.ak,;°��; � �
��3� .l � 1J`r7
_LL.�
DISADVANTAGES IF NOTAPPROVED:
TOTAL AMOUNT OF TRANSACTION $ COSTlREVENUE BUDGETED (CIRCLE ONE) YES ti0
FUNDIfBG SOURCE ACTIVITY NUMBER
FINANCIALINFORFnATION.(EXPLAIN)
Greensheet # 37943 L.I.E.P. REVIEW CHECKLIST Date: 4/25J97 /
In Tracker? P,pp'n Received J App'n Processed
�� - d t-l3
LicenselD # 77741 License Type: Wine On Sale, On Sale Malt (3.2), Restaurant-B
Company Name: �ims Inc. DBA: Rorean Restaurant Shilla
Business Addresss: 694 Snelling Avenue North Business Phone: 645-0�06
Contact Name/Address: Namki Rim, 8212 Lyndale Ave So Home Phone: 884-8357
Date to Council Researoh: $loomington, NIN 55420
Public Hearing Date:
Notice Sent to Applicant; � %
Labels Ordered: �+� I ��i �
oistrict Councif #: �{
Notice Sent to Public: `�� �ull 0 �� /� Ward #: �
Department/ Date Inspections Comments
City Attorney
�. �- .�j�.. �, .
Environmental
Health
�•�.•`��- D.IC .
Fire
� � '��- a � .
License Site Plan Received:_
Lease Received:
� � 2� ��� �� ��
� j<<[��
� �,..� ���-�.� a'�—
Poiice
�•� •°!�' �`j•�. •
2oning
�: 21 �� �- o. � -
-----�.
Type of License(s)
THIS APPLICATION 3S SL3SJECT TO RE W BY P IC
PLEASE TYPE OR PRINT IN INK
Company Name:
Coryoration / Partnrnhip / Sote Proprietorship
If business is incorporated, gi��e date of incorporation:
Doing Business As:
Business Address:
Betueen
Are the premises nou� occupiedl �e i
Mail To Address:
G
Strcet AdcSress
Where7
CITY OF SAINT PAUL
office oPtuaue, inspectimu
and En.vommrntai Proteclion
3WSCPetaSLS�vk3W •J , w
Sc.tRUl'Hnmaoh51101 ��
(51:j:56o?u i<:`-"'::'.E.c:: • .
• i
CiTy
Home Address: _ _pe2� �
Business Phone:�� `a —(- � —onr> �
Applicant Infomation: , / �/
Name and Title: _�� � 1 '�4�t� �l 1 ��� �.1 v i� i yyl ��,�} 1�P�
Fint >2iddte (\Saidcn} 1,mt Title
Date of Bvth: .3 P3ace of Birih: ot. C�
Have you ever been comicted of any felony, crime or ��olation of any city ordinance other than tra$ic7
Date of errest:
Chazge: _
Con�icfion:
Sentrnce:
S�stt Zip
Home Phone: � � 2— �L�. 8��
YES NO _�
List the naznes and residences of three persons of good moral character, living within the Twin Cities Metro Area, not related to the applicant
or financially interested in the premises or business, who may be referred to as to the applicanf s chazacter:
CLASS III
LICENSE APPLICATION
�3
ADDRESS
PHONE
Sttiso-n �lo� .��oo w. �p� s�. � taZ ��na M�l 5�3G, SZ�l�oG79
k e'2 (� f� t' IM � g h � 3 Yd f��/ ' h� {� � t�'lltin4'4 H �✓1 1�) 7 J�t�Y 't"��F?I 1.�,
—b��un_ T� �� 5. 6 �h S�-. C-ti to y,,� t�,nl � 33 -8 2G
Li licenses u�hich you currenIly hold, formerly held, or may have an interest in: �
1 \� �
Ha��e sny of the above named Iicenses e�'er been revoked7 YES _� NO Ifyes, list the dates and reasons for re��ocation:
2/18/97
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Are you going to operaie this business personally7 _� YES
NO If not, who will operate it?
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First\amc 1.tiddlelcntinl (!Jwiben) Last DateofB'utA
HomeAddrn+: Strcet'.�ame Cin� Stete Zip PhoneN�ber
Are you going to ha��e a manager orassisiant in this business7 _� YES NO If the manager is not the same as the operator,
please complete the following infonnation:
Firs[ A`ame ALddlc Ltitial Q.faidrn) Last Date of Birth
HomeAddreSS: Sfrcct:�ame
City
Please lis[ your emplo}ment hisiory for the previous five (5) }'ear period:
Businccs/EmQlo�7nent Address
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List all other officers of the corporation:
OFFICER TITLE HOME
NAME (Office Held) ADDRESS
2
HOME
PHOI�IE
-5 a
Stau Zip Phone Nomber
�1U - S 1
BUSINESS
DATE OF
BIl2TH
If business is a partnership, please include the following information for each partner (use additional pages if necessary):
Fitat\nme
!Niddle Initisl
(!�-0siden)
ier.t
Date of Hirth
Home Addras: Strxt 2:ame City S�a4 Zip Phone Number
F'valldame Middlelnilid (�kidm) Lasl DaieofBirth
HomeAddresa: Stm[I�ame City Sute Zip
MI13NESOTA TAX IDENTiFICATION NUMBER - Pursuant to tFie Laws of Minnesota, 798A, Chapter 502, Article 8, Seclion 2(276.72)
(Tax Clearance; Issuance of Licenses), licensing authorities ase required to provide to the State of Minnesota Commissioner of Revenue, the
Minnesota business tax identificalion number and the social security number of each license applicant.
Under the Minnesota Govemment Data Practice Act and the Federat Privacy Act of 1974, we are required to advise you of the following
regarding the use of the Minnesota Ta�t Identification Number:
- This information may be used to deny the issuance or renewal of your license in the eveni you o�ue Mim�esota sales, employer s
withholding or motor vehicle excise taaces;
- Upon receiving this information, the licensing authority w111 supply it on]y to the Mumesota Depaftment of Itevenue. However,
under the Federal Exchange of Infomiation Agreement, the Department of Revenue may supply tivs information to the Intemal
Revenue Service.
Minnesota Tax Ideotification N�be� (Sales & Use Tax Number) may be obtained from the State of Minnesota, Business Records Department,
10 Rives Pazk Plaza (612-246-6181).
Social Security Ntunber: �� I g `it'o Minnesota Tax Identification Number: �j 1 T�� 8S�
_ IS a Minnesota Tax Idrnlificalion I3umber is not required for the business being operated, indicate so by placing an"X" in the box.
2/18'97