97-1288-`k���a� � �
v� �� 1 �
5�
,_ - . :
Presented By_
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
Re£erred To
RESOLUTION
A�L(VT PAUL, MI
RESOLVED: That application, ID #16046, for an
Inc. DBA CaEe Latte (Peter Quinn, P
same is hereby approved with the fo
The applicant shall obtain
street parking zoning requ
condition of the variance,
Committee: Date
�
� i
inment-A License by Style 2000
)at 850 Gzand Avenue, be and the
condition:
ariance of the off-
ents and shall meet any
granted.
Adoption Cert/`ified by Council Secretary
By:
Approved by Mayor:
Date
Requested by Department of:
Office of License. Ins�ections and
/ E�nvironmental Protection
By: l,il�f..�-a.wn.� i"� �""l.�yu
Form Appro by City A o ey
$Y � �//h O �i+.e�C/� � C� G�-/ �-v�i i
Approved by Mayor for Submission to
council
By:
Council File # � { - �a��
0
Sheet � 50230
By:
Adopted by Coux�il: Date
N° 50230
LIEP/License
Christine A. Rozek - 266-9108
TOTAL # OF SIGPlATURE
1CilON FiEQUESiE�'
DATEINIT�—1 GREEN SHEET �����
INITIAVDATE INITIAUDATE —
O DEPaRTMENT DIREGTOR � CT' COUNCIL
NUMBEN FOR ❑ CINATTORNEI' O pTYCLERK
HOMNG O BUOGETD�RECTOR � FIN. 8 MGT, SEFVICES OIR.
OflOE(i O MAYOR (OB ASSISTANT) O
(CLIP ALL LOCATIONS FOR SIGNATUREy
Style 2000 Inc. DSA Cafe Laete (Peter Quinn, President) requests Gouncil
approval of their apglication for an Entertainment - A License, ID //16046, at
850 Grand Avenue.
__ PLANNWG CQMMISSION _ (
_ CIB COMMITTEE _ _
_ STAfF _ _
_ DISTqICT COURT _ _
SUPPORiS WHICH COUNdL 063ECTNE?
IF APPROVED:
PERSONAI SERYICE CA!lTRACTS MUST qNSWER THE FOILOWING �tlESTIONS:
L Has this person/firm ever worked untler a cOntract for this Oepatlment?
YES NO
2. Has this person/firm ever been a city employee?
YES td0
3. Does this perSOnHirm possess a skiil no� normally pOSSessed by any current aty employBe�
YES NO
Explaln ali yes answers on separeta aFeet and attaeh to green sheet
wnere.
..N'a�.''��...,. '
��k" �, � ����
]ISAOVANTACaES IF NOT APPROVEO.
�TAL AMOUNT OF TRANSACTION S
COST/REVENUE BUDGETED (CIRCLE ONE)
VES NO
NDIWG SOURCE 0.CTfVlTY NUMBER
4NCIAl INFORlnATIQN. (EXPtA1N)
�
��a�
CLASS III
LICENSE APPLICATION
M
�
ic:
Typ�cer�e(s) being
�� � E
��.: o
��
�
�:� �
�,
�
s
Company Name: *-���--`C— �� � � �
Coryaration / PaMrnhip / Solc Propxietonhip -
If business is incoiporated, give date of incorporation:
iJou:g Business As:
Business Address:
- 1- S l
�
Business Phone: e7'i_d_'
Shce: Addroxs , +�� City Stnte Zip �
£sztwezn what cross streets is the basiness located? �l `G� R-�� Which side of the street`7 �e3 il jZ�4
Are thepremises now occupied? �'CS What Type of Business? �� SV7�fv�Lf�i.T�
Mait To A�dress:
so-me naa��.,. ciry s•,� z�p
Applicant In.fom
Name a.zd TiYle: , C�l `f c— �-.1 C�t ld `N'\ 1 ���-z� "
Fint r' � � . J M _ iddlc `�� (.�faiden) La+t Titic
HomeAddress: �-I�`1 V�`$2. F—e> SZi ��F�m,.,.� 111r,,1 S��`C3
StrectAddmse City Statc t � Zip
Bate of Birth: ��- ��` ��P Place of Birth: �L�_� � t�(' 0.� Home Phone: `T��� �7
Hd'Je y0u EV� � een cor.vict�. of az;y felony, cri:.e or violatien of any ciry ordinance other than traffic7 �5 NO _�
Date of azrest:
Charge: _
Conviction:
Sentence:
List the names and residences of three persons of good moral chazacter, living withsn the Twin Cities Meffo Area, not related to the applicant
or financially interested in the premises or business, who m ay be referred to as to the applicanYs character:
�
NAME
�1CIC2
ADDRESS
Have any of the above named licenses ever bzrn revoked?
'�IIS APPLICATION I5 SUBIECT TO REVIEW BY THE PUBLIC
PLEASE TYPE ORPRINT IN INK
for:
CITY OF SAINT PAUL
o&;ce oeUccnse, tnspeatons
end Envitomnrntal Profection
3w s� r:..� u s� aao
s�r„a��a ssiaz
(612)2 212 9i1:
ls �
2� �, � � j 0 `d `:.
S oZ/ � °�.°-
S
s a �� �
's
PHONE
YES � NO If yes, list the dates and reasons for revocation'
"�d
List licen �s �vhich you currentiy hold, fonnerly heid, or may have an�terest in:
Are you going to operate this business personally? _� XES
FintNmc
u;aa�� we;et
�s�:�>
City
YES
(�Aa�3rn)
City
HomcAddress: Strcc[�sne
Are you going to have a manager or assistant in tbis business�
please complete the following information:
Fixst Nnme
Maat� v�;tiat
Home Addrean: St+ut Namc
Please list your employment history for the previous five (5) yeaz period:
Business/Emplovment Address
NO If not, who will operate it? '
9't - �zds'
Ls*� Dam of Hwi
Sta[e Zip Phonc Numbr,
� NO If the vnanager is not ihe same as the operx[or,
La+t
Stete Zip
Da.e of B'uti
Phone . �umbc
�"T'L-V l.-� 7_U6L5 1 t�5 �
List all other officers of the corporation:
OFFICER TITLE HOME HOME BUSINESS DATE OF
NAME (Office Held) ADDRESS PHONE PHONE BIRTH
�-��`�- �.�t�� �� s��
If business is a partnership, please include the foL'owing infoirnation for each partner (use additional pages ii necessazy):
Fust Namc
N,&adlc &,itiat
(.�faiden)
Last
Date of Bitth
HomeAddreaa: Streetl3ame City State Zip PhoneNumbcr
Fin[Name Middlelnitial " (�3aidm) Isst ' DaPeoFS'vih
Homc Addtcvs: Strat Name City State Zip Phonc Number
MII�RQESOTA TAX IDENTIFICATION 1QIIMBER - Pursuent to ttte Laws of Minnesot� 1984, Chapter SQ2, Article 8, Section 2(270.72)
(Tar Clearance; Issuance of Licenses), licensing authorities are required to provide to the State of Minnesota Commissioner of Revenue, the
Minnesota business tati identification number and the sxial security number of each license applicant.
Under the Minnesota Govemment Data Practices Act and the Federal Privacy Act of 1974, we are required to advise you of the folloning
regarding the use of the Miimesota Ta� Identification Number: ,,,,
- This information may be used to deny the issuance or renewal of your�icense in the event you owe Minnesota sales, emplopzr's
wiihholding or motor vehicle excise taxes;
- Upon receiving ihis information, the licensing authority will supply it only to the Minnesota Department of Revenue. However,
under the Federal Exchange of Infotmation Agreement, the Department of Revenue may supply this information to the Intzma!
IZevenue Service.
Minnesota TaY Identification Numbe� (Sales & Use Ta� Number) may be obtained from the State of Minnesota, Business Records Departmznt,
10 River Pazk Plaza (612-296-6181).
Socisl Security Number: ��� "�J�' �b�?� Minnesota Tak Iden�calion Number: ''+Z3Ir�I _�1D
^ If a Minnesota Tax Idrntification Number is not required for the business being operatzd, indicate so by placing an "X" in the bo�.
` Y
9/l A!0'1
CEF2TIFICATION OF WORKERS' COMPENSATION COVERAGE PURSUANf 70 MII�iNESOTA STANTE 176.182 �� � }pY
I r aatify that ?, or my campany, azn in cAmpliance witk: the workecs' compensation insurance coverage requirements of Minnesota Statute
176.182, subdivisian 2 I also under5eand that provision of faLse info.*mation in this cert�cation constitutes �cient grounds for adverse acIlOa
against all licenses held, including revocation and suspension of said licenses:
NameofInsuranceCompany:,�Q�`t'r�.FelS _Lvv�;ar�v�C4� �G\?✓7
Policy Numher: � 2226 - 1?-`f� Coverage from `S I�� to �l r� .`�
I have no employees covered under warkers' compensation insurance (INITIALS)
ANY FAISIFTCATION OF ANSWERS GIVEN OR MATERIAL SUBMTPTED
WII.L RESULT IN DE1�fAL OR THIS APPLICATTON
I hereby state that I have answered all of the preceding questions, and that the information contained herein is true and cotrect to the best of
my lmowledge and belief I hereby state further that I have received no money or other considerafion, by way of loan, gift, contribution, or
othenvise, other than already disclosed in the application wtach T hereu�ith submitted. I also understand this premise may be inspected by police,
fire, health and other city officials at any and all times whe�e�u�iness is in operalion.
��
for all applications)
We wiil accept payment by cash, check (ma�'a payable to City of Saint Paul) or credit card (M!C or Visa).
-� 7
Date
IFPAYINGBYCREDITCARDPLEASECOMPLETETHEFOLLOWINGINFORMATION: � MasterCard u Visa
EXPIIt4TION DATE:
� � � 0
5" �. � �,�.�
� c� �Z �
"*Note: If ttus application is FoodlLiquor related, please contact a Ciry of Saint Paul Health Inspector, Steve Olson (266-9139), to review
plans.
If any substantial changes to structure are anticipated, please contact a City of Saint Paul Plan Examiner at 266-9007 to apply for
building perauts.
If ihere are any changes to the pazking lot, floor space, or for new operations, plzase contact a City of Saint Paul Zoning Inspector at
256-9008.
All applicaYions requim the foilawing documents. Please attach these documents when submitting your application:
l. A detailul description of the desigi, location and square footage of the premises to be licensed (site plan).
The following data should be on the site plan (preferabty on an 8 1/2" x 11" or 8 1!2" x 14" paper):
- Name, address, and phone ntunber. �
- The scale should be stated such as 1"= 20'. ^N should be indicated towazd the top.
- Placement of all pertinent features of the interior of the licensed facility such as seating azeas, kitchens, offices, repas area,
parking, rest rooms, etc.
- If a request is for an addition or expansion of the licensed facIliry, indicate both the current area and the proposed expansion.
2. A copy of your lease agreement or proof of ownership of the property.
SPECIFIC LICENSE A.PPLICATIONS REQUII2E ADBTTIONAL IlVF'ORMATION.
PLEASE SEE RE VERSE FOI2 DETAIZS >>>>
ACCOUNT N[TMBER:
�� nc�� nr��� r.��no �e�r�n
�.,,:
2/18/97
-`k���a� � �
v� �� 1 �
5�
,_ - . :
Presented By_
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
Re£erred To
RESOLUTION
A�L(VT PAUL, MI
RESOLVED: That application, ID #16046, for an
Inc. DBA CaEe Latte (Peter Quinn, P
same is hereby approved with the fo
The applicant shall obtain
street parking zoning requ
condition of the variance,
Committee: Date
�
� i
inment-A License by Style 2000
)at 850 Gzand Avenue, be and the
condition:
ariance of the off-
ents and shall meet any
granted.
Adoption Cert/`ified by Council Secretary
By:
Approved by Mayor:
Date
Requested by Department of:
Office of License. Ins�ections and
/ E�nvironmental Protection
By: l,il�f..�-a.wn.� i"� �""l.�yu
Form Appro by City A o ey
$Y � �//h O �i+.e�C/� � C� G�-/ �-v�i i
Approved by Mayor for Submission to
council
By:
Council File # � { - �a��
0
Sheet � 50230
By:
Adopted by Coux�il: Date
N° 50230
LIEP/License
Christine A. Rozek - 266-9108
TOTAL # OF SIGPlATURE
1CilON FiEQUESiE�'
DATEINIT�—1 GREEN SHEET �����
INITIAVDATE INITIAUDATE —
O DEPaRTMENT DIREGTOR � CT' COUNCIL
NUMBEN FOR ❑ CINATTORNEI' O pTYCLERK
HOMNG O BUOGETD�RECTOR � FIN. 8 MGT, SEFVICES OIR.
OflOE(i O MAYOR (OB ASSISTANT) O
(CLIP ALL LOCATIONS FOR SIGNATUREy
Style 2000 Inc. DSA Cafe Laete (Peter Quinn, President) requests Gouncil
approval of their apglication for an Entertainment - A License, ID //16046, at
850 Grand Avenue.
__ PLANNWG CQMMISSION _ (
_ CIB COMMITTEE _ _
_ STAfF _ _
_ DISTqICT COURT _ _
SUPPORiS WHICH COUNdL 063ECTNE?
IF APPROVED:
PERSONAI SERYICE CA!lTRACTS MUST qNSWER THE FOILOWING �tlESTIONS:
L Has this person/firm ever worked untler a cOntract for this Oepatlment?
YES NO
2. Has this person/firm ever been a city employee?
YES td0
3. Does this perSOnHirm possess a skiil no� normally pOSSessed by any current aty employBe�
YES NO
Explaln ali yes answers on separeta aFeet and attaeh to green sheet
wnere.
..N'a�.''��...,. '
��k" �, � ����
]ISAOVANTACaES IF NOT APPROVEO.
�TAL AMOUNT OF TRANSACTION S
COST/REVENUE BUDGETED (CIRCLE ONE)
VES NO
NDIWG SOURCE 0.CTfVlTY NUMBER
4NCIAl INFORlnATIQN. (EXPtA1N)
�
��a�
CLASS III
LICENSE APPLICATION
M
�
ic:
Typ�cer�e(s) being
�� � E
��.: o
��
�
�:� �
�,
�
s
Company Name: *-���--`C— �� � � �
Coryaration / PaMrnhip / Solc Propxietonhip -
If business is incoiporated, give date of incorporation:
iJou:g Business As:
Business Address:
- 1- S l
�
Business Phone: e7'i_d_'
Shce: Addroxs , +�� City Stnte Zip �
£sztwezn what cross streets is the basiness located? �l `G� R-�� Which side of the street`7 �e3 il jZ�4
Are thepremises now occupied? �'CS What Type of Business? �� SV7�fv�Lf�i.T�
Mait To A�dress:
so-me naa��.,. ciry s•,� z�p
Applicant In.fom
Name a.zd TiYle: , C�l `f c— �-.1 C�t ld `N'\ 1 ���-z� "
Fint r' � � . J M _ iddlc `�� (.�faiden) La+t Titic
HomeAddress: �-I�`1 V�`$2. F—e> SZi ��F�m,.,.� 111r,,1 S��`C3
StrectAddmse City Statc t � Zip
Bate of Birth: ��- ��` ��P Place of Birth: �L�_� � t�(' 0.� Home Phone: `T��� �7
Hd'Je y0u EV� � een cor.vict�. of az;y felony, cri:.e or violatien of any ciry ordinance other than traffic7 �5 NO _�
Date of azrest:
Charge: _
Conviction:
Sentence:
List the names and residences of three persons of good moral chazacter, living withsn the Twin Cities Meffo Area, not related to the applicant
or financially interested in the premises or business, who m ay be referred to as to the applicanYs character:
�
NAME
�1CIC2
ADDRESS
Have any of the above named licenses ever bzrn revoked?
'�IIS APPLICATION I5 SUBIECT TO REVIEW BY THE PUBLIC
PLEASE TYPE ORPRINT IN INK
for:
CITY OF SAINT PAUL
o&;ce oeUccnse, tnspeatons
end Envitomnrntal Profection
3w s� r:..� u s� aao
s�r„a��a ssiaz
(612)2 212 9i1:
ls �
2� �, � � j 0 `d `:.
S oZ/ � °�.°-
S
s a �� �
's
PHONE
YES � NO If yes, list the dates and reasons for revocation'
"�d
List licen �s �vhich you currentiy hold, fonnerly heid, or may have an�terest in:
Are you going to operate this business personally? _� XES
FintNmc
u;aa�� we;et
�s�:�>
City
YES
(�Aa�3rn)
City
HomcAddress: Strcc[�sne
Are you going to have a manager or assistant in tbis business�
please complete the following information:
Fixst Nnme
Maat� v�;tiat
Home Addrean: St+ut Namc
Please list your employment history for the previous five (5) yeaz period:
Business/Emplovment Address
NO If not, who will operate it? '
9't - �zds'
Ls*� Dam of Hwi
Sta[e Zip Phonc Numbr,
� NO If the vnanager is not ihe same as the operx[or,
La+t
Stete Zip
Da.e of B'uti
Phone . �umbc
�"T'L-V l.-� 7_U6L5 1 t�5 �
List all other officers of the corporation:
OFFICER TITLE HOME HOME BUSINESS DATE OF
NAME (Office Held) ADDRESS PHONE PHONE BIRTH
�-��`�- �.�t�� �� s��
If business is a partnership, please include the foL'owing infoirnation for each partner (use additional pages ii necessazy):
Fust Namc
N,&adlc &,itiat
(.�faiden)
Last
Date of Bitth
HomeAddreaa: Streetl3ame City State Zip PhoneNumbcr
Fin[Name Middlelnitial " (�3aidm) Isst ' DaPeoFS'vih
Homc Addtcvs: Strat Name City State Zip Phonc Number
MII�RQESOTA TAX IDENTIFICATION 1QIIMBER - Pursuent to ttte Laws of Minnesot� 1984, Chapter SQ2, Article 8, Section 2(270.72)
(Tar Clearance; Issuance of Licenses), licensing authorities are required to provide to the State of Minnesota Commissioner of Revenue, the
Minnesota business tati identification number and the sxial security number of each license applicant.
Under the Minnesota Govemment Data Practices Act and the Federal Privacy Act of 1974, we are required to advise you of the folloning
regarding the use of the Miimesota Ta� Identification Number: ,,,,
- This information may be used to deny the issuance or renewal of your�icense in the event you owe Minnesota sales, emplopzr's
wiihholding or motor vehicle excise taxes;
- Upon receiving ihis information, the licensing authority will supply it only to the Minnesota Department of Revenue. However,
under the Federal Exchange of Infotmation Agreement, the Department of Revenue may supply this information to the Intzma!
IZevenue Service.
Minnesota TaY Identification Numbe� (Sales & Use Ta� Number) may be obtained from the State of Minnesota, Business Records Departmznt,
10 River Pazk Plaza (612-296-6181).
Socisl Security Number: ��� "�J�' �b�?� Minnesota Tak Iden�calion Number: ''+Z3Ir�I _�1D
^ If a Minnesota Tax Idrntification Number is not required for the business being operatzd, indicate so by placing an "X" in the bo�.
` Y
9/l A!0'1
CEF2TIFICATION OF WORKERS' COMPENSATION COVERAGE PURSUANf 70 MII�iNESOTA STANTE 176.182 �� � }pY
I r aatify that ?, or my campany, azn in cAmpliance witk: the workecs' compensation insurance coverage requirements of Minnesota Statute
176.182, subdivisian 2 I also under5eand that provision of faLse info.*mation in this cert�cation constitutes �cient grounds for adverse acIlOa
against all licenses held, including revocation and suspension of said licenses:
NameofInsuranceCompany:,�Q�`t'r�.FelS _Lvv�;ar�v�C4� �G\?✓7
Policy Numher: � 2226 - 1?-`f� Coverage from `S I�� to �l r� .`�
I have no employees covered under warkers' compensation insurance (INITIALS)
ANY FAISIFTCATION OF ANSWERS GIVEN OR MATERIAL SUBMTPTED
WII.L RESULT IN DE1�fAL OR THIS APPLICATTON
I hereby state that I have answered all of the preceding questions, and that the information contained herein is true and cotrect to the best of
my lmowledge and belief I hereby state further that I have received no money or other considerafion, by way of loan, gift, contribution, or
othenvise, other than already disclosed in the application wtach T hereu�ith submitted. I also understand this premise may be inspected by police,
fire, health and other city officials at any and all times whe�e�u�iness is in operalion.
��
for all applications)
We wiil accept payment by cash, check (ma�'a payable to City of Saint Paul) or credit card (M!C or Visa).
-� 7
Date
IFPAYINGBYCREDITCARDPLEASECOMPLETETHEFOLLOWINGINFORMATION: � MasterCard u Visa
EXPIIt4TION DATE:
� � � 0
5" �. � �,�.�
� c� �Z �
"*Note: If ttus application is FoodlLiquor related, please contact a Ciry of Saint Paul Health Inspector, Steve Olson (266-9139), to review
plans.
If any substantial changes to structure are anticipated, please contact a City of Saint Paul Plan Examiner at 266-9007 to apply for
building perauts.
If ihere are any changes to the pazking lot, floor space, or for new operations, plzase contact a City of Saint Paul Zoning Inspector at
256-9008.
All applicaYions requim the foilawing documents. Please attach these documents when submitting your application:
l. A detailul description of the desigi, location and square footage of the premises to be licensed (site plan).
The following data should be on the site plan (preferabty on an 8 1/2" x 11" or 8 1!2" x 14" paper):
- Name, address, and phone ntunber. �
- The scale should be stated such as 1"= 20'. ^N should be indicated towazd the top.
- Placement of all pertinent features of the interior of the licensed facility such as seating azeas, kitchens, offices, repas area,
parking, rest rooms, etc.
- If a request is for an addition or expansion of the licensed facIliry, indicate both the current area and the proposed expansion.
2. A copy of your lease agreement or proof of ownership of the property.
SPECIFIC LICENSE A.PPLICATIONS REQUII2E ADBTTIONAL IlVF'ORMATION.
PLEASE SEE RE VERSE FOI2 DETAIZS >>>>
ACCOUNT N[TMBER:
�� nc�� nr��� r.��no �e�r�n
�.,,:
2/18/97
-`k���a� � �
v� �� 1 �
5�
,_ - . :
Presented By_
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
Re£erred To
RESOLUTION
A�L(VT PAUL, MI
RESOLVED: That application, ID #16046, for an
Inc. DBA CaEe Latte (Peter Quinn, P
same is hereby approved with the fo
The applicant shall obtain
street parking zoning requ
condition of the variance,
Committee: Date
�
� i
inment-A License by Style 2000
)at 850 Gzand Avenue, be and the
condition:
ariance of the off-
ents and shall meet any
granted.
Adoption Cert/`ified by Council Secretary
By:
Approved by Mayor:
Date
Requested by Department of:
Office of License. Ins�ections and
/ E�nvironmental Protection
By: l,il�f..�-a.wn.� i"� �""l.�yu
Form Appro by City A o ey
$Y � �//h O �i+.e�C/� � C� G�-/ �-v�i i
Approved by Mayor for Submission to
council
By:
Council File # � { - �a��
0
Sheet � 50230
By:
Adopted by Coux�il: Date
N° 50230
LIEP/License
Christine A. Rozek - 266-9108
TOTAL # OF SIGPlATURE
1CilON FiEQUESiE�'
DATEINIT�—1 GREEN SHEET �����
INITIAVDATE INITIAUDATE —
O DEPaRTMENT DIREGTOR � CT' COUNCIL
NUMBEN FOR ❑ CINATTORNEI' O pTYCLERK
HOMNG O BUOGETD�RECTOR � FIN. 8 MGT, SEFVICES OIR.
OflOE(i O MAYOR (OB ASSISTANT) O
(CLIP ALL LOCATIONS FOR SIGNATUREy
Style 2000 Inc. DSA Cafe Laete (Peter Quinn, President) requests Gouncil
approval of their apglication for an Entertainment - A License, ID //16046, at
850 Grand Avenue.
__ PLANNWG CQMMISSION _ (
_ CIB COMMITTEE _ _
_ STAfF _ _
_ DISTqICT COURT _ _
SUPPORiS WHICH COUNdL 063ECTNE?
IF APPROVED:
PERSONAI SERYICE CA!lTRACTS MUST qNSWER THE FOILOWING �tlESTIONS:
L Has this person/firm ever worked untler a cOntract for this Oepatlment?
YES NO
2. Has this person/firm ever been a city employee?
YES td0
3. Does this perSOnHirm possess a skiil no� normally pOSSessed by any current aty employBe�
YES NO
Explaln ali yes answers on separeta aFeet and attaeh to green sheet
wnere.
..N'a�.''��...,. '
��k" �, � ����
]ISAOVANTACaES IF NOT APPROVEO.
�TAL AMOUNT OF TRANSACTION S
COST/REVENUE BUDGETED (CIRCLE ONE)
VES NO
NDIWG SOURCE 0.CTfVlTY NUMBER
4NCIAl INFORlnATIQN. (EXPtA1N)
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CLASS III
LICENSE APPLICATION
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Typ�cer�e(s) being
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Company Name: *-���--`C— �� � � �
Coryaration / PaMrnhip / Solc Propxietonhip -
If business is incoiporated, give date of incorporation:
iJou:g Business As:
Business Address:
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Business Phone: e7'i_d_'
Shce: Addroxs , +�� City Stnte Zip �
£sztwezn what cross streets is the basiness located? �l `G� R-�� Which side of the street`7 �e3 il jZ�4
Are thepremises now occupied? �'CS What Type of Business? �� SV7�fv�Lf�i.T�
Mait To A�dress:
so-me naa��.,. ciry s•,� z�p
Applicant In.fom
Name a.zd TiYle: , C�l `f c— �-.1 C�t ld `N'\ 1 ���-z� "
Fint r' � � . J M _ iddlc `�� (.�faiden) La+t Titic
HomeAddress: �-I�`1 V�`$2. F—e> SZi ��F�m,.,.� 111r,,1 S��`C3
StrectAddmse City Statc t � Zip
Bate of Birth: ��- ��` ��P Place of Birth: �L�_� � t�(' 0.� Home Phone: `T��� �7
Hd'Je y0u EV� � een cor.vict�. of az;y felony, cri:.e or violatien of any ciry ordinance other than traffic7 �5 NO _�
Date of azrest:
Charge: _
Conviction:
Sentence:
List the names and residences of three persons of good moral chazacter, living withsn the Twin Cities Meffo Area, not related to the applicant
or financially interested in the premises or business, who m ay be referred to as to the applicanYs character:
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NAME
�1CIC2
ADDRESS
Have any of the above named licenses ever bzrn revoked?
'�IIS APPLICATION I5 SUBIECT TO REVIEW BY THE PUBLIC
PLEASE TYPE ORPRINT IN INK
for:
CITY OF SAINT PAUL
o&;ce oeUccnse, tnspeatons
end Envitomnrntal Profection
3w s� r:..� u s� aao
s�r„a��a ssiaz
(612)2 212 9i1:
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PHONE
YES � NO If yes, list the dates and reasons for revocation'
"�d
List licen �s �vhich you currentiy hold, fonnerly heid, or may have an�terest in:
Are you going to operate this business personally? _� XES
FintNmc
u;aa�� we;et
�s�:�>
City
YES
(�Aa�3rn)
City
HomcAddress: Strcc[�sne
Are you going to have a manager or assistant in tbis business�
please complete the following information:
Fixst Nnme
Maat� v�;tiat
Home Addrean: St+ut Namc
Please list your employment history for the previous five (5) yeaz period:
Business/Emplovment Address
NO If not, who will operate it? '
9't - �zds'
Ls*� Dam of Hwi
Sta[e Zip Phonc Numbr,
� NO If the vnanager is not ihe same as the operx[or,
La+t
Stete Zip
Da.e of B'uti
Phone . �umbc
�"T'L-V l.-� 7_U6L5 1 t�5 �
List all other officers of the corporation:
OFFICER TITLE HOME HOME BUSINESS DATE OF
NAME (Office Held) ADDRESS PHONE PHONE BIRTH
�-��`�- �.�t�� �� s��
If business is a partnership, please include the foL'owing infoirnation for each partner (use additional pages ii necessazy):
Fust Namc
N,&adlc &,itiat
(.�faiden)
Last
Date of Bitth
HomeAddreaa: Streetl3ame City State Zip PhoneNumbcr
Fin[Name Middlelnitial " (�3aidm) Isst ' DaPeoFS'vih
Homc Addtcvs: Strat Name City State Zip Phonc Number
MII�RQESOTA TAX IDENTIFICATION 1QIIMBER - Pursuent to ttte Laws of Minnesot� 1984, Chapter SQ2, Article 8, Section 2(270.72)
(Tar Clearance; Issuance of Licenses), licensing authorities are required to provide to the State of Minnesota Commissioner of Revenue, the
Minnesota business tati identification number and the sxial security number of each license applicant.
Under the Minnesota Govemment Data Practices Act and the Federal Privacy Act of 1974, we are required to advise you of the folloning
regarding the use of the Miimesota Ta� Identification Number: ,,,,
- This information may be used to deny the issuance or renewal of your�icense in the event you owe Minnesota sales, emplopzr's
wiihholding or motor vehicle excise taxes;
- Upon receiving ihis information, the licensing authority will supply it only to the Minnesota Department of Revenue. However,
under the Federal Exchange of Infotmation Agreement, the Department of Revenue may supply this information to the Intzma!
IZevenue Service.
Minnesota TaY Identification Numbe� (Sales & Use Ta� Number) may be obtained from the State of Minnesota, Business Records Departmznt,
10 River Pazk Plaza (612-296-6181).
Socisl Security Number: ��� "�J�' �b�?� Minnesota Tak Iden�calion Number: ''+Z3Ir�I _�1D
^ If a Minnesota Tax Idrntification Number is not required for the business being operatzd, indicate so by placing an "X" in the bo�.
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9/l A!0'1
CEF2TIFICATION OF WORKERS' COMPENSATION COVERAGE PURSUANf 70 MII�iNESOTA STANTE 176.182 �� � }pY
I r aatify that ?, or my campany, azn in cAmpliance witk: the workecs' compensation insurance coverage requirements of Minnesota Statute
176.182, subdivisian 2 I also under5eand that provision of faLse info.*mation in this cert�cation constitutes �cient grounds for adverse acIlOa
against all licenses held, including revocation and suspension of said licenses:
NameofInsuranceCompany:,�Q�`t'r�.FelS _Lvv�;ar�v�C4� �G\?✓7
Policy Numher: � 2226 - 1?-`f� Coverage from `S I�� to �l r� .`�
I have no employees covered under warkers' compensation insurance (INITIALS)
ANY FAISIFTCATION OF ANSWERS GIVEN OR MATERIAL SUBMTPTED
WII.L RESULT IN DE1�fAL OR THIS APPLICATTON
I hereby state that I have answered all of the preceding questions, and that the information contained herein is true and cotrect to the best of
my lmowledge and belief I hereby state further that I have received no money or other considerafion, by way of loan, gift, contribution, or
othenvise, other than already disclosed in the application wtach T hereu�ith submitted. I also understand this premise may be inspected by police,
fire, health and other city officials at any and all times whe�e�u�iness is in operalion.
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for all applications)
We wiil accept payment by cash, check (ma�'a payable to City of Saint Paul) or credit card (M!C or Visa).
-� 7
Date
IFPAYINGBYCREDITCARDPLEASECOMPLETETHEFOLLOWINGINFORMATION: � MasterCard u Visa
EXPIIt4TION DATE:
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"*Note: If ttus application is FoodlLiquor related, please contact a Ciry of Saint Paul Health Inspector, Steve Olson (266-9139), to review
plans.
If any substantial changes to structure are anticipated, please contact a City of Saint Paul Plan Examiner at 266-9007 to apply for
building perauts.
If ihere are any changes to the pazking lot, floor space, or for new operations, plzase contact a City of Saint Paul Zoning Inspector at
256-9008.
All applicaYions requim the foilawing documents. Please attach these documents when submitting your application:
l. A detailul description of the desigi, location and square footage of the premises to be licensed (site plan).
The following data should be on the site plan (preferabty on an 8 1/2" x 11" or 8 1!2" x 14" paper):
- Name, address, and phone ntunber. �
- The scale should be stated such as 1"= 20'. ^N should be indicated towazd the top.
- Placement of all pertinent features of the interior of the licensed facility such as seating azeas, kitchens, offices, repas area,
parking, rest rooms, etc.
- If a request is for an addition or expansion of the licensed facIliry, indicate both the current area and the proposed expansion.
2. A copy of your lease agreement or proof of ownership of the property.
SPECIFIC LICENSE A.PPLICATIONS REQUII2E ADBTTIONAL IlVF'ORMATION.
PLEASE SEE RE VERSE FOI2 DETAIZS >>>>
ACCOUNT N[TMBER:
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2/18/97