97-1558Council File # �� � � 5 'J
� .- ' � " ' ,
Ordinance #
Green Sheet # ������
RESOLUTION
CITY OF SA1NT PAUL, MINNESOTA
Presented Hy
Referred To
23
Committees Date
i RESOLVED: That application (ID #14740) for a Game Room License by Bihn Nguyen DBA Truc Mi Billiards
2 (Binh Dat Nguyen, Owner) at 2422 University Avenue Wes[ be and the sa�ne is hereby appmved
with the following conditions:
fl
2
The parking lot must be kept free of litter.
Management must call the police to report problems.
3. There sha11 be no weapons on the premises at any time and the
licensee shall observe the same restrictions regarding weapons as -
liquor establishments, as contained in paragraph 409.06M of the
Saint Paul Legislative Code.
4. No gang colors shall be allowed to be worn by the patrons on the
licensed premises. Signs shall be posted to this effect and the
licensee shall consult with the Saint Paul Police to determine how
to identify gang colors.
5. Adequate lighting for rear parking 1ot must be maintained.
6. The licensee shall make sure that there are no minors present in
the establishment in violation of Saint Paul curfew restrictions.
3
4 Requested by Department of:
5 Y Navs Absen+
6 B a�Tev -
7 Bostrom
$ .cr�..,-. e
1� �
11 Cs e a
aa
ia ° °
15 Adopted by Council: Date \��
16
17 Adoption Certified by Council Secretary
18
19
20 By:
ai
22 Appr
23
24
25 By:
26
• - -�.- �-r- .e- .ec
.. e •��a - •t
$Y: ���{-f-� �- �
Form Approved by City Attorney
B ��� ., �1 �w�
U
Approved by Mayor for Submission to
Council
By:
° ��-1 S S8'
DEA1fliMENTNFFICE/COUNCIL DATE INITIATED 3 7 9 5 0
LIEP/Licensin GREEN SHEE
CON�ACTPERSON&PHONE INITIAVDATE _. INITIAVDATE
� DEPARTMENT DIRECTOR � � CITY CAUNCIL
ASSIGN CRY ATTOFiNEY C1TY CLERK
Christine Rozek 266-9108 NUNBEqFOR � �
MUST BE ON COUNCIL AGENDA BY (�ATE� pp��qG �@UDGET DIRECTOR O FIN. & MGT. SERVICES DIR.
/ OPCEP � MAYOR (OR ASSISTAPJT) �
For e r'n : 1
TOTAL # OF SIGNATURE PAGES (CLiP ALL IOCATIONS FOR SiGNATURE)
ACTIDN REQUESTED:
Binh Nguyen DBA Truc Mi Billiaxds requests Gouncil approval of its application for a
Game Room License located at 2422 University Avenue West (ID �/14740).
RECOMi+fENDA710NS: npprove (A) or peject (A) pEflSONAL SEFiVICE CONTRACTS MUST ANSWER TNE FOLLOWING �UESTIONS:
_ PLANNINfi COMMISSION _ CIVIL SERVICE COMMISSION �� Has Mis personlFirm ever woifced under a coMract for this depanmeM?
_ G�e COMMiTfEE _ YES NO
2. Has [his person/firm ever been a city employee?
__ STAFF — YES NO
_ o1SiRIC7 cAURT _ 3. Does this personRirm possess a skill not normafVy possessetl by any curteM ciry employee?
SUPPORTS WHICH COUNCIL OBJECTIVE7 YES NO
Explafn all yes anawers on separate sheet and ettach to green sheet
INITIATING PROBLEM. ISSUE, OPPEIHTUNITY (Who, Whffi. When, Where, WM1y): - -
��a��� E�
iv9AY G' 3 1997
���� � � € � ��� � ;.:�.�, .
ADVANTAGES IF APPqOVED:
DISADVANTA6E5 IF APPROVED:
DISAOVANTAGES IF NOT APPROVED:
��0Ut1CN �AtC�1 �1il�T
►vov 2s �5s�
TOTAL AMQUNT OF TRANSACTION $ COST/REVENUE BUDGE7ED (CIRCLE ONE) VES NO
FUNDIfdG SOURCE ACTIVITY NUMBEH
FINANCIAL INFORHiATION. (EXPLAIN)
CLASS III
LICENSE APPLICATION
9'1-I S58'
CITX OF SAINT PAUL
Office of Licensc Uup�xtions
and En��irovncntai Protection
3tp Si Pea St Su��e?0.t
Gim Paul. �tin�aRa <9102
(6�])=EFwJ R<(EI?)](3�SL"a
THtS APPLICATIOV IS SLBIECT TO REVIE�V BY 77� pt'BLIC
PLEASE Tti'PE OR PRL\T L� I�K
T��pe of Licease(s) being applied for:
Company;�aa�:
Cetpoztion / pazmership ! Sok proprietorship
If business is incorporated, gi��e date ef incorporation: �—
Doina Bu<iness As:
Buciness Addrzss: Zy� G��(il/; y✓C�p'fi j�S/ �� f�
sa��aaarus —�
Benreen uhat cross streets is the businesc lo;ated? �j� `,"
Are the prenrises nou� occupied? �1. `�'' .j ��'hat T}�pe of Buc�ness?
C. � / —
.'�Iai3ToAddress: !'7�7 Tj<<'iaLc�!%'Q/,c' �iT
$trcet .Address
Applicant Information:
�ame and Title: �
Firsc
�4iddle
�
c�ry
'1�
�
r ,
, Business Phone:
i �
Sute Zip
1t'hich side of lhe stseec? `7
��
Stace
(TSaidenJ
Zip
C w.c
TiUe
Ho�m Address: �� j%�G:.��./�Z( ST �-- 7
A Sn�tAddrets �l CC�f/ GG / >�y�O(
Ciry State Zip
Datc of Birth: /^�—�� `� Place of Birth: ]f; �= T/f1'i_ 7az Home Phone: � 7 y y� S
Have qou ever beeo com�icted of any felony, crime or violazion of any ciry ordinance other than tratfic? YES _\'O �
Date of arrest: R'here?
Charge: � - —
Coneicdon: Sentence:
List the names and residences of ehree persons of good moral chazacter, li�•iag aithin the Twin Cities Met�o Area, not related to the
applicant or financial)y iocerested in the premises or business, u•ho may be referred to as to tiie applicanCs cbazuter:
NAME annAFCC _ _ _
List licenses whic6 }•ou currendy hold, forc[�rly 6eld, or may 6a� e an interest in: T �(� ( Z� �6 '��3'
�c-J/-?>1Ni^ f'o/�i�l��l�C'�•S�' cz` SLt �y"'GC... 5 � s� y't '/Gl/1J
Ha� c an}' of the abo�•e named Lcense5 eeet been revoked� _ YES � j�0 lf yes, list the dates and reasons for tevocation:
Are you going to operate ehi�b��ness personatly? � YE$ _�O If not, a�ho w�ill operate it?
tirst \ame
Home Address: StreG lame
T4�881c
(Afaiden) � j,�
G.y
Swte Z�P
Da�e of 9inh
Phone Tumber
.,yG� J '� P > � O �C' �I a A
Are }'ou going to ha�•e a mana�er or v�sistant in this business? _ 1'ES � �O If the manager is not the s.?,t� � r `�/'� . • f, •�o �O� �j
comple[e the fo1loW�ing infom�atioo: �$,9��. a �G� v
Frst':acck
HemeAdBras: Sueet\zne
C�.y
Ple:vice list your emplo}ment history fer the pre�ious fi��e (:) ;eaz period:
List a3l othei efficers of the corporatien:
OFF3CER 7'ITLF HOME
\A'�4E (OfficgHeld) ADDRESS
?;id�Ie [nitial (>iaiden)
a�� A '�.
P
�y�� � Date of n,. �
q�-Iss
Sute Zip Phone�um?+cr
HO?�'IE BliSI:��ESS D.4TE OF
PHO\E PHO\E BIRTH
If business is a partnership, plea.ae include tbe following infermalion for eac6 partner (u<e additional paQes if necessary'):
First'<ame
Home Address: Svea �xme
Frst !:ame
HomeAddress: Stteet!�zme
'..1iddle L�:tial
Tliddle Huual
Ciry
('.faiden)
(D9aiden)
Lut
S�a[e
J.a51
State
Date oi Binh
Zip Phone Number
' Date of Binh
Zip Phone'�umber
NII.`�T'FSOTA TAX IDE`�`'3�3CATS0� hiJMBER - Pursuant to the Law�s of Minnesota. 1954, Chapter 502, Article 8, Section 2(270.72)
(I'aa Clearance; Issvance of Licenses), licensing autborities aze required to pro��ide to tbe State of Ati�nesota Commissioner of Recenue,
tbe h4innesota business eaz ideneificaGon numbes and the s.:ial security numbec of each licence applicanL
Undet the Minnesota Govem¢xot Daza Practices Act and t� Federal Privacy Act of 1974, we ate required to ad�'i<e }'ou of tSe following
regarding the use of e6e Minnesota Tau Ideoafication Number.
- Ttus informauon may be used to deny the issuaoce or renewal of }�our license io the eveot you ow•e Dtinnesota sales, employer s
W�ithholding ot mo[or ��ehicle ezcise tazes;
- Upoo receiving this information, tbe licensing autboriry will supply it only to the Minnesota Depart�nt of Reeenue. However,
under the Federal Exchange of Information Agreement, the Department of Reveoue may supply this information to t6e Intemal
Re��enue Service.
?viinnesota Tax Idenafication Numbers (Sales & Use Taz \'umber) may be obtaioed from the State of Nlinnesota, Busioess Records
Department, ]0 River Park Plaza (612-296-618I).
Social SecurityNumber: 7/ Z' /� b�./�'O
h4innesota ?az Ideoa6catioo r'umber: 1�� /���
_ If a Minnesota Taz Identifica[ion humber is not required for the business being operated indicate so by placing an "X" in the
boz.
o.._: ___. ic.-._1.,........... e .l.i�oe�
Council File # �� � � 5 'J
� .- ' � " ' ,
Ordinance #
Green Sheet # ������
RESOLUTION
CITY OF SA1NT PAUL, MINNESOTA
Presented Hy
Referred To
23
Committees Date
i RESOLVED: That application (ID #14740) for a Game Room License by Bihn Nguyen DBA Truc Mi Billiards
2 (Binh Dat Nguyen, Owner) at 2422 University Avenue Wes[ be and the sa�ne is hereby appmved
with the following conditions:
fl
2
The parking lot must be kept free of litter.
Management must call the police to report problems.
3. There sha11 be no weapons on the premises at any time and the
licensee shall observe the same restrictions regarding weapons as -
liquor establishments, as contained in paragraph 409.06M of the
Saint Paul Legislative Code.
4. No gang colors shall be allowed to be worn by the patrons on the
licensed premises. Signs shall be posted to this effect and the
licensee shall consult with the Saint Paul Police to determine how
to identify gang colors.
5. Adequate lighting for rear parking 1ot must be maintained.
6. The licensee shall make sure that there are no minors present in
the establishment in violation of Saint Paul curfew restrictions.
3
4 Requested by Department of:
5 Y Navs Absen+
6 B a�Tev -
7 Bostrom
$ .cr�..,-. e
1� �
11 Cs e a
aa
ia ° °
15 Adopted by Council: Date \��
16
17 Adoption Certified by Council Secretary
18
19
20 By:
ai
22 Appr
23
24
25 By:
26
• - -�.- �-r- .e- .ec
.. e •��a - •t
$Y: ���{-f-� �- �
Form Approved by City Attorney
B ��� ., �1 �w�
U
Approved by Mayor for Submission to
Council
By:
° ��-1 S S8'
DEA1fliMENTNFFICE/COUNCIL DATE INITIATED 3 7 9 5 0
LIEP/Licensin GREEN SHEE
CON�ACTPERSON&PHONE INITIAVDATE _. INITIAVDATE
� DEPARTMENT DIRECTOR � � CITY CAUNCIL
ASSIGN CRY ATTOFiNEY C1TY CLERK
Christine Rozek 266-9108 NUNBEqFOR � �
MUST BE ON COUNCIL AGENDA BY (�ATE� pp��qG �@UDGET DIRECTOR O FIN. & MGT. SERVICES DIR.
/ OPCEP � MAYOR (OR ASSISTAPJT) �
For e r'n : 1
TOTAL # OF SIGNATURE PAGES (CLiP ALL IOCATIONS FOR SiGNATURE)
ACTIDN REQUESTED:
Binh Nguyen DBA Truc Mi Billiaxds requests Gouncil approval of its application for a
Game Room License located at 2422 University Avenue West (ID �/14740).
RECOMi+fENDA710NS: npprove (A) or peject (A) pEflSONAL SEFiVICE CONTRACTS MUST ANSWER TNE FOLLOWING �UESTIONS:
_ PLANNINfi COMMISSION _ CIVIL SERVICE COMMISSION �� Has Mis personlFirm ever woifced under a coMract for this depanmeM?
_ G�e COMMiTfEE _ YES NO
2. Has [his person/firm ever been a city employee?
__ STAFF — YES NO
_ o1SiRIC7 cAURT _ 3. Does this personRirm possess a skill not normafVy possessetl by any curteM ciry employee?
SUPPORTS WHICH COUNCIL OBJECTIVE7 YES NO
Explafn all yes anawers on separate sheet and ettach to green sheet
INITIATING PROBLEM. ISSUE, OPPEIHTUNITY (Who, Whffi. When, Where, WM1y): - -
��a��� E�
iv9AY G' 3 1997
���� � � € � ��� � ;.:�.�, .
ADVANTAGES IF APPqOVED:
DISADVANTA6E5 IF APPROVED:
DISAOVANTAGES IF NOT APPROVED:
��0Ut1CN �AtC�1 �1il�T
►vov 2s �5s�
TOTAL AMQUNT OF TRANSACTION $ COST/REVENUE BUDGE7ED (CIRCLE ONE) VES NO
FUNDIfdG SOURCE ACTIVITY NUMBEH
FINANCIAL INFORHiATION. (EXPLAIN)
CLASS III
LICENSE APPLICATION
9'1-I S58'
CITX OF SAINT PAUL
Office of Licensc Uup�xtions
and En��irovncntai Protection
3tp Si Pea St Su��e?0.t
Gim Paul. �tin�aRa <9102
(6�])=EFwJ R<(EI?)](3�SL"a
THtS APPLICATIOV IS SLBIECT TO REVIE�V BY 77� pt'BLIC
PLEASE Tti'PE OR PRL\T L� I�K
T��pe of Licease(s) being applied for:
Company;�aa�:
Cetpoztion / pazmership ! Sok proprietorship
If business is incorporated, gi��e date ef incorporation: �—
Doina Bu<iness As:
Buciness Addrzss: Zy� G��(il/; y✓C�p'fi j�S/ �� f�
sa��aaarus —�
Benreen uhat cross streets is the businesc lo;ated? �j� `,"
Are the prenrises nou� occupied? �1. `�'' .j ��'hat T}�pe of Buc�ness?
C. � / —
.'�Iai3ToAddress: !'7�7 Tj<<'iaLc�!%'Q/,c' �iT
$trcet .Address
Applicant Information:
�ame and Title: �
Firsc
�4iddle
�
c�ry
'1�
�
r ,
, Business Phone:
i �
Sute Zip
1t'hich side of lhe stseec? `7
��
Stace
(TSaidenJ
Zip
C w.c
TiUe
Ho�m Address: �� j%�G:.��./�Z( ST �-- 7
A Sn�tAddrets �l CC�f/ GG / >�y�O(
Ciry State Zip
Datc of Birth: /^�—�� `� Place of Birth: ]f; �= T/f1'i_ 7az Home Phone: � 7 y y� S
Have qou ever beeo com�icted of any felony, crime or violazion of any ciry ordinance other than tratfic? YES _\'O �
Date of arrest: R'here?
Charge: � - —
Coneicdon: Sentence:
List the names and residences of ehree persons of good moral chazacter, li�•iag aithin the Twin Cities Met�o Area, not related to the
applicant or financial)y iocerested in the premises or business, u•ho may be referred to as to tiie applicanCs cbazuter:
NAME annAFCC _ _ _
List licenses whic6 }•ou currendy hold, forc[�rly 6eld, or may 6a� e an interest in: T �(� ( Z� �6 '��3'
�c-J/-?>1Ni^ f'o/�i�l��l�C'�•S�' cz` SLt �y"'GC... 5 � s� y't '/Gl/1J
Ha� c an}' of the abo�•e named Lcense5 eeet been revoked� _ YES � j�0 lf yes, list the dates and reasons for tevocation:
Are you going to operate ehi�b��ness personatly? � YE$ _�O If not, a�ho w�ill operate it?
tirst \ame
Home Address: StreG lame
T4�881c
(Afaiden) � j,�
G.y
Swte Z�P
Da�e of 9inh
Phone Tumber
.,yG� J '� P > � O �C' �I a A
Are }'ou going to ha�•e a mana�er or v�sistant in this business? _ 1'ES � �O If the manager is not the s.?,t� � r `�/'� . • f, •�o �O� �j
comple[e the fo1loW�ing infom�atioo: �$,9��. a �G� v
Frst':acck
HemeAdBras: Sueet\zne
C�.y
Ple:vice list your emplo}ment history fer the pre�ious fi��e (:) ;eaz period:
List a3l othei efficers of the corporatien:
OFF3CER 7'ITLF HOME
\A'�4E (OfficgHeld) ADDRESS
?;id�Ie [nitial (>iaiden)
a�� A '�.
P
�y�� � Date of n,. �
q�-Iss
Sute Zip Phone�um?+cr
HO?�'IE BliSI:��ESS D.4TE OF
PHO\E PHO\E BIRTH
If business is a partnership, plea.ae include tbe following infermalion for eac6 partner (u<e additional paQes if necessary'):
First'<ame
Home Address: Svea �xme
Frst !:ame
HomeAddress: Stteet!�zme
'..1iddle L�:tial
Tliddle Huual
Ciry
('.faiden)
(D9aiden)
Lut
S�a[e
J.a51
State
Date oi Binh
Zip Phone Number
' Date of Binh
Zip Phone'�umber
NII.`�T'FSOTA TAX IDE`�`'3�3CATS0� hiJMBER - Pursuant to the Law�s of Minnesota. 1954, Chapter 502, Article 8, Section 2(270.72)
(I'aa Clearance; Issvance of Licenses), licensing autborities aze required to pro��ide to tbe State of Ati�nesota Commissioner of Recenue,
tbe h4innesota business eaz ideneificaGon numbes and the s.:ial security numbec of each licence applicanL
Undet the Minnesota Govem¢xot Daza Practices Act and t� Federal Privacy Act of 1974, we ate required to ad�'i<e }'ou of tSe following
regarding the use of e6e Minnesota Tau Ideoafication Number.
- Ttus informauon may be used to deny the issuaoce or renewal of }�our license io the eveot you ow•e Dtinnesota sales, employer s
W�ithholding ot mo[or ��ehicle ezcise tazes;
- Upoo receiving this information, tbe licensing autboriry will supply it only to the Minnesota Depart�nt of Reeenue. However,
under the Federal Exchange of Information Agreement, the Department of Reveoue may supply this information to t6e Intemal
Re��enue Service.
?viinnesota Tax Idenafication Numbers (Sales & Use Taz \'umber) may be obtaioed from the State of Nlinnesota, Busioess Records
Department, ]0 River Park Plaza (612-296-618I).
Social SecurityNumber: 7/ Z' /� b�./�'O
h4innesota ?az Ideoa6catioo r'umber: 1�� /���
_ If a Minnesota Taz Identifica[ion humber is not required for the business being operated indicate so by placing an "X" in the
boz.
o.._: ___. ic.-._1.,........... e .l.i�oe�
Council File # �� � � 5 'J
� .- ' � " ' ,
Ordinance #
Green Sheet # ������
RESOLUTION
CITY OF SA1NT PAUL, MINNESOTA
Presented Hy
Referred To
23
Committees Date
i RESOLVED: That application (ID #14740) for a Game Room License by Bihn Nguyen DBA Truc Mi Billiards
2 (Binh Dat Nguyen, Owner) at 2422 University Avenue Wes[ be and the sa�ne is hereby appmved
with the following conditions:
fl
2
The parking lot must be kept free of litter.
Management must call the police to report problems.
3. There sha11 be no weapons on the premises at any time and the
licensee shall observe the same restrictions regarding weapons as -
liquor establishments, as contained in paragraph 409.06M of the
Saint Paul Legislative Code.
4. No gang colors shall be allowed to be worn by the patrons on the
licensed premises. Signs shall be posted to this effect and the
licensee shall consult with the Saint Paul Police to determine how
to identify gang colors.
5. Adequate lighting for rear parking 1ot must be maintained.
6. The licensee shall make sure that there are no minors present in
the establishment in violation of Saint Paul curfew restrictions.
3
4 Requested by Department of:
5 Y Navs Absen+
6 B a�Tev -
7 Bostrom
$ .cr�..,-. e
1� �
11 Cs e a
aa
ia ° °
15 Adopted by Council: Date \��
16
17 Adoption Certified by Council Secretary
18
19
20 By:
ai
22 Appr
23
24
25 By:
26
• - -�.- �-r- .e- .ec
.. e •��a - •t
$Y: ���{-f-� �- �
Form Approved by City Attorney
B ��� ., �1 �w�
U
Approved by Mayor for Submission to
Council
By:
° ��-1 S S8'
DEA1fliMENTNFFICE/COUNCIL DATE INITIATED 3 7 9 5 0
LIEP/Licensin GREEN SHEE
CON�ACTPERSON&PHONE INITIAVDATE _. INITIAVDATE
� DEPARTMENT DIRECTOR � � CITY CAUNCIL
ASSIGN CRY ATTOFiNEY C1TY CLERK
Christine Rozek 266-9108 NUNBEqFOR � �
MUST BE ON COUNCIL AGENDA BY (�ATE� pp��qG �@UDGET DIRECTOR O FIN. & MGT. SERVICES DIR.
/ OPCEP � MAYOR (OR ASSISTAPJT) �
For e r'n : 1
TOTAL # OF SIGNATURE PAGES (CLiP ALL IOCATIONS FOR SiGNATURE)
ACTIDN REQUESTED:
Binh Nguyen DBA Truc Mi Billiaxds requests Gouncil approval of its application for a
Game Room License located at 2422 University Avenue West (ID �/14740).
RECOMi+fENDA710NS: npprove (A) or peject (A) pEflSONAL SEFiVICE CONTRACTS MUST ANSWER TNE FOLLOWING �UESTIONS:
_ PLANNINfi COMMISSION _ CIVIL SERVICE COMMISSION �� Has Mis personlFirm ever woifced under a coMract for this depanmeM?
_ G�e COMMiTfEE _ YES NO
2. Has [his person/firm ever been a city employee?
__ STAFF — YES NO
_ o1SiRIC7 cAURT _ 3. Does this personRirm possess a skill not normafVy possessetl by any curteM ciry employee?
SUPPORTS WHICH COUNCIL OBJECTIVE7 YES NO
Explafn all yes anawers on separate sheet and ettach to green sheet
INITIATING PROBLEM. ISSUE, OPPEIHTUNITY (Who, Whffi. When, Where, WM1y): - -
��a��� E�
iv9AY G' 3 1997
���� � � € � ��� � ;.:�.�, .
ADVANTAGES IF APPqOVED:
DISADVANTA6E5 IF APPROVED:
DISAOVANTAGES IF NOT APPROVED:
��0Ut1CN �AtC�1 �1il�T
►vov 2s �5s�
TOTAL AMQUNT OF TRANSACTION $ COST/REVENUE BUDGE7ED (CIRCLE ONE) VES NO
FUNDIfdG SOURCE ACTIVITY NUMBEH
FINANCIAL INFORHiATION. (EXPLAIN)
CLASS III
LICENSE APPLICATION
9'1-I S58'
CITX OF SAINT PAUL
Office of Licensc Uup�xtions
and En��irovncntai Protection
3tp Si Pea St Su��e?0.t
Gim Paul. �tin�aRa <9102
(6�])=EFwJ R<(EI?)](3�SL"a
THtS APPLICATIOV IS SLBIECT TO REVIE�V BY 77� pt'BLIC
PLEASE Tti'PE OR PRL\T L� I�K
T��pe of Licease(s) being applied for:
Company;�aa�:
Cetpoztion / pazmership ! Sok proprietorship
If business is incorporated, gi��e date ef incorporation: �—
Doina Bu<iness As:
Buciness Addrzss: Zy� G��(il/; y✓C�p'fi j�S/ �� f�
sa��aaarus —�
Benreen uhat cross streets is the businesc lo;ated? �j� `,"
Are the prenrises nou� occupied? �1. `�'' .j ��'hat T}�pe of Buc�ness?
C. � / —
.'�Iai3ToAddress: !'7�7 Tj<<'iaLc�!%'Q/,c' �iT
$trcet .Address
Applicant Information:
�ame and Title: �
Firsc
�4iddle
�
c�ry
'1�
�
r ,
, Business Phone:
i �
Sute Zip
1t'hich side of lhe stseec? `7
��
Stace
(TSaidenJ
Zip
C w.c
TiUe
Ho�m Address: �� j%�G:.��./�Z( ST �-- 7
A Sn�tAddrets �l CC�f/ GG / >�y�O(
Ciry State Zip
Datc of Birth: /^�—�� `� Place of Birth: ]f; �= T/f1'i_ 7az Home Phone: � 7 y y� S
Have qou ever beeo com�icted of any felony, crime or violazion of any ciry ordinance other than tratfic? YES _\'O �
Date of arrest: R'here?
Charge: � - —
Coneicdon: Sentence:
List the names and residences of ehree persons of good moral chazacter, li�•iag aithin the Twin Cities Met�o Area, not related to the
applicant or financial)y iocerested in the premises or business, u•ho may be referred to as to tiie applicanCs cbazuter:
NAME annAFCC _ _ _
List licenses whic6 }•ou currendy hold, forc[�rly 6eld, or may 6a� e an interest in: T �(� ( Z� �6 '��3'
�c-J/-?>1Ni^ f'o/�i�l��l�C'�•S�' cz` SLt �y"'GC... 5 � s� y't '/Gl/1J
Ha� c an}' of the abo�•e named Lcense5 eeet been revoked� _ YES � j�0 lf yes, list the dates and reasons for tevocation:
Are you going to operate ehi�b��ness personatly? � YE$ _�O If not, a�ho w�ill operate it?
tirst \ame
Home Address: StreG lame
T4�881c
(Afaiden) � j,�
G.y
Swte Z�P
Da�e of 9inh
Phone Tumber
.,yG� J '� P > � O �C' �I a A
Are }'ou going to ha�•e a mana�er or v�sistant in this business? _ 1'ES � �O If the manager is not the s.?,t� � r `�/'� . • f, •�o �O� �j
comple[e the fo1loW�ing infom�atioo: �$,9��. a �G� v
Frst':acck
HemeAdBras: Sueet\zne
C�.y
Ple:vice list your emplo}ment history fer the pre�ious fi��e (:) ;eaz period:
List a3l othei efficers of the corporatien:
OFF3CER 7'ITLF HOME
\A'�4E (OfficgHeld) ADDRESS
?;id�Ie [nitial (>iaiden)
a�� A '�.
P
�y�� � Date of n,. �
q�-Iss
Sute Zip Phone�um?+cr
HO?�'IE BliSI:��ESS D.4TE OF
PHO\E PHO\E BIRTH
If business is a partnership, plea.ae include tbe following infermalion for eac6 partner (u<e additional paQes if necessary'):
First'<ame
Home Address: Svea �xme
Frst !:ame
HomeAddress: Stteet!�zme
'..1iddle L�:tial
Tliddle Huual
Ciry
('.faiden)
(D9aiden)
Lut
S�a[e
J.a51
State
Date oi Binh
Zip Phone Number
' Date of Binh
Zip Phone'�umber
NII.`�T'FSOTA TAX IDE`�`'3�3CATS0� hiJMBER - Pursuant to the Law�s of Minnesota. 1954, Chapter 502, Article 8, Section 2(270.72)
(I'aa Clearance; Issvance of Licenses), licensing autborities aze required to pro��ide to tbe State of Ati�nesota Commissioner of Recenue,
tbe h4innesota business eaz ideneificaGon numbes and the s.:ial security numbec of each licence applicanL
Undet the Minnesota Govem¢xot Daza Practices Act and t� Federal Privacy Act of 1974, we ate required to ad�'i<e }'ou of tSe following
regarding the use of e6e Minnesota Tau Ideoafication Number.
- Ttus informauon may be used to deny the issuaoce or renewal of }�our license io the eveot you ow•e Dtinnesota sales, employer s
W�ithholding ot mo[or ��ehicle ezcise tazes;
- Upoo receiving this information, tbe licensing autboriry will supply it only to the Minnesota Depart�nt of Reeenue. However,
under the Federal Exchange of Information Agreement, the Department of Reveoue may supply this information to t6e Intemal
Re��enue Service.
?viinnesota Tax Idenafication Numbers (Sales & Use Taz \'umber) may be obtaioed from the State of Nlinnesota, Busioess Records
Department, ]0 River Park Plaza (612-296-618I).
Social SecurityNumber: 7/ Z' /� b�./�'O
h4innesota ?az Ideoa6catioo r'umber: 1�� /���
_ If a Minnesota Taz Identifica[ion humber is not required for the business being operated indicate so by placing an "X" in the
boz.
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