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97-915Council File � 1 l� 9 �� Ordinance # � 7 r Green Sheet # � ^ -� ' � ; ° F ^ . RESOLUTION CITY OF SAINT PAUL, MINNESOTA �� Presented By Referred To 1 RESOLVED: That application (ID #92381) for a Cigazette, Grocery-C, Gas Station, and Auto Repair Garage 2 License by L St S Automotive Inc. DBA Pazkway Amoco (Scott Olson) at 304 Wheelwk Pazkway 3 East be and the same is hereby approved. 4 5 Requested by Department of: 6 Y� Navs Absent 7 B a�Tcev 8 Bostrom Office of License Inspections and 9 Harris � 10 Meaa� �� Environmental Protection _ 11 Morton � 12 T un� �— 14 Co� �n� �� /� 15 `�,,,� By: ��1��/ / 16 Adopted by Council: Date 3\'1`1 17 �` 18 Adoption Certified by Council Se retary 19 Form Approved by City Attorney 20 '� /<� � \ -�a� 21 By: � By: l/lZ� � � .-.�.. 22 23 arrr�vcfl Ly May�r: /ate � L� �4� 24 25 �-� � Approved by Mayor for Submission to 26 BY. � VV Council 27 � By: q?-9�S DEWIBTMENTAFFICER:OUNdL DATE INITIATED 3 i 9 5 6 LIEP/Liceusing G R EEN SH E E CONTACT PERSON & PHONE �NITIAUDATE INITIAVDATE � DEPARTMENTDIRECTOR � CINCOUNCIL Christine Rozek, 266-9108 A��N OCT'ATfOflNEY OCITV0.EflK MUST BE ON CAUNCIL AGENDA BV (DA7E) NUNBER FOB � BUDGET DIAECTOR O FM & MGL SERVICES D1R. flOUfING For hearing: 7/Z3�97 OflDEq OMAYOR(OflASSISTANn � TOTAL # OF SIGNATURE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE) ACTION flEQUESTED: L& S Automotive Inc. DBA Parkway Amoco requests Council approval of its application for a Cigarette, Grocery-C, Gas Station, and Auto Repair License located at 304 Wheelock Parkway EasC (ID �E92381). flECOMMENDATIONS: Approve (A) or Reject (R) pERSONAL SERVICE CONTRACTS MUS7 ANSWER TNE FOLLOWING �UESTIONS: _ PLANNINCa COMMISSION _ CIVIL SERVICE COMMISSION 1. Has this personRirm ever worked under a cornrect for this department? — CIB COMMITTEE YES NO _ STAFF 2. Has this personRirm ever been a ciry employee? — YES NO — �iSTAi�T CoURT — 3. Does this person/firm possess a skiil not normally possessetl by any current city employee? SUPPOR7S WNICH COUNCIL O&IECTIVE? YES NO Explain ell yes answers on separate sheet and aitech [o green sheet INITIATING PROB�EM, ISSUE. OPPORTUNITV (Who, What, When, Where. Why): ADVANTAGES IFAPPROVED RECEIVED JUL 15 i937 J(�E COLLINS DISADVANTAGES IF APPPOVEP: � , �� 1 JUL � � 1�� _�. �.� s � � � ; DfSADVANTAGE$ IF NOT APPRDVED. TOTAL AMOUN7 OF THANSACTIOM $ COST7HEVENUE BUDGE7ED (CIRCLE OPiE) YES NO FUNUIfiG SOURCE ACTIVITY NUMBER FINANCIAL INFORhfA710N� (EXPLAIN) Greensheet# 37956 L.I.E.P. REVfEW CHECKLIST Date: 5/13/97 L��— In Trackef? app'n Rec:eryed / npp'n arocessed LicenselD # 92381 License Type: Cigarette, Grocery-C, Gas Station, and Auto Renair Gara€ Compatty Name: L& S Automotive Inc. DBA: Parlcway Amoco Business Addresss: 304 Wheelock Pkwv E Business Phone: 774-0495 Contact Name/Address: Scott Olson, 6227 2nd Ave Soutt� Home Phone: g61-4378 Ric ie d 55 23 Date to Council Research: Public Hearing Date: Notice Sent to Applicant: � � Labels Ordered: District Council #: S � ��/�l. ��i f Notice Sent to Public: � 7� Ward #: `� , Department/ Date Inspections Comments City Attorney `� 2 L�. Environmental Health ��` Fire �� J� �'� ' License s��e Pian aeceivea:_ Lease Received: Police � 2 � q� �. K . Zoning 7 °J � �' � ' "l �� CLASS ITI LICENSE APPLICATION THIS APPLICATION IS SUBJECT TO REVIEW BY TF� PUBLIC PT.RACF TVPF C1R PRTNT TN TT.1TC Type of License(s) being applied for: Comnanv Name: sa� naa.a, Between what cross streets as the business located� 35 f-F— Are the premises now occupied? �_ Wha T}P of Business7 Mail To Address: `�'G � L�. �yil pq/KlL � CITY OF SAINT PAUL osa orucrnu, ta,pttt�ons �d �.a�� o,�;� � .915 3w sc rna u s� xo Serthvl,Mamaoh SSIOl (61l)�669090 fiz(61l)]66913d �� ! �S �i li S Zo0 ' s 3/7 s �"f00 — c�ry csry ApplicantInformation: � Name and Tide: � Fvat you cu:rendy hol� formerly held, or may have an interest in: Middle ��Ql� (Mniden) Home Address: _ <Gt-� / �;%!t/ I�7LC.� JO /��C'%f�fU 4/ OL'f� J J �fof f s� aam. ciry s�te z;P Date of Birth: f r 6 y place of Birth: � Home Phone: /� j2 — 8loL—S� 3��? N9�CP Cll1I %�P.r IlP2?� CQOVIC�n .,F amr fpinnV r.;mP nr atir�+fjr^ :s a�g �i?�� n.djp �-.....0.e.•4..� r�_4...0 pcc v!1 �" Date of arrest: Where7 Charge: Conviction: Sentence: I.ist the names and residences of three persons of good moral character, living within the Twin Cities Metro Area, not related to the applicant or financialiy interested in the pretnises or business, who may be referzed to as to the applicanPs character: N�ME �� ' ADDRESS ,/ J � PHONE �t�Pse n n./'.Mb) � Jr�9 <l f�. S.' .� i 1�G /i/ 1 iAr� �� 7f� �'764 f� List Stetc Zip � Wfrich side of the slreetl � �� /»� S'1' /a / sc�u z;p �� _ � Leet Tit]e � i3 Have any of the�bove named licenses ever been revoked7 YES _�NO If yes, list the dates end rea�wns for revocation: 2/18/97 Cmporation / Partnaship! Sele Pcoprielo�ship If business is incorporated, 've date of incorporation: ��6✓� . 7�, ��l y'7 Doing Business As: R✓'j� 1CC-0 Business Phone: � �� Busirnss Address: � �'� I` Lclf.t e Cc�4 Are you goiug to operaze this business personally2 � YES Home Add�ess: Strect'.Came Middle Initid (!�1a+den) Are }rou gomg to have a msnaga or azsistant in this business? please complete the follouing information: Firrt Ame Add�e�s: StreaN�e YES ��) City NO If not, who NiA operate it7 Q/� ��` 7,aR • Dmc of Bicih Stnte . Zip YnoneNumbc � NO ff ihe manager is not the same as the operator, I.aR Sintc List all other officers of the corporation: OFFICER TITLE HOME HOME BUSINESS AATE OF NAME (OfficeHeld) ADDRESS PHONE PHONE BIRTH If business is a partnership, please include the fol]owing information for each partner (use additional pages if necessary): Firrt Name Middle Ltitinl I.aR Date of Birth Zip Pfionei�'umber Date of Si+th Home Add'cas: Sirat t:eme Ciry Sute Zip Phone Numbcr FirrtAame Middlelnitial (1Neidcn) Lavt DeuofBirth Home Addreae: Strat 1:eme City Srnte Zip Pfionc Nmuber MINNF,SOTA TAX IDENTIf'ICATION NUMBER - Pursuant to the Laws of Minnesot� 1984, Chapter 502, Article 8, Section 2(270.72) (T� Cleazance; Issuance of Licenses), licensing authorilies aze requ'ved to provide to the Stste of Minnesota Comaussioner of Rcvcnue, the Minnesota business tax idrntification number and the social security number of each license applicant Under the Minnesota Goveaunent Data Practices Act and the Federal Privacy Act of 1974, we ere required to advise you of thc follow�ing regarding the use of the Minnesota Tax Identification Numbes: - This information may be used to drny the issuance or renewal of your licrnse in the evrnt you owe Minnesota sales, anploya's witlil�olding or motor vehicle excise taxes; - Upon receiving ttus information, ffie licensing authority will supply it only to Ihe Minnaota Dcperimrnt of Revenue. Howcva, under the Federal Exchange of Infonnation Agreemrnt, the Departmart of Rcvmue mey supply this infortnation to tha Intemal Revenue Service. Muss�aota Tax Ida�tification Numbers (Sales & Use Tac Number) mey be obteined 5om the State of Minnesota, B�uiness Records Depertment, 10 River Park Plaza (612-296-6181). Social Security Number: `7 ��— /Y �J T� Minnesota Tax FdcntiGcation Numba: O � Z � lf e Minnesota Tar ldentification Number is not requircd for ihe business being opueted, indicate so by placing en'X' in the box. 2q897 Please list your employment history for the previous five (5) }�ear period: Council File � 1 l� 9 �� Ordinance # � 7 r Green Sheet # � ^ -� ' � ; ° F ^ . RESOLUTION CITY OF SAINT PAUL, MINNESOTA �� Presented By Referred To 1 RESOLVED: That application (ID #92381) for a Cigazette, Grocery-C, Gas Station, and Auto Repair Garage 2 License by L St S Automotive Inc. DBA Pazkway Amoco (Scott Olson) at 304 Wheelwk Pazkway 3 East be and the same is hereby approved. 4 5 Requested by Department of: 6 Y� Navs Absent 7 B a�Tcev 8 Bostrom Office of License Inspections and 9 Harris � 10 Meaa� �� Environmental Protection _ 11 Morton � 12 T un� �— 14 Co� �n� �� /� 15 `�,,,� By: ��1��/ / 16 Adopted by Council: Date 3\'1`1 17 �` 18 Adoption Certified by Council Se retary 19 Form Approved by City Attorney 20 '� /<� � \ -�a� 21 By: � By: l/lZ� � � .-.�.. 22 23 arrr�vcfl Ly May�r: /ate � L� �4� 24 25 �-� � Approved by Mayor for Submission to 26 BY. � VV Council 27 � By: q?-9�S DEWIBTMENTAFFICER:OUNdL DATE INITIATED 3 i 9 5 6 LIEP/Liceusing G R EEN SH E E CONTACT PERSON & PHONE �NITIAUDATE INITIAVDATE � DEPARTMENTDIRECTOR � CINCOUNCIL Christine Rozek, 266-9108 A��N OCT'ATfOflNEY OCITV0.EflK MUST BE ON CAUNCIL AGENDA BV (DA7E) NUNBER FOB � BUDGET DIAECTOR O FM & MGL SERVICES D1R. flOUfING For hearing: 7/Z3�97 OflDEq OMAYOR(OflASSISTANn � TOTAL # OF SIGNATURE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE) ACTION flEQUESTED: L& S Automotive Inc. DBA Parkway Amoco requests Council approval of its application for a Cigarette, Grocery-C, Gas Station, and Auto Repair License located at 304 Wheelock Parkway EasC (ID �E92381). flECOMMENDATIONS: Approve (A) or Reject (R) pERSONAL SERVICE CONTRACTS MUS7 ANSWER TNE FOLLOWING �UESTIONS: _ PLANNINCa COMMISSION _ CIVIL SERVICE COMMISSION 1. Has this personRirm ever worked under a cornrect for this department? — CIB COMMITTEE YES NO _ STAFF 2. Has this personRirm ever been a ciry employee? — YES NO — �iSTAi�T CoURT — 3. Does this person/firm possess a skiil not normally possessetl by any current city employee? SUPPOR7S WNICH COUNCIL O&IECTIVE? YES NO Explain ell yes answers on separate sheet and aitech [o green sheet INITIATING PROB�EM, ISSUE. OPPORTUNITV (Who, What, When, Where. Why): ADVANTAGES IFAPPROVED RECEIVED JUL 15 i937 J(�E COLLINS DISADVANTAGES IF APPPOVEP: � , �� 1 JUL � � 1�� _�. �.� s � � � ; DfSADVANTAGE$ IF NOT APPRDVED. TOTAL AMOUN7 OF THANSACTIOM $ COST7HEVENUE BUDGE7ED (CIRCLE OPiE) YES NO FUNUIfiG SOURCE ACTIVITY NUMBER FINANCIAL INFORhfA710N� (EXPLAIN) Greensheet# 37956 L.I.E.P. REVfEW CHECKLIST Date: 5/13/97 L��— In Trackef? app'n Rec:eryed / npp'n arocessed LicenselD # 92381 License Type: Cigarette, Grocery-C, Gas Station, and Auto Renair Gara€ Compatty Name: L& S Automotive Inc. DBA: Parlcway Amoco Business Addresss: 304 Wheelock Pkwv E Business Phone: 774-0495 Contact Name/Address: Scott Olson, 6227 2nd Ave Soutt� Home Phone: g61-4378 Ric ie d 55 23 Date to Council Research: Public Hearing Date: Notice Sent to Applicant: � � Labels Ordered: District Council #: S � ��/�l. ��i f Notice Sent to Public: � 7� Ward #: `� , Department/ Date Inspections Comments City Attorney `� 2 L�. Environmental Health ��` Fire �� J� �'� ' License s��e Pian aeceivea:_ Lease Received: Police � 2 � q� �. K . Zoning 7 °J � �' � ' "l �� CLASS ITI LICENSE APPLICATION THIS APPLICATION IS SUBJECT TO REVIEW BY TF� PUBLIC PT.RACF TVPF C1R PRTNT TN TT.1TC Type of License(s) being applied for: Comnanv Name: sa� naa.a, Between what cross streets as the business located� 35 f-F— Are the premises now occupied? �_ Wha T}P of Business7 Mail To Address: `�'G � L�. �yil pq/KlL � CITY OF SAINT PAUL osa orucrnu, ta,pttt�ons �d �.a�� o,�;� � .915 3w sc rna u s� xo Serthvl,Mamaoh SSIOl (61l)�669090 fiz(61l)]66913d �� ! �S �i li S Zo0 ' s 3/7 s �"f00 — c�ry csry ApplicantInformation: � Name and Tide: � Fvat you cu:rendy hol� formerly held, or may have an interest in: Middle ��Ql� (Mniden) Home Address: _ <Gt-� / �;%!t/ I�7LC.� JO /��C'%f�fU 4/ OL'f� J J �fof f s� aam. ciry s�te z;P Date of Birth: f r 6 y place of Birth: � Home Phone: /� j2 — 8loL—S� 3��? N9�CP Cll1I %�P.r IlP2?� CQOVIC�n .,F amr fpinnV r.;mP nr atir�+fjr^ :s a�g �i?�� n.djp �-.....0.e.•4..� r�_4...0 pcc v!1 �" Date of arrest: Where7 Charge: Conviction: Sentence: I.ist the names and residences of three persons of good moral character, living within the Twin Cities Metro Area, not related to the applicant or financialiy interested in the pretnises or business, who may be referzed to as to the applicanPs character: N�ME �� ' ADDRESS ,/ J � PHONE �t�Pse n n./'.Mb) � Jr�9 <l f�. S.' .� i 1�G /i/ 1 iAr� �� 7f� �'764 f� List Stetc Zip � Wfrich side of the slreetl � �� /»� S'1' /a / sc�u z;p �� _ � Leet Tit]e � i3 Have any of the�bove named licenses ever been revoked7 YES _�NO If yes, list the dates end rea�wns for revocation: 2/18/97 Cmporation / Partnaship! Sele Pcoprielo�ship If business is incorporated, 've date of incorporation: ��6✓� . 7�, ��l y'7 Doing Business As: R✓'j� 1CC-0 Business Phone: � �� Busirnss Address: � �'� I` Lclf.t e Cc�4 Are you goiug to operaze this business personally2 � YES Home Add�ess: Strect'.Came Middle Initid (!�1a+den) Are }rou gomg to have a msnaga or azsistant in this business? please complete the follouing information: Firrt Ame Add�e�s: StreaN�e YES ��) City NO If not, who NiA operate it7 Q/� ��` 7,aR • Dmc of Bicih Stnte . Zip YnoneNumbc � NO ff ihe manager is not the same as the operator, I.aR Sintc List all other officers of the corporation: OFFICER TITLE HOME HOME BUSINESS AATE OF NAME (OfficeHeld) ADDRESS PHONE PHONE BIRTH If business is a partnership, please include the fol]owing information for each partner (use additional pages if necessary): Firrt Name Middle Ltitinl I.aR Date of Birth Zip Pfionei�'umber Date of Si+th Home Add'cas: Sirat t:eme Ciry Sute Zip Phone Numbcr FirrtAame Middlelnitial (1Neidcn) Lavt DeuofBirth Home Addreae: Strat 1:eme City Srnte Zip Pfionc Nmuber MINNF,SOTA TAX IDENTIf'ICATION NUMBER - Pursuant to the Laws of Minnesot� 1984, Chapter 502, Article 8, Section 2(270.72) (T� Cleazance; Issuance of Licenses), licensing authorilies aze requ'ved to provide to the Stste of Minnesota Comaussioner of Rcvcnue, the Minnesota business tax idrntification number and the social security number of each license applicant Under the Minnesota Goveaunent Data Practices Act and the Federal Privacy Act of 1974, we ere required to advise you of thc follow�ing regarding the use of the Minnesota Tax Identification Numbes: - This information may be used to drny the issuance or renewal of your licrnse in the evrnt you owe Minnesota sales, anploya's witlil�olding or motor vehicle excise taxes; - Upon receiving ttus information, ffie licensing authority will supply it only to Ihe Minnaota Dcperimrnt of Revenue. Howcva, under the Federal Exchange of Infonnation Agreemrnt, the Departmart of Rcvmue mey supply this infortnation to tha Intemal Revenue Service. Muss�aota Tax Ida�tification Numbers (Sales & Use Tac Number) mey be obteined 5om the State of Minnesota, B�uiness Records Depertment, 10 River Park Plaza (612-296-6181). Social Security Number: `7 ��— /Y �J T� Minnesota Tax FdcntiGcation Numba: O � Z � lf e Minnesota Tar ldentification Number is not requircd for ihe business being opueted, indicate so by placing en'X' in the box. 2q897 Please list your employment history for the previous five (5) }�ear period: Council File � 1 l� 9 �� Ordinance # � 7 r Green Sheet # � ^ -� ' � ; ° F ^ . RESOLUTION CITY OF SAINT PAUL, MINNESOTA �� Presented By Referred To 1 RESOLVED: That application (ID #92381) for a Cigazette, Grocery-C, Gas Station, and Auto Repair Garage 2 License by L St S Automotive Inc. DBA Pazkway Amoco (Scott Olson) at 304 Wheelwk Pazkway 3 East be and the same is hereby approved. 4 5 Requested by Department of: 6 Y� Navs Absent 7 B a�Tcev 8 Bostrom Office of License Inspections and 9 Harris � 10 Meaa� �� Environmental Protection _ 11 Morton � 12 T un� �— 14 Co� �n� �� /� 15 `�,,,� By: ��1��/ / 16 Adopted by Council: Date 3\'1`1 17 �` 18 Adoption Certified by Council Se retary 19 Form Approved by City Attorney 20 '� /<� � \ -�a� 21 By: � By: l/lZ� � � .-.�.. 22 23 arrr�vcfl Ly May�r: /ate � L� �4� 24 25 �-� � Approved by Mayor for Submission to 26 BY. � VV Council 27 � By: q?-9�S DEWIBTMENTAFFICER:OUNdL DATE INITIATED 3 i 9 5 6 LIEP/Liceusing G R EEN SH E E CONTACT PERSON & PHONE �NITIAUDATE INITIAVDATE � DEPARTMENTDIRECTOR � CINCOUNCIL Christine Rozek, 266-9108 A��N OCT'ATfOflNEY OCITV0.EflK MUST BE ON CAUNCIL AGENDA BV (DA7E) NUNBER FOB � BUDGET DIAECTOR O FM & MGL SERVICES D1R. flOUfING For hearing: 7/Z3�97 OflDEq OMAYOR(OflASSISTANn � TOTAL # OF SIGNATURE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE) ACTION flEQUESTED: L& S Automotive Inc. DBA Parkway Amoco requests Council approval of its application for a Cigarette, Grocery-C, Gas Station, and Auto Repair License located at 304 Wheelock Parkway EasC (ID �E92381). flECOMMENDATIONS: Approve (A) or Reject (R) pERSONAL SERVICE CONTRACTS MUS7 ANSWER TNE FOLLOWING �UESTIONS: _ PLANNINCa COMMISSION _ CIVIL SERVICE COMMISSION 1. Has this personRirm ever worked under a cornrect for this department? — CIB COMMITTEE YES NO _ STAFF 2. Has this personRirm ever been a ciry employee? — YES NO — �iSTAi�T CoURT — 3. Does this person/firm possess a skiil not normally possessetl by any current city employee? SUPPOR7S WNICH COUNCIL O&IECTIVE? YES NO Explain ell yes answers on separate sheet and aitech [o green sheet INITIATING PROB�EM, ISSUE. OPPORTUNITV (Who, What, When, Where. Why): ADVANTAGES IFAPPROVED RECEIVED JUL 15 i937 J(�E COLLINS DISADVANTAGES IF APPPOVEP: � , �� 1 JUL � � 1�� _�. �.� s � � � ; DfSADVANTAGE$ IF NOT APPRDVED. TOTAL AMOUN7 OF THANSACTIOM $ COST7HEVENUE BUDGE7ED (CIRCLE OPiE) YES NO FUNUIfiG SOURCE ACTIVITY NUMBER FINANCIAL INFORhfA710N� (EXPLAIN) Greensheet# 37956 L.I.E.P. REVfEW CHECKLIST Date: 5/13/97 L��— In Trackef? app'n Rec:eryed / npp'n arocessed LicenselD # 92381 License Type: Cigarette, Grocery-C, Gas Station, and Auto Renair Gara€ Compatty Name: L& S Automotive Inc. DBA: Parlcway Amoco Business Addresss: 304 Wheelock Pkwv E Business Phone: 774-0495 Contact Name/Address: Scott Olson, 6227 2nd Ave Soutt� Home Phone: g61-4378 Ric ie d 55 23 Date to Council Research: Public Hearing Date: Notice Sent to Applicant: � � Labels Ordered: District Council #: S � ��/�l. ��i f Notice Sent to Public: � 7� Ward #: `� , Department/ Date Inspections Comments City Attorney `� 2 L�. Environmental Health ��` Fire �� J� �'� ' License s��e Pian aeceivea:_ Lease Received: Police � 2 � q� �. K . Zoning 7 °J � �' � ' "l �� CLASS ITI LICENSE APPLICATION THIS APPLICATION IS SUBJECT TO REVIEW BY TF� PUBLIC PT.RACF TVPF C1R PRTNT TN TT.1TC Type of License(s) being applied for: Comnanv Name: sa� naa.a, Between what cross streets as the business located� 35 f-F— Are the premises now occupied? �_ Wha T}P of Business7 Mail To Address: `�'G � L�. �yil pq/KlL � CITY OF SAINT PAUL osa orucrnu, ta,pttt�ons �d �.a�� o,�;� � .915 3w sc rna u s� xo Serthvl,Mamaoh SSIOl (61l)�669090 fiz(61l)]66913d �� ! �S �i li S Zo0 ' s 3/7 s �"f00 — c�ry csry ApplicantInformation: � Name and Tide: � Fvat you cu:rendy hol� formerly held, or may have an interest in: Middle ��Ql� (Mniden) Home Address: _ <Gt-� / �;%!t/ I�7LC.� JO /��C'%f�fU 4/ OL'f� J J �fof f s� aam. ciry s�te z;P Date of Birth: f r 6 y place of Birth: � Home Phone: /� j2 — 8loL—S� 3��? N9�CP Cll1I %�P.r IlP2?� CQOVIC�n .,F amr fpinnV r.;mP nr atir�+fjr^ :s a�g �i?�� n.djp �-.....0.e.•4..� r�_4...0 pcc v!1 �" Date of arrest: Where7 Charge: Conviction: Sentence: I.ist the names and residences of three persons of good moral character, living within the Twin Cities Metro Area, not related to the applicant or financialiy interested in the pretnises or business, who may be referzed to as to the applicanPs character: N�ME �� ' ADDRESS ,/ J � PHONE �t�Pse n n./'.Mb) � Jr�9 <l f�. S.' .� i 1�G /i/ 1 iAr� �� 7f� �'764 f� List Stetc Zip � Wfrich side of the slreetl � �� /»� S'1' /a / sc�u z;p �� _ � Leet Tit]e � i3 Have any of the�bove named licenses ever been revoked7 YES _�NO If yes, list the dates end rea�wns for revocation: 2/18/97 Cmporation / Partnaship! Sele Pcoprielo�ship If business is incorporated, 've date of incorporation: ��6✓� . 7�, ��l y'7 Doing Business As: R✓'j� 1CC-0 Business Phone: � �� Busirnss Address: � �'� I` Lclf.t e Cc�4 Are you goiug to operaze this business personally2 � YES Home Add�ess: Strect'.Came Middle Initid (!�1a+den) Are }rou gomg to have a msnaga or azsistant in this business? please complete the follouing information: Firrt Ame Add�e�s: StreaN�e YES ��) City NO If not, who NiA operate it7 Q/� ��` 7,aR • Dmc of Bicih Stnte . Zip YnoneNumbc � NO ff ihe manager is not the same as the operator, I.aR Sintc List all other officers of the corporation: OFFICER TITLE HOME HOME BUSINESS AATE OF NAME (OfficeHeld) ADDRESS PHONE PHONE BIRTH If business is a partnership, please include the fol]owing information for each partner (use additional pages if necessary): Firrt Name Middle Ltitinl I.aR Date of Birth Zip Pfionei�'umber Date of Si+th Home Add'cas: Sirat t:eme Ciry Sute Zip Phone Numbcr FirrtAame Middlelnitial (1Neidcn) Lavt DeuofBirth Home Addreae: Strat 1:eme City Srnte Zip Pfionc Nmuber MINNF,SOTA TAX IDENTIf'ICATION NUMBER - Pursuant to the Laws of Minnesot� 1984, Chapter 502, Article 8, Section 2(270.72) (T� Cleazance; Issuance of Licenses), licensing authorilies aze requ'ved to provide to the Stste of Minnesota Comaussioner of Rcvcnue, the Minnesota business tax idrntification number and the social security number of each license applicant Under the Minnesota Goveaunent Data Practices Act and the Federal Privacy Act of 1974, we ere required to advise you of thc follow�ing regarding the use of the Minnesota Tax Identification Numbes: - This information may be used to drny the issuance or renewal of your licrnse in the evrnt you owe Minnesota sales, anploya's witlil�olding or motor vehicle excise taxes; - Upon receiving ttus information, ffie licensing authority will supply it only to Ihe Minnaota Dcperimrnt of Revenue. Howcva, under the Federal Exchange of Infonnation Agreemrnt, the Departmart of Rcvmue mey supply this infortnation to tha Intemal Revenue Service. Muss�aota Tax Ida�tification Numbers (Sales & Use Tac Number) mey be obteined 5om the State of Minnesota, B�uiness Records Depertment, 10 River Park Plaza (612-296-6181). Social Security Number: `7 ��— /Y �J T� Minnesota Tax FdcntiGcation Numba: O � Z � lf e Minnesota Tar ldentification Number is not requircd for ihe business being opueted, indicate so by placing en'X' in the box. 2q897 Please list your employment history for the previous five (5) }�ear period: