97-974W
� � t`1" � '+;
l�`�.E��;�'�i
Presented By
Re£erred To
Committee: Date
i
2
3
RESOLVED: That application (ID #24733) for a Grocery-C; Cigazette, aud-9�Sale-h�fafit License by Amira
Elbazi DBA Sally's Food Mazket (Amira Elbazi, Owner) at 104b Arcade Street be and the same is
hereby approved
4
5 Requested by Department o£:
6 Y a Nays Absent
7 B a ev _Si
8 Bostrom ��
9 Harr.zs
10 Meoa�
11 Morton �
12 S un� �
13 Co sns �
15 �
16 Adopted by Council: Date
17
18 Adoption Certi£ied by Council Secretary
19
20
21 By: =���—
22 � �
23 Approved by Mayor: Date Q, �� 4`Y
24
25
26 Bys �"��... `
27
Council File $ �
�me���-°� - g J�, �� ordinance #
Green Sheet # ✓ � �
RESOLUTION
CITY OF SAINT PAUL, MfNNESOTA 5'(p
Office of License Inspections and
Enviroximental Protect�on
BY: � �'u�; � /�,u�
Form Approved by City Attorney
/ l.�.�lz.�r.�-e�
Approved by Mayor for Submission to
Council
By:
�t� -�ny
o�,��T��o����L Dl(TE INITIATED GREEN SHEET 3 7� 5 8
LIEP/Licensin
CONTAGT PERSON & PHONE INITIA VDATE INITIA VDATE
O OEPASRMENT DIREGTOR � CITY CAUNCIL
Christine Rozek 266-9108 ASSIGN OCITYATfOflNEY �CITYCLERK
MUST BE ON CAUNCIL AGENOA BV (DATE) M7MBEA FOR
flOUTING � BUDGET DIRECTOR � FIN. & MGT. SEFVICES DIR.
For hearin : G' Oi10EH � MAVOp (ORASSISTANn �
TOTAL # OF SIGNATURE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE)
ACTION RE�UESTED:
Amira Elbazi DBA Sally's Food Market requests Council approval of its application for a
Grocery-C, Cigarette, and Off Sale Malt License located at 1046 Arcade Street (ID ��29733).
RECAMMENDA7iONS: Approve (n) or Reject (R) pERSONAL SERVICE CONTFiACTS MUST ANSWER iHE FOLLOWING pUESTIONS:
_ PLANNING COMMISSION _ CIVIL SERVICE COMMISSION �� Has this per5on/firm ever worKed under a contract for this tlepartment?
_ CIB COMMITTEE _ VES NO
_ S7AFF 2. Has this personttirm ever been a c�ry employee?
— YES NO
_ D57a1C7 COURT — 3. Does this petson/frtm possess a sKill not normally possessed by any current city employee?
SUPPaRTS WHICH COUNqI O&IECTIVE? YES NO
Explain all yes answero on separete sheet and attach to green sheet
INITIATING PROBLEM, ISSUE, OPPOflTUNITY (Wha, What. Wlten, Where, Why):
ADYANTA6ESIFAPPROVED:
DISADVANTAGES IF APPROVED:
DI$ADVANTAGES IF NOTAPPROVED'
TOTAL AMOUNTOF7RANSACTION $ COST/HEVENUE BUDGETED (CIHCLE ONE) YES NO
FUNDIIaG SOURCE ACTIVITV NUMeER
PINANCIAL INFORNiAT10N' (EXPLAIN)
�reensneet# 37958 L.I.E.P. REVIEW CHECKLIST Date: SJ16/97 /�� —���
In Trackeh nppro aeceived J App'n Processed
LicenselD # z9733 License Type: Grocery-C, Cigarette, and Off Sale Malt
COmpany Name: �ira Elbazi DBA: Sally's Food Market
Business Addresss: 1046 Axcade Street Business Phone: 774-8692
Contact Name/Address: Amira Elbazi, Home Phone:
Date to Council ResearCh: a� /���✓� j �
Public Hearing Date: g����� Labefs Ordered: ��/ �
Notice Sent to App{icant: �� 7/ � District Councit #: �
�i tvr . ,'�U
Q m•-
Notice Sent to Public: �/��/ � �7��- Ward #:
Departmentf Date Inspections Comments
City Attomey
�d 3 d. .
Environmental
Health
� � 1,�. � ,
Fire
� �� �-{ T ' �' � •
License Sise Pian aeceived:_
Leese aeceived:
� � i� � �� �
Potice
�l ��9 �- o •�. .
Zoning
� � �-� •
,�=�. ' �l'1 — ° �''1'-�
CLASS III
LICENSE APPLICATION
� r '
CITY OF SAINT PAUL
os;u otL;cxnu, In:aectio,u
ana Em�rartnemal Protection
35051. Pcic St Swh 300
Se'v¢Pad,MamesoL 53IOi
(fiI7J S669D30 fix (613)166-9134
s
$� o Od
� �I 7�
S �?Z��� ��
s
Company 13ame: _ 5��,[ L �-�i �� F� �� G� /�'�G[Vkc f
('Arpmacion / Perincnhip / Sole Proprittonhip
If business is incorporate� give date of inaorporation:
Doing Business As: S �-f L t�� S fc�c� i/f //f't GGy^ �d �' � Business Phone: 77 L� �P n'1.
Business Address: _ l�?tt �i /� 6' C'rx t,�C.' S� 5 C n�l ct � l�(/I/ �.i �I� (S
strxt Addresa City sinm Zip
Between w�hat cross streets is the business IocatedT _� y�'��i ta.0 �� � oi:� Which side of the street7 ' E'„�""_
Are the premises now occupied7 1 it� What Type of Business? G✓�•.+ Co c� ��/`P •
Maii To Address: ( D �F ( �1 �r ��� ,,�fp s �- ,c fi �cau-f� �N ' ,�5f o �'
StreG Addrcu City Ste4 Zip
ApplicantInformaUon:
Name and 7'iUe: _-� in't ►� G� S ' j� �1- 8{�Zi /� f.ttt� t'�1--
Firs[ Middit p (Maiden) Laet Titic
HomeAddress: �C�L7 rj /.;«r �i�f C�� -�r l�d/1�S N71V .5 r!L 1�?
s+�et naaraa ' ciry� smk tip
Date of Birth: {� _,1,}�— � t', Place of Buth:
Home Phone:
.. _..__ .., . . _ _. . .. _
_. y _ , ..._;__ - -...:a;::[..— j" , :='.:— :'.u..:'_.'�zj-.1�.yvi�:l�.uaG.`°y_'iul>�_"' '_. — "-
, � ,.—._ .__,
J .. � ...: . . . .. . ... ... ... . ,.� .
Date of arrest:
Chazge: _
Conviction:
�' �� � � �
THIS APPLICATION IS SUBJECT TO REVIEW BY THE PUSLIC
Where7
—. - — — -- — Srntence:
List tbe nemes and residences of tUree persons of good moral charactec, 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 applicanPs chazacter:
NAME ADDRESS PHONE
-1� C�' ` 5�l, [, � %P�r S�i-zg'
List licenses which you cuirendy hold, formerly helc� or may have an interest in:
�'�, � ��J� - fl-�' IP�, �r.
J —"'
Have any of the above named licenses ever been tevoked7 YES _� NO If yes, list the dates and reasons for revocation:
2t18l97
PLEASE TYPE OIt PRIN'I IlS INK
Are you going to operafe this business personally7 � YES
F6at t��c
E3amcAddre.+: S7mtivsms
Areyou going to have a manager or ass�scant in this businessY
please complete the following information:
F'vri Name
tvfiddle
HomeAddns+: Streetl�smc
(�Seiden)
_�.
YES
(Maiden)
City
Please list your employment history for the previous five (5) }'eaz period:
Business/Empio«nent Address
List all other officers of the corporadon:
OFFICER TITLE HOME
NAME (Office Held) ADDRES5
N���
��
NO If no� Nfio will operate it? �� � q � ���� .-` l
y� DIDe otB'vih
Sta1e � Zip PLone Number
_� NO If the manager is not the same as the operator,
I.a+[
State Z�p
HOME BUSINESS
PHONE PHONE
Date of B'utfi
I.S�mber
DATE OF
BIIt?H
If business is a partnership, please include the following infoimation for each partner (nse additional pages if necessar}•):
Fintt�ame
Middle Initid
(M,idrn)
�
D�
Home Addaae: Shxt
�itiv
(Maidrn)
State
I.aQ
Dete of Birth
Home AAdrs+: Sveet Neme -_'.. . C0.y „_... . . Sletc _ . ZiP Pho�e Numbcr
MINNESOTA TAX IDENTIFICATION NUMBER • Pursuant to the Laws of Minnesot� 1984, Chapter 502, Article 8, Section 2(270.72)
(Tax Clearance; Issuance of Licenses), licensing authorities are required to provide to the State of Minnesota Commissiona of Revenue, the
Minnesote business ta�c identifir,auon munber and the social security_ number of each license applicant _
Under the Minnesota Govemment Data Praclices Act and the Federal Privacy Act of 1974, we are required to advise you of the followuig
regarding the use of the Minnesota Tax Identi5cation Number:
- This infmmatian may be used to deny the issuance a renewal of your license in the evcnt you owe Miru�esota sales, employer s
withholding or motor vetticte excise taxes;
- Upon receiving ttus information, the licensing aWhority will supply it only to the Mumesota Department of Revenue. However,
under the Federal Exchange of Infotmation Agreement, the Depm of Revenue may supply this information to the Intemat
Revenue Service.
Mumesota Tsx IdentiScarion Numbers (Sales & Use Tax Number) may be obtained from the State of Minnesota, Business Records Depaztment,
10 River Park Plaza (612-296-6181).
Sociat Securiiy Number: ,� � t -"� 3 - �� j�� �nesots Tvc Identification Number:
ff a Minnesota Tax Identification Number is not required for lhe business being operated, indicate so by p3acing an"X" in ihe box.
Zip Phone Number
2/18/97
W
� � t`1" � '+;
l�`�.E��;�'�i
Presented By
Re£erred To
Committee: Date
i
2
3
RESOLVED: That application (ID #24733) for a Grocery-C; Cigazette, aud-9�Sale-h�fafit License by Amira
Elbazi DBA Sally's Food Mazket (Amira Elbazi, Owner) at 104b Arcade Street be and the same is
hereby approved
4
5 Requested by Department o£:
6 Y a Nays Absent
7 B a ev _Si
8 Bostrom ��
9 Harr.zs
10 Meoa�
11 Morton �
12 S un� �
13 Co sns �
15 �
16 Adopted by Council: Date
17
18 Adoption Certi£ied by Council Secretary
19
20
21 By: =���—
22 � �
23 Approved by Mayor: Date Q, �� 4`Y
24
25
26 Bys �"��... `
27
Council File $ �
�me���-°� - g J�, �� ordinance #
Green Sheet # ✓ � �
RESOLUTION
CITY OF SAINT PAUL, MfNNESOTA 5'(p
Office of License Inspections and
Enviroximental Protect�on
BY: � �'u�; � /�,u�
Form Approved by City Attorney
/ l.�.�lz.�r.�-e�
Approved by Mayor for Submission to
Council
By:
�t� -�ny
o�,��T��o����L Dl(TE INITIATED GREEN SHEET 3 7� 5 8
LIEP/Licensin
CONTAGT PERSON & PHONE INITIA VDATE INITIA VDATE
O OEPASRMENT DIREGTOR � CITY CAUNCIL
Christine Rozek 266-9108 ASSIGN OCITYATfOflNEY �CITYCLERK
MUST BE ON CAUNCIL AGENOA BV (DATE) M7MBEA FOR
flOUTING � BUDGET DIRECTOR � FIN. & MGT. SEFVICES DIR.
For hearin : G' Oi10EH � MAVOp (ORASSISTANn �
TOTAL # OF SIGNATURE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE)
ACTION RE�UESTED:
Amira Elbazi DBA Sally's Food Market requests Council approval of its application for a
Grocery-C, Cigarette, and Off Sale Malt License located at 1046 Arcade Street (ID ��29733).
RECAMMENDA7iONS: Approve (n) or Reject (R) pERSONAL SERVICE CONTFiACTS MUST ANSWER iHE FOLLOWING pUESTIONS:
_ PLANNING COMMISSION _ CIVIL SERVICE COMMISSION �� Has this per5on/firm ever worKed under a contract for this tlepartment?
_ CIB COMMITTEE _ VES NO
_ S7AFF 2. Has this personttirm ever been a c�ry employee?
— YES NO
_ D57a1C7 COURT — 3. Does this petson/frtm possess a sKill not normally possessed by any current city employee?
SUPPaRTS WHICH COUNqI O&IECTIVE? YES NO
Explain all yes answero on separete sheet and attach to green sheet
INITIATING PROBLEM, ISSUE, OPPOflTUNITY (Wha, What. Wlten, Where, Why):
ADYANTA6ESIFAPPROVED:
DISADVANTAGES IF APPROVED:
DI$ADVANTAGES IF NOTAPPROVED'
TOTAL AMOUNTOF7RANSACTION $ COST/HEVENUE BUDGETED (CIHCLE ONE) YES NO
FUNDIIaG SOURCE ACTIVITV NUMeER
PINANCIAL INFORNiAT10N' (EXPLAIN)
�reensneet# 37958 L.I.E.P. REVIEW CHECKLIST Date: SJ16/97 /�� —���
In Trackeh nppro aeceived J App'n Processed
LicenselD # z9733 License Type: Grocery-C, Cigarette, and Off Sale Malt
COmpany Name: �ira Elbazi DBA: Sally's Food Market
Business Addresss: 1046 Axcade Street Business Phone: 774-8692
Contact Name/Address: Amira Elbazi, Home Phone:
Date to Council ResearCh: a� /���✓� j �
Public Hearing Date: g����� Labefs Ordered: ��/ �
Notice Sent to App{icant: �� 7/ � District Councit #: �
�i tvr . ,'�U
Q m•-
Notice Sent to Public: �/��/ � �7��- Ward #:
Departmentf Date Inspections Comments
City Attomey
�d 3 d. .
Environmental
Health
� � 1,�. � ,
Fire
� �� �-{ T ' �' � •
License Sise Pian aeceived:_
Leese aeceived:
� � i� � �� �
Potice
�l ��9 �- o •�. .
Zoning
� � �-� •
,�=�. ' �l'1 — ° �''1'-�
CLASS III
LICENSE APPLICATION
� r '
CITY OF SAINT PAUL
os;u otL;cxnu, In:aectio,u
ana Em�rartnemal Protection
35051. Pcic St Swh 300
Se'v¢Pad,MamesoL 53IOi
(fiI7J S669D30 fix (613)166-9134
s
$� o Od
� �I 7�
S �?Z��� ��
s
Company 13ame: _ 5��,[ L �-�i �� F� �� G� /�'�G[Vkc f
('Arpmacion / Perincnhip / Sole Proprittonhip
If business is incorporate� give date of inaorporation:
Doing Business As: S �-f L t�� S fc�c� i/f //f't GGy^ �d �' � Business Phone: 77 L� �P n'1.
Business Address: _ l�?tt �i /� 6' C'rx t,�C.' S� 5 C n�l ct � l�(/I/ �.i �I� (S
strxt Addresa City sinm Zip
Between w�hat cross streets is the business IocatedT _� y�'��i ta.0 �� � oi:� Which side of the street7 ' E'„�""_
Are the premises now occupied7 1 it� What Type of Business? G✓�•.+ Co c� ��/`P •
Maii To Address: ( D �F ( �1 �r ��� ,,�fp s �- ,c fi �cau-f� �N ' ,�5f o �'
StreG Addrcu City Ste4 Zip
ApplicantInformaUon:
Name and 7'iUe: _-� in't ►� G� S ' j� �1- 8{�Zi /� f.ttt� t'�1--
Firs[ Middit p (Maiden) Laet Titic
HomeAddress: �C�L7 rj /.;«r �i�f C�� -�r l�d/1�S N71V .5 r!L 1�?
s+�et naaraa ' ciry� smk tip
Date of Birth: {� _,1,}�— � t', Place of Buth:
Home Phone:
.. _..__ .., . . _ _. . .. _
_. y _ , ..._;__ - -...:a;::[..— j" , :='.:— :'.u..:'_.'�zj-.1�.yvi�:l�.uaG.`°y_'iul>�_"' '_. — "-
, � ,.—._ .__,
J .. � ...: . . . .. . ... ... ... . ,.� .
Date of arrest:
Chazge: _
Conviction:
�' �� � � �
THIS APPLICATION IS SUBJECT TO REVIEW BY THE PUSLIC
Where7
—. - — — -- — Srntence:
List tbe nemes and residences of tUree persons of good moral charactec, 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 applicanPs chazacter:
NAME ADDRESS PHONE
-1� C�' ` 5�l, [, � %P�r S�i-zg'
List licenses which you cuirendy hold, formerly helc� or may have an interest in:
�'�, � ��J� - fl-�' IP�, �r.
J —"'
Have any of the above named licenses ever been tevoked7 YES _� NO If yes, list the dates and reasons for revocation:
2t18l97
PLEASE TYPE OIt PRIN'I IlS INK
Are you going to operafe this business personally7 � YES
F6at t��c
E3amcAddre.+: S7mtivsms
Areyou going to have a manager or ass�scant in this businessY
please complete the following information:
F'vri Name
tvfiddle
HomeAddns+: Streetl�smc
(�Seiden)
_�.
YES
(Maiden)
City
Please list your employment history for the previous five (5) }'eaz period:
Business/Empio«nent Address
List all other officers of the corporadon:
OFFICER TITLE HOME
NAME (Office Held) ADDRES5
N���
��
NO If no� Nfio will operate it? �� � q � ���� .-` l
y� DIDe otB'vih
Sta1e � Zip PLone Number
_� NO If the manager is not the same as the operator,
I.a+[
State Z�p
HOME BUSINESS
PHONE PHONE
Date of B'utfi
I.S�mber
DATE OF
BIIt?H
If business is a partnership, please include the following infoimation for each partner (nse additional pages if necessar}•):
Fintt�ame
Middle Initid
(M,idrn)
�
D�
Home Addaae: Shxt
�itiv
(Maidrn)
State
I.aQ
Dete of Birth
Home AAdrs+: Sveet Neme -_'.. . C0.y „_... . . Sletc _ . ZiP Pho�e Numbcr
MINNESOTA TAX IDENTIFICATION NUMBER • Pursuant to the Laws of Minnesot� 1984, Chapter 502, Article 8, Section 2(270.72)
(Tax Clearance; Issuance of Licenses), licensing authorities are required to provide to the State of Minnesota Commissiona of Revenue, the
Minnesote business ta�c identifir,auon munber and the social security_ number of each license applicant _
Under the Minnesota Govemment Data Praclices Act and the Federal Privacy Act of 1974, we are required to advise you of the followuig
regarding the use of the Minnesota Tax Identi5cation Number:
- This infmmatian may be used to deny the issuance a renewal of your license in the evcnt you owe Miru�esota sales, employer s
withholding or motor vetticte excise taxes;
- Upon receiving ttus information, the licensing aWhority will supply it only to the Mumesota Department of Revenue. However,
under the Federal Exchange of Infotmation Agreement, the Depm of Revenue may supply this information to the Intemat
Revenue Service.
Mumesota Tsx IdentiScarion Numbers (Sales & Use Tax Number) may be obtained from the State of Minnesota, Business Records Depaztment,
10 River Park Plaza (612-296-6181).
Sociat Securiiy Number: ,� � t -"� 3 - �� j�� �nesots Tvc Identification Number:
ff a Minnesota Tax Identification Number is not required for lhe business being operated, indicate so by p3acing an"X" in ihe box.
Zip Phone Number
2/18/97
W
� � t`1" � '+;
l�`�.E��;�'�i
Presented By
Re£erred To
Committee: Date
i
2
3
RESOLVED: That application (ID #24733) for a Grocery-C; Cigazette, aud-9�Sale-h�fafit License by Amira
Elbazi DBA Sally's Food Mazket (Amira Elbazi, Owner) at 104b Arcade Street be and the same is
hereby approved
4
5 Requested by Department o£:
6 Y a Nays Absent
7 B a ev _Si
8 Bostrom ��
9 Harr.zs
10 Meoa�
11 Morton �
12 S un� �
13 Co sns �
15 �
16 Adopted by Council: Date
17
18 Adoption Certi£ied by Council Secretary
19
20
21 By: =���—
22 � �
23 Approved by Mayor: Date Q, �� 4`Y
24
25
26 Bys �"��... `
27
Council File $ �
�me���-°� - g J�, �� ordinance #
Green Sheet # ✓ � �
RESOLUTION
CITY OF SAINT PAUL, MfNNESOTA 5'(p
Office of License Inspections and
Enviroximental Protect�on
BY: � �'u�; � /�,u�
Form Approved by City Attorney
/ l.�.�lz.�r.�-e�
Approved by Mayor for Submission to
Council
By:
�t� -�ny
o�,��T��o����L Dl(TE INITIATED GREEN SHEET 3 7� 5 8
LIEP/Licensin
CONTAGT PERSON & PHONE INITIA VDATE INITIA VDATE
O OEPASRMENT DIREGTOR � CITY CAUNCIL
Christine Rozek 266-9108 ASSIGN OCITYATfOflNEY �CITYCLERK
MUST BE ON CAUNCIL AGENOA BV (DATE) M7MBEA FOR
flOUTING � BUDGET DIRECTOR � FIN. & MGT. SEFVICES DIR.
For hearin : G' Oi10EH � MAVOp (ORASSISTANn �
TOTAL # OF SIGNATURE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE)
ACTION RE�UESTED:
Amira Elbazi DBA Sally's Food Market requests Council approval of its application for a
Grocery-C, Cigarette, and Off Sale Malt License located at 1046 Arcade Street (ID ��29733).
RECAMMENDA7iONS: Approve (n) or Reject (R) pERSONAL SERVICE CONTFiACTS MUST ANSWER iHE FOLLOWING pUESTIONS:
_ PLANNING COMMISSION _ CIVIL SERVICE COMMISSION �� Has this per5on/firm ever worKed under a contract for this tlepartment?
_ CIB COMMITTEE _ VES NO
_ S7AFF 2. Has this personttirm ever been a c�ry employee?
— YES NO
_ D57a1C7 COURT — 3. Does this petson/frtm possess a sKill not normally possessed by any current city employee?
SUPPaRTS WHICH COUNqI O&IECTIVE? YES NO
Explain all yes answero on separete sheet and attach to green sheet
INITIATING PROBLEM, ISSUE, OPPOflTUNITY (Wha, What. Wlten, Where, Why):
ADYANTA6ESIFAPPROVED:
DISADVANTAGES IF APPROVED:
DI$ADVANTAGES IF NOTAPPROVED'
TOTAL AMOUNTOF7RANSACTION $ COST/HEVENUE BUDGETED (CIHCLE ONE) YES NO
FUNDIIaG SOURCE ACTIVITV NUMeER
PINANCIAL INFORNiAT10N' (EXPLAIN)
�reensneet# 37958 L.I.E.P. REVIEW CHECKLIST Date: SJ16/97 /�� —���
In Trackeh nppro aeceived J App'n Processed
LicenselD # z9733 License Type: Grocery-C, Cigarette, and Off Sale Malt
COmpany Name: �ira Elbazi DBA: Sally's Food Market
Business Addresss: 1046 Axcade Street Business Phone: 774-8692
Contact Name/Address: Amira Elbazi, Home Phone:
Date to Council ResearCh: a� /���✓� j �
Public Hearing Date: g����� Labefs Ordered: ��/ �
Notice Sent to App{icant: �� 7/ � District Councit #: �
�i tvr . ,'�U
Q m•-
Notice Sent to Public: �/��/ � �7��- Ward #:
Departmentf Date Inspections Comments
City Attomey
�d 3 d. .
Environmental
Health
� � 1,�. � ,
Fire
� �� �-{ T ' �' � •
License Sise Pian aeceived:_
Leese aeceived:
� � i� � �� �
Potice
�l ��9 �- o •�. .
Zoning
� � �-� •
,�=�. ' �l'1 — ° �''1'-�
CLASS III
LICENSE APPLICATION
� r '
CITY OF SAINT PAUL
os;u otL;cxnu, In:aectio,u
ana Em�rartnemal Protection
35051. Pcic St Swh 300
Se'v¢Pad,MamesoL 53IOi
(fiI7J S669D30 fix (613)166-9134
s
$� o Od
� �I 7�
S �?Z��� ��
s
Company 13ame: _ 5��,[ L �-�i �� F� �� G� /�'�G[Vkc f
('Arpmacion / Perincnhip / Sole Proprittonhip
If business is incorporate� give date of inaorporation:
Doing Business As: S �-f L t�� S fc�c� i/f //f't GGy^ �d �' � Business Phone: 77 L� �P n'1.
Business Address: _ l�?tt �i /� 6' C'rx t,�C.' S� 5 C n�l ct � l�(/I/ �.i �I� (S
strxt Addresa City sinm Zip
Between w�hat cross streets is the business IocatedT _� y�'��i ta.0 �� � oi:� Which side of the street7 ' E'„�""_
Are the premises now occupied7 1 it� What Type of Business? G✓�•.+ Co c� ��/`P •
Maii To Address: ( D �F ( �1 �r ��� ,,�fp s �- ,c fi �cau-f� �N ' ,�5f o �'
StreG Addrcu City Ste4 Zip
ApplicantInformaUon:
Name and 7'iUe: _-� in't ►� G� S ' j� �1- 8{�Zi /� f.ttt� t'�1--
Firs[ Middit p (Maiden) Laet Titic
HomeAddress: �C�L7 rj /.;«r �i�f C�� -�r l�d/1�S N71V .5 r!L 1�?
s+�et naaraa ' ciry� smk tip
Date of Birth: {� _,1,}�— � t', Place of Buth:
Home Phone:
.. _..__ .., . . _ _. . .. _
_. y _ , ..._;__ - -...:a;::[..— j" , :='.:— :'.u..:'_.'�zj-.1�.yvi�:l�.uaG.`°y_'iul>�_"' '_. — "-
, � ,.—._ .__,
J .. � ...: . . . .. . ... ... ... . ,.� .
Date of arrest:
Chazge: _
Conviction:
�' �� � � �
THIS APPLICATION IS SUBJECT TO REVIEW BY THE PUSLIC
Where7
—. - — — -- — Srntence:
List tbe nemes and residences of tUree persons of good moral charactec, 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 applicanPs chazacter:
NAME ADDRESS PHONE
-1� C�' ` 5�l, [, � %P�r S�i-zg'
List licenses which you cuirendy hold, formerly helc� or may have an interest in:
�'�, � ��J� - fl-�' IP�, �r.
J —"'
Have any of the above named licenses ever been tevoked7 YES _� NO If yes, list the dates and reasons for revocation:
2t18l97
PLEASE TYPE OIt PRIN'I IlS INK
Are you going to operafe this business personally7 � YES
F6at t��c
E3amcAddre.+: S7mtivsms
Areyou going to have a manager or ass�scant in this businessY
please complete the following information:
F'vri Name
tvfiddle
HomeAddns+: Streetl�smc
(�Seiden)
_�.
YES
(Maiden)
City
Please list your employment history for the previous five (5) }'eaz period:
Business/Empio«nent Address
List all other officers of the corporadon:
OFFICER TITLE HOME
NAME (Office Held) ADDRES5
N���
��
NO If no� Nfio will operate it? �� � q � ���� .-` l
y� DIDe otB'vih
Sta1e � Zip PLone Number
_� NO If the manager is not the same as the operator,
I.a+[
State Z�p
HOME BUSINESS
PHONE PHONE
Date of B'utfi
I.S�mber
DATE OF
BIIt?H
If business is a partnership, please include the following infoimation for each partner (nse additional pages if necessar}•):
Fintt�ame
Middle Initid
(M,idrn)
�
D�
Home Addaae: Shxt
�itiv
(Maidrn)
State
I.aQ
Dete of Birth
Home AAdrs+: Sveet Neme -_'.. . C0.y „_... . . Sletc _ . ZiP Pho�e Numbcr
MINNESOTA TAX IDENTIFICATION NUMBER • Pursuant to the Laws of Minnesot� 1984, Chapter 502, Article 8, Section 2(270.72)
(Tax Clearance; Issuance of Licenses), licensing authorities are required to provide to the State of Minnesota Commissiona of Revenue, the
Minnesote business ta�c identifir,auon munber and the social security_ number of each license applicant _
Under the Minnesota Govemment Data Praclices Act and the Federal Privacy Act of 1974, we are required to advise you of the followuig
regarding the use of the Minnesota Tax Identi5cation Number:
- This infmmatian may be used to deny the issuance a renewal of your license in the evcnt you owe Miru�esota sales, employer s
withholding or motor vetticte excise taxes;
- Upon receiving ttus information, the licensing aWhority will supply it only to the Mumesota Department of Revenue. However,
under the Federal Exchange of Infotmation Agreement, the Depm of Revenue may supply this information to the Intemat
Revenue Service.
Mumesota Tsx IdentiScarion Numbers (Sales & Use Tax Number) may be obtained from the State of Minnesota, Business Records Depaztment,
10 River Park Plaza (612-296-6181).
Sociat Securiiy Number: ,� � t -"� 3 - �� j�� �nesots Tvc Identification Number:
ff a Minnesota Tax Identification Number is not required for lhe business being operated, indicate so by p3acing an"X" in ihe box.
Zip Phone Number
2/18/97