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98-106S V. �l S�' �� ,,,� �. -� ��. 5 � g$' Council File� 1� ��} tp RESOLUTION CITY OF SAINT PAUL. MINNESOTA Presented By Referred To RESOLVED: Ordinance # �reen Sheet ; LP60007 Committee: Date 1 That application (ID #0024690) for a Malt Off Sale License(s) 2 by ELSIE MAYARD DBA FROGTOWN MARKET at 631 UNIVERSITY AVE W be 3 and the same is hereby approved with the following conditionae 4 1) No sale of single or broken six packs of 3.2 malt beverage. 5 2) No sale of 40 oz. bottles of 3.2 malt beverage. Requested by Department of: O£fice oE License, Inspections and Environmental Protection By; ��J�: �"s�� Adoption Certified by Council Secretary Form A proved b�City Attorney By: By: �� Z7 ` 7 7I n � Approved by/23a o: Approved by Mayor Eor Submission to / � �� \ Council By: By: Adopted by Council: Date � c�. aS ��`��$� Q8-�D(o DEPARTMENT/OFFICElCOUNCIL Dn7EiNi7W7ED LIEP/Licer�sing GREEN SHEET No. S,P60007 CON7ACT PERSON & PHONE �niriaware mitiawzre BIOOM SAMES (JIM) (672)26E9073 � CityAttomey UST BE ON COUNCIL AGENDA BY (DATE) S yt1/98 ��(p�{ ❑2 CouncilResearch RBIIT{FIG OR� TOTAL # OF SIGNATURE PAGES (CIIP ALL LOCATIONS FOR SIGNATURE) ACTION REQUESTED: Couxil approval of the fGiowing 1'�cense appl"�cation: License # 0024690, for ELSIE MAYARD, Doing Business As FROGTOWN MARKET, at 631 UNIVERSITY AVE W, and type of business(es): Matt Off Sale. F2ECOMMENDATIONS:ApptoVe(A)Rej¢Ct(R) ERSONALSERVICECANTRACTSMUSTANSWERTHEFOLLOWINGQUESTIONS: i. Has this perso�rm ever worked under a contrad for this departmeM? PIANNIt3G COMMiSSION ves No CI6 COMMITTEE 2. Has this persoMrtn ever been a ciry employce? CIVIL SVC CINN, YES No 3. Does this person/fittn possess a skill nof nortnafly possessed by arry curteM city empfv�ce? YES NO - 4. Is �his perso�rtn a targeted vendoR - YES NO Explain all yes answers on sepa�ate sheet and attach to green sheet INITIATING PROBLEM, ISSUE, OPPORTUNITY (Nlho, What, When, Where, Why): Requesling Council appro�ai for Eisie Mayard DBA Frogtown Market for an Off-Saie Matt License at 635 Universily Ave. W. ADVANTAGES IF APPROVED: �tECEf�IED Cotnac+l ��e��ch CMs�teP MAR 0 4 1998 4r P- C i, ty@ :" y4"4*� � �Sb� � DISADVANTAGES IF APPROVED: DISADVANTAGES IF NOT APPf20VED: TOTALAMOUNT OF TRANSACTION $ COST/REVENUE BUDGETED (GIRCLE ONE) YES NO FUNDING SOURCE ACTIVITY NUMBER FINANCIAL INFORMATION: (EXPLAIN) ORlGINAL RESOLl1TION CITY OF SAINT PAUL, MINNESOTA Presented By Referred To RSSOLVED: 1 2 3 That application (ID #0024690) for a M by ELSIE MAYARD DBA FROGTOWN MARKET at and the same is hereby approved. ff Sale LiCense(s) IINIVERSITY AVE W be 3� Yeas Absent Requested by Department o£: Office of License, Inspections and Environmental Protection Adopted by�uncil: Date Adoption C rtified by Council Secretary By: Approved by Mayor: Commit�ee: Date Date By: \ /��+•<J Y"1" r"'�C.L,1 Form Approved by City Attorney $ �.�,�� Approved by Mayor for Submission to Council Council File# /Q ��0� Ordinance # Green Sheet # Lp 6000? By: Bye 48-l06 � cLass ur LICENSE APPLICATION THIS APPLICATION IS SUSJECT TO REVIEW BY Tf� PUBLIC PLEASE TYPE QR PRINT IN TNK Type of License(s) being applied for: Company Nazne: �J7L- CITY OF SAINT PAUL �ce ofLicertu, Inspections and EmSronmrntal Protection 350 SL Pctel SG Sti¢ 30J SmMPeW,.Vi'uv�esote SSIOl (61i)16S909J fac{cll)166911II s ls 7. �Cl Coryorniion ! Paztnc�slup 7 So7e Proprietoiship If business is incorpor�ited, give date of incorporation: _ Doing Business As: Business Address: ��/ U AJ r��P h Pi T Business Phone: oCQ4 ' street Ada�css ciTy " state Zip , Between what cross streets is the business located? �UA-��' eL.�c Ll.t� ��/e �z S,� Which side of the street? Are the prrnuses now ocoupied? y e T VJhat Type of Business7 � �2g �a.nt.r1 Mail To Address: ��/ �./ �l t�? k S� ��(��P Lc/ oTi%Q� � �n _ C�7o �/- sv«= naa� Applicant Information: Nazne and Title: _ _� s�m ztP Fin[ Middle (h{aidm) � Lnat Title Home Address: SbcetAddress � City ° Ste[e Z�p Date of Birth: �— /� 7-- Place of I3irth: � h/ �1-t. L� �r � �* ��Iome Phone: �� / 7� ! � Have you ever been convicted of any felony, crime or violation of any city ordinance other than traffic7 YES NO Date of arr � Where? Charge: Conviction: List [he names and residences of [hree persons of good moral chazacter, living within the Twin Cities e t reiated to the applicant or financially intetested in the premises or business, who may be referted to as to the applicant's chazacter: Nl�ME ADDRESS PHONE List licenses which you currenlly hold, formerly held, or may have an interes[ in: Have any of the ai�ove named licenses ever been revoked7 YES NO If yes, list the dates and reasons for revxation: 2/18/97 Are you going to operate this business personaiy? � YES NO If not, who will operate it? Fintldamc Home Aifdress: Strcet Nnme Middlc initiel 98-�06 Date ofBiM Statc Zip ' Phone Numbcr YES _� O If thz manager is not the same as the operator, Are you going to have a manager or assistant in this business? please complete the following informa[ion: F;��r�m� Hame Addreu: Strect Neme City Please list your employment history for ttte previous five (5) year period: Business/Emplovment Address I.�c Statc Dam of Birth Zip Phone Number Nt;aai��;nat (�teta�n) List all other officers of the corporation: OFFICER TITLE HO : NAME (Office Held) ADDRESS HOME BUSINESS PI-IONE PHONE If business is a partnership, please include the following infoimation for each partner (use additional pages if necessary): Middlc Initiel Home Addrtse: Strcc[ Name FintName Home Add�css: 5 Veet Neme (Maiden) City Clty Lest S[atc Last Statc DATE OF BIItTH Date of Birth Phone Number Datc of Birth Phone Number MINNESOTA TAX IDENTIFICATION NUMBER - Pursuant to the Laws of Minnesota, 1984, Chapter 502, Article 8, Section 2(270J2) (Tax Cleaz'ance; Issuance of Licenses), licensing authorities are required to provide to the State of Minnesota Commissioner of Revrnue, the Minnesota business tax identification number and ihe social security number of each license applicant. Under the Minnesota Govemment Data Praclices Act and the Federal Privacy Act of 1974, we are required to advise you of the following regarding the use of the Minnesota Tax IdentificaUOn Number: - This infonnation may be used to deny the issuance or renewa] of your license in the event you owe Minnesota sales, employer's withholding or motor vehicle excise [axes; - Upon receiving this information, the licensing authority will supply it only to the Minnesota Department of Revenue. However, under the Federal Exchange of Information Agreement, the Department of Revenue may supply this information to the Internal Revenue Service. Mirn�esota TaY Identiticalion Numbers (Sates & Use Ta� Number) may be obtained t'rom Ihe State of Minnesota, Business Records Department, 10 River Park Plaza (612-29G-6181). Social Security Number: �= Q z��'�� 7 Minnesota Tax Identification Number: + If a Minnesota Tax Identification Number is not required for the business being operated, indicate so by placing en "X" in the box. Middle Initiel 2/18/97 48=io� CERTIFICATION OP WORKERS' COMPLNSATION COV�RAGE PURSUANT TO MINNESOTA STATUTE 176.182 I hereby certify that I, or my company, am in compliance ti��th the rvorkers' compensation insurance coverage requuements of Minnesota Statute 176.182, subdi�3sion 2. I aiso understand that provision of false infom�alion in this cet[ification constitutes sufficient grounds for adverse action against all licenses held, including revocation and suspznsion of said licznses. Nazne ofInsurance Company: PolicyNumber: Covzragefrom to I have no employees covered under ��orkers' compensation insurance (INITIALS) , )/ �J � �� ANY FALSIFICATION OF ANSWEIiS GIVEN OR MATERIAL SUBMITTED WILL RESULT IN DENIP.L OF THIS APPLICATION I haeby state that I have answered all of the preceding questions, and Lhat the information contained herein is true and cortect to the best of my knowledge and belief. I hereby state fur(her that I have received no money or other aonsideration, by evay of loan, gifr, contribution, or othenuise, other than aiready disclosed in the application �vhich I herewith submitted. I also understand this premise may be inspected by police, fue, health and ocher city officials at any and all times �3•hen the business is in operation. Signature (REQUTAED fbr all We will accept payment by cash, check (made payable to City of Saint Paul) or credit card {MJC oe Visa). /��i�� Bate IFPAYlNGBYCREDITCARDPLEASECOMPLETETHEFOLLOWINGINFORMATION: �MasterCard ❑ Visa EXP7RATION DATE: � � � � � Name of Cazdholder for all ""Note: If this application is Food/Liquor related, please contact a Ciry� of Saint Paul Health Inspector, Steve Olson (266-9139), to review plans. If any substantial changes to structure aze aniicipated, please contact a City of Saint Paul Plan Exazniner at 266-9007 to apply for building pennits. 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 require the following documents. Please attach these documente when submitting your spplication: 1. A detailed description of the design, location and square footage of the premises to be licensed (site plan). The following data should be on the site plan (preferably on an 8 I/2" x] I" or S]/2" x 14" paper): - Nazne, address, and phone number. - The scale should be stated such as 1" = 20'. ^N should be indicated toward the top. - Placement of all pertinent features of the in[erior of the hcensed facility such as seating areas, kitchens, offices, repair area, parking, rest rooms, ete. - If a request is for an addi[ion or expansion of the ]icznsed facility, indicate both the current ares and the proposed expansion. 2. A copy of your ]ease agreement or proof o£ ownership of thz property. SPECIFIC LICENSE A.PPLICATTONS REQUIIiE ADDITIONAL INFORMATION. PLEASE SEE REVERS� FOR DETAILS >>>> ACCOUNT NUMBER: � � � � � � � � � � � � � � � � I 2/IS/97 S V. �l S�' �� ,,,� �. -� ��. 5 � g$' Council File� 1� ��} tp RESOLUTION CITY OF SAINT PAUL. MINNESOTA Presented By Referred To RESOLVED: Ordinance # �reen Sheet ; LP60007 Committee: Date 1 That application (ID #0024690) for a Malt Off Sale License(s) 2 by ELSIE MAYARD DBA FROGTOWN MARKET at 631 UNIVERSITY AVE W be 3 and the same is hereby approved with the following conditionae 4 1) No sale of single or broken six packs of 3.2 malt beverage. 5 2) No sale of 40 oz. bottles of 3.2 malt beverage. Requested by Department of: O£fice oE License, Inspections and Environmental Protection By; ��J�: �"s�� Adoption Certified by Council Secretary Form A proved b�City Attorney By: By: �� Z7 ` 7 7I n � Approved by/23a o: Approved by Mayor Eor Submission to / � �� \ Council By: By: Adopted by Council: Date � c�. aS ��`��$� Q8-�D(o DEPARTMENT/OFFICElCOUNCIL Dn7EiNi7W7ED LIEP/Licer�sing GREEN SHEET No. S,P60007 CON7ACT PERSON & PHONE �niriaware mitiawzre BIOOM SAMES (JIM) (672)26E9073 � CityAttomey UST BE ON COUNCIL AGENDA BY (DATE) S yt1/98 ��(p�{ ❑2 CouncilResearch RBIIT{FIG OR� TOTAL # OF SIGNATURE PAGES (CIIP ALL LOCATIONS FOR SIGNATURE) ACTION REQUESTED: Couxil approval of the fGiowing 1'�cense appl"�cation: License # 0024690, for ELSIE MAYARD, Doing Business As FROGTOWN MARKET, at 631 UNIVERSITY AVE W, and type of business(es): Matt Off Sale. F2ECOMMENDATIONS:ApptoVe(A)Rej¢Ct(R) ERSONALSERVICECANTRACTSMUSTANSWERTHEFOLLOWINGQUESTIONS: i. Has this perso�rm ever worked under a contrad for this departmeM? PIANNIt3G COMMiSSION ves No CI6 COMMITTEE 2. Has this persoMrtn ever been a ciry employce? CIVIL SVC CINN, YES No 3. Does this person/fittn possess a skill nof nortnafly possessed by arry curteM city empfv�ce? YES NO - 4. Is �his perso�rtn a targeted vendoR - YES NO Explain all yes answers on sepa�ate sheet and attach to green sheet INITIATING PROBLEM, ISSUE, OPPORTUNITY (Nlho, What, When, Where, Why): Requesling Council appro�ai for Eisie Mayard DBA Frogtown Market for an Off-Saie Matt License at 635 Universily Ave. W. ADVANTAGES IF APPROVED: �tECEf�IED Cotnac+l ��e��ch CMs�teP MAR 0 4 1998 4r P- C i, ty@ :" y4"4*� � �Sb� � DISADVANTAGES IF APPROVED: DISADVANTAGES IF NOT APPf20VED: TOTALAMOUNT OF TRANSACTION $ COST/REVENUE BUDGETED (GIRCLE ONE) YES NO FUNDING SOURCE ACTIVITY NUMBER FINANCIAL INFORMATION: (EXPLAIN) ORlGINAL RESOLl1TION CITY OF SAINT PAUL, MINNESOTA Presented By Referred To RSSOLVED: 1 2 3 That application (ID #0024690) for a M by ELSIE MAYARD DBA FROGTOWN MARKET at and the same is hereby approved. ff Sale LiCense(s) IINIVERSITY AVE W be 3� Yeas Absent Requested by Department o£: Office of License, Inspections and Environmental Protection Adopted by�uncil: Date Adoption C rtified by Council Secretary By: Approved by Mayor: Commit�ee: Date Date By: \ /��+•<J Y"1" r"'�C.L,1 Form Approved by City Attorney $ �.�,�� Approved by Mayor for Submission to Council Council File# /Q ��0� Ordinance # Green Sheet # Lp 6000? By: Bye 48-l06 � cLass ur LICENSE APPLICATION THIS APPLICATION IS SUSJECT TO REVIEW BY Tf� PUBLIC PLEASE TYPE QR PRINT IN TNK Type of License(s) being applied for: Company Nazne: �J7L- CITY OF SAINT PAUL �ce ofLicertu, Inspections and EmSronmrntal Protection 350 SL Pctel SG Sti¢ 30J SmMPeW,.Vi'uv�esote SSIOl (61i)16S909J fac{cll)166911II s ls 7. �Cl Coryorniion ! Paztnc�slup 7 So7e Proprietoiship If business is incorpor�ited, give date of incorporation: _ Doing Business As: Business Address: ��/ U AJ r��P h Pi T Business Phone: oCQ4 ' street Ada�css ciTy " state Zip , Between what cross streets is the business located? �UA-��' eL.�c Ll.t� ��/e �z S,� Which side of the street? Are the prrnuses now ocoupied? y e T VJhat Type of Business7 � �2g �a.nt.r1 Mail To Address: ��/ �./ �l t�? k S� ��(��P Lc/ oTi%Q� � �n _ C�7o �/- sv«= naa� Applicant Information: Nazne and Title: _ _� s�m ztP Fin[ Middle (h{aidm) � Lnat Title Home Address: SbcetAddress � City ° Ste[e Z�p Date of Birth: �— /� 7-- Place of I3irth: � h/ �1-t. L� �r � �* ��Iome Phone: �� / 7� ! � Have you ever been convicted of any felony, crime or violation of any city ordinance other than traffic7 YES NO Date of arr � Where? Charge: Conviction: List [he names and residences of [hree persons of good moral chazacter, living within the Twin Cities e t reiated to the applicant or financially intetested in the premises or business, who may be referted to as to the applicant's chazacter: Nl�ME ADDRESS PHONE List licenses which you currenlly hold, formerly held, or may have an interes[ in: Have any of the ai�ove named licenses ever been revoked7 YES NO If yes, list the dates and reasons for revxation: 2/18/97 Are you going to operate this business personaiy? � YES NO If not, who will operate it? Fintldamc Home Aifdress: Strcet Nnme Middlc initiel 98-�06 Date ofBiM Statc Zip ' Phone Numbcr YES _� O If thz manager is not the same as the operator, Are you going to have a manager or assistant in this business? please complete the following informa[ion: F;��r�m� Hame Addreu: Strect Neme City Please list your employment history for ttte previous five (5) year period: Business/Emplovment Address I.�c Statc Dam of Birth Zip Phone Number Nt;aai��;nat (�teta�n) List all other officers of the corporation: OFFICER TITLE HO : NAME (Office Held) ADDRESS HOME BUSINESS PI-IONE PHONE If business is a partnership, please include the following infoimation for each partner (use additional pages if necessary): Middlc Initiel Home Addrtse: Strcc[ Name FintName Home Add�css: 5 Veet Neme (Maiden) City Clty Lest S[atc Last Statc DATE OF BIItTH Date of Birth Phone Number Datc of Birth Phone Number MINNESOTA TAX IDENTIFICATION NUMBER - Pursuant to the Laws of Minnesota, 1984, Chapter 502, Article 8, Section 2(270J2) (Tax Cleaz'ance; Issuance of Licenses), licensing authorities are required to provide to the State of Minnesota Commissioner of Revrnue, the Minnesota business tax identification number and ihe social security number of each license applicant. Under the Minnesota Govemment Data Praclices Act and the Federal Privacy Act of 1974, we are required to advise you of the following regarding the use of the Minnesota Tax IdentificaUOn Number: - This infonnation may be used to deny the issuance or renewa] of your license in the event you owe Minnesota sales, employer's withholding or motor vehicle excise [axes; - Upon receiving this information, the licensing authority will supply it only to the Minnesota Department of Revenue. However, under the Federal Exchange of Information Agreement, the Department of Revenue may supply this information to the Internal Revenue Service. Mirn�esota TaY Identiticalion Numbers (Sates & Use Ta� Number) may be obtained t'rom Ihe State of Minnesota, Business Records Department, 10 River Park Plaza (612-29G-6181). Social Security Number: �= Q z��'�� 7 Minnesota Tax Identification Number: + If a Minnesota Tax Identification Number is not required for the business being operated, indicate so by placing en "X" in the box. Middle Initiel 2/18/97 48=io� CERTIFICATION OP WORKERS' COMPLNSATION COV�RAGE PURSUANT TO MINNESOTA STATUTE 176.182 I hereby certify that I, or my company, am in compliance ti��th the rvorkers' compensation insurance coverage requuements of Minnesota Statute 176.182, subdi�3sion 2. I aiso understand that provision of false infom�alion in this cet[ification constitutes sufficient grounds for adverse action against all licenses held, including revocation and suspznsion of said licznses. Nazne ofInsurance Company: PolicyNumber: Covzragefrom to I have no employees covered under ��orkers' compensation insurance (INITIALS) , )/ �J � �� ANY FALSIFICATION OF ANSWEIiS GIVEN OR MATERIAL SUBMITTED WILL RESULT IN DENIP.L OF THIS APPLICATION I haeby state that I have answered all of the preceding questions, and Lhat the information contained herein is true and cortect to the best of my knowledge and belief. I hereby state fur(her that I have received no money or other aonsideration, by evay of loan, gifr, contribution, or othenuise, other than aiready disclosed in the application �vhich I herewith submitted. I also understand this premise may be inspected by police, fue, health and ocher city officials at any and all times �3•hen the business is in operation. Signature (REQUTAED fbr all We will accept payment by cash, check (made payable to City of Saint Paul) or credit card {MJC oe Visa). /��i�� Bate IFPAYlNGBYCREDITCARDPLEASECOMPLETETHEFOLLOWINGINFORMATION: �MasterCard ❑ Visa EXP7RATION DATE: � � � � � Name of Cazdholder for all ""Note: If this application is Food/Liquor related, please contact a Ciry� of Saint Paul Health Inspector, Steve Olson (266-9139), to review plans. If any substantial changes to structure aze aniicipated, please contact a City of Saint Paul Plan Exazniner at 266-9007 to apply for building pennits. 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 require the following documents. Please attach these documente when submitting your spplication: 1. A detailed description of the design, location and square footage of the premises to be licensed (site plan). The following data should be on the site plan (preferably on an 8 I/2" x] I" or S]/2" x 14" paper): - Nazne, address, and phone number. - The scale should be stated such as 1" = 20'. ^N should be indicated toward the top. - Placement of all pertinent features of the in[erior of the hcensed facility such as seating areas, kitchens, offices, repair area, parking, rest rooms, ete. - If a request is for an addi[ion or expansion of the ]icznsed facility, indicate both the current ares and the proposed expansion. 2. A copy of your ]ease agreement or proof o£ ownership of thz property. SPECIFIC LICENSE A.PPLICATTONS REQUIIiE ADDITIONAL INFORMATION. PLEASE SEE REVERS� FOR DETAILS >>>> ACCOUNT NUMBER: � � � � � � � � � � � � � � � � I 2/IS/97 S V. �l S�' �� ,,,� �. -� ��. 5 � g$' Council File� 1� ��} tp RESOLUTION CITY OF SAINT PAUL. MINNESOTA Presented By Referred To RESOLVED: Ordinance # �reen Sheet ; LP60007 Committee: Date 1 That application (ID #0024690) for a Malt Off Sale License(s) 2 by ELSIE MAYARD DBA FROGTOWN MARKET at 631 UNIVERSITY AVE W be 3 and the same is hereby approved with the following conditionae 4 1) No sale of single or broken six packs of 3.2 malt beverage. 5 2) No sale of 40 oz. bottles of 3.2 malt beverage. Requested by Department of: O£fice oE License, Inspections and Environmental Protection By; ��J�: �"s�� Adoption Certified by Council Secretary Form A proved b�City Attorney By: By: �� Z7 ` 7 7I n � Approved by/23a o: Approved by Mayor Eor Submission to / � �� \ Council By: By: Adopted by Council: Date � c�. aS ��`��$� Q8-�D(o DEPARTMENT/OFFICElCOUNCIL Dn7EiNi7W7ED LIEP/Licer�sing GREEN SHEET No. S,P60007 CON7ACT PERSON & PHONE �niriaware mitiawzre BIOOM SAMES (JIM) (672)26E9073 � CityAttomey UST BE ON COUNCIL AGENDA BY (DATE) S yt1/98 ��(p�{ ❑2 CouncilResearch RBIIT{FIG OR� TOTAL # OF SIGNATURE PAGES (CIIP ALL LOCATIONS FOR SIGNATURE) ACTION REQUESTED: Couxil approval of the fGiowing 1'�cense appl"�cation: License # 0024690, for ELSIE MAYARD, Doing Business As FROGTOWN MARKET, at 631 UNIVERSITY AVE W, and type of business(es): Matt Off Sale. F2ECOMMENDATIONS:ApptoVe(A)Rej¢Ct(R) ERSONALSERVICECANTRACTSMUSTANSWERTHEFOLLOWINGQUESTIONS: i. Has this perso�rm ever worked under a contrad for this departmeM? PIANNIt3G COMMiSSION ves No CI6 COMMITTEE 2. Has this persoMrtn ever been a ciry employce? CIVIL SVC CINN, YES No 3. Does this person/fittn possess a skill nof nortnafly possessed by arry curteM city empfv�ce? YES NO - 4. Is �his perso�rtn a targeted vendoR - YES NO Explain all yes answers on sepa�ate sheet and attach to green sheet INITIATING PROBLEM, ISSUE, OPPORTUNITY (Nlho, What, When, Where, Why): Requesling Council appro�ai for Eisie Mayard DBA Frogtown Market for an Off-Saie Matt License at 635 Universily Ave. W. ADVANTAGES IF APPROVED: �tECEf�IED Cotnac+l ��e��ch CMs�teP MAR 0 4 1998 4r P- C i, ty@ :" y4"4*� � �Sb� � DISADVANTAGES IF APPROVED: DISADVANTAGES IF NOT APPf20VED: TOTALAMOUNT OF TRANSACTION $ COST/REVENUE BUDGETED (GIRCLE ONE) YES NO FUNDING SOURCE ACTIVITY NUMBER FINANCIAL INFORMATION: (EXPLAIN) ORlGINAL RESOLl1TION CITY OF SAINT PAUL, MINNESOTA Presented By Referred To RSSOLVED: 1 2 3 That application (ID #0024690) for a M by ELSIE MAYARD DBA FROGTOWN MARKET at and the same is hereby approved. ff Sale LiCense(s) IINIVERSITY AVE W be 3� Yeas Absent Requested by Department o£: Office of License, Inspections and Environmental Protection Adopted by�uncil: Date Adoption C rtified by Council Secretary By: Approved by Mayor: Commit�ee: Date Date By: \ /��+•<J Y"1" r"'�C.L,1 Form Approved by City Attorney $ �.�,�� Approved by Mayor for Submission to Council Council File# /Q ��0� Ordinance # Green Sheet # Lp 6000? By: Bye 48-l06 � cLass ur LICENSE APPLICATION THIS APPLICATION IS SUSJECT TO REVIEW BY Tf� PUBLIC PLEASE TYPE QR PRINT IN TNK Type of License(s) being applied for: Company Nazne: �J7L- CITY OF SAINT PAUL �ce ofLicertu, Inspections and EmSronmrntal Protection 350 SL Pctel SG Sti¢ 30J SmMPeW,.Vi'uv�esote SSIOl (61i)16S909J fac{cll)166911II s ls 7. �Cl Coryorniion ! Paztnc�slup 7 So7e Proprietoiship If business is incorpor�ited, give date of incorporation: _ Doing Business As: Business Address: ��/ U AJ r��P h Pi T Business Phone: oCQ4 ' street Ada�css ciTy " state Zip , Between what cross streets is the business located? �UA-��' eL.�c Ll.t� ��/e �z S,� Which side of the street? Are the prrnuses now ocoupied? y e T VJhat Type of Business7 � �2g �a.nt.r1 Mail To Address: ��/ �./ �l t�? k S� ��(��P Lc/ oTi%Q� � �n _ C�7o �/- sv«= naa� Applicant Information: Nazne and Title: _ _� s�m ztP Fin[ Middle (h{aidm) � Lnat Title Home Address: SbcetAddress � City ° Ste[e Z�p Date of Birth: �— /� 7-- Place of I3irth: � h/ �1-t. L� �r � �* ��Iome Phone: �� / 7� ! � Have you ever been convicted of any felony, crime or violation of any city ordinance other than traffic7 YES NO Date of arr � Where? Charge: Conviction: List [he names and residences of [hree persons of good moral chazacter, living within the Twin Cities e t reiated to the applicant or financially intetested in the premises or business, who may be referted to as to the applicant's chazacter: Nl�ME ADDRESS PHONE List licenses which you currenlly hold, formerly held, or may have an interes[ in: Have any of the ai�ove named licenses ever been revoked7 YES NO If yes, list the dates and reasons for revxation: 2/18/97 Are you going to operate this business personaiy? � YES NO If not, who will operate it? Fintldamc Home Aifdress: Strcet Nnme Middlc initiel 98-�06 Date ofBiM Statc Zip ' Phone Numbcr YES _� O If thz manager is not the same as the operator, Are you going to have a manager or assistant in this business? please complete the following informa[ion: F;��r�m� Hame Addreu: Strect Neme City Please list your employment history for ttte previous five (5) year period: Business/Emplovment Address I.�c Statc Dam of Birth Zip Phone Number Nt;aai��;nat (�teta�n) List all other officers of the corporation: OFFICER TITLE HO : NAME (Office Held) ADDRESS HOME BUSINESS PI-IONE PHONE If business is a partnership, please include the following infoimation for each partner (use additional pages if necessary): Middlc Initiel Home Addrtse: Strcc[ Name FintName Home Add�css: 5 Veet Neme (Maiden) City Clty Lest S[atc Last Statc DATE OF BIItTH Date of Birth Phone Number Datc of Birth Phone Number MINNESOTA TAX IDENTIFICATION NUMBER - Pursuant to the Laws of Minnesota, 1984, Chapter 502, Article 8, Section 2(270J2) (Tax Cleaz'ance; Issuance of Licenses), licensing authorities are required to provide to the State of Minnesota Commissioner of Revrnue, the Minnesota business tax identification number and ihe social security number of each license applicant. Under the Minnesota Govemment Data Praclices Act and the Federal Privacy Act of 1974, we are required to advise you of the following regarding the use of the Minnesota Tax IdentificaUOn Number: - This infonnation may be used to deny the issuance or renewa] of your license in the event you owe Minnesota sales, employer's withholding or motor vehicle excise [axes; - Upon receiving this information, the licensing authority will supply it only to the Minnesota Department of Revenue. However, under the Federal Exchange of Information Agreement, the Department of Revenue may supply this information to the Internal Revenue Service. Mirn�esota TaY Identiticalion Numbers (Sates & Use Ta� Number) may be obtained t'rom Ihe State of Minnesota, Business Records Department, 10 River Park Plaza (612-29G-6181). Social Security Number: �= Q z��'�� 7 Minnesota Tax Identification Number: + If a Minnesota Tax Identification Number is not required for the business being operated, indicate so by placing en "X" in the box. Middle Initiel 2/18/97 48=io� CERTIFICATION OP WORKERS' COMPLNSATION COV�RAGE PURSUANT TO MINNESOTA STATUTE 176.182 I hereby certify that I, or my company, am in compliance ti��th the rvorkers' compensation insurance coverage requuements of Minnesota Statute 176.182, subdi�3sion 2. I aiso understand that provision of false infom�alion in this cet[ification constitutes sufficient grounds for adverse action against all licenses held, including revocation and suspznsion of said licznses. Nazne ofInsurance Company: PolicyNumber: Covzragefrom to I have no employees covered under ��orkers' compensation insurance (INITIALS) , )/ �J � �� ANY FALSIFICATION OF ANSWEIiS GIVEN OR MATERIAL SUBMITTED WILL RESULT IN DENIP.L OF THIS APPLICATION I haeby state that I have answered all of the preceding questions, and Lhat the information contained herein is true and cortect to the best of my knowledge and belief. I hereby state fur(her that I have received no money or other aonsideration, by evay of loan, gifr, contribution, or othenuise, other than aiready disclosed in the application �vhich I herewith submitted. I also understand this premise may be inspected by police, fue, health and ocher city officials at any and all times �3•hen the business is in operation. Signature (REQUTAED fbr all We will accept payment by cash, check (made payable to City of Saint Paul) or credit card {MJC oe Visa). /��i�� Bate IFPAYlNGBYCREDITCARDPLEASECOMPLETETHEFOLLOWINGINFORMATION: �MasterCard ❑ Visa EXP7RATION DATE: � � � � � Name of Cazdholder for all ""Note: If this application is Food/Liquor related, please contact a Ciry� of Saint Paul Health Inspector, Steve Olson (266-9139), to review plans. If any substantial changes to structure aze aniicipated, please contact a City of Saint Paul Plan Exazniner at 266-9007 to apply for building pennits. 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 require the following documents. Please attach these documente when submitting your spplication: 1. A detailed description of the design, location and square footage of the premises to be licensed (site plan). The following data should be on the site plan (preferably on an 8 I/2" x] I" or S]/2" x 14" paper): - Nazne, address, and phone number. - The scale should be stated such as 1" = 20'. ^N should be indicated toward the top. - Placement of all pertinent features of the in[erior of the hcensed facility such as seating areas, kitchens, offices, repair area, parking, rest rooms, ete. - If a request is for an addi[ion or expansion of the ]icznsed facility, indicate both the current ares and the proposed expansion. 2. A copy of your ]ease agreement or proof o£ ownership of thz property. SPECIFIC LICENSE A.PPLICATTONS REQUIIiE ADDITIONAL INFORMATION. PLEASE SEE REVERS� FOR DETAILS >>>> ACCOUNT NUMBER: � � � � � � � � � � � � � � � � I 2/IS/97