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97-1554Presented By 5 ��5� ��k� G � Council File #� � 1��7 y � Ju'a p� Ordinance # / '-� 1 V Green Sheet $ 35316 RESOLUTION CITY OF SAINT PAUL, MINNESOTA �� /J�� J ��C Referred To Committee: Date 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 I8 19 2� 21 22 23 24 2$ 26 27 28 29 RESOLVED: That application, ID #54805, for an Auto Body Repair Garage license by Centerline Frame Inc. DBA Centerline Frame Inc. (David Bergum, President) at 100 Cottage Avenue West, be and the same is hereby approved with the following conditions: 1) All work required Eor the change in the use of the building is completed and a certificate of occupancy is obtained from this office. We will not issue the official licensing document until this condition is satisfied. 2) The off-street parking sur£ace in fronti of the building muat be used only as employee parking space and/or the short term parking for customers, salesperson, etc. This space may not be used for storage of vehicles awaiting service or as drop-off area for vehicles towed to the site. Vehicles coming to this site for servicing must be parked inside the fence area. 3) The business of obtaining vehicles with the sole purpose of salvaging them exclusively for this value as scrap metal is expressly forbidden. Auto salvage is not a permitted use in the 1-1 zoning district the property is located. 4) It is underatood that an auto body repair business will generate parte that will be discarded as scrap. This later activity is permisaible ae part of the normal servicing required to repair the vehicle. These discarded parts must be removed from the property weekly. The discarded parts will be stored inside the fence area either in an enclosed container or in a location that is not visible from the street. 5) No spray painting permitted without proper ventilation and apray booth per Fire Inspection. Requested by Department of: Adoption By: � Approved i By: by Council Secretary � F � , �. � - !v Office of License Ins�ections and Environmental Protection By: � �� A�i -� Form App 9ved by Cit,I Attorney By: � z-�l�� Approved by Ma or for ubmission to Council By: Adopted by Council: Date� �.,_y �,gq� � a�-�s54 �EPAq'fMENT/OFFICE/CqUNCIL OATEINRIATED GREEN SHEE �O 35316 LIEP/Licensi,ng INRIAVDATE INR�AVDATE CANTACT PEpSON 8 PHON£ O DEPARTMEM DIRECTOR O CRY CAUNCIL Christine Rozek, 266-9108 "��cx �cmaTroaNer aCITYCLERK MUST BE ON COUNCIL AGENDA BY (OATE) NUYBER FOP O BUDGET DIRECTOF O FIN. & MGT. SERVICES DIR. POUTING F'OY hearin ;/a oZoZ. �J' ONDER OMpYOR{ORASSISTAlfn O TOTAL # OF SIGNATURE PAGES (CLIP ALL LOCAT{ONS FOR SIGNATUR£) ACT70N REW1E57ED: Centerline Frame Inc. DBA CenCerline Frame Inc. requests Council approval of its application for an Auto�te air Garage License located at 100 Cottage Avenue West (ID /�54805). da& RECOMMENDAnONS: Approve (A) r Reject (fi) PERSONAL SERYICE CANTRACTS MUST ANSWER TXE GOLLOWING QUESTiONS: _ PLANNING COMMISSION _ GVIL SERVICE COMMISSION �� Has Nis person/firtn ever worketl under a contract for thi5 departmeM? - _ CIBCOMMR7EE YES NO _ STAFF 2. Has this person/firm ever been a city employee? — YES NO _ DISTRICT CAURi _ 3. Does this person/firm possess a skill not normally possessed by any current city employee? SUPPORTS WNICH CAUNCIL O&IECTIVE4 YES NO Explsin all yes answers on seperate sheet antl attach tp green sheat ��e�' e ".. . 6.', INITIATING PROBLEM, ISSUE, OPPoRTUNITY (Who. What. When, Where, Why): �,_ �� '" �? iAAR 2 5 1997 CITY A�'�OR�E�' ADVANTAGESIFAPPROVED: OISADVAPlTAGES IF APPFOYED: DISADVANTAGES IF NOT APPROVED: � DEG 0 $ 1997 TOTAL AMOUNT OF TRANSACTION S COST/REVENUE BUDGEiED (CIRCLE ONE) YES NO FUNDING SOURCE AC7IVITY NUMBER FINANCIAL INFORMATION: (EXPLAIN) Council File # � S S� Ordinance # Green Sheefl # 35316 1 4 5 8 9 10 11 12 13 14 15 16 17 i8 19 2� 21 22 23 24 25 26 27 28 29 3) The business of obta them exclusively for Auto salvage ia not/ property is locateyi. 4) It is unders that will be part of the discarded pa discarded p enclosed c� street. RESOLUTION CITY OF SAINT PAUL, MINNESOTA �ng vehicles with the sole purpose of salvaging his value as scrap metal is expressly forbidden. permitted use in the 1-1 zoning district the �that an auto body repair business wi11 generate parts carded as acrap. This later activity is permisaible as ial servicing required to repair the vehicle. These must be removed from the property weekly. The will be stored inside the fence area either in an ,er ar in a location that is not visible from the Presented Bp�� Referred To 2) The off-street parking surface in front of the building must be used only as employee parking apac andJor the ahort term parking for customers, salesperson, etc. This apace may not be used for atiorage of vehicles awaitinq service as drop-off area for vehicles towed to the site. Vehicles coming to his site for servicing must be parked inside the fence area. Date 32 RESOLVSD: That application, iD #54805, for an Auto Repair Garage License by Centerline Frame Inc. DBA Centerline Frame Inc. (David B gum, President) at 100 Cottaqe Avenue West be and the same is hereby approv with the following conditions: 1) All work required for the change in e use of the building is completed and a certificate of occu ancy is obtained from this office. We will not iseue the official lic nsing document until this condition is satisfied. Requested by Department of: • - '�-- �- - -�= -.�• - - .. Hy: Adopted by Co cil Adoption Ce ified By: Approved by Mayor: By' Date by Council Secretary Date Form Approved by City Attorney By: °�� _ _ Approved b Mayor for Submission to Council By: CLASS III LICENSE APPLICATIOIvT v ��p� ��-�ssy CITY OF SA11�TT PAUL O�ce of Licrnse, Iacpeaions a.id Emvmmrnizl Protectioa 55. 5:?r.a Sc S�x 3f�J' Sz;,;?zc, 4ti �h 55103 C614)?bGo04J fzx(612J2669i24 THIS APPLICATION IS SUBJECT TO I2EVIEW BY THE PUBLIC PLEASE TYPE OR PRINT IN IIvTK Ca�� j_,_ � T}pe of Licensz(s) being applied for_ _�Ca 0 f'Y/�(��- ��f (/—_�� \ J S�� 7e / c Cou pany Name: ��p If business is incorporated, give date of incorporation: AoingBusinessAs: �7�kVl/\�7 Business Address: Business Phone: � s4eet ndaresx � / c � iry s�are z[p Berit�een uhat cross streets is the b located? i ' < / S� Which sid�e of the street? Ot�� Are tLz premises now occupied7 T�� What Type of Business? c9T'C"� tZ�i �� — �-� - K.l+w�' ,�1.,.,� � Mail To Address: � �f7 c,J . ( .rrrv � £, F�Q� �i : Pia �L V✓�d..j �S�t \`� , strcct Addsss . - - c�ry - � . state zip . . Applicant Information: Name and Ti4e: f � F,m _tiLaatc ��a�� t,�c rsU� HomeAddress: 1 5`'I �C� �`t� �i . 1V• S7�' ul/1�V CZ�'Z _ _ Street Addnv " - : - � � CiTy - Statc Zip Date of Birth: /�' —� — JZ� Place of Birth: f 5 s�vv� i(�n �l �� -{ �l�Iome Phone: ��) :?are rca ev� b� :ani�c:ed of a�� f lony, cri.:,e o: ;zolzL�cn cf a:.y c:ty e: di�ance at�':er thz*. +s�c? I'ES NO Date of arrest: Where? Chargz: _ Conviction: Sentence: Lis[ tbe names and residences of three perwns of good moral character, living within the Twin Cities Metro Area, not related to the appLcant or financia2ly interested in the premises or business, who may be referred to as to the applicanPs character: NAME ADDRESS -, 1 ;� you current]y hold, formerly he]d, or may have an interest in: Have azry of the above name3licenses ever been revoked7 __ YES NO If yes, list the dates and reasons for revocalion: y. 2/18/97 Are you going to operate this business personall}'? ,� YES Firsc xeme .'vtiddle Initisl ('�iaidrn) Homc Addicss: Stred \zme Are you gomg to ha��e a manaezr or_assistant in ttais buiness? please complete the folloa�ins infomiation: Cin" YES �_ NO If not, �3 ho �till operate it? �1 �� 5 S�'4, Last Da�e ofBirth Stxte Zip Pume \umb- _� 2�T0 If the manaeer is not the szme zs Cne operaior, First\'eme ?.1iddleInitial (�f^rd-°n) Lsst DateofBiY.n Home Add�css: Stxeet \ame Ci:y Siate Zip Pnrnc \�ber 'Tt- List all other officers of the corporation: OFFICER TIII,E HOME NAME (OfficeHeld) ADDRESS HOME BUSINESS DATE 0� PHOIvE PHOIvTE BIRTH � �� If business is a partnership, please inciude the following information for each parmer (use additional pages if necessary): �oY�,e/ Fisst2:ame MiddlcInitisl (VSaiden) Lavt DatcofBirth HomeAddrexe: Strut�ame CiTy State Zip Pf�one?�umbcr Fart Name Home /+ddnss: Street t�amc City L� State Zip Dnte ofB"uth Phonc :�'umbcr MRQI�SOTA TAX IDENTIFICATION NUMBER - Piusuant to the Laws of Minnesota, 1984, Chapter 502, Articie 8, Section 2(270.72) (Ta�c Cle� ance; Issuance of Licenses), licensing autl�orities aze required to provide to tt�e State of 2vTinnesota Commissioner of Revenue, the Minnesota business ta�c idrnvfication number and the socisl 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 following regarding ihe use of the Minnesota TaY Identification Number: - This infoimation may be used to deny the issuance or renewal of your license in tbe event you owe Minnesota sales, employer's withholding or motor vehicle excise taxes; - Upon receiving tlris infoimation, the licensing authority will suppiy at only to the Minnesota Aepartment of Revenue. However, under the Federal Exchange of Tnformation Ageement, the Departrnent of Revenue may supply this infozmation to the Intetnal Revenue Service. ivfinnesota Tax Identificarion Nmnbeis (Sales & Use TaK Number) may be obtained fram the State of Minnesot� Business Records Deparhnent, 10 River Park Plaza (612-296-6181). Social Security Number: `J ' `-� ZL( Minnesota Tax Identificalion Number: 7 Z 5�/-�Z � If a Minnesota Ta�c Identification Number is not required for the business being operated, indicate so by piacing an"X" in the box. Middlc Initiel 2/18,91 Please list your emplo}�ment history for the pre�ious five (5} }ear period: _ a�-�ssy CERTffICATION OF WORKERS' COMPENSATION COVERAGE PURSU:vNT TO MIN:QESOTA STANTE 176182 I hereby certify that I, or m} compazry, am in compliance �32Sh the �� o.kers' compensation i;.surance coverage requirements of ;viinnesota S�T�te 176.182, subdi�ision 2. I also undzrs'��d �hzt p,-ovision of false info�nation in th.is czctification constitutes sufficient grounds for ad��erse actioa zee�st all liceases held, including re�yc�on and sespension of said lice-ises. N�,me of Insurance Compang: Polic} Nu. /�,� �� { Co��eragzfro:a � �"�� io ��`��`�� I hace no emplo}'�s cocered under u�o;kz;s compznsation i�su:-znce (_1'_vTITL1LS) r�NY FALSIFZCATIO?�� OF Al\'S�'ERS GIVEN OR MATERIAI, SUBMTTTED F4ILI, RESULT IN DEI�TAL OF THIS APPLICATION I hereby state that I ha�•e answered all of tbe preceding queslions, and that the infonnalion containzd herein is true and correct to the be� of my know(edge and betief I here6y state iurther that I have receii ed no monec or othec co deration, by w'ay of loan, gift, con�ibutirn, or othhezra�se, other than already disclosed in the application which I here� h submitted I also�stand this premise may be inspected by po!ice, fire, health and othez city officials at an}� and all times u�hen the ess is m operatio�� z �� Date We�rill accept pa}•ment by casb, check (made PAYING BY CREDIT CARD PLEASE 7'17 •� I• I�■ ■■ \ame of Car�older Date *'Note: ff this applicaGon is Food/Liquor related, please contact a City of Saint Paul Heaith Inspector, Steve Olson (266-9139), to re�iew plans. If any substanlial ohanges to structure are anticipated, please contaet a City of Saint Paul Plan Exazniner at 266-9007 to applp for building permits. If there are any changes to the parking lot, floor space, or for new operations, please contact a City of Saint Paul Zoning Inspector at 266-9008. All applications requim the follo�ing documents. Please attach these documents �c�he¢ submitting yo¢r application: 1. A detailed description of the desig� location and square footage of the premises to be Iicensed (site plan). The following data should be on the site plan (preferably on an 8 1/2" x 11" or 8 I/2" x 14" paper): - Name, address, and phone number. - The scaSe shouid be stated such as 1" = 20'. ^N should be indicated toward the top. - Placement of all pertinent features of the interior of the licensed facility such as seating areas, kitchens, offices, repair area, parking, rest rooms, efc. - ff a request is for an addition or expansion of the licensed facility, indicate both the current azea and the proposed eapansion. 2. A copy af pour lease agreement or proof of o�n�nesship of tt�e property. SPECIFIC LICENSE APPLICATIOiVS, REQULRE ADDTTIONAL INFORMATION. PLEASE SEE REVERSE FOR DETAII,S >>>> to City of(S�'�aye[) or 6fedit card (M/C or Visa). � � THEFOLLOWINGINFORMATION: � MasterCard � Visa ACCOtTNT NCTMBER: ��Lf�� 2;18i97 Are you going to operate this business personallyl �YES Firft \amc �fiddle Initial (�iaidcn) �-� NO If not, wNo will operate it? � Date of Binh HomeAddrw: Stlut?:ame Ciry� / Swe Zip PhoneNumbet Are you going to have a manager or assistant in this business7 v YES NO If the manager is not the sazne as the operator, please complete the fol]owing information: Fua?:,me .saa��In;�,� (�re;a�,> Last Das�oravu, HomcAddrtss: Sirat\*ame City State Zip Phone?��bcr Please list your emplo}rtnent history for ihe previous five (5) �'eaz period: Busines�Em�]o�mrnY Address List all other officers of the corporation: OFFICER TITLE HOME HOME BUSINESS DATE OF NAME (Office Held) ADDRESS PHONE PHONE BIFtTT-I �/z. . i�i�lr-- c�t cr,c ) /�-/� > � s� <�,� �� 5,�- �/�l �� iO� �s-o6—H , If business is a par�ership, please include the following information for each partner (use additional pages if necessary): FitrtName Middlelritid (.Maidcn) Las[ DatcofBirth HomeAddrw: Streclt�ame City Shto Zip Phone.Vumber Fint I:ame Middle Initial (!4faidcn) Lsst Dau of Sirth Homc Addns�: Skeet Namo City Smte Zip Phone h'umbcf MIS�RQESOTA TAX IDENTIFICATIO23 NUt�ER - Pursuant to the Lau�s of Minnesota, ] 984, Chapter 502, Article 8, Section 2(270J 2) (Tex Clearance; Issuance of Licenses), licensing authorities are required to provide co lhe State of Ivlinnesota Comtnissioner of Revenue, the Minnesota business tax identification number and the social security number of each license apglican� Undet the Minnesota Govemment Data Praclices Act and the Federal Privacy Ac[ of 1974, we aze required to advise you of the following re$arding the use of the Minnesota T� ldrntification Number: - This information cnsy be used to deny the issuance or renewal of yout license in fhe event you owe Minnesota sales, employet's withholding or motor vehicle excise taxes; • Upon receiving this informatioq the licensing authority W�i11 supply it only to the Nfinnesota Department of Revenue. However, under the Federal Exchange of Tnfoitnation Agreement, the Departmrnt of Revenue may supply thas infoimation to the Intemal Revenue Service. Mumesots Tax Ida�tiScation Numbers (Sales & Use Ta�c Niunber) may be obtained 5rom the State of Minnesota, Business Records Department, 10 River Park Plaza (612-296-b ] 81). . Social Security Number: �� =�-? ��! Ivlinnesota TaK Identification Number: ,�,� ��F' � If a Minnesota Tax Identification Number is not required for the business being operated, indicate so by placing an"X" in the box. a�-�ssy ziis�a CERTTFICATION OF WORKERS' COMPSNSATION COVIiRAGE PUI2SUANT TO MINNESOTA STATUTE 176.182 �' _ 1SS 1 I hereby cenify that I, or my company, am in compliance with the workers' compensation insursnce coverage requirements of Minnesota Statute 176. I 82, subdivision 2. I also understand that provision of false infortnalion in this certification constitutes sufficient grounds For adverse aclion against all licenses hcld, including revocation a�d suspension of said licenses. Nazne of Insurance Company: Policy Numbet: Coverage from �� %� to y-f I have no employees covered under workers' compensation insurance (INITIALS) ANY FAISIFICATION OF ANSWERS GNEN OR MATERIAL SUBMITTED WILL RESULT IN DEMAL OF THIS APPLICATION I hereby state [hat I have answered all of ihe preceding questions, and that the information contained herein is true and correct to the best of my knowledge and be]icf. I hereby state Iwther that I have received no money or other consideration, by way of loan, gift, conhibuUOn, or othenvise, other than already disclosed in the application which I hetewith submitted I also understand this premise may be inspected by police, fire, health and other city o�cials at any and all times when the business is in operation. / � We will accept payment by cash, check (made payable to Signatum UIRED fpF�U applications) Saint Paun or credit card (M/C or Vlsa). Date PAYING BY CREDIT CARD PLEASE COMPLETE THE FOLLON'ING INFORMATION: � MasterCazd � Visa EXPIItATION DATE: ❑�/�❑ ACCOUNT NUMBER: � � � � � � � � � � � � � � � � �' "Note: ]f this app]ication is Food/Liquor related, please contact a Ciry of Saint Paul Heulth Inspector, Steve Olson (266-9139), to review plans. if any subslantial changes to sWeture are anticipated, please com�ct a Ciry of Saint Pau1 Plan Examiner at 266-9007 to apply for building permits. If there are any changes to the parking lot, iloor space, or for new operations, please eontaet a City of Saint Paul Zoning Inspector at 266-9008. All applications require thc lollowing documcnts. Plcase attacfi these documents when submitting your appiication: !, A detailed description o(the design, location and square footage oCthe premises to be licensed (site plan). The £ollowing data should be on the site plan (prefera6ly on an 8 I/2" x 11" or 8 1(Z" x 14" paper): - Name, address, and phone number. - The scale should be stated such xs 1" = 2Q'. ^N sh�uld 6e indicated towazd ttte top. - Placement of ail pertinent features of the interior of the licensed Cacility such as seating areas, lcitchens, offices, repair area, parking, rest rooms, etc. - If a request is for an addition or expansion of the licensed facility, indicate both the currrnt area and the proposed expansion. 2. A copy of your lease agreement or proof of ownership of the property. SPECTP'TC LICENSE APPLICATIONS REQUIR� ADDITIONAL INTORMATION. PLEASE S�E REVERSE FOR D�TATLS >>>> aia sis� Presented By 5 ��5� ��k� G � Council File #� � 1��7 y � Ju'a p� Ordinance # / '-� 1 V Green Sheet $ 35316 RESOLUTION CITY OF SAINT PAUL, MINNESOTA �� /J�� J ��C Referred To Committee: Date 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 I8 19 2� 21 22 23 24 2$ 26 27 28 29 RESOLVED: That application, ID #54805, for an Auto Body Repair Garage license by Centerline Frame Inc. DBA Centerline Frame Inc. (David Bergum, President) at 100 Cottage Avenue West, be and the same is hereby approved with the following conditions: 1) All work required Eor the change in the use of the building is completed and a certificate of occupancy is obtained from this office. We will not issue the official licensing document until this condition is satisfied. 2) The off-street parking sur£ace in fronti of the building muat be used only as employee parking space and/or the short term parking for customers, salesperson, etc. This space may not be used for storage of vehicles awaiting service or as drop-off area for vehicles towed to the site. Vehicles coming to this site for servicing must be parked inside the fence area. 3) The business of obtaining vehicles with the sole purpose of salvaging them exclusively for this value as scrap metal is expressly forbidden. Auto salvage is not a permitted use in the 1-1 zoning district the property is located. 4) It is underatood that an auto body repair business will generate parte that will be discarded as scrap. This later activity is permisaible ae part of the normal servicing required to repair the vehicle. These discarded parts must be removed from the property weekly. The discarded parts will be stored inside the fence area either in an enclosed container or in a location that is not visible from the street. 5) No spray painting permitted without proper ventilation and apray booth per Fire Inspection. Requested by Department of: Adoption By: � Approved i By: by Council Secretary � F � , �. � - !v Office of License Ins�ections and Environmental Protection By: � �� A�i -� Form App 9ved by Cit,I Attorney By: � z-�l�� Approved by Ma or for ubmission to Council By: Adopted by Council: Date� �.,_y �,gq� � a�-�s54 �EPAq'fMENT/OFFICE/CqUNCIL OATEINRIATED GREEN SHEE �O 35316 LIEP/Licensi,ng INRIAVDATE INR�AVDATE CANTACT PEpSON 8 PHON£ O DEPARTMEM DIRECTOR O CRY CAUNCIL Christine Rozek, 266-9108 "��cx �cmaTroaNer aCITYCLERK MUST BE ON COUNCIL AGENDA BY (OATE) NUYBER FOP O BUDGET DIRECTOF O FIN. & MGT. SERVICES DIR. POUTING F'OY hearin ;/a oZoZ. �J' ONDER OMpYOR{ORASSISTAlfn O TOTAL # OF SIGNATURE PAGES (CLIP ALL LOCAT{ONS FOR SIGNATUR£) ACT70N REW1E57ED: Centerline Frame Inc. DBA CenCerline Frame Inc. requests Council approval of its application for an Auto�te air Garage License located at 100 Cottage Avenue West (ID /�54805). da& RECOMMENDAnONS: Approve (A) r Reject (fi) PERSONAL SERYICE CANTRACTS MUST ANSWER TXE GOLLOWING QUESTiONS: _ PLANNING COMMISSION _ GVIL SERVICE COMMISSION �� Has Nis person/firtn ever worketl under a contract for thi5 departmeM? - _ CIBCOMMR7EE YES NO _ STAFF 2. Has this person/firm ever been a city employee? — YES NO _ DISTRICT CAURi _ 3. Does this person/firm possess a skill not normally possessed by any current city employee? SUPPORTS WNICH CAUNCIL O&IECTIVE4 YES NO Explsin all yes answers on seperate sheet antl attach tp green sheat ��e�' e ".. . 6.', INITIATING PROBLEM, ISSUE, OPPoRTUNITY (Who. What. When, Where, Why): �,_ �� '" �? iAAR 2 5 1997 CITY A�'�OR�E�' ADVANTAGESIFAPPROVED: OISADVAPlTAGES IF APPFOYED: DISADVANTAGES IF NOT APPROVED: � DEG 0 $ 1997 TOTAL AMOUNT OF TRANSACTION S COST/REVENUE BUDGEiED (CIRCLE ONE) YES NO FUNDING SOURCE AC7IVITY NUMBER FINANCIAL INFORMATION: (EXPLAIN) Council File # � S S� Ordinance # Green Sheefl # 35316 1 4 5 8 9 10 11 12 13 14 15 16 17 i8 19 2� 21 22 23 24 25 26 27 28 29 3) The business of obta them exclusively for Auto salvage ia not/ property is locateyi. 4) It is unders that will be part of the discarded pa discarded p enclosed c� street. RESOLUTION CITY OF SAINT PAUL, MINNESOTA �ng vehicles with the sole purpose of salvaging his value as scrap metal is expressly forbidden. permitted use in the 1-1 zoning district the �that an auto body repair business wi11 generate parts carded as acrap. This later activity is permisaible as ial servicing required to repair the vehicle. These must be removed from the property weekly. The will be stored inside the fence area either in an ,er ar in a location that is not visible from the Presented Bp�� Referred To 2) The off-street parking surface in front of the building must be used only as employee parking apac andJor the ahort term parking for customers, salesperson, etc. This apace may not be used for atiorage of vehicles awaitinq service as drop-off area for vehicles towed to the site. Vehicles coming to his site for servicing must be parked inside the fence area. Date 32 RESOLVSD: That application, iD #54805, for an Auto Repair Garage License by Centerline Frame Inc. DBA Centerline Frame Inc. (David B gum, President) at 100 Cottaqe Avenue West be and the same is hereby approv with the following conditions: 1) All work required for the change in e use of the building is completed and a certificate of occu ancy is obtained from this office. We will not iseue the official lic nsing document until this condition is satisfied. Requested by Department of: • - '�-- �- - -�= -.�• - - .. Hy: Adopted by Co cil Adoption Ce ified By: Approved by Mayor: By' Date by Council Secretary Date Form Approved by City Attorney By: °�� _ _ Approved b Mayor for Submission to Council By: CLASS III LICENSE APPLICATIOIvT v ��p� ��-�ssy CITY OF SA11�TT PAUL O�ce of Licrnse, Iacpeaions a.id Emvmmrnizl Protectioa 55. 5:?r.a Sc S�x 3f�J' Sz;,;?zc, 4ti �h 55103 C614)?bGo04J fzx(612J2669i24 THIS APPLICATION IS SUBJECT TO I2EVIEW BY THE PUBLIC PLEASE TYPE OR PRINT IN IIvTK Ca�� j_,_ � T}pe of Licensz(s) being applied for_ _�Ca 0 f'Y/�(��- ��f (/—_�� \ J S�� 7e / c Cou pany Name: ��p If business is incorporated, give date of incorporation: AoingBusinessAs: �7�kVl/\�7 Business Address: Business Phone: � s4eet ndaresx � / c � iry s�are z[p Berit�een uhat cross streets is the b located? i ' < / S� Which sid�e of the street? Ot�� Are tLz premises now occupied7 T�� What Type of Business? c9T'C"� tZ�i �� — �-� - K.l+w�' ,�1.,.,� � Mail To Address: � �f7 c,J . ( .rrrv � £, F�Q� �i : Pia �L V✓�d..j �S�t \`� , strcct Addsss . - - c�ry - � . state zip . . Applicant Information: Name and Ti4e: f � F,m _tiLaatc ��a�� t,�c rsU� HomeAddress: 1 5`'I �C� �`t� �i . 1V• S7�' ul/1�V CZ�'Z _ _ Street Addnv " - : - � � CiTy - Statc Zip Date of Birth: /�' —� — JZ� Place of Birth: f 5 s�vv� i(�n �l �� -{ �l�Iome Phone: ��) :?are rca ev� b� :ani�c:ed of a�� f lony, cri.:,e o: ;zolzL�cn cf a:.y c:ty e: di�ance at�':er thz*. +s�c? I'ES NO Date of arrest: Where? Chargz: _ Conviction: Sentence: Lis[ tbe names and residences of three perwns of good moral character, living within the Twin Cities Metro Area, not related to the appLcant or financia2ly interested in the premises or business, who may be referred to as to the applicanPs character: NAME ADDRESS -, 1 ;� you current]y hold, formerly he]d, or may have an interest in: Have azry of the above name3licenses ever been revoked7 __ YES NO If yes, list the dates and reasons for revocalion: y. 2/18/97 Are you going to operate this business personall}'? ,� YES Firsc xeme .'vtiddle Initisl ('�iaidrn) Homc Addicss: Stred \zme Are you gomg to ha��e a manaezr or_assistant in ttais buiness? please complete the folloa�ins infomiation: Cin" YES �_ NO If not, �3 ho �till operate it? �1 �� 5 S�'4, Last Da�e ofBirth Stxte Zip Pume \umb- _� 2�T0 If the manaeer is not the szme zs Cne operaior, First\'eme ?.1iddleInitial (�f^rd-°n) Lsst DateofBiY.n Home Add�css: Stxeet \ame Ci:y Siate Zip Pnrnc \�ber 'Tt- List all other officers of the corporation: OFFICER TIII,E HOME NAME (OfficeHeld) ADDRESS HOME BUSINESS DATE 0� PHOIvE PHOIvTE BIRTH � �� If business is a partnership, please inciude the following information for each parmer (use additional pages if necessary): �oY�,e/ Fisst2:ame MiddlcInitisl (VSaiden) Lavt DatcofBirth HomeAddrexe: Strut�ame CiTy State Zip Pf�one?�umbcr Fart Name Home /+ddnss: Street t�amc City L� State Zip Dnte ofB"uth Phonc :�'umbcr MRQI�SOTA TAX IDENTIFICATION NUMBER - Piusuant to the Laws of Minnesota, 1984, Chapter 502, Articie 8, Section 2(270.72) (Ta�c Cle� ance; Issuance of Licenses), licensing autl�orities aze required to provide to tt�e State of 2vTinnesota Commissioner of Revenue, the Minnesota business ta�c idrnvfication number and the socisl 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 following regarding ihe use of the Minnesota TaY Identification Number: - This infoimation may be used to deny the issuance or renewal of your license in tbe event you owe Minnesota sales, employer's withholding or motor vehicle excise taxes; - Upon receiving tlris infoimation, the licensing authority will suppiy at only to the Minnesota Aepartment of Revenue. However, under the Federal Exchange of Tnformation Ageement, the Departrnent of Revenue may supply this infozmation to the Intetnal Revenue Service. ivfinnesota Tax Identificarion Nmnbeis (Sales & Use TaK Number) may be obtained fram the State of Minnesot� Business Records Deparhnent, 10 River Park Plaza (612-296-6181). Social Security Number: `J ' `-� ZL( Minnesota Tax Identificalion Number: 7 Z 5�/-�Z � If a Minnesota Ta�c Identification Number is not required for the business being operated, indicate so by piacing an"X" in the box. Middlc Initiel 2/18,91 Please list your emplo}�ment history for the pre�ious five (5} }ear period: _ a�-�ssy CERTffICATION OF WORKERS' COMPENSATION COVERAGE PURSU:vNT TO MIN:QESOTA STANTE 176182 I hereby certify that I, or m} compazry, am in compliance �32Sh the �� o.kers' compensation i;.surance coverage requirements of ;viinnesota S�T�te 176.182, subdi�ision 2. I also undzrs'��d �hzt p,-ovision of false info�nation in th.is czctification constitutes sufficient grounds for ad��erse actioa zee�st all liceases held, including re�yc�on and sespension of said lice-ises. N�,me of Insurance Compang: Polic} Nu. /�,� �� { Co��eragzfro:a � �"�� io ��`��`�� I hace no emplo}'�s cocered under u�o;kz;s compznsation i�su:-znce (_1'_vTITL1LS) r�NY FALSIFZCATIO?�� OF Al\'S�'ERS GIVEN OR MATERIAI, SUBMTTTED F4ILI, RESULT IN DEI�TAL OF THIS APPLICATION I hereby state that I ha�•e answered all of tbe preceding queslions, and that the infonnalion containzd herein is true and correct to the be� of my know(edge and betief I here6y state iurther that I have receii ed no monec or othec co deration, by w'ay of loan, gift, con�ibutirn, or othhezra�se, other than already disclosed in the application which I here� h submitted I also�stand this premise may be inspected by po!ice, fire, health and othez city officials at an}� and all times u�hen the ess is m operatio�� z �� Date We�rill accept pa}•ment by casb, check (made PAYING BY CREDIT CARD PLEASE 7'17 •� I• I�■ ■■ \ame of Car�older Date *'Note: ff this applicaGon is Food/Liquor related, please contact a City of Saint Paul Heaith Inspector, Steve Olson (266-9139), to re�iew plans. If any substanlial ohanges to structure are anticipated, please contaet a City of Saint Paul Plan Exazniner at 266-9007 to applp for building permits. If there are any changes to the parking lot, floor space, or for new operations, please contact a City of Saint Paul Zoning Inspector at 266-9008. All applications requim the follo�ing documents. Please attach these documents �c�he¢ submitting yo¢r application: 1. A detailed description of the desig� location and square footage of the premises to be Iicensed (site plan). The following data should be on the site plan (preferably on an 8 1/2" x 11" or 8 I/2" x 14" paper): - Name, address, and phone number. - The scaSe shouid be stated such as 1" = 20'. ^N should be indicated toward the top. - Placement of all pertinent features of the interior of the licensed facility such as seating areas, kitchens, offices, repair area, parking, rest rooms, efc. - ff a request is for an addition or expansion of the licensed facility, indicate both the current azea and the proposed eapansion. 2. A copy af pour lease agreement or proof of o�n�nesship of tt�e property. SPECIFIC LICENSE APPLICATIOiVS, REQULRE ADDTTIONAL INFORMATION. PLEASE SEE REVERSE FOR DETAII,S >>>> to City of(S�'�aye[) or 6fedit card (M/C or Visa). � � THEFOLLOWINGINFORMATION: � MasterCard � Visa ACCOtTNT NCTMBER: ��Lf�� 2;18i97 Are you going to operate this business personallyl �YES Firft \amc �fiddle Initial (�iaidcn) �-� NO If not, wNo will operate it? � Date of Binh HomeAddrw: Stlut?:ame Ciry� / Swe Zip PhoneNumbet Are you going to have a manager or assistant in this business7 v YES NO If the manager is not the sazne as the operator, please complete the fol]owing information: Fua?:,me .saa��In;�,� (�re;a�,> Last Das�oravu, HomcAddrtss: Sirat\*ame City State Zip Phone?��bcr Please list your emplo}rtnent history for ihe previous five (5) �'eaz period: Busines�Em�]o�mrnY Address List all other officers of the corporation: OFFICER TITLE HOME HOME BUSINESS DATE OF NAME (Office Held) ADDRESS PHONE PHONE BIFtTT-I �/z. . i�i�lr-- c�t cr,c ) /�-/� > � s� <�,� �� 5,�- �/�l �� iO� �s-o6—H , If business is a par�ership, please include the following information for each partner (use additional pages if necessary): FitrtName Middlelritid (.Maidcn) Las[ DatcofBirth HomeAddrw: Streclt�ame City Shto Zip Phone.Vumber Fint I:ame Middle Initial (!4faidcn) Lsst Dau of Sirth Homc Addns�: Skeet Namo City Smte Zip Phone h'umbcf MIS�RQESOTA TAX IDENTIFICATIO23 NUt�ER - Pursuant to the Lau�s of Minnesota, ] 984, Chapter 502, Article 8, Section 2(270J 2) (Tex Clearance; Issuance of Licenses), licensing authorities are required to provide co lhe State of Ivlinnesota Comtnissioner of Revenue, the Minnesota business tax identification number and the social security number of each license apglican� Undet the Minnesota Govemment Data Praclices Act and the Federal Privacy Ac[ of 1974, we aze required to advise you of the following re$arding the use of the Minnesota T� ldrntification Number: - This information cnsy be used to deny the issuance or renewal of yout license in fhe event you owe Minnesota sales, employet's withholding or motor vehicle excise taxes; • Upon receiving this informatioq the licensing authority W�i11 supply it only to the Nfinnesota Department of Revenue. However, under the Federal Exchange of Tnfoitnation Agreement, the Departmrnt of Revenue may supply thas infoimation to the Intemal Revenue Service. Mumesots Tax Ida�tiScation Numbers (Sales & Use Ta�c Niunber) may be obtained 5rom the State of Minnesota, Business Records Department, 10 River Park Plaza (612-296-b ] 81). . Social Security Number: �� =�-? ��! Ivlinnesota TaK Identification Number: ,�,� ��F' � If a Minnesota Tax Identification Number is not required for the business being operated, indicate so by placing an"X" in the box. a�-�ssy ziis�a CERTTFICATION OF WORKERS' COMPSNSATION COVIiRAGE PUI2SUANT TO MINNESOTA STATUTE 176.182 �' _ 1SS 1 I hereby cenify that I, or my company, am in compliance with the workers' compensation insursnce coverage requirements of Minnesota Statute 176. I 82, subdivision 2. I also understand that provision of false infortnalion in this certification constitutes sufficient grounds For adverse aclion against all licenses hcld, including revocation a�d suspension of said licenses. Nazne of Insurance Company: Policy Numbet: Coverage from �� %� to y-f I have no employees covered under workers' compensation insurance (INITIALS) ANY FAISIFICATION OF ANSWERS GNEN OR MATERIAL SUBMITTED WILL RESULT IN DEMAL OF THIS APPLICATION I hereby state [hat I have answered all of ihe preceding questions, and that the information contained herein is true and correct to the best of my knowledge and be]icf. I hereby state Iwther that I have received no money or other consideration, by way of loan, gift, conhibuUOn, or othenvise, other than already disclosed in the application which I hetewith submitted I also understand this premise may be inspected by police, fire, health and other city o�cials at any and all times when the business is in operation. / � We will accept payment by cash, check (made payable to Signatum UIRED fpF�U applications) Saint Paun or credit card (M/C or Vlsa). Date PAYING BY CREDIT CARD PLEASE COMPLETE THE FOLLON'ING INFORMATION: � MasterCazd � Visa EXPIItATION DATE: ❑�/�❑ ACCOUNT NUMBER: � � � � � � � � � � � � � � � � �' "Note: ]f this app]ication is Food/Liquor related, please contact a Ciry of Saint Paul Heulth Inspector, Steve Olson (266-9139), to review plans. if any subslantial changes to sWeture are anticipated, please com�ct a Ciry of Saint Pau1 Plan Examiner at 266-9007 to apply for building permits. If there are any changes to the parking lot, iloor space, or for new operations, please eontaet a City of Saint Paul Zoning Inspector at 266-9008. All applications require thc lollowing documcnts. Plcase attacfi these documents when submitting your appiication: !, A detailed description o(the design, location and square footage oCthe premises to be licensed (site plan). The £ollowing data should be on the site plan (prefera6ly on an 8 I/2" x 11" or 8 1(Z" x 14" paper): - Name, address, and phone number. - The scale should be stated such xs 1" = 2Q'. ^N sh�uld 6e indicated towazd ttte top. - Placement of ail pertinent features of the interior of the licensed Cacility such as seating areas, lcitchens, offices, repair area, parking, rest rooms, etc. - If a request is for an addition or expansion of the licensed facility, indicate both the currrnt area and the proposed expansion. 2. A copy of your lease agreement or proof of ownership of the property. SPECTP'TC LICENSE APPLICATIONS REQUIR� ADDITIONAL INTORMATION. PLEASE S�E REVERSE FOR D�TATLS >>>> aia sis� Presented By 5 ��5� ��k� G � Council File #� � 1��7 y � Ju'a p� Ordinance # / '-� 1 V Green Sheet $ 35316 RESOLUTION CITY OF SAINT PAUL, MINNESOTA �� /J�� J ��C Referred To Committee: Date 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 I8 19 2� 21 22 23 24 2$ 26 27 28 29 RESOLVED: That application, ID #54805, for an Auto Body Repair Garage license by Centerline Frame Inc. DBA Centerline Frame Inc. (David Bergum, President) at 100 Cottage Avenue West, be and the same is hereby approved with the following conditions: 1) All work required Eor the change in the use of the building is completed and a certificate of occupancy is obtained from this office. We will not issue the official licensing document until this condition is satisfied. 2) The off-street parking sur£ace in fronti of the building muat be used only as employee parking space and/or the short term parking for customers, salesperson, etc. This space may not be used for storage of vehicles awaiting service or as drop-off area for vehicles towed to the site. Vehicles coming to this site for servicing must be parked inside the fence area. 3) The business of obtaining vehicles with the sole purpose of salvaging them exclusively for this value as scrap metal is expressly forbidden. Auto salvage is not a permitted use in the 1-1 zoning district the property is located. 4) It is underatood that an auto body repair business will generate parte that will be discarded as scrap. This later activity is permisaible ae part of the normal servicing required to repair the vehicle. These discarded parts must be removed from the property weekly. The discarded parts will be stored inside the fence area either in an enclosed container or in a location that is not visible from the street. 5) No spray painting permitted without proper ventilation and apray booth per Fire Inspection. Requested by Department of: Adoption By: � Approved i By: by Council Secretary � F � , �. � - !v Office of License Ins�ections and Environmental Protection By: � �� A�i -� Form App 9ved by Cit,I Attorney By: � z-�l�� Approved by Ma or for ubmission to Council By: Adopted by Council: Date� �.,_y �,gq� � a�-�s54 �EPAq'fMENT/OFFICE/CqUNCIL OATEINRIATED GREEN SHEE �O 35316 LIEP/Licensi,ng INRIAVDATE INR�AVDATE CANTACT PEpSON 8 PHON£ O DEPARTMEM DIRECTOR O CRY CAUNCIL Christine Rozek, 266-9108 "��cx �cmaTroaNer aCITYCLERK MUST BE ON COUNCIL AGENDA BY (OATE) NUYBER FOP O BUDGET DIRECTOF O FIN. & MGT. SERVICES DIR. POUTING F'OY hearin ;/a oZoZ. �J' ONDER OMpYOR{ORASSISTAlfn O TOTAL # OF SIGNATURE PAGES (CLIP ALL LOCAT{ONS FOR SIGNATUR£) ACT70N REW1E57ED: Centerline Frame Inc. DBA CenCerline Frame Inc. requests Council approval of its application for an Auto�te air Garage License located at 100 Cottage Avenue West (ID /�54805). da& RECOMMENDAnONS: Approve (A) r Reject (fi) PERSONAL SERYICE CANTRACTS MUST ANSWER TXE GOLLOWING QUESTiONS: _ PLANNING COMMISSION _ GVIL SERVICE COMMISSION �� Has Nis person/firtn ever worketl under a contract for thi5 departmeM? - _ CIBCOMMR7EE YES NO _ STAFF 2. Has this person/firm ever been a city employee? — YES NO _ DISTRICT CAURi _ 3. Does this person/firm possess a skill not normally possessed by any current city employee? SUPPORTS WNICH CAUNCIL O&IECTIVE4 YES NO Explsin all yes answers on seperate sheet antl attach tp green sheat ��e�' e ".. . 6.', INITIATING PROBLEM, ISSUE, OPPoRTUNITY (Who. What. When, Where, Why): �,_ �� '" �? iAAR 2 5 1997 CITY A�'�OR�E�' ADVANTAGESIFAPPROVED: OISADVAPlTAGES IF APPFOYED: DISADVANTAGES IF NOT APPROVED: � DEG 0 $ 1997 TOTAL AMOUNT OF TRANSACTION S COST/REVENUE BUDGEiED (CIRCLE ONE) YES NO FUNDING SOURCE AC7IVITY NUMBER FINANCIAL INFORMATION: (EXPLAIN) Council File # � S S� Ordinance # Green Sheefl # 35316 1 4 5 8 9 10 11 12 13 14 15 16 17 i8 19 2� 21 22 23 24 25 26 27 28 29 3) The business of obta them exclusively for Auto salvage ia not/ property is locateyi. 4) It is unders that will be part of the discarded pa discarded p enclosed c� street. RESOLUTION CITY OF SAINT PAUL, MINNESOTA �ng vehicles with the sole purpose of salvaging his value as scrap metal is expressly forbidden. permitted use in the 1-1 zoning district the �that an auto body repair business wi11 generate parts carded as acrap. This later activity is permisaible as ial servicing required to repair the vehicle. These must be removed from the property weekly. The will be stored inside the fence area either in an ,er ar in a location that is not visible from the Presented Bp�� Referred To 2) The off-street parking surface in front of the building must be used only as employee parking apac andJor the ahort term parking for customers, salesperson, etc. This apace may not be used for atiorage of vehicles awaitinq service as drop-off area for vehicles towed to the site. Vehicles coming to his site for servicing must be parked inside the fence area. Date 32 RESOLVSD: That application, iD #54805, for an Auto Repair Garage License by Centerline Frame Inc. DBA Centerline Frame Inc. (David B gum, President) at 100 Cottaqe Avenue West be and the same is hereby approv with the following conditions: 1) All work required for the change in e use of the building is completed and a certificate of occu ancy is obtained from this office. We will not iseue the official lic nsing document until this condition is satisfied. Requested by Department of: • - '�-- �- - -�= -.�• - - .. Hy: Adopted by Co cil Adoption Ce ified By: Approved by Mayor: By' Date by Council Secretary Date Form Approved by City Attorney By: °�� _ _ Approved b Mayor for Submission to Council By: CLASS III LICENSE APPLICATIOIvT v ��p� ��-�ssy CITY OF SA11�TT PAUL O�ce of Licrnse, Iacpeaions a.id Emvmmrnizl Protectioa 55. 5:?r.a Sc S�x 3f�J' Sz;,;?zc, 4ti �h 55103 C614)?bGo04J fzx(612J2669i24 THIS APPLICATION IS SUBJECT TO I2EVIEW BY THE PUBLIC PLEASE TYPE OR PRINT IN IIvTK Ca�� j_,_ � T}pe of Licensz(s) being applied for_ _�Ca 0 f'Y/�(��- ��f (/—_�� \ J S�� 7e / c Cou pany Name: ��p If business is incorporated, give date of incorporation: AoingBusinessAs: �7�kVl/\�7 Business Address: Business Phone: � s4eet ndaresx � / c � iry s�are z[p Berit�een uhat cross streets is the b located? i ' < / S� Which sid�e of the street? Ot�� Are tLz premises now occupied7 T�� What Type of Business? c9T'C"� tZ�i �� — �-� - K.l+w�' ,�1.,.,� � Mail To Address: � �f7 c,J . ( .rrrv � £, F�Q� �i : Pia �L V✓�d..j �S�t \`� , strcct Addsss . - - c�ry - � . state zip . . Applicant Information: Name and Ti4e: f � F,m _tiLaatc ��a�� t,�c rsU� HomeAddress: 1 5`'I �C� �`t� �i . 1V• S7�' ul/1�V CZ�'Z _ _ Street Addnv " - : - � � CiTy - Statc Zip Date of Birth: /�' —� — JZ� Place of Birth: f 5 s�vv� i(�n �l �� -{ �l�Iome Phone: ��) :?are rca ev� b� :ani�c:ed of a�� f lony, cri.:,e o: ;zolzL�cn cf a:.y c:ty e: di�ance at�':er thz*. +s�c? I'ES NO Date of arrest: Where? Chargz: _ Conviction: Sentence: Lis[ tbe names and residences of three perwns of good moral character, living within the Twin Cities Metro Area, not related to the appLcant or financia2ly interested in the premises or business, who may be referred to as to the applicanPs character: NAME ADDRESS -, 1 ;� you current]y hold, formerly he]d, or may have an interest in: Have azry of the above name3licenses ever been revoked7 __ YES NO If yes, list the dates and reasons for revocalion: y. 2/18/97 Are you going to operate this business personall}'? ,� YES Firsc xeme .'vtiddle Initisl ('�iaidrn) Homc Addicss: Stred \zme Are you gomg to ha��e a manaezr or_assistant in ttais buiness? please complete the folloa�ins infomiation: Cin" YES �_ NO If not, �3 ho �till operate it? �1 �� 5 S�'4, Last Da�e ofBirth Stxte Zip Pume \umb- _� 2�T0 If the manaeer is not the szme zs Cne operaior, First\'eme ?.1iddleInitial (�f^rd-°n) Lsst DateofBiY.n Home Add�css: Stxeet \ame Ci:y Siate Zip Pnrnc \�ber 'Tt- List all other officers of the corporation: OFFICER TIII,E HOME NAME (OfficeHeld) ADDRESS HOME BUSINESS DATE 0� PHOIvE PHOIvTE BIRTH � �� If business is a partnership, please inciude the following information for each parmer (use additional pages if necessary): �oY�,e/ Fisst2:ame MiddlcInitisl (VSaiden) Lavt DatcofBirth HomeAddrexe: Strut�ame CiTy State Zip Pf�one?�umbcr Fart Name Home /+ddnss: Street t�amc City L� State Zip Dnte ofB"uth Phonc :�'umbcr MRQI�SOTA TAX IDENTIFICATION NUMBER - Piusuant to the Laws of Minnesota, 1984, Chapter 502, Articie 8, Section 2(270.72) (Ta�c Cle� ance; Issuance of Licenses), licensing autl�orities aze required to provide to tt�e State of 2vTinnesota Commissioner of Revenue, the Minnesota business ta�c idrnvfication number and the socisl 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 following regarding ihe use of the Minnesota TaY Identification Number: - This infoimation may be used to deny the issuance or renewal of your license in tbe event you owe Minnesota sales, employer's withholding or motor vehicle excise taxes; - Upon receiving tlris infoimation, the licensing authority will suppiy at only to the Minnesota Aepartment of Revenue. However, under the Federal Exchange of Tnformation Ageement, the Departrnent of Revenue may supply this infozmation to the Intetnal Revenue Service. ivfinnesota Tax Identificarion Nmnbeis (Sales & Use TaK Number) may be obtained fram the State of Minnesot� Business Records Deparhnent, 10 River Park Plaza (612-296-6181). Social Security Number: `J ' `-� ZL( Minnesota Tax Identificalion Number: 7 Z 5�/-�Z � If a Minnesota Ta�c Identification Number is not required for the business being operated, indicate so by piacing an"X" in the box. Middlc Initiel 2/18,91 Please list your emplo}�ment history for the pre�ious five (5} }ear period: _ a�-�ssy CERTffICATION OF WORKERS' COMPENSATION COVERAGE PURSU:vNT TO MIN:QESOTA STANTE 176182 I hereby certify that I, or m} compazry, am in compliance �32Sh the �� o.kers' compensation i;.surance coverage requirements of ;viinnesota S�T�te 176.182, subdi�ision 2. I also undzrs'��d �hzt p,-ovision of false info�nation in th.is czctification constitutes sufficient grounds for ad��erse actioa zee�st all liceases held, including re�yc�on and sespension of said lice-ises. N�,me of Insurance Compang: Polic} Nu. /�,� �� { Co��eragzfro:a � �"�� io ��`��`�� I hace no emplo}'�s cocered under u�o;kz;s compznsation i�su:-znce (_1'_vTITL1LS) r�NY FALSIFZCATIO?�� OF Al\'S�'ERS GIVEN OR MATERIAI, SUBMTTTED F4ILI, RESULT IN DEI�TAL OF THIS APPLICATION I hereby state that I ha�•e answered all of tbe preceding queslions, and that the infonnalion containzd herein is true and correct to the be� of my know(edge and betief I here6y state iurther that I have receii ed no monec or othec co deration, by w'ay of loan, gift, con�ibutirn, or othhezra�se, other than already disclosed in the application which I here� h submitted I also�stand this premise may be inspected by po!ice, fire, health and othez city officials at an}� and all times u�hen the ess is m operatio�� z �� Date We�rill accept pa}•ment by casb, check (made PAYING BY CREDIT CARD PLEASE 7'17 •� I• I�■ ■■ \ame of Car�older Date *'Note: ff this applicaGon is Food/Liquor related, please contact a City of Saint Paul Heaith Inspector, Steve Olson (266-9139), to re�iew plans. If any substanlial ohanges to structure are anticipated, please contaet a City of Saint Paul Plan Exazniner at 266-9007 to applp for building permits. If there are any changes to the parking lot, floor space, or for new operations, please contact a City of Saint Paul Zoning Inspector at 266-9008. All applications requim the follo�ing documents. Please attach these documents �c�he¢ submitting yo¢r application: 1. A detailed description of the desig� location and square footage of the premises to be Iicensed (site plan). The following data should be on the site plan (preferably on an 8 1/2" x 11" or 8 I/2" x 14" paper): - Name, address, and phone number. - The scaSe shouid be stated such as 1" = 20'. ^N should be indicated toward the top. - Placement of all pertinent features of the interior of the licensed facility such as seating areas, kitchens, offices, repair area, parking, rest rooms, efc. - ff a request is for an addition or expansion of the licensed facility, indicate both the current azea and the proposed eapansion. 2. A copy af pour lease agreement or proof of o�n�nesship of tt�e property. SPECIFIC LICENSE APPLICATIOiVS, REQULRE ADDTTIONAL INFORMATION. PLEASE SEE REVERSE FOR DETAII,S >>>> to City of(S�'�aye[) or 6fedit card (M/C or Visa). � � THEFOLLOWINGINFORMATION: � MasterCard � Visa ACCOtTNT NCTMBER: ��Lf�� 2;18i97 Are you going to operate this business personallyl �YES Firft \amc �fiddle Initial (�iaidcn) �-� NO If not, wNo will operate it? � Date of Binh HomeAddrw: Stlut?:ame Ciry� / Swe Zip PhoneNumbet Are you going to have a manager or assistant in this business7 v YES NO If the manager is not the sazne as the operator, please complete the fol]owing information: Fua?:,me .saa��In;�,� (�re;a�,> Last Das�oravu, HomcAddrtss: Sirat\*ame City State Zip Phone?��bcr Please list your emplo}rtnent history for ihe previous five (5) �'eaz period: Busines�Em�]o�mrnY Address List all other officers of the corporation: OFFICER TITLE HOME HOME BUSINESS DATE OF NAME (Office Held) ADDRESS PHONE PHONE BIFtTT-I �/z. . i�i�lr-- c�t cr,c ) /�-/� > � s� <�,� �� 5,�- �/�l �� iO� �s-o6—H , If business is a par�ership, please include the following information for each partner (use additional pages if necessary): FitrtName Middlelritid (.Maidcn) Las[ DatcofBirth HomeAddrw: Streclt�ame City Shto Zip Phone.Vumber Fint I:ame Middle Initial (!4faidcn) Lsst Dau of Sirth Homc Addns�: Skeet Namo City Smte Zip Phone h'umbcf MIS�RQESOTA TAX IDENTIFICATIO23 NUt�ER - Pursuant to the Lau�s of Minnesota, ] 984, Chapter 502, Article 8, Section 2(270J 2) (Tex Clearance; Issuance of Licenses), licensing authorities are required to provide co lhe State of Ivlinnesota Comtnissioner of Revenue, the Minnesota business tax identification number and the social security number of each license apglican� Undet the Minnesota Govemment Data Praclices Act and the Federal Privacy Ac[ of 1974, we aze required to advise you of the following re$arding the use of the Minnesota T� ldrntification Number: - This information cnsy be used to deny the issuance or renewal of yout license in fhe event you owe Minnesota sales, employet's withholding or motor vehicle excise taxes; • Upon receiving this informatioq the licensing authority W�i11 supply it only to the Nfinnesota Department of Revenue. However, under the Federal Exchange of Tnfoitnation Agreement, the Departmrnt of Revenue may supply thas infoimation to the Intemal Revenue Service. Mumesots Tax Ida�tiScation Numbers (Sales & Use Ta�c Niunber) may be obtained 5rom the State of Minnesota, Business Records Department, 10 River Park Plaza (612-296-b ] 81). . Social Security Number: �� =�-? ��! Ivlinnesota TaK Identification Number: ,�,� ��F' � If a Minnesota Tax Identification Number is not required for the business being operated, indicate so by placing an"X" in the box. a�-�ssy ziis�a CERTTFICATION OF WORKERS' COMPSNSATION COVIiRAGE PUI2SUANT TO MINNESOTA STATUTE 176.182 �' _ 1SS 1 I hereby cenify that I, or my company, am in compliance with the workers' compensation insursnce coverage requirements of Minnesota Statute 176. I 82, subdivision 2. I also understand that provision of false infortnalion in this certification constitutes sufficient grounds For adverse aclion against all licenses hcld, including revocation a�d suspension of said licenses. Nazne of Insurance Company: Policy Numbet: Coverage from �� %� to y-f I have no employees covered under workers' compensation insurance (INITIALS) ANY FAISIFICATION OF ANSWERS GNEN OR MATERIAL SUBMITTED WILL RESULT IN DEMAL OF THIS APPLICATION I hereby state [hat I have answered all of ihe preceding questions, and that the information contained herein is true and correct to the best of my knowledge and be]icf. I hereby state Iwther that I have received no money or other consideration, by way of loan, gift, conhibuUOn, or othenvise, other than already disclosed in the application which I hetewith submitted I also understand this premise may be inspected by police, fire, health and other city o�cials at any and all times when the business is in operation. / � We will accept payment by cash, check (made payable to Signatum UIRED fpF�U applications) Saint Paun or credit card (M/C or Vlsa). Date PAYING BY CREDIT CARD PLEASE COMPLETE THE FOLLON'ING INFORMATION: � MasterCazd � Visa EXPIItATION DATE: ❑�/�❑ ACCOUNT NUMBER: � � � � � � � � � � � � � � � � �' "Note: ]f this app]ication is Food/Liquor related, please contact a Ciry of Saint Paul Heulth Inspector, Steve Olson (266-9139), to review plans. if any subslantial changes to sWeture are anticipated, please com�ct a Ciry of Saint Pau1 Plan Examiner at 266-9007 to apply for building permits. If there are any changes to the parking lot, iloor space, or for new operations, please eontaet a City of Saint Paul Zoning Inspector at 266-9008. All applications require thc lollowing documcnts. Plcase attacfi these documents when submitting your appiication: !, A detailed description o(the design, location and square footage oCthe premises to be licensed (site plan). The £ollowing data should be on the site plan (prefera6ly on an 8 I/2" x 11" or 8 1(Z" x 14" paper): - Name, address, and phone number. - The scale should be stated such xs 1" = 2Q'. ^N sh�uld 6e indicated towazd ttte top. - Placement of ail pertinent features of the interior of the licensed Cacility such as seating areas, lcitchens, offices, repair area, parking, rest rooms, etc. - If a request is for an addition or expansion of the licensed facility, indicate both the currrnt area and the proposed expansion. 2. A copy of your lease agreement or proof of ownership of the property. SPECTP'TC LICENSE APPLICATIONS REQUIR� ADDITIONAL INTORMATION. PLEASE S�E REVERSE FOR D�TATLS >>>> aia sis�