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98-107Council File,$ 7 ��0 ordinance # ORIGiNAL Presented By Referred To Committee: Date RESQLVSDa 1 That application (ID $0013819) for a Ma1t Off Sa1e, Grocery (C), 2 CigarettefTobacco License(s) by HAMMADEH AIROUSA DBA &INGS MARKET 3 II at 842 Wf�IITE BEAR AVE N be and the same is hereby approved. Yeas Nays Absent Requeated by Department o£: Benanav � Blakey _�� Bostrom Coleman � Harris � Lantrv Reiter �— Adopted by Council : Date � �, . � � }, � 1 � Office of License, Inspections and Environmental Protection B ��=- � Adoption Certified by Council Secretary Form Approved by City Attorney By: a � By: I i/(�1A' ��•��7yNJ, �' ZD - 7� Approved by r: Date a (� � Approved by Mayor for Submission to / Council / Bye By: RESOLUTIpN Green Sheet # LP60010 CfTY OF SAINT PAUL, MINNESOTA 2? DEPARTMENT/OFFICE/COUNCri �nn'rEamrw�o !d—IO7 uEP"'�r� GREEN SHEET No. LP60070 ONTACT PERSON & PHONE �� UNTHER WILLIAM (BILL) cs,z,zsss,� � cayaao�,er UST 8E ON COUNCfL AGENDA SY (DAT� A � 2/t1198 " �� ❑2 CouncO Res�rch ROIIiHf � TOTAL # OF SIGNATURE PAGES (CLIP ALL LOCATIONS FOR SiGNATURE) ACTION REQUESTED: Camcit approval oTthe Tdbxing N� appliptbn: Licem,e � 0073619, for t1AMMADEH AIKOUSA, Dan� Business As IQNGS MARKET II, at 842 WHITE BEAR AVE N. induding the fdlowing busi� type(s): Malt OfF Sale. Grocery (C). Cigarelte/TObaeco. RECOMMENDATIONS: Approve(A) Reject(R) RSCINAL SERVECE COMRACTS MUST ANSWER THE FOLLOIMNG OUESTIONS: 7. Flas this perso�rtn everworked urider a eonVact iw Mis departmen(7 PLANNING COMMISSION YES No Ct8 COMAAITT£E 2. HaslFiis persaJfmm ewer teen a ciy empfoyee? CIVIL SVC CINN, ves NO . Does mis aersunr�m possess a s�a�� na nwma�N v�sess� br a�y currem oilyy empbyeel YES NO . Is ihispersoMrtn a targeted vendoY/ — YES NO Expfain all yes answers on separate sheet antl attach to green shee[ INITIATING PROBLEM, ISSUE, OPPORTUNITY (Who, What, When, Where, Why): Requesting Council approval for Hammadeh Aikousa for an Off-Sale Matt, Grocery (C) 8 Cigarette License at 842 Whde B�r Avenue. ADVANTAGESIFAPPROVED: n � _ �� Wf� Ji�� 2 6 1�9� ISADVANTAGES IF APPROVED: ' - - �- ° DISADVANTAGES IF NOT APPROVED: OTAL AMOUNT OF TRANSACTION $ COST/REVENUE BUDGETED (CIRCLE ONE) YES NO FUNDING SOURCE ACTIVITY NUMBER FINANCIAL INFORMATION: (EXPLAIN) 4 � � CLASS III LICENSE APPLICATION PLEASE TYPE OR PRINT IN INK Type of License(s) being applied for: Company Name: If business is incorporated, give clate of incorporation: lioing Business As: Business Addtess: , � stleet AdGeu ' � � W � 1 II GC tst� Zi� � S'f G�' �� ltJd� r` c side of the street? � Between what cross streets is the business located. �` Are the premises now occupied? �/' V What Type�of Business? � _. ,, „ --- � Mail To Address: Strat Md'sss Name and TiUe: Home Address: Sentence: /� ;�.� ,�; lE � � ciry CTTY OF SAINT PAl o�« oru«�, �«vo� � �� «� ��u�� ..� s:�� (61�tb6A090 6x(6Il]26691b /0 7 � �j� �-r7�'a S a S c��O s O S c�17e� a Sute Zip � �/i� •' /�'� sv��,�ea�„ �� U s� Z�P ,/ Date of Birth: D�/�7 I,� Place of Birth: Home Phone: — ��'X Have you ever bern convicted of any felony, crime or violation � any ciry ordinance other than traffic? YES NO,� Date of arrest Charge: _ Conviction: Lis1 the names and residences of three persons of good moral chazacter, living within the Twin Cilies Metro Area, not related to the applicant or financially interested in the premises or business, who may be referred to as to the applicant's chazacter: � ADDRESS List licenses which you currenfly hold, formerly held, or may have an Hace any of the above named licenses evec bern revoked7 ��5�t��e G�S�.� � as �/�2� �.� . � • �: • c � � : r.� 1: � WhereT PHONE ,� u� 9� � w YES _�, NO If yes, list the dates and reasous for revocarion: � _'•1 �/A �;9'� Are going to opaaie this business personally? � YES _Q .�t� J'Y)/.� ��(� �. � F� .� r�aaio w�� u�a�� Jn, �c1�) lS7ct' �,S�r� �r�.�T �� I�l -�r-`� � �«.: s�a x.m� c��r pre you gomg to tiave amanega a essistant in this busincss7 � YES plea�e�complete thg followiPg infor �atio � h ^� F'u+t �a+c�a �'.�i R,r,�am> Addcas: StratNmme Picase list your employmrnt kvslory for thc previous five (5) yeaz periad: List ali other officers of the cocparation: OFFICER TITLE HOME NAivfE (OfficeHeld) ADDRESS Nfl If not, who w _�� s'"�L su�e 230 If � Lut V Suta HOME PHONE 98-io� operete it4 , „ � /—a?lJ (S ��rB�, � Yh . �5�38" 4�(/n-� , z; es«�e u� y . snager ts not the same as the opecatoc, /�� "Z_ D.te of 8'vih jS4_3b'� �llc'/C�� Zip P6one Numbec BUSINESS DATE OF PHONE BB�� tv � �- - If business is a partnership, please include the following informadoa for each paitna (use addidonal pages if nxessary): N � � -- � �i�) yy� uaw va cuu� Home AddRta: Sheet N�mn Ciry St�ta Zip Pl+one Number FintNme Middlelnitid M�iden) Ld D�tboCB'utfi Home Mdtas: Sircct Nme Ciry Stnta 2ip Phonc N�ber MIl�IDIESOTA TAX IDENTIFIGATIODI NUMSER - Pwsuant to the I,aws of Minnesota, 1984, Chapter 502, Article 8, Section 2(270.72) (Ta+c Ctearenee; Issuance of Licenses), licensing authori[ies are required to provide to the State of Minnesota Conu[tissiona of Revenue, the Minnesata business tar identification number and ihe social security number of each license applicant Undet the Minnesota Govemment Data Practices Act and the Fedaal Privacy Act of 1974, we are required to advise you of the following regarding the use of the Minnesota Tar ldrnt�cation Numba: - This infotmation may be used to deny the issuance or renewal oFyour license in the evrnt you owe Minnesota sales, employer s withholding or motor vehicle excise taxes; - ZSpon receiving this infocmation, the licrnsing authoriey witl supply it oniy to the Minnesota Department of Revenue. However, under the Federal Exchange of Info�nation Agreement, thz Deparlmrnt of Revrnue may supply tlus infotmation to the Intema! Revrnue Service. ' Minnaota Ta�c Identificacon Numb«s (Sales & Use Tax Number) may ba obtained from ttx Stete of Minnesota, Busiuess Records Department, 10 Riva Park Ptaza (612-296-61 Sl ). Social Security Number: _��' ��' �� 1vl�nnesota Ta�c Idwtification Numba: lf a iviicmesota Ta�c Idzntification Number is not required for the b�uiness being opexated, indicate so by placing an"X" in the bo�. � `^` 2l18,"97 �_ 9�-�07 CERTIFIC aTION OF WORKERS' COMPENSATPON COVERAGE PURSUANf TO MII�INESOTA STATUTE 176.182 I hereby certify thaz I, or my company, azn in compliance with the workers' compensation insurance coverage requirements of Minnesota Statute 176.182, subdivision 2. I aLso understand tk�at provision of faLse information in this certificarion constitutes s�cieni graunds for adverse action against all licenses held, including revocation and suspension of said licenses. Nazne of Insurance Compaay: PolicyNumber: Coverag om W I have no employees covered under workers' compensalion insurance � �TIAI,S� � {� ` . , � � f' � - �'�' �-'� ANY FALSIFICATION OF ANSWERS GIVEN OR MATERIAL SUBMITTED WILL RESULT IN DENTIAL OF THIS APPLICATION I hereby state that I have answered all of the preceding ques[ions, and that the infotmation contained herein is true end cocrect to the best of my knowledge and belief. I hereby state fiuther that I have received no money or other consideration, by way of loan, gift, contribution, or othenvise, other than already disclosed in the application which I herewith submitted I also understend this premise may be inspected by police, fire, health and other city o$'icials at any and all times when the business is in operation. �� Signature (REQUIRED for al! appGcations) Date We wi11 accept payment by cash, check (made payable to City of Saint Paun or credk card (M/C or Visa). !F PAYING BYCREDlT CARD PLEASE COMPLETE THE FOLLOWING lNFORhL4TlON: � MasterCard � Visa EXPfftATION DATE: ACCOUNT NiJMBER: ❑C]/o❑ ❑oo❑ ❑oo❑ ❑oo❑ ❑oo❑ of Caz�oider of Cud ""Note: If this application is Food(Liquor related, please contact a City of Saint Paul Health Inspector, Steve Olson (266-9139), to review plans. If any substantial changes to structure are anticipated, please coneact a Ciry of Saint Paul Plan Exatniner at 266-9007 to apply for 6uilding peimiu. If there are azry changes to the parking loc, floor space, or foc new operations, please contact a City of Saint Paul Zoning Inspeetor at 266-9008. All appGcations mquire t6e following documente. Please attach these documents when submitting your application: 1. A detailed description of the design, location and squaze footage of the premises to be licensed (sile plan). The following data should be on the site plan (preferably on an 8 1/2" x 11 " or 8 1/2" x 14" paper): - Name, address, and phone number. - The scale should be stated such as 1"= 20'. ^N should be indicated toward the top. - Placement of all pertinent features of the interior of the licensed facility such as seating areas, kitchens, o�ces, repair area, parking, rest rooms, etc. - If a request is for an addition or expansion of the licensed facility, indicate both the curtent azea and the proposed expansion. 2. A copy of your lease agreement or proof of ownership of the property. SPECIFIC LICENSE APPLICATIONS REQUIRE ADDTTIONAL INFORMATION. PLEASE SEE REVERSE FOR DETAILS >>>> :i;' 2/b8/97 Council File,$ 7 ��0 ordinance # ORIGiNAL Presented By Referred To Committee: Date RESQLVSDa 1 That application (ID $0013819) for a Ma1t Off Sa1e, Grocery (C), 2 CigarettefTobacco License(s) by HAMMADEH AIROUSA DBA &INGS MARKET 3 II at 842 Wf�IITE BEAR AVE N be and the same is hereby approved. Yeas Nays Absent Requeated by Department o£: Benanav � Blakey _�� Bostrom Coleman � Harris � Lantrv Reiter �— Adopted by Council : Date � �, . � � }, � 1 � Office of License, Inspections and Environmental Protection B ��=- � Adoption Certified by Council Secretary Form Approved by City Attorney By: a � By: I i/(�1A' ��•��7yNJ, �' ZD - 7� Approved by r: Date a (� � Approved by Mayor for Submission to / Council / Bye By: RESOLUTIpN Green Sheet # LP60010 CfTY OF SAINT PAUL, MINNESOTA 2? DEPARTMENT/OFFICE/COUNCri �nn'rEamrw�o !d—IO7 uEP"'�r� GREEN SHEET No. LP60070 ONTACT PERSON & PHONE �� UNTHER WILLIAM (BILL) cs,z,zsss,� � cayaao�,er UST 8E ON COUNCfL AGENDA SY (DAT� A � 2/t1198 " �� ❑2 CouncO Res�rch ROIIiHf � TOTAL # OF SIGNATURE PAGES (CLIP ALL LOCATIONS FOR SiGNATURE) ACTION REQUESTED: Camcit approval oTthe Tdbxing N� appliptbn: Licem,e � 0073619, for t1AMMADEH AIKOUSA, Dan� Business As IQNGS MARKET II, at 842 WHITE BEAR AVE N. induding the fdlowing busi� type(s): Malt OfF Sale. Grocery (C). Cigarelte/TObaeco. RECOMMENDATIONS: Approve(A) Reject(R) RSCINAL SERVECE COMRACTS MUST ANSWER THE FOLLOIMNG OUESTIONS: 7. Flas this perso�rtn everworked urider a eonVact iw Mis departmen(7 PLANNING COMMISSION YES No Ct8 COMAAITT£E 2. HaslFiis persaJfmm ewer teen a ciy empfoyee? CIVIL SVC CINN, ves NO . Does mis aersunr�m possess a s�a�� na nwma�N v�sess� br a�y currem oilyy empbyeel YES NO . Is ihispersoMrtn a targeted vendoY/ — YES NO Expfain all yes answers on separate sheet antl attach to green shee[ INITIATING PROBLEM, ISSUE, OPPORTUNITY (Who, What, When, Where, Why): Requesting Council approval for Hammadeh Aikousa for an Off-Sale Matt, Grocery (C) 8 Cigarette License at 842 Whde B�r Avenue. ADVANTAGESIFAPPROVED: n � _ �� Wf� Ji�� 2 6 1�9� ISADVANTAGES IF APPROVED: ' - - �- ° DISADVANTAGES IF NOT APPROVED: OTAL AMOUNT OF TRANSACTION $ COST/REVENUE BUDGETED (CIRCLE ONE) YES NO FUNDING SOURCE ACTIVITY NUMBER FINANCIAL INFORMATION: (EXPLAIN) 4 � � CLASS III LICENSE APPLICATION PLEASE TYPE OR PRINT IN INK Type of License(s) being applied for: Company Name: If business is incorporated, give clate of incorporation: lioing Business As: Business Addtess: , � stleet AdGeu ' � � W � 1 II GC tst� Zi� � S'f G�' �� ltJd� r` c side of the street? � Between what cross streets is the business located. �` Are the premises now occupied? �/' V What Type�of Business? � _. ,, „ --- � Mail To Address: Strat Md'sss Name and TiUe: Home Address: Sentence: /� ;�.� ,�; lE � � ciry CTTY OF SAINT PAl o�« oru«�, �«vo� � �� «� ��u�� ..� s:�� (61�tb6A090 6x(6Il]26691b /0 7 � �j� �-r7�'a S a S c��O s O S c�17e� a Sute Zip � �/i� •' /�'� sv��,�ea�„ �� U s� Z�P ,/ Date of Birth: D�/�7 I,� Place of Birth: Home Phone: — ��'X Have you ever bern convicted of any felony, crime or violation � any ciry ordinance other than traffic? YES NO,� Date of arrest Charge: _ Conviction: Lis1 the names and residences of three persons of good moral chazacter, living within the Twin Cilies Metro Area, not related to the applicant or financially interested in the premises or business, who may be referred to as to the applicant's chazacter: � ADDRESS List licenses which you currenfly hold, formerly held, or may have an Hace any of the above named licenses evec bern revoked7 ��5�t��e G�S�.� � as �/�2� �.� . � • �: • c � � : r.� 1: � WhereT PHONE ,� u� 9� � w YES _�, NO If yes, list the dates and reasous for revocarion: � _'•1 �/A �;9'� Are going to opaaie this business personally? � YES _Q .�t� J'Y)/.� ��(� �. � F� .� r�aaio w�� u�a�� Jn, �c1�) lS7ct' �,S�r� �r�.�T �� I�l -�r-`� � �«.: s�a x.m� c��r pre you gomg to tiave amanega a essistant in this busincss7 � YES plea�e�complete thg followiPg infor �atio � h ^� F'u+t �a+c�a �'.�i R,r,�am> Addcas: StratNmme Picase list your employmrnt kvslory for thc previous five (5) yeaz periad: List ali other officers of the cocparation: OFFICER TITLE HOME NAivfE (OfficeHeld) ADDRESS Nfl If not, who w _�� s'"�L su�e 230 If � Lut V Suta HOME PHONE 98-io� operete it4 , „ � /—a?lJ (S ��rB�, � Yh . �5�38" 4�(/n-� , z; es«�e u� y . snager ts not the same as the opecatoc, /�� "Z_ D.te of 8'vih jS4_3b'� �llc'/C�� Zip P6one Numbec BUSINESS DATE OF PHONE BB�� tv � �- - If business is a partnership, please include the following informadoa for each paitna (use addidonal pages if nxessary): N � � -- � �i�) yy� uaw va cuu� Home AddRta: Sheet N�mn Ciry St�ta Zip Pl+one Number FintNme Middlelnitid M�iden) Ld D�tboCB'utfi Home Mdtas: Sircct Nme Ciry Stnta 2ip Phonc N�ber MIl�IDIESOTA TAX IDENTIFIGATIODI NUMSER - Pwsuant to the I,aws of Minnesota, 1984, Chapter 502, Article 8, Section 2(270.72) (Ta+c Ctearenee; Issuance of Licenses), licensing authori[ies are required to provide to the State of Minnesota Conu[tissiona of Revenue, the Minnesata business tar identification number and ihe social security number of each license applicant Undet the Minnesota Govemment Data Practices Act and the Fedaal Privacy Act of 1974, we are required to advise you of the following regarding the use of the Minnesota Tar ldrnt�cation Numba: - This infotmation may be used to deny the issuance or renewal oFyour license in the evrnt you owe Minnesota sales, employer s withholding or motor vehicle excise taxes; - ZSpon receiving this infocmation, the licrnsing authoriey witl supply it oniy to the Minnesota Department of Revenue. However, under the Federal Exchange of Info�nation Agreement, thz Deparlmrnt of Revrnue may supply tlus infotmation to the Intema! Revrnue Service. ' Minnaota Ta�c Identificacon Numb«s (Sales & Use Tax Number) may ba obtained from ttx Stete of Minnesota, Busiuess Records Department, 10 Riva Park Ptaza (612-296-61 Sl ). Social Security Number: _��' ��' �� 1vl�nnesota Ta�c Idwtification Numba: lf a iviicmesota Ta�c Idzntification Number is not required for the b�uiness being opexated, indicate so by placing an"X" in the bo�. � `^` 2l18,"97 �_ 9�-�07 CERTIFIC aTION OF WORKERS' COMPENSATPON COVERAGE PURSUANf TO MII�INESOTA STATUTE 176.182 I hereby certify thaz I, or my company, azn in compliance with the workers' compensation insurance coverage requirements of Minnesota Statute 176.182, subdivision 2. I aLso understand tk�at provision of faLse information in this certificarion constitutes s�cieni graunds for adverse action against all licenses held, including revocation and suspension of said licenses. Nazne of Insurance Compaay: PolicyNumber: Coverag om W I have no employees covered under workers' compensalion insurance � �TIAI,S� � {� ` . , � � f' � - �'�' �-'� ANY FALSIFICATION OF ANSWERS GIVEN OR MATERIAL SUBMITTED WILL RESULT IN DENTIAL OF THIS APPLICATION I hereby state that I have answered all of the preceding ques[ions, and that the infotmation contained herein is true end cocrect to the best of my knowledge and belief. I hereby state fiuther that I have received no money or other consideration, by way of loan, gift, contribution, or othenvise, other than already disclosed in the application which I herewith submitted I also understend this premise may be inspected by police, fire, health and other city o$'icials at any and all times when the business is in operation. �� Signature (REQUIRED for al! appGcations) Date We wi11 accept payment by cash, check (made payable to City of Saint Paun or credk card (M/C or Visa). !F PAYING BYCREDlT CARD PLEASE COMPLETE THE FOLLOWING lNFORhL4TlON: � MasterCard � Visa EXPfftATION DATE: ACCOUNT NiJMBER: ❑C]/o❑ ❑oo❑ ❑oo❑ ❑oo❑ ❑oo❑ of Caz�oider of Cud ""Note: If this application is Food(Liquor related, please contact a City of Saint Paul Health Inspector, Steve Olson (266-9139), to review plans. If any substantial changes to structure are anticipated, please coneact a Ciry of Saint Paul Plan Exatniner at 266-9007 to apply for 6uilding peimiu. If there are azry changes to the parking loc, floor space, or foc new operations, please contact a City of Saint Paul Zoning Inspeetor at 266-9008. All appGcations mquire t6e following documente. Please attach these documents when submitting your application: 1. A detailed description of the design, location and squaze footage of the premises to be licensed (sile plan). The following data should be on the site plan (preferably on an 8 1/2" x 11 " or 8 1/2" x 14" paper): - Name, address, and phone number. - The scale should be stated such as 1"= 20'. ^N should be indicated toward the top. - Placement of all pertinent features of the interior of the licensed facility such as seating areas, kitchens, o�ces, repair area, parking, rest rooms, etc. - If a request is for an addition or expansion of the licensed facility, indicate both the curtent azea and the proposed expansion. 2. A copy of your lease agreement or proof of ownership of the property. SPECIFIC LICENSE APPLICATIONS REQUIRE ADDTTIONAL INFORMATION. PLEASE SEE REVERSE FOR DETAILS >>>> :i;' 2/b8/97 Council File,$ 7 ��0 ordinance # ORIGiNAL Presented By Referred To Committee: Date RESQLVSDa 1 That application (ID $0013819) for a Ma1t Off Sa1e, Grocery (C), 2 CigarettefTobacco License(s) by HAMMADEH AIROUSA DBA &INGS MARKET 3 II at 842 Wf�IITE BEAR AVE N be and the same is hereby approved. Yeas Nays Absent Requeated by Department o£: Benanav � Blakey _�� Bostrom Coleman � Harris � Lantrv Reiter �— Adopted by Council : Date � �, . � � }, � 1 � Office of License, Inspections and Environmental Protection B ��=- � Adoption Certified by Council Secretary Form Approved by City Attorney By: a � By: I i/(�1A' ��•��7yNJ, �' ZD - 7� Approved by r: Date a (� � Approved by Mayor for Submission to / Council / Bye By: RESOLUTIpN Green Sheet # LP60010 CfTY OF SAINT PAUL, MINNESOTA 2? DEPARTMENT/OFFICE/COUNCri �nn'rEamrw�o !d—IO7 uEP"'�r� GREEN SHEET No. LP60070 ONTACT PERSON & PHONE �� UNTHER WILLIAM (BILL) cs,z,zsss,� � cayaao�,er UST 8E ON COUNCfL AGENDA SY (DAT� A � 2/t1198 " �� ❑2 CouncO Res�rch ROIIiHf � TOTAL # OF SIGNATURE PAGES (CLIP ALL LOCATIONS FOR SiGNATURE) ACTION REQUESTED: Camcit approval oTthe Tdbxing N� appliptbn: Licem,e � 0073619, for t1AMMADEH AIKOUSA, Dan� Business As IQNGS MARKET II, at 842 WHITE BEAR AVE N. induding the fdlowing busi� type(s): Malt OfF Sale. Grocery (C). Cigarelte/TObaeco. RECOMMENDATIONS: Approve(A) Reject(R) RSCINAL SERVECE COMRACTS MUST ANSWER THE FOLLOIMNG OUESTIONS: 7. Flas this perso�rtn everworked urider a eonVact iw Mis departmen(7 PLANNING COMMISSION YES No Ct8 COMAAITT£E 2. HaslFiis persaJfmm ewer teen a ciy empfoyee? CIVIL SVC CINN, ves NO . Does mis aersunr�m possess a s�a�� na nwma�N v�sess� br a�y currem oilyy empbyeel YES NO . Is ihispersoMrtn a targeted vendoY/ — YES NO Expfain all yes answers on separate sheet antl attach to green shee[ INITIATING PROBLEM, ISSUE, OPPORTUNITY (Who, What, When, Where, Why): Requesting Council approval for Hammadeh Aikousa for an Off-Sale Matt, Grocery (C) 8 Cigarette License at 842 Whde B�r Avenue. ADVANTAGESIFAPPROVED: n � _ �� Wf� Ji�� 2 6 1�9� ISADVANTAGES IF APPROVED: ' - - �- ° DISADVANTAGES IF NOT APPROVED: OTAL AMOUNT OF TRANSACTION $ COST/REVENUE BUDGETED (CIRCLE ONE) YES NO FUNDING SOURCE ACTIVITY NUMBER FINANCIAL INFORMATION: (EXPLAIN) 4 � � CLASS III LICENSE APPLICATION PLEASE TYPE OR PRINT IN INK Type of License(s) being applied for: Company Name: If business is incorporated, give clate of incorporation: lioing Business As: Business Addtess: , � stleet AdGeu ' � � W � 1 II GC tst� Zi� � S'f G�' �� ltJd� r` c side of the street? � Between what cross streets is the business located. �` Are the premises now occupied? �/' V What Type�of Business? � _. ,, „ --- � Mail To Address: Strat Md'sss Name and TiUe: Home Address: Sentence: /� ;�.� ,�; lE � � ciry CTTY OF SAINT PAl o�« oru«�, �«vo� � �� «� ��u�� ..� s:�� (61�tb6A090 6x(6Il]26691b /0 7 � �j� �-r7�'a S a S c��O s O S c�17e� a Sute Zip � �/i� •' /�'� sv��,�ea�„ �� U s� Z�P ,/ Date of Birth: D�/�7 I,� Place of Birth: Home Phone: — ��'X Have you ever bern convicted of any felony, crime or violation � any ciry ordinance other than traffic? YES NO,� Date of arrest Charge: _ Conviction: Lis1 the names and residences of three persons of good moral chazacter, living within the Twin Cilies Metro Area, not related to the applicant or financially interested in the premises or business, who may be referred to as to the applicant's chazacter: � ADDRESS List licenses which you currenfly hold, formerly held, or may have an Hace any of the above named licenses evec bern revoked7 ��5�t��e G�S�.� � as �/�2� �.� . � • �: • c � � : r.� 1: � WhereT PHONE ,� u� 9� � w YES _�, NO If yes, list the dates and reasous for revocarion: � _'•1 �/A �;9'� Are going to opaaie this business personally? � YES _Q .�t� J'Y)/.� ��(� �. � F� .� r�aaio w�� u�a�� Jn, �c1�) lS7ct' �,S�r� �r�.�T �� I�l -�r-`� � �«.: s�a x.m� c��r pre you gomg to tiave amanega a essistant in this busincss7 � YES plea�e�complete thg followiPg infor �atio � h ^� F'u+t �a+c�a �'.�i R,r,�am> Addcas: StratNmme Picase list your employmrnt kvslory for thc previous five (5) yeaz periad: List ali other officers of the cocparation: OFFICER TITLE HOME NAivfE (OfficeHeld) ADDRESS Nfl If not, who w _�� s'"�L su�e 230 If � Lut V Suta HOME PHONE 98-io� operete it4 , „ � /—a?lJ (S ��rB�, � Yh . �5�38" 4�(/n-� , z; es«�e u� y . snager ts not the same as the opecatoc, /�� "Z_ D.te of 8'vih jS4_3b'� �llc'/C�� Zip P6one Numbec BUSINESS DATE OF PHONE BB�� tv � �- - If business is a partnership, please include the following informadoa for each paitna (use addidonal pages if nxessary): N � � -- � �i�) yy� uaw va cuu� Home AddRta: Sheet N�mn Ciry St�ta Zip Pl+one Number FintNme Middlelnitid M�iden) Ld D�tboCB'utfi Home Mdtas: Sircct Nme Ciry Stnta 2ip Phonc N�ber MIl�IDIESOTA TAX IDENTIFIGATIODI NUMSER - Pwsuant to the I,aws of Minnesota, 1984, Chapter 502, Article 8, Section 2(270.72) (Ta+c Ctearenee; Issuance of Licenses), licensing authori[ies are required to provide to the State of Minnesota Conu[tissiona of Revenue, the Minnesata business tar identification number and ihe social security number of each license applicant Undet the Minnesota Govemment Data Practices Act and the Fedaal Privacy Act of 1974, we are required to advise you of the following regarding the use of the Minnesota Tar ldrnt�cation Numba: - This infotmation may be used to deny the issuance or renewal oFyour license in the evrnt you owe Minnesota sales, employer s withholding or motor vehicle excise taxes; - ZSpon receiving this infocmation, the licrnsing authoriey witl supply it oniy to the Minnesota Department of Revenue. However, under the Federal Exchange of Info�nation Agreement, thz Deparlmrnt of Revrnue may supply tlus infotmation to the Intema! Revrnue Service. ' Minnaota Ta�c Identificacon Numb«s (Sales & Use Tax Number) may ba obtained from ttx Stete of Minnesota, Busiuess Records Department, 10 Riva Park Ptaza (612-296-61 Sl ). Social Security Number: _��' ��' �� 1vl�nnesota Ta�c Idwtification Numba: lf a iviicmesota Ta�c Idzntification Number is not required for the b�uiness being opexated, indicate so by placing an"X" in the bo�. � `^` 2l18,"97 �_ 9�-�07 CERTIFIC aTION OF WORKERS' COMPENSATPON COVERAGE PURSUANf TO MII�INESOTA STATUTE 176.182 I hereby certify thaz I, or my company, azn in compliance with the workers' compensation insurance coverage requirements of Minnesota Statute 176.182, subdivision 2. I aLso understand tk�at provision of faLse information in this certificarion constitutes s�cieni graunds for adverse action against all licenses held, including revocation and suspension of said licenses. Nazne of Insurance Compaay: PolicyNumber: Coverag om W I have no employees covered under workers' compensalion insurance � �TIAI,S� � {� ` . , � � f' � - �'�' �-'� ANY FALSIFICATION OF ANSWERS GIVEN OR MATERIAL SUBMITTED WILL RESULT IN DENTIAL OF THIS APPLICATION I hereby state that I have answered all of the preceding ques[ions, and that the infotmation contained herein is true end cocrect to the best of my knowledge and belief. I hereby state fiuther that I have received no money or other consideration, by way of loan, gift, contribution, or othenvise, other than already disclosed in the application which I herewith submitted I also understend this premise may be inspected by police, fire, health and other city o$'icials at any and all times when the business is in operation. �� Signature (REQUIRED for al! appGcations) Date We wi11 accept payment by cash, check (made payable to City of Saint Paun or credk card (M/C or Visa). !F PAYING BYCREDlT CARD PLEASE COMPLETE THE FOLLOWING lNFORhL4TlON: � MasterCard � Visa EXPfftATION DATE: ACCOUNT NiJMBER: ❑C]/o❑ ❑oo❑ ❑oo❑ ❑oo❑ ❑oo❑ of Caz�oider of Cud ""Note: If this application is Food(Liquor related, please contact a City of Saint Paul Health Inspector, Steve Olson (266-9139), to review plans. If any substantial changes to structure are anticipated, please coneact a Ciry of Saint Paul Plan Exatniner at 266-9007 to apply for 6uilding peimiu. If there are azry changes to the parking loc, floor space, or foc new operations, please contact a City of Saint Paul Zoning Inspeetor at 266-9008. All appGcations mquire t6e following documente. Please attach these documents when submitting your application: 1. A detailed description of the design, location and squaze footage of the premises to be licensed (sile plan). The following data should be on the site plan (preferably on an 8 1/2" x 11 " or 8 1/2" x 14" paper): - Name, 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 interior of the licensed facility such as seating areas, kitchens, o�ces, repair area, parking, rest rooms, etc. - If a request is for an addition or expansion of the licensed facility, indicate both the curtent azea and the proposed expansion. 2. A copy of your lease agreement or proof of ownership of the property. SPECIFIC LICENSE APPLICATIONS REQUIRE ADDTTIONAL INFORMATION. PLEASE SEE REVERSE FOR DETAILS >>>> :i;' 2/b8/97