97-965Council File # �� ' 9 �S
Ordinance #
# �7910�
Presented By
��F��``�' � ri 1
CIT`( OF
�
Committee: Date
Re£erred To
i
2
3
�ly
RESOLVED: That application (ID #63859) for a Liquor On Sale-B License by Sawatdee Thai Restaurant Inc.
DBA Sawatdee Thai Restaurant Ina (Robert J. Jones, Owner) at 289 Sth Street East be and the
same is hereby approved.
4
5 Requested by Department of:
6 Yeas Navs Absent
7 B a� �
8 Bostrom !�—
9 Harris � — 7
10 Meaard
il Morton
12 T un�i� E — � �—
13 Co�
14 � �
is
16 Adopted by Council: Date �°��.
17
18 Adoption Certified by Council Secretary
19
20
21 By: � � /Y1�
22 � � J
23 Approved by Mayor: Date ° a�t)(9�
24 �
25
26 By:
27
Office of License Inspections and
Environmental Protection
s � I� �} �211��.
Form Approved by City Attorney
$Y� `'�____
Approved by Mayor £or Submission to
Council
By:
R� - 9b5
DEMRTMENT/OFFlCElCOUNGIL DA7E INITIATED 3 7 9 6 8
LIEPfLicensing GREEN SHEE
CAMTACT PERSON & PHONE O DEPAPTMENT DIRECTORNITIAUDATE O CIiY COUNCIL �NITIAUDATE
Christine Rozek, 266-9108 ASSIGN �CENATfORNEY apTVCLEflK
NUMBER POfi
MUST BE ON COUNCIL AGENDA BV (DATE) RO��� � BU�GET DIflECTOR � FIN. & MGT. SERVIGES DIR.
For hearin : (Q �� OflOEF �MAVOR{ORASSISTAN� �
TOTAL # OF SIGNATURE PAGES (CLiP ALL LOCATION5 FOR SIGNATURE)
ACTION REQUESTED:
Sawatdee Thai Restaurant Inc. DBA Sawatdee Thai Restaurant Inc. requests Council approval of
its application for a Liquor On Sale-B License lcoated at 289 Sth Street East (ID 1163859).
RECAMMENDATIONS: Appfaie (A) w Reject (R) PERSONAL SERVICE CONTRACTS MUST ANSWER THE FOLLOWING QUESTIONS:
_ PLqNNINCa COMMISSION _ CNIL SERVICE COMMISSION 1. Has this personttirm ever worked under a contract for this department?
_ CIB COMMITTEE _ YES NO
_ S7ACf 2. Has tnis personttirm ever been a city employee?
— YES NO
_ DIS7RICT cAURi — 3. Does this person/firm possess a skill not normelly possessetl by any current city employee?
SUPPOflTS WHICH COUNCiI O&IECTIVEI YES NO
Explain all yes answers on aeparate sheet and ettach to green sheet
INITIATING PROBLEM, ISSUE, OPPORTUNITV (Who, Whel, When, W�ere, Why)�
AOYANTAGESIFAPPROVED�
DISAOVANTPGESIFAPPROVED�
DISA�VANTA6ES IF NOT APPAOVED:
4a4i63t1LS1 �",��^�'��ar;i E.�r''"P`"i�:3�
JUL 2 3 "i;,,�I
TOTAL AMOUNT OF TRANSACTION $ COSTfREYENUE BUDGETED (CIRCLE ONE) YES NO
FUNDIIeG SOURCE AC7IVITY NUMBER
FINANCIAL INFORNSATION' (EXPLAIN)
Greensheet # 37968 L.I.E.P. REVfEW CHECKLIST
In TrackeR a3 � ,
LiCense ID # 63859 License Type: Liquor On Sale-B
6/17/97 / 9?�q�s
ApP'n Received 1 APP'n Processed
Company NamB: Sawatdee Thai Restaurant Inc. DBA: same
Business Addresss: 289 5th Street East Business Phone: 222-5859
Contact Name f
Date to Councit
Pubtic Hearing '
Notice Sent to i
c�
Home Phone: 455-9419
s, 55077 �3��at�1���
Labels Ordered: /�+d _
District Council #: � /
� �„E, �•- ,
Notice Sent to Public: j"��� ���' Ward #: �
Department/ Date inspections Commenis
City Attorney
(g'� ���' Qf� .
Environmental
Heaith
� � � `� � • '/`^� ` � �
Fire
�9�9�- �.� .
License �,p,,us� ��-�'^�� Si�e aian [mceivea:
i.�a� a��ea: �
S�l-,�.u..�.�u`.tie.; sa�-ri.e.
`� — � � �- 1 .�'.p-�-�-�-�-e�.� ��� �-�- ,
a�.:� u,�.aa� -�� �r��
Police
�O'�'�� �•� .
Zoning
b•3D �`� �- D�� .
._
CLASS III
LICENSE APPLICATION
�tav°�2� I �` �D r�� ��
U ��1�u
THIS APPLICATION IS SUBJECT TO REVIEW BY Tf� PUBLIC
PLEASE TYPE OR PRII3T IN INK (���
-„ � y � �oc� ieh=!`s
T}pe of License(s) being applied for. t�l�. (.}c'9� — C�� �{' �.e ��paj�o
Company Nazne:
CITY OF SAINT PAUL��
oss� �rU«�, �;�
ana &rvvocs„enfa) r.med;oo
3505L PM St Sutc]00
����� s��a�
<su7us9asa 6z�stx)zr,evua
Coryoration! PutnecalSp! Sole Proprie[o�slup
ff business is incorporate.� give date of incotporation: �`"
Doing Business As: _ �1� U1 � ��—Q �h ��
Business Address: _ �_[_,�-�=�� J + _ ��
s��
Behveen whaz cross streets is the business located?
Are the premises now occupied'1 � Wha
Mail To Address:
Applicant Infomiation;
Name and Title: /L �
Firai
Business Phone:
�i�'—'� --� Fh�� . �'S1a1
ctty s,.k �u�p�� �..
�1' '� �,
Title
Home Address: _ /! �!J J�' / YI �> �T I 7� , �N UP�N/'>/�CU l! Q HT� /{Z N�
� / S � 4 1 ectAd ( dre � es ( � City Sfatc Zip !
DateofButh: � �"`/ `TcJ PiaceofButh: !!a �5'G°N �i��. .-��� � HomePhone: q�'l y
He�e �ou e:a beer3 cum�icied of ury felw:y, oiit,::. �. :iolai:;.:: ;;i aiy :.::� ss�: �,;n� �,: ;,c; . � ivf (�
Date of arrest:
Charge:
C.omiction: _, ,...
Where7
Ce.ntencr.•
Lis[ tl�e names and residenc¢s of ttir� personc of good mora( chazacter, living within the Twin Cities Metro Area, not related to the applicant
or financially interested in the preutises or business, who may be referred to as to the applicanYs chazacter:
1TA\FT:
♦TTTTCt�
Have any of the above named Iicenses ever bcen revoked7 " YES �NO If yes, list the dates and reasons fot revocation:
2/18l47
Str«t Addfne City Stste Zip
L�t I'scenses which you currenil}j ho�c� formerly held, or may have an intejest in:
Are you go'sng to operate this husiness personally? � YES _
JCb (�52i l 'r^' �
Furt Middle Initial (�5aidrn)
� 7 '! J� . �R'�� ��, -� r 7_',u �er
HomeAdc4m: Street\ame City �/�
Ate you gomg to have a manager or assistant in 4ris business? _y� YES
please compJete the following information:
R�^�
Please list your employmrnt history for the previous $ve (S) year period:
�-9G5� w � �'�
NO If not, who will operate it? U-C ,�b' •�5
�,� ���'�' ~ ' � .
ysa De4 of H'vth
l'� uQ ,�"�_ nv S✓� � 2�t�sv� i 9
Stnt� . Zip PlioxN�ber
NO If the manager is not the same as the operator,
Sirie
�� i
D+te of B'vth
P6one Number
�Hi
List all other officers of the corporation:
OFFICER TITLE
NAME . (Office Held�'r
HOME
PHONE
BUSINESS
PHONE
DATE OF
BIItTH
F'vst A*ame Middle 7nitid (Me+drn) Isat Dete of Birih
Hom<Addme: Svectl�ame City � Stau Zip PhaneNumbw'
Fintlhame NHdd3elmtis{ (Msidcu) La6 DateofBirth
HomeAAdrw: SiteelName City Sinle Zip Phmw
MINI3ESOTA TAX IDENTIPICATION NLIMBER - ftusuant to the Laws of Ivfinnesota. 1984, Chapter 502, Article 8, Seclion 2(270.72)
(Ta� Cleazavice�, Issuance of Licenses), licensing authorities are required to provide to the State of Minnesota Commissioner of Revenve, the
Minnesota business tax ident;fi�ate2 n�ux+br.r and thP sociai sectuiry number of each license applicant
Under the Minnesota Goveramrnt Data Practices Act and the Federal Privacy Act of 1974, we are required to advise you of the £allowing
regarding the use of the Minnesota Tax Identification Number:
- T6is information may be used to deny tLe issuance or renewai of your license in ilae event you owe Mumesota sa]es, employer s
withholding a motor vehicle excise ta�ces;
- Upon receiving this information, the licensing authority will supply it only to the Minnesota Department of Revenue. However,
under the Federal Exchange of Information Agreement, the Department of Revenue may supply tlils infonnation to the Intemal
Revenue Service.
iv5nnesota Tax Identification N�nbers (Sales & Use Tax Number) maybe obtain� fmm fl�e State of Minnesota, Business Records Department,
10 River Park Plazs (612-296-b 181).
Social Security Number�� ���� � Minnesota Tax Identification Number: ,�0.2 �4�' ! t11 J�
If a Minnesota Tax ldentification Number is not required fw the business being operated, indicate so by placing an "X' in che box.
2/] 8r97
ff business is a partnership, please include tl�e following information for each pac�er (use additionai pages if necessary):
Council File # �� ' 9 �S
Ordinance #
# �7910�
Presented By
��F��``�' � ri 1
CIT`( OF
�
Committee: Date
Re£erred To
i
2
3
�ly
RESOLVED: That application (ID #63859) for a Liquor On Sale-B License by Sawatdee Thai Restaurant Inc.
DBA Sawatdee Thai Restaurant Ina (Robert J. Jones, Owner) at 289 Sth Street East be and the
same is hereby approved.
4
5 Requested by Department of:
6 Yeas Navs Absent
7 B a� �
8 Bostrom !�—
9 Harris � — 7
10 Meaard
il Morton
12 T un�i� E — � �—
13 Co�
14 � �
is
16 Adopted by Council: Date �°��.
17
18 Adoption Certified by Council Secretary
19
20
21 By: � � /Y1�
22 � � J
23 Approved by Mayor: Date ° a�t)(9�
24 �
25
26 By:
27
Office of License Inspections and
Environmental Protection
s � I� �} �211��.
Form Approved by City Attorney
$Y� `'�____
Approved by Mayor £or Submission to
Council
By:
R� - 9b5
DEMRTMENT/OFFlCElCOUNGIL DA7E INITIATED 3 7 9 6 8
LIEPfLicensing GREEN SHEE
CAMTACT PERSON & PHONE O DEPAPTMENT DIRECTORNITIAUDATE O CIiY COUNCIL �NITIAUDATE
Christine Rozek, 266-9108 ASSIGN �CENATfORNEY apTVCLEflK
NUMBER POfi
MUST BE ON COUNCIL AGENDA BV (DATE) RO��� � BU�GET DIflECTOR � FIN. & MGT. SERVIGES DIR.
For hearin : (Q �� OflOEF �MAVOR{ORASSISTAN� �
TOTAL # OF SIGNATURE PAGES (CLiP ALL LOCATION5 FOR SIGNATURE)
ACTION REQUESTED:
Sawatdee Thai Restaurant Inc. DBA Sawatdee Thai Restaurant Inc. requests Council approval of
its application for a Liquor On Sale-B License lcoated at 289 Sth Street East (ID 1163859).
RECAMMENDATIONS: Appfaie (A) w Reject (R) PERSONAL SERVICE CONTRACTS MUST ANSWER THE FOLLOWING QUESTIONS:
_ PLqNNINCa COMMISSION _ CNIL SERVICE COMMISSION 1. Has this personttirm ever worked under a contract for this department?
_ CIB COMMITTEE _ YES NO
_ S7ACf 2. Has tnis personttirm ever been a city employee?
— YES NO
_ DIS7RICT cAURi — 3. Does this person/firm possess a skill not normelly possessetl by any current city employee?
SUPPOflTS WHICH COUNCiI O&IECTIVEI YES NO
Explain all yes answers on aeparate sheet and ettach to green sheet
INITIATING PROBLEM, ISSUE, OPPORTUNITV (Who, Whel, When, W�ere, Why)�
AOYANTAGESIFAPPROVED�
DISAOVANTPGESIFAPPROVED�
DISA�VANTA6ES IF NOT APPAOVED:
4a4i63t1LS1 �",��^�'��ar;i E.�r''"P`"i�:3�
JUL 2 3 "i;,,�I
TOTAL AMOUNT OF TRANSACTION $ COSTfREYENUE BUDGETED (CIRCLE ONE) YES NO
FUNDIIeG SOURCE AC7IVITY NUMBER
FINANCIAL INFORNSATION' (EXPLAIN)
Greensheet # 37968 L.I.E.P. REVfEW CHECKLIST
In TrackeR a3 � ,
LiCense ID # 63859 License Type: Liquor On Sale-B
6/17/97 / 9?�q�s
ApP'n Received 1 APP'n Processed
Company NamB: Sawatdee Thai Restaurant Inc. DBA: same
Business Addresss: 289 5th Street East Business Phone: 222-5859
Contact Name f
Date to Councit
Pubtic Hearing '
Notice Sent to i
c�
Home Phone: 455-9419
s, 55077 �3��at�1���
Labels Ordered: /�+d _
District Council #: � /
� �„E, �•- ,
Notice Sent to Public: j"��� ���' Ward #: �
Department/ Date inspections Commenis
City Attorney
(g'� ���' Qf� .
Environmental
Heaith
� � � `� � • '/`^� ` � �
Fire
�9�9�- �.� .
License �,p,,us� ��-�'^�� Si�e aian [mceivea:
i.�a� a��ea: �
S�l-,�.u..�.�u`.tie.; sa�-ri.e.
`� — � � �- 1 .�'.p-�-�-�-�-e�.� ��� �-�- ,
a�.:� u,�.aa� -�� �r��
Police
�O'�'�� �•� .
Zoning
b•3D �`� �- D�� .
._
CLASS III
LICENSE APPLICATION
�tav°�2� I �` �D r�� ��
U ��1�u
THIS APPLICATION IS SUBJECT TO REVIEW BY Tf� PUBLIC
PLEASE TYPE OR PRII3T IN INK (���
-„ � y � �oc� ieh=!`s
T}pe of License(s) being applied for. t�l�. (.}c'9� — C�� �{' �.e ��paj�o
Company Nazne:
CITY OF SAINT PAUL��
oss� �rU«�, �;�
ana &rvvocs„enfa) r.med;oo
3505L PM St Sutc]00
����� s��a�
<su7us9asa 6z�stx)zr,evua
Coryoration! PutnecalSp! Sole Proprie[o�slup
ff business is incorporate.� give date of incotporation: �`"
Doing Business As: _ �1� U1 � ��—Q �h ��
Business Address: _ �_[_,�-�=�� J + _ ��
s��
Behveen whaz cross streets is the business located?
Are the premises now occupied'1 � Wha
Mail To Address:
Applicant Infomiation;
Name and Title: /L �
Firai
Business Phone:
�i�'—'� --� Fh�� . �'S1a1
ctty s,.k �u�p�� �..
�1' '� �,
Title
Home Address: _ /! �!J J�' / YI �> �T I 7� , �N UP�N/'>/�CU l! Q HT� /{Z N�
� / S � 4 1 ectAd ( dre � es ( � City Sfatc Zip !
DateofButh: � �"`/ `TcJ PiaceofButh: !!a �5'G°N �i��. .-��� � HomePhone: q�'l y
He�e �ou e:a beer3 cum�icied of ury felw:y, oiit,::. �. :iolai:;.:: ;;i aiy :.::� ss�: �,;n� �,: ;,c; . � ivf (�
Date of arrest:
Charge:
C.omiction: _, ,...
Where7
Ce.ntencr.•
Lis[ tl�e names and residenc¢s of ttir� personc of good mora( chazacter, living within the Twin Cities Metro Area, not related to the applicant
or financially interested in the preutises or business, who may be referred to as to the applicanYs chazacter:
1TA\FT:
♦TTTTCt�
Have any of the above named Iicenses ever bcen revoked7 " YES �NO If yes, list the dates and reasons fot revocation:
2/18l47
Str«t Addfne City Stste Zip
L�t I'scenses which you currenil}j ho�c� formerly held, or may have an intejest in:
Are you go'sng to operate this husiness personally? � YES _
JCb (�52i l 'r^' �
Furt Middle Initial (�5aidrn)
� 7 '! J� . �R'�� ��, -� r 7_',u �er
HomeAdc4m: Street\ame City �/�
Ate you gomg to have a manager or assistant in 4ris business? _y� YES
please compJete the following information:
R�^�
Please list your employmrnt history for the previous $ve (S) year period:
�-9G5� w � �'�
NO If not, who will operate it? U-C ,�b' •�5
�,� ���'�' ~ ' � .
ysa De4 of H'vth
l'� uQ ,�"�_ nv S✓� � 2�t�sv� i 9
Stnt� . Zip PlioxN�ber
NO If the manager is not the same as the operator,
Sirie
�� i
D+te of B'vth
P6one Number
�Hi
List all other officers of the corporation:
OFFICER TITLE
NAME . (Office Held�'r
HOME
PHONE
BUSINESS
PHONE
DATE OF
BIItTH
F'vst A*ame Middle 7nitid (Me+drn) Isat Dete of Birih
Hom<Addme: Svectl�ame City � Stau Zip PhaneNumbw'
Fintlhame NHdd3elmtis{ (Msidcu) La6 DateofBirth
HomeAAdrw: SiteelName City Sinle Zip Phmw
MINI3ESOTA TAX IDENTIPICATION NLIMBER - ftusuant to the Laws of Ivfinnesota. 1984, Chapter 502, Article 8, Seclion 2(270.72)
(Ta� Cleazavice�, Issuance of Licenses), licensing authorities are required to provide to the State of Minnesota Commissioner of Revenve, the
Minnesota business tax ident;fi�ate2 n�ux+br.r and thP sociai sectuiry number of each license applicant
Under the Minnesota Goveramrnt Data Practices Act and the Federal Privacy Act of 1974, we are required to advise you of the £allowing
regarding the use of the Minnesota Tax Identification Number:
- T6is information may be used to deny tLe issuance or renewai of your license in ilae event you owe Mumesota sa]es, employer s
withholding a motor vehicle excise ta�ces;
- Upon receiving this information, the licensing authority will supply it only to the Minnesota Department of Revenue. However,
under the Federal Exchange of Information Agreement, the Department of Revenue may supply tlils infonnation to the Intemal
Revenue Service.
iv5nnesota Tax Identification N�nbers (Sales & Use Tax Number) maybe obtain� fmm fl�e State of Minnesota, Business Records Department,
10 River Park Plazs (612-296-b 181).
Social Security Number�� ���� � Minnesota Tax Identification Number: ,�0.2 �4�' ! t11 J�
If a Minnesota Tax ldentification Number is not required fw the business being operated, indicate so by placing an "X' in che box.
2/] 8r97
ff business is a partnership, please include tl�e following information for each pac�er (use additionai pages if necessary):
Council File # �� ' 9 �S
Ordinance #
# �7910�
Presented By
��F��``�' � ri 1
CIT`( OF
�
Committee: Date
Re£erred To
i
2
3
�ly
RESOLVED: That application (ID #63859) for a Liquor On Sale-B License by Sawatdee Thai Restaurant Inc.
DBA Sawatdee Thai Restaurant Ina (Robert J. Jones, Owner) at 289 Sth Street East be and the
same is hereby approved.
4
5 Requested by Department of:
6 Yeas Navs Absent
7 B a� �
8 Bostrom !�—
9 Harris � — 7
10 Meaard
il Morton
12 T un�i� E — � �—
13 Co�
14 � �
is
16 Adopted by Council: Date �°��.
17
18 Adoption Certified by Council Secretary
19
20
21 By: � � /Y1�
22 � � J
23 Approved by Mayor: Date ° a�t)(9�
24 �
25
26 By:
27
Office of License Inspections and
Environmental Protection
s � I� �} �211��.
Form Approved by City Attorney
$Y� `'�____
Approved by Mayor £or Submission to
Council
By:
R� - 9b5
DEMRTMENT/OFFlCElCOUNGIL DA7E INITIATED 3 7 9 6 8
LIEPfLicensing GREEN SHEE
CAMTACT PERSON & PHONE O DEPAPTMENT DIRECTORNITIAUDATE O CIiY COUNCIL �NITIAUDATE
Christine Rozek, 266-9108 ASSIGN �CENATfORNEY apTVCLEflK
NUMBER POfi
MUST BE ON COUNCIL AGENDA BV (DATE) RO��� � BU�GET DIflECTOR � FIN. & MGT. SERVIGES DIR.
For hearin : (Q �� OflOEF �MAVOR{ORASSISTAN� �
TOTAL # OF SIGNATURE PAGES (CLiP ALL LOCATION5 FOR SIGNATURE)
ACTION REQUESTED:
Sawatdee Thai Restaurant Inc. DBA Sawatdee Thai Restaurant Inc. requests Council approval of
its application for a Liquor On Sale-B License lcoated at 289 Sth Street East (ID 1163859).
RECAMMENDATIONS: Appfaie (A) w Reject (R) PERSONAL SERVICE CONTRACTS MUST ANSWER THE FOLLOWING QUESTIONS:
_ PLqNNINCa COMMISSION _ CNIL SERVICE COMMISSION 1. Has this personttirm ever worked under a contract for this department?
_ CIB COMMITTEE _ YES NO
_ S7ACf 2. Has tnis personttirm ever been a city employee?
— YES NO
_ DIS7RICT cAURi — 3. Does this person/firm possess a skill not normelly possessetl by any current city employee?
SUPPOflTS WHICH COUNCiI O&IECTIVEI YES NO
Explain all yes answers on aeparate sheet and ettach to green sheet
INITIATING PROBLEM, ISSUE, OPPORTUNITV (Who, Whel, When, W�ere, Why)�
AOYANTAGESIFAPPROVED�
DISAOVANTPGESIFAPPROVED�
DISA�VANTA6ES IF NOT APPAOVED:
4a4i63t1LS1 �",��^�'��ar;i E.�r''"P`"i�:3�
JUL 2 3 "i;,,�I
TOTAL AMOUNT OF TRANSACTION $ COSTfREYENUE BUDGETED (CIRCLE ONE) YES NO
FUNDIIeG SOURCE AC7IVITY NUMBER
FINANCIAL INFORNSATION' (EXPLAIN)
Greensheet # 37968 L.I.E.P. REVfEW CHECKLIST
In TrackeR a3 � ,
LiCense ID # 63859 License Type: Liquor On Sale-B
6/17/97 / 9?�q�s
ApP'n Received 1 APP'n Processed
Company NamB: Sawatdee Thai Restaurant Inc. DBA: same
Business Addresss: 289 5th Street East Business Phone: 222-5859
Contact Name f
Date to Councit
Pubtic Hearing '
Notice Sent to i
c�
Home Phone: 455-9419
s, 55077 �3��at�1���
Labels Ordered: /�+d _
District Council #: � /
� �„E, �•- ,
Notice Sent to Public: j"��� ���' Ward #: �
Department/ Date inspections Commenis
City Attorney
(g'� ���' Qf� .
Environmental
Heaith
� � � `� � • '/`^� ` � �
Fire
�9�9�- �.� .
License �,p,,us� ��-�'^�� Si�e aian [mceivea:
i.�a� a��ea: �
S�l-,�.u..�.�u`.tie.; sa�-ri.e.
`� — � � �- 1 .�'.p-�-�-�-�-e�.� ��� �-�- ,
a�.:� u,�.aa� -�� �r��
Police
�O'�'�� �•� .
Zoning
b•3D �`� �- D�� .
._
CLASS III
LICENSE APPLICATION
�tav°�2� I �` �D r�� ��
U ��1�u
THIS APPLICATION IS SUBJECT TO REVIEW BY Tf� PUBLIC
PLEASE TYPE OR PRII3T IN INK (���
-„ � y � �oc� ieh=!`s
T}pe of License(s) being applied for. t�l�. (.}c'9� — C�� �{' �.e ��paj�o
Company Nazne:
CITY OF SAINT PAUL��
oss� �rU«�, �;�
ana &rvvocs„enfa) r.med;oo
3505L PM St Sutc]00
����� s��a�
<su7us9asa 6z�stx)zr,evua
Coryoration! PutnecalSp! Sole Proprie[o�slup
ff business is incorporate.� give date of incotporation: �`"
Doing Business As: _ �1� U1 � ��—Q �h ��
Business Address: _ �_[_,�-�=�� J + _ ��
s��
Behveen whaz cross streets is the business located?
Are the premises now occupied'1 � Wha
Mail To Address:
Applicant Infomiation;
Name and Title: /L �
Firai
Business Phone:
�i�'—'� --� Fh�� . �'S1a1
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Title
Home Address: _ /! �!J J�' / YI �> �T I 7� , �N UP�N/'>/�CU l! Q HT� /{Z N�
� / S � 4 1 ectAd ( dre � es ( � City Sfatc Zip !
DateofButh: � �"`/ `TcJ PiaceofButh: !!a �5'G°N �i��. .-��� � HomePhone: q�'l y
He�e �ou e:a beer3 cum�icied of ury felw:y, oiit,::. �. :iolai:;.:: ;;i aiy :.::� ss�: �,;n� �,: ;,c; . � ivf (�
Date of arrest:
Charge:
C.omiction: _, ,...
Where7
Ce.ntencr.•
Lis[ tl�e names and residenc¢s of ttir� personc of good mora( chazacter, living within the Twin Cities Metro Area, not related to the applicant
or financially interested in the preutises or business, who may be referred to as to the applicanYs chazacter:
1TA\FT:
♦TTTTCt�
Have any of the above named Iicenses ever bcen revoked7 " YES �NO If yes, list the dates and reasons fot revocation:
2/18l47
Str«t Addfne City Stste Zip
L�t I'scenses which you currenil}j ho�c� formerly held, or may have an intejest in:
Are you go'sng to operate this husiness personally? � YES _
JCb (�52i l 'r^' �
Furt Middle Initial (�5aidrn)
� 7 '! J� . �R'�� ��, -� r 7_',u �er
HomeAdc4m: Street\ame City �/�
Ate you gomg to have a manager or assistant in 4ris business? _y� YES
please compJete the following information:
R�^�
Please list your employmrnt history for the previous $ve (S) year period:
�-9G5� w � �'�
NO If not, who will operate it? U-C ,�b' •�5
�,� ���'�' ~ ' � .
ysa De4 of H'vth
l'� uQ ,�"�_ nv S✓� � 2�t�sv� i 9
Stnt� . Zip PlioxN�ber
NO If the manager is not the same as the operator,
Sirie
�� i
D+te of B'vth
P6one Number
�Hi
List all other officers of the corporation:
OFFICER TITLE
NAME . (Office Held�'r
HOME
PHONE
BUSINESS
PHONE
DATE OF
BIItTH
F'vst A*ame Middle 7nitid (Me+drn) Isat Dete of Birih
Hom<Addme: Svectl�ame City � Stau Zip PhaneNumbw'
Fintlhame NHdd3elmtis{ (Msidcu) La6 DateofBirth
HomeAAdrw: SiteelName City Sinle Zip Phmw
MINI3ESOTA TAX IDENTIPICATION NLIMBER - ftusuant to the Laws of Ivfinnesota. 1984, Chapter 502, Article 8, Seclion 2(270.72)
(Ta� Cleazavice�, Issuance of Licenses), licensing authorities are required to provide to the State of Minnesota Commissioner of Revenve, the
Minnesota business tax ident;fi�ate2 n�ux+br.r and thP sociai sectuiry number of each license applicant
Under the Minnesota Goveramrnt Data Practices Act and the Federal Privacy Act of 1974, we are required to advise you of the £allowing
regarding the use of the Minnesota Tax Identification Number:
- T6is information may be used to deny tLe issuance or renewai of your license in ilae event you owe Mumesota sa]es, employer s
withholding a motor vehicle excise ta�ces;
- Upon receiving this information, the licensing authority will supply it only to the Minnesota Department of Revenue. However,
under the Federal Exchange of Information Agreement, the Department of Revenue may supply tlils infonnation to the Intemal
Revenue Service.
iv5nnesota Tax Identification N�nbers (Sales & Use Tax Number) maybe obtain� fmm fl�e State of Minnesota, Business Records Department,
10 River Park Plazs (612-296-b 181).
Social Security Number�� ���� � Minnesota Tax Identification Number: ,�0.2 �4�' ! t11 J�
If a Minnesota Tax ldentification Number is not required fw the business being operated, indicate so by placing an "X' in che box.
2/] 8r97
ff business is a partnership, please include tl�e following information for each pac�er (use additionai pages if necessary):