97-969Council Fi1e # 9 � ,(`�
Ordinance �
Green Sheet # �
QR���i����.
Presented By
Referred To
Committee: Date
1
2
3
RESOLVED: T'haz application (ID #52180) far an Auto Body Repair Garage License by Value Auto Body &
Paint, LLC DBA Value Auto Body & Paint (Timothy Adelmann, Manager) at 1865 University
Avenue West be and the same is hereby approved.
4
5 Requested by Department of:
6 Yea Navs Absent
7 B a e�� �
8 Bostrom � �
9 Ha
10 T e ,
11
12 n �
13 Morton
14
15 �
16 Adopted by Council: Date � �
17
18 Adoption Certified by Council Secretary
19
yp
• - - - - - • - - �
..___ .. rr.- r . — • e
By: 1��+- � /""t,vt�
Form Approved by City Attorney
20
21 By: �� / -- al: �/,t.��ad_
22 ( � _
23 Approved by Mayor: Date ${("�4"}
24
25 Approved by Mayor for Submission to
26 By: L Council
27
RESOLUT{ON
CiTY OF SAINT PAUL, MINNESOTA
By:
a� � �Gq
DEPANiMENTAFFICElC�UNCIL DATE INITIATED �� J� J
LIEPJLicensing GREEN SHEE
CONTACTPEFSON & PHONE INITIAUDATE INITIAUDATE
� DEPARTMENTDIRE � CINCOUNCIL
Christine Rozek, 266-9108 ASSIGN � CITYATTORNEY � CRV CLERK
MUST BE ON GOUNCIL AGENDA BY DATE) �MBER FOR O BUDGET DIRECTOR � FIN. & MGT. SEflVICES DIR.
BoU71NG
r'02' hearing: � /: ONDER OMqyOR(ORASSISTANT� O
'1
TOTAL # OF SIGNATURE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE}
ACfION RE�UESTE�:
Value Auto Body & Paint LLC DBA Va1ue Auto $ody & Paint requests Gouncil approval of its
application for an Auto Body Repair Garage License located at 1865 University Avenue West
(ID 1152180).
RECOMMENDnTIONS: Approve (A) or Reject (H) PERSOIiAL SERVICE CONTHACTS MUST ANSWER TNE FOLLOWING QUESTIONS:
_ PLANNING COMMISSION _ CIVIL SERVICE COMMISSION t Has this personflirm ever worked untler a contrect for this department?
_ q6 COMMITTEE __ YES NO
_ SiAFF 2. Has this person/firm ever been a ciry employee?
— YES NO
_ DISTRiC7 CoUR'r _ 3. Does this ersonttirm possess a skill not �ormall
P Y Possessetl by any currant city amPloYea?
SUPP�qTS WHICH COUNGI, 08JECTIVE� YES NO
Explain alt yes answers on sepsrete sheet and attach to green sheet
INITIATiNG PROBLEM, ISSUE. OPPORTUNITY �W�o, Wheq Whan. Where, Why):
ADVANTAGESIFAPPAOVED:
DISADVANTAGES IF APPROVED.
DISADVANTAGES IF NOTAPPROVED'
�"°° �^�+ 1d�545�1
u '!�� � � it���
v:_ �J.�
SOTAL AMOUNT OF TRANSACTION $ COST/REVENUE BUDGETED (CIRCLE ONE) YES NO
FUNDIIdG SOURCE ACTIVITY NUMBER
FINANCIAL INFORFSATION' (EXPLAIN)
Greensheet # 37939
in Tracker? et3 9
License ID # 52180
L.I.E.P. REVIEW CHECKLIST Date: 4/1/97 ��?-��'9
ApP'n Received / ApP'n Processed
License Type: Auto Body Repair Garage
COmpany Name: Value Auto Body & Paint LLC DBA: Value Auto Bo� & Paint
Business Addresss: 1865 University Avenue West Business Phone: 647-6355
Contact Name/,
Date to Council
Public Hearing
NotiCe Sent to
479 Mary St Home Phone: 578-0306
Labels Ordered: /�✓�
District Council
� f J ��r�J �1D� '�
Notice Sent to Public: �� �' I ���� Ward #:
Departmern/ Date Inspections Comments
City Attomey
��ZI 'g� a� �
Environmental
Health
M� `
Fire
O ' .
License Site Plan Received:
Lease Received:
�1— ) c�-- � �r ��.
Police
�21-9�- d�� �
Zoning
�. ZI • ��� `
� ��/�D
' CLASS IiI CITY OF SAINf PAUL
' LICENSE APPLICATION oer,« oru�, i„��
ana En�uoonmc�rai r�oo�wo�
, 330 SL Pov St Sui�e lOJ
StintP�Mmuncu SSIU2 �/j
C6131 z669090 fu'(6I2) 266912t Q Y �
_ r
Type of License
Company Name:
If business u incocpotated,
Doing Busineu As: �
Business Address: /6/i
Street Addtas
THIS APPLICATION IS SUBJECT TO REVIEW BY 7'f� pUgLIC �� �
PLEASE TYPE OR PRINT IN INK
Benveen what cross streeu is the business locaud?
Are the premises now occupied? �_
MaiJ To Address: /15107
SGect Address
Appticant Information:
Name and Tide:
� j�vl; ;;� �,�t�,��i', i
� _"�`-�:
Type of Business?
��h�� . . S7'. F/l/11
Ciry
�
BusineuPhone: (�
�11V u��ll �
State Zi
hich side oi She svent? �_�� f'M(
S� Zip
�
111 /,l"!1 � CCX�i�.' � � �S;
� F'v / st ryj � t.+�d .. .. . - - -- (Mai { / ��� Latr � T
Home Addmss: 7 � {/ (!-L� �/ _ l!/l (p (.�[�i'�� !�lN� � �f r'
Fnec[ Addrcs, iry State Zip
� � /
Date of Birth: �' j `' Ptace of Birth: ,/ , j sC ,, /�.� �IJ /!� I-Iome Phone: �.� =�'��' ��� ��J�
Are you a citizen of the United Siatez? Native? /�f' � Naturaliud?
It you are not a U.S. citizen, you must have work autho ' tioa from tbe U.S. Immigrstion & Naturalization Servicc
Have you ever been convicted of any fe3ony, rrime or violation of any city ordinance other than traffic? YES _ NO �
Dare of arresc:
Charee:
Conviciion:
Where?
Sentence:
List the naznes and residences of tiuee penons oi good morai character, iiving wituin me Twin Cities Ivievo Area, not relxtcd to :he
applicant or financiatly interested in the premises o� business, who may be refernd to as to the appiicant's chamcter.
NAME
AnnRFCC
PHONE
i
Have any of the a6ove named licenses ever been revoked?, YES _ NO If yes, list the dates and reasons for revocation:
Are you g�o to opemte this busines
IlI���U�lf�
fivs� xa� Miaalc tnitial
�/ �7I l )11z1' S %t�
Flomc Add'css: SRxi artx
penoaally? � YES , NO If not, who will
(2Naidrn)
Ciry
State
it? �
� �`�-f�� J�
Date oCButh
Zip PFwne Numbcr
List licenses which you currently hold, foanerly held, or may have an interest in:
aUe you going to have a manager or assistant in this business?
pleas complete the folfowing information:
��i�/�l �
Ficst Name Middte Initia( . (Maid
x YES _ NO If the manager is not the same as the opetator,
� ��
Dam of Bis
List all othtr officers of the cocporation:
OFFICER TITLE HOME HOME BUSINESS IIATE CF
,j4AME �Office Held) ADDIZESS PHO PHONE BIRTH i
c � � `� � � — /5�' 0 S �l�,�`�P� �� _ ' -�//s� �' � -o �'�/� ��
`n h � =� � � ' � � / S� �/�.cr� :>�-%� as � - -
���
iri�ia;° 1� %�.�e,�t�� i��i�� 5����i- ��� Calw��� 1���. ��urr�r f�u �f�s��s�� ��� ���.��
If businegs is a partnership._please include the following information for each parme� (use additional pages if nece�ry): ��'�yf(
r -
Fust Name
Homc AddrcsS: Strect Name
Fust Nsmc
MiddlNnitial,
A6ddie Inifiet
Home Address: Smet Afame
(�ta+a�3
Ciry
(Maiden)
t�
State
Zip P}wnc Nmnber
� Iatt �
�
Sum 2ip Phox Number
MINNESQTA TAX IDENTIFICAT'ION NUMBER - Punuant to the Laws of Minnesota, 3984, Chapter 502, Article 8, Section 2
(270.72) (Ta�c Clearance; Issuance of Licenses), licensing authorities are required io provide to the State of Minnesota Commissioner
of Revenue, the Minnesota business tax identification number and the social security number of e2!�h 3icease app:ica�t.
Under the Minnesota Govemment pata Practices Act aud the Fedemi A Aci of 7974, we are required to advise you of the
following tegazding the use of tfie Minnesota Tax Idenrification Number.
- This information may be used to deny the issuance or renewal of your license in the event you owe Minnesota sales,
empfoyer's witbholding or motor vehicle excise taxes;
- Upon receiving this information, the licensing authoriry will supply it only to the Minnesota Departmenc of Revenue.
However, under the Fedenl Exchange of ]nformation Agreement, the Depaztment of Revenue may supply this information
to the Intemal Revenue Service.
Minnesou Tax Identification t�iumbers (Sa}es & Use 7'ax 13umber) may be obtained from the State of Minnesou, Business Recotds
Department, IQ River Park Plaza (612-246-6181).
Social Security Number. ��(/�� � � �b � `��
Minnesota Tax Identification Number. �7� ��U%�c� �t�
, If a Minnesota Tax Identification Number is not required fas the basiness being operated, indicate so by placing an"X" in
the box. .
Home Address: Sttcct Name Gry / Srare Zip Phone Numbcr A�d
Please lisi your employraent history for tl�e previous five (5) year period: �� � N 4
Council Fi1e # 9 � ,(`�
Ordinance �
Green Sheet # �
QR���i����.
Presented By
Referred To
Committee: Date
1
2
3
RESOLVED: T'haz application (ID #52180) far an Auto Body Repair Garage License by Value Auto Body &
Paint, LLC DBA Value Auto Body & Paint (Timothy Adelmann, Manager) at 1865 University
Avenue West be and the same is hereby approved.
4
5 Requested by Department of:
6 Yea Navs Absent
7 B a e�� �
8 Bostrom � �
9 Ha
10 T e ,
11
12 n �
13 Morton
14
15 �
16 Adopted by Council: Date � �
17
18 Adoption Certified by Council Secretary
19
yp
• - - - - - • - - �
..___ .. rr.- r . — • e
By: 1��+- � /""t,vt�
Form Approved by City Attorney
20 \
21 By: a �,.�.�1�n sa—�
22 `� ( �/ � : _1�� ��d_
23 Approved by Mayor: Date ${("�4"}
24
25 Approved by Mayor for Submission to
26 By: L Council
27
RESOLUT{ON
CiTY OF SAINT PAUL, MINNESOTA
By:
a� � �Gq
DEPANiMENTAFFICElC�UNCIL DATE INITIATED �� J� J
LIEPJLicensing GREEN SHEE
CONTACTPEFSON & PHONE INITIAUDATE INITIAUDATE
� DEPARTMENTDIRE � CINCOUNCIL
Christine Rozek, 266-9108 ASSIGN � CITYATTORNEY � CRV CLERK
MUST BE ON GOUNCIL AGENDA BY DATE) �MBER FOR O BUDGET DIRECTOR � FIN. & MGT. SEflVICES DIR.
BoU71NG
r'02' hearing: � /: ONDER OMqyOR(ORASSISTANT� O
'1
TOTAL # OF SIGNATURE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE}
ACfION RE�UESTE�:
Value Auto Body & Paint LLC DBA Va1ue Auto $ody & Paint requests Gouncil approval of its
application for an Auto Body Repair Garage License located at 1865 University Avenue West
(ID 1152180).
RECOMMENDnTIONS: Approve (A) or Reject (H) PERSOIiAL SERVICE CONTHACTS MUST ANSWER TNE FOLLOWING QUESTIONS:
_ PLANNING COMMISSION _ CIVIL SERVICE COMMISSION t Has this personflirm ever worked untler a contrect for this department?
_ q6 COMMITTEE __ YES NO
_ SiAFF 2. Has this person/firm ever been a ciry employee?
— YES NO
_ DISTRiC7 CoUR'r _ 3. Does this ersonttirm possess a skill not �ormall
P Y Possessetl by any currant city amPloYea?
SUPP�qTS WHICH COUNGI, 08JECTIVE� YES NO
Explain alt yes answers on sepsrete sheet and attach to green sheet
INITIATiNG PROBLEM, ISSUE. OPPORTUNITY �W�o, Wheq Whan. Where, Why):
ADVANTAGESIFAPPAOVED:
DISADVANTAGES IF APPROVED.
DISADVANTAGES IF NOTAPPROVED'
�"°° �^�+ 1d�545�1
u '!�� � � it���
v:_ �J.�
SOTAL AMOUNT OF TRANSACTION $ COST/REVENUE BUDGETED (CIRCLE ONE) YES NO
FUNDIIdG SOURCE ACTIVITY NUMBER
FINANCIAL INFORFSATION' (EXPLAIN)
Greensheet # 37939
in Tracker? et3 9
License ID # 52180
L.I.E.P. REVIEW CHECKLIST Date: 4/1/97 ��?-��'9
ApP'n Received / ApP'n Processed
License Type: Auto Body Repair Garage
COmpany Name: Value Auto Body & Paint LLC DBA: Value Auto Bo� & Paint
Business Addresss: 1865 University Avenue West Business Phone: 647-6355
Contact Name/,
Date to Council
Public Hearing
NotiCe Sent to
479 Mary St Home Phone: 578-0306
Labels Ordered: /�✓�
District Council
� f J ��r�J �1D� '�
Notice Sent to Public: �� �' I ���� Ward #:
Departmern/ Date Inspections Comments
City Attomey
��ZI 'g� a� �
Environmental
Health
M� `
Fire
O ' .
License Site Plan Received:
Lease Received:
�1— ) c�-- � �r ��.
Police
�21-9�- d�� �
Zoning
�. ZI • ��� `
� ��/�D
' CLASS IiI CITY OF SAINf PAUL
' LICENSE APPLICATION oer,« oru�, i„��
ana En�uoonmc�rai r�oo�wo�
, 330 SL Pov St Sui�e lOJ
StintP�Mmuncu SSIU2 �/j
C6131 z669090 fu'(6I2) 266912t Q Y �
_ r
Type of License
Company Name:
If business u incocpotated,
Doing Busineu As: �
Business Address: /6/i
Street Addtas
THIS APPLICATION IS SUBJECT TO REVIEW BY 7'f� pUgLIC �� �
PLEASE TYPE OR PRINT IN INK
Benveen what cross streeu is the business locaud?
Are the premises now occupied? �_
MaiJ To Address: /15107
SGect Address
Appticant Information:
Name and Tide:
� j�vl; ;;� �,�t�,��i', i
� _"�`-�:
Type of Business?
��h�� . . S7'. F/l/11
Ciry
�
BusineuPhone: (�
�11V u��ll �
State Zi
hich side oi She svent? �_�� f'M(
S� Zip
�
111 /,l"!1 � CCX�i�.' � � �S;
� F'v / st ryj � t.+�d .. .. . - - -- (Mai { / ��� Latr � T
Home Addmss: 7 � {/ (!-L� �/ _ l!/l (p (.�[�i'�� !�lN� � �f r'
Fnec[ Addrcs, iry State Zip
� � /
Date of Birth: �' j `' Ptace of Birth: ,/ , j sC ,, /�.� �IJ /!� I-Iome Phone: �.� =�'��' ��� ��J�
Are you a citizen of the United Siatez? Native? /�f' � Naturaliud?
It you are not a U.S. citizen, you must have work autho ' tioa from tbe U.S. Immigrstion & Naturalization Servicc
Have you ever been convicted of any fe3ony, rrime or violation of any city ordinance other than traffic? YES _ NO �
Dare of arresc:
Charee:
Conviciion:
Where?
Sentence:
List the naznes and residences of tiuee penons oi good morai character, iiving wituin me Twin Cities Ivievo Area, not relxtcd to :he
applicant or financiatly interested in the premises o� business, who may be refernd to as to the appiicant's chamcter.
NAME
AnnRFCC
PHONE
i
Have any of the a6ove named licenses ever been revoked?, YES _ NO If yes, list the dates and reasons for revocation:
Are you g�o to opemte this busines
IlI���U�lf�
fivs� xa� Miaalc tnitial
�/ �7I l )11z1' S %t�
Flomc Add'css: SRxi artx
penoaally? � YES , NO If not, who will
(2Naidrn)
Ciry
State
it? �
� �`�-f�� J�
Date oCButh
Zip PFwne Numbcr
List licenses which you currently hold, foanerly held, or may have an interest in:
aUe you going to have a manager or assistant in this business?
pleas complete the folfowing information:
��i�/�l �
Ficst Name Middte Initia( . (Maid
x YES _ NO If the manager is not the same as the opetator,
� ��
Dam of Bis
List all othtr officers of the cocporation:
OFFICER TITLE HOME HOME BUSINESS IIATE CF
,j4AME �Office Held) ADDIZESS PHO PHONE BIRTH i
c � � `� � � — /5�' 0 S �l�,�`�P� �� _ ' -�//s� �' � -o �'�/� ��
`n h � =� � � ' � � / S� �/�.cr� :>�-%� as � - -
���
iri�ia;° 1� %�.�e,�t�� i��i�� 5����i- ��� Calw��� 1���. ��urr�r f�u �f�s��s�� ��� ���.��
If businegs is a partnership._please include the following information for each parme� (use additional pages if nece�ry): ��'�yf(
r -
Fust Name
Homc AddrcsS: Strect Name
Fust Nsmc
MiddlNnitial,
A6ddie Inifiet
Home Address: Smet Afame
(�ta+a�3
Ciry
(Maiden)
t�
State
Zip P}wnc Nmnber
� Iatt �
�
Sum 2ip Phox Number
MINNESQTA TAX IDENTIFICAT'ION NUMBER - Punuant to the Laws of Minnesota, 3984, Chapter 502, Article 8, Section 2
(270.72) (Ta�c Clearance; Issuance of Licenses), licensing authorities are required io provide to the State of Minnesota Commissioner
of Revenue, the Minnesota business tax identification number and the social security number of e2!�h 3icease app:ica�t.
Under the Minnesota Govemment pata Practices Act aud the Fedemi A Aci of 7974, we are required to advise you of the
following tegazding the use of tfie Minnesota Tax Idenrification Number.
- This information may be used to deny the issuance or renewal of your license in the event you owe Minnesota sales,
empfoyer's witbholding or motor vehicle excise taxes;
- Upon receiving this information, the licensing authoriry will supply it only to the Minnesota Departmenc of Revenue.
However, under the Fedenl Exchange of ]nformation Agreement, the Depaztment of Revenue may supply this information
to the Intemal Revenue Service.
Minnesou Tax Identification t�iumbers (Sa}es & Use 7'ax 13umber) may be obtained from the State of Minnesou, Business Recotds
Department, IQ River Park Plaza (612-246-6181).
Social Security Number. ��(/�� � � �b � `��
Minnesota Tax Identification Number. �7� ��U%�c� �t�
, If a Minnesota Tax Identification Number is not required fas the basiness being operated, indicate so by placing an"X" in
the box. .
Home Address: Sttcct Name Gry / Srare Zip Phone Numbcr A�d
Please lisi your employraent history for tl�e previous five (5) year period: �� � N 4
Council Fi1e # 9 � ,(`�
Ordinance �
Green Sheet # �
QR���i����.
Presented By
Referred To
Committee: Date
1
2
3
RESOLVED: T'haz application (ID #52180) far an Auto Body Repair Garage License by Value Auto Body &
Paint, LLC DBA Value Auto Body & Paint (Timothy Adelmann, Manager) at 1865 University
Avenue West be and the same is hereby approved.
4
5 Requested by Department of:
6 Yea Navs Absent
7 B a e�� �
8 Bostrom � �
9 Ha
10 T e ,
11
12 n �
13 Morton
14
15 �
16 Adopted by Council: Date � �
17
18 Adoption Certified by Council Secretary
19
yp
• - - - - - • - - �
..___ .. rr.- r . — • e
By: 1��+- � /""t,vt�
Form Approved by City Attorney
20 \
21 By: a �,.�.�1�n sa—�
22 `� ( �/ � : _1�� ��d_
23 Approved by Mayor: Date ${("�4"}
24
25 Approved by Mayor for Submission to
26 By: L Council
27
RESOLUT{ON
CiTY OF SAINT PAUL, MINNESOTA
By:
a� � �Gq
DEPANiMENTAFFICElC�UNCIL DATE INITIATED �� J� J
LIEPJLicensing GREEN SHEE
CONTACTPEFSON & PHONE INITIAUDATE INITIAUDATE
� DEPARTMENTDIRE � CINCOUNCIL
Christine Rozek, 266-9108 ASSIGN � CITYATTORNEY � CRV CLERK
MUST BE ON GOUNCIL AGENDA BY DATE) �MBER FOR O BUDGET DIRECTOR � FIN. & MGT. SEflVICES DIR.
BoU71NG
r'02' hearing: � /: ONDER OMqyOR(ORASSISTANT� O
'1
TOTAL # OF SIGNATURE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE}
ACfION RE�UESTE�:
Value Auto Body & Paint LLC DBA Va1ue Auto $ody & Paint requests Gouncil approval of its
application for an Auto Body Repair Garage License located at 1865 University Avenue West
(ID 1152180).
RECOMMENDnTIONS: Approve (A) or Reject (H) PERSOIiAL SERVICE CONTHACTS MUST ANSWER TNE FOLLOWING QUESTIONS:
_ PLANNING COMMISSION _ CIVIL SERVICE COMMISSION t Has this personflirm ever worked untler a contrect for this department?
_ q6 COMMITTEE __ YES NO
_ SiAFF 2. Has this person/firm ever been a ciry employee?
— YES NO
_ DISTRiC7 CoUR'r _ 3. Does this ersonttirm possess a skill not �ormall
P Y Possessetl by any currant city amPloYea?
SUPP�qTS WHICH COUNGI, 08JECTIVE� YES NO
Explain alt yes answers on sepsrete sheet and attach to green sheet
INITIATiNG PROBLEM, ISSUE. OPPORTUNITY �W�o, Wheq Whan. Where, Why):
ADVANTAGESIFAPPAOVED:
DISADVANTAGES IF APPROVED.
DISADVANTAGES IF NOTAPPROVED'
�"°° �^�+ 1d�545�1
u '!�� � � it���
v:_ �J.�
SOTAL AMOUNT OF TRANSACTION $ COST/REVENUE BUDGETED (CIRCLE ONE) YES NO
FUNDIIdG SOURCE ACTIVITY NUMBER
FINANCIAL INFORFSATION' (EXPLAIN)
Greensheet # 37939
in Tracker? et3 9
License ID # 52180
L.I.E.P. REVIEW CHECKLIST Date: 4/1/97 ��?-��'9
ApP'n Received / ApP'n Processed
License Type: Auto Body Repair Garage
COmpany Name: Value Auto Body & Paint LLC DBA: Value Auto Bo� & Paint
Business Addresss: 1865 University Avenue West Business Phone: 647-6355
Contact Name/,
Date to Council
Public Hearing
NotiCe Sent to
479 Mary St Home Phone: 578-0306
Labels Ordered: /�✓�
District Council
� f J ��r�J �1D� '�
Notice Sent to Public: �� �' I ���� Ward #:
Departmern/ Date Inspections Comments
City Attomey
��ZI 'g� a� �
Environmental
Health
M� `
Fire
O ' .
License Site Plan Received:
Lease Received:
�1— ) c�-- � �r ��.
Police
�21-9�- d�� �
Zoning
�. ZI • ��� `
� ��/�D
' CLASS IiI CITY OF SAINf PAUL
' LICENSE APPLICATION oer,« oru�, i„��
ana En�uoonmc�rai r�oo�wo�
, 330 SL Pov St Sui�e lOJ
StintP�Mmuncu SSIU2 �/j
C6131 z669090 fu'(6I2) 266912t Q Y �
_ r
Type of License
Company Name:
If business u incocpotated,
Doing Busineu As: �
Business Address: /6/i
Street Addtas
THIS APPLICATION IS SUBJECT TO REVIEW BY 7'f� pUgLIC �� �
PLEASE TYPE OR PRINT IN INK
Benveen what cross streeu is the business locaud?
Are the premises now occupied? �_
MaiJ To Address: /15107
SGect Address
Appticant Information:
Name and Tide:
� j�vl; ;;� �,�t�,��i', i
� _"�`-�:
Type of Business?
��h�� . . S7'. F/l/11
Ciry
�
BusineuPhone: (�
�11V u��ll �
State Zi
hich side oi She svent? �_�� f'M(
S� Zip
�
111 /,l"!1 � CCX�i�.' � � �S;
� F'v / st ryj � t.+�d .. .. . - - -- (Mai { / ��� Latr � T
Home Addmss: 7 � {/ (!-L� �/ _ l!/l (p (.�[�i'�� !�lN� � �f r'
Fnec[ Addrcs, iry State Zip
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Date of Birth: �' j `' Ptace of Birth: ,/ , j sC ,, /�.� �IJ /!� I-Iome Phone: �.� =�'��' ��� ��J�
Are you a citizen of the United Siatez? Native? /�f' � Naturaliud?
It you are not a U.S. citizen, you must have work autho ' tioa from tbe U.S. Immigrstion & Naturalization Servicc
Have you ever been convicted of any fe3ony, rrime or violation of any city ordinance other than traffic? YES _ NO �
Dare of arresc:
Charee:
Conviciion:
Where?
Sentence:
List the naznes and residences of tiuee penons oi good morai character, iiving wituin me Twin Cities Ivievo Area, not relxtcd to :he
applicant or financiatly interested in the premises o� business, who may be refernd to as to the appiicant's chamcter.
NAME
AnnRFCC
PHONE
i
Have any of the a6ove named licenses ever been revoked?, YES _ NO If yes, list the dates and reasons for revocation:
Are you g�o to opemte this busines
IlI���U�lf�
fivs� xa� Miaalc tnitial
�/ �7I l )11z1' S %t�
Flomc Add'css: SRxi artx
penoaally? � YES , NO If not, who will
(2Naidrn)
Ciry
State
it? �
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Date oCButh
Zip PFwne Numbcr
List licenses which you currently hold, foanerly held, or may have an interest in:
aUe you going to have a manager or assistant in this business?
pleas complete the folfowing information:
��i�/�l �
Ficst Name Middte Initia( . (Maid
x YES _ NO If the manager is not the same as the opetator,
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Dam of Bis
List all othtr officers of the cocporation:
OFFICER TITLE HOME HOME BUSINESS IIATE CF
,j4AME �Office Held) ADDIZESS PHO PHONE BIRTH i
c � � `� � � — /5�' 0 S �l�,�`�P� �� _ ' -�//s� �' � -o �'�/� ��
`n h � =� � � ' � � / S� �/�.cr� :>�-%� as � - -
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iri�ia;° 1� %�.�e,�t�� i��i�� 5����i- ��� Calw��� 1���. ��urr�r f�u �f�s��s�� ��� ���.��
If businegs is a partnership._please include the following information for each parme� (use additional pages if nece�ry): ��'�yf(
r -
Fust Name
Homc AddrcsS: Strect Name
Fust Nsmc
MiddlNnitial,
A6ddie Inifiet
Home Address: Smet Afame
(�ta+a�3
Ciry
(Maiden)
t�
State
Zip P}wnc Nmnber
� Iatt �
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Sum 2ip Phox Number
MINNESQTA TAX IDENTIFICAT'ION NUMBER - Punuant to the Laws of Minnesota, 3984, Chapter 502, Article 8, Section 2
(270.72) (Ta�c Clearance; Issuance of Licenses), licensing authorities are required io provide to the State of Minnesota Commissioner
of Revenue, the Minnesota business tax identification number and the social security number of e2!�h 3icease app:ica�t.
Under the Minnesota Govemment pata Practices Act aud the Fedemi A Aci of 7974, we are required to advise you of the
following tegazding the use of tfie Minnesota Tax Idenrification Number.
- This information may be used to deny the issuance or renewal of your license in the event you owe Minnesota sales,
empfoyer's witbholding or motor vehicle excise taxes;
- Upon receiving this information, the licensing authoriry will supply it only to the Minnesota Departmenc of Revenue.
However, under the Fedenl Exchange of ]nformation Agreement, the Depaztment of Revenue may supply this information
to the Intemal Revenue Service.
Minnesou Tax Identification t�iumbers (Sa}es & Use 7'ax 13umber) may be obtained from the State of Minnesou, Business Recotds
Department, IQ River Park Plaza (612-246-6181).
Social Security Number. ��(/�� � � �b � `��
Minnesota Tax Identification Number. �7� ��U%�c� �t�
, If a Minnesota Tax Identification Number is not required fas the basiness being operated, indicate so by placing an"X" in
the box. .
Home Address: Sttcct Name Gry / Srare Zip Phone Numbcr A�d
Please lisi your employraent history for tl�e previous five (5) year period: �� � N 4