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98-151 2 3 4 5 6 7 9 10 �� 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 _ �`�� ` `� �� ` � �� .$- �� . Date (3.2) and Restaurant (A) , Inc. (Gerald S. Freeman, is hereby approved. ("•. j ` i ('`� ,`• : f ,P i ` t P= E i \.! . � i ��e . r . _ , ,_. Presented Referred To Council File # r a I J ordinance # �� Green Sheet 50243 RESOLUTION CITY OF SA1NT PAUL, MINNESOTA �.��'�-- RESOLVED: That application, ID #15406, for an On-Sale License by Inside Sports, Inc. DBA Inside S President) at 1500 Rice Street, be and the � � Requested by Department of: • - - •�- •s_�-t - •: Bye Adoption C�ztified by Council Secretary By: Apgrov d by Mayor: Date By: Form Approved by City At . By : � �-� � Approved by yor for Submiasion to Council By: Adogted by C�uncil: Date GREEN SHEET INIT1AUf)ATF - a DEPARTMENT O�RECTOR — 266-9108 asacx �cmarroaroev NIJMBEp FON � BUDGET D�RECTOFl ilOUTING > Ofl�ER � MAYOR (OR ASS�STANT) TOTAL # OF SIGNA7URE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE) N° 50243 q�-�S iNfTiAVDATE � CINCOUNCII O CITY CLEFK � FIN. 8 MGT. SERVICES �IR. a Inside Sports, Inc. DBA Inside Sports, Inc. (Gerald S. Freeman, President) requests Council approval of their application for an On-Sale Malt (3.2) and Restaurant (A) License located at 1500 Rice Street. (ID �15406) _ PI.ANNING COMMISSION _ CNIL SERVICE COMMISSION _ Cf8 COMMIiTEE _ _ $TpFF _ _ DISTRICTCOURT _ SUPPoHT5 WHICH CqUNCI� O&IECTNE? ADVANTAGES IFAPPPOVED' iC�51 PERSONAL SERVICE CONTRAC75 MUST ANSWER TNE FOLLOWING QUES710NS: t. Has this person/firm ever worketl under a contrect for this department? YES NO 2. Has ihis perSOnKrm ever been a ciN employee? YES NO 3. Ooes this personlfirm possess a sitiil not normally Qossessed by any cunent ciry empioyea� YES NO Explain alt yes answers on separate shaet entl nttaeh to greon shcet TOTAL AMOUNT OF TRANSACTION COST/pEVENUE BUDGETED (CIRCLE ONE) VES NO FUNDIWG SOURCE °INANCIAL MFOflIfiA710N; (EXPIAIN) . 9�-�s _ � r's�ld � Type of License(s) being applied fot: Company Name: Coipo�atian / Paztnanhip / PLEASB TYPE OR Srntence: If business is incorporated, give date of incorporation: `�� J;?s �oing Business As: _ �n�+ S i r� �`�n� S ��,; i_ Business Phone: ��'1�/ - � 1° / Business Address: _ % SL%t� � � CE �- �'r 1�G�+� M� a``�. 1 i� Sx« aaa,� csry sr� ztp $etween what cross streets is the business located? __�1 R.L �nx� TOne �y p r,JrAn.A Which side of the street� �AS i Are the premises now occupied? � What Type of Business? �t � S �/2�Z/ZEA�ic'h� Mail To Address: IS�[? �� L'r S �: ST 1��N �� n� � 1!� so-«� nda� ctry s�u z� ApplicantInformation: NazneandTitle: Ga�A�-� �M�e'Z �'l"i� `�jt� Fint Middlc (4[aidrn) Lnst Titt< Home Address: �� i°t �.O(-FfWS� /`��uJ) �cta� �� ,�.�r: SSt 1"� Skeet Address --7 City State Zip Date of Buth: / J 1 �'� `� Place of Birth: �r �F'N � Home Phone: �4 `v' 7 � S�� Have you ever been cAnvicted of any felony, crime ar violation of any ciry ordinance other than traffic? YES NO ,�_ Date of azrest: Whete7 Chuge: _ Conviction: Lis[ the names and residences of three persons of good moral characier, living within the Twin Cities Metro Area, not related to the applicant or financially interested in the premises or business, who may be refened to as to the applicant's chuacter: � List licenses which you CLASS III LICENSE APPLICATION ADDRESS formerly held, or may have an interest in: Hace any of the above nazned licenses ever bzen revoked7 CITY OF SA1NT PAUZ o�',« oeU�a�, ��cs� and Envirocunrnta( Protectior. 3N1 SL P>c St Sw¢ 700 ti SSIO2 (612)266NA0 (612)1659131 S a�� S �- h : �iJ � � S '�'� •�1� YE5 ��NO If yes, ]ist the dates and reasons for revocation: ;�? THIS APPLICATION IS SUBJFCT TO REV3EW BY THE Pi3BLIC Are you going to operate this business personally7 � YES N�� HocicMLras: Sk-.,ettiame 0 :v7iddlc Ciry Are you going to have a manager or assistant in this business? �YES please complete the following information: raadi� �u� NO If noi, who will operate it? I.ent Ststc 9� -�S � Date af Bir,h Zip phonel�umbcr NO If the manager is not the same as the operator, �/�S �� 5� l 0�-- na� orsw, � —��' HomeAddicsc StreetName CiTy SieL- Zip Phonc\umbcr Please list your employment history for the previous five (5) year period: $usiness/Em�lo�ment ddress jN Sra�t4 S t�c�liYS /�� C� 5c', S�. {�;vi f�� ( 7 List all other officers of the corporalion: OFFICER TITLE J HOME HOME BUSINESS DATE OF NAME (Office Held) � ADDRESS PHONE PHONE BIRTH !=. S � �-�+t�� W �N�=�� (1.i', �ck,o GAi�, 64io �,03 ��;-2�, 7l*5 /�? If business is a parfnership, please include the following information for each partner (use additional pages if necessary): Fint Name Homc Address: SUeet Nnmc FintName Home Md`r.v: Shxet Name Middle Initial Middk Initial �+�) CiTy (�laidrnj City Lavt Stste Zip I.ast Siate 2ip Dau of Buth Phonc Number Da£c of Birth Phone Number MINNESOTA TAX IDENLIFICATIQN NUMBER - Pursuant to the Laws of Mianesota, 1984, Chapter 502, Article 8, Section 2(27Q.72) (TaK Cleazance; Issuance of Licenses), licensing authoritie's are required to provide to the State of Minnesota Commissioner of Revenue, the Minnesota business tax identifioatian number and the soc;al 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 the use of the Minnesota Ta� Identification Number: - This infonnafion may be used to deny the issuance or renewal of your license in the evrnt you owe Minnesota sales, employer's withholding or motor vehicle excise taxes; - Upon receiving this infomiation, the licensing �uthority will supply it only to the Minnesota Depaztment of Revenue. However, under thz Federal Exchange of Information AgFeement, the Departmznt of Revenue may supply this information to the Intemal Revenue Service. Minnesota TaY Identification Numbe� (Sales & Use Tati Number) may be obtained from the State of Minnesota, Business Records Depar[ment, 10 River Pazk Plua (612-296-6181). Social Security Number: �� '� � 5 �`� Minnesota TaY Identification Number: � �`�� _ If a Minnesota TaY Tdrnt�cation Numbzr is not iequired for the businzss being operated, indicate so by placing an "X" in thz box `^L 2/18'97 qs-�s CERTIFICATION OF WORKERS' COMPENSATION COVERAGE PURSUANT TO MINNESOTA STANTE 176.182 I tizreby ceRify that I, or rny company, am in cqmpliance with the workers' compensation insurance coverage requuements of Minnesota Statutz 176.182, subdivision 2 I also uuderst�d that provision of false infoimation in this certification constiNtes sufficient grounds for adverse action against all licenses held, including revocauon and suspension of said licenses. Name of Insurance Company: S� 1. �?v I ^�k �� . 7:u � ��t12 � i,Ry � N>, Policy Number: W��(.� � i.+_s �?�} Coverzge from 31 � 4 15 7 to I have no employees covered under workers' compensation insurance (INITIALS) �itd�51 ANY FALSIFICATION OF ANS'WERS GIVEN OR MATERIAL SUBD�IITTED WII.L RESULT IN DENIAL OF THIS APPLICATION I hereby state that I have answered all of the preceding questions, and that the infoimation contained herein is true and correct to the best of my l�owledge and belief I hereby state fiuther that I have received no money or other consideration, by way of loan, gif� contribution, or othenvise, other than alreasly disclosed in the applicalion which I herewith submitted. I also understand this premise may be inspected by police, fire, health and other ciry officials at any and all times when the business is in operation. �G (REQUIRED for all applications) We will accept payment by cash, check (made payable to City of Saint Paul) or c-tlit card (MJC or Visa). Date IF PAYING BY CREDIT CARD PLEASE COMPLETE THE FOLLOWING INFORMATION: � MasterCard ❑ Visa EXPIItATION DATE: ❑o/o❑ Name for all Date *"Note: Tf this application is Food/Liquor related, please contact a City of Saint Paul Health Inspector, Steve Olson (266-9139), to review plans. Tf any substantiai changes to shucture are anticipated, please contact a City oi Saint Paul Plan Examiner at 266-9007 to apply fo: building permits. Ifthere aze any ch�ages 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 documents when submitting your applicatioo: 1. A detailed description of the design, location and squaze footage of the premises to be licensed (site plan). The foltowing data should be on the site plan (preferably on an 8 1/2" x I 1" or 8 1/2" x 14" paper): - Name, address, and phone number. - The scale should be stated such as I"= 20'. ^N should be indicated towazd the top. - Placetnent of all pertinent features of the interior of the licensed facility such as seating areas, kitchens, offices, repair azea, puking, rest rooms, etc. - If a request is for an addition or expansion of the licensed facility, indicate both the current area and thz proposed e�pansion. 2. A copy of your lease agteement or proof of ownership of the properry'. 5PECIFIC LICENSE APPLTCATIONS REQilII2E ADDTTIONAL INFORMATION. PLEASE SEE REVERSE FQR DETAII�S >>>> ,� i ACCOUNTNUMBER: ■■■■ ■■■■ ■■■■ ■■■■ vLSro� 1 2 3 4 5 6 7 9 10 �� 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 _ �`�� ` `� �� ` � �� .$- �� . Date (3.2) and Restaurant (A) , Inc. (Gerald S. Freeman, is hereby approved. ("•. j ` i ('`� ,`• : f ,P i ` t P= E i \.! . � i ��e . r . _ , ,_. Presented Referred To Council File # r a I J ordinance # �� Green Sheet 50243 RESOLUTION CITY OF SA1NT PAUL, MINNESOTA �.��'�-- RESOLVED: That application, ID #15406, for an On-Sale License by Inside Sports, Inc. DBA Inside S President) at 1500 Rice Street, be and the � � Requested by Department of: • - - •�- •s_�-t - •: Bye Adoption C�ztified by Council Secretary By: Apgrov d by Mayor: Date By: Form Approved by City At . By : � �-� � Approved by yor for Submiasion to Council By: Adogted by C�uncil: Date GREEN SHEET INIT1AUf)ATF - a DEPARTMENT O�RECTOR — 266-9108 asacx �cmarroaroev NIJMBEp FON � BUDGET D�RECTOFl ilOUTING > Ofl�ER � MAYOR (OR ASS�STANT) TOTAL # OF SIGNA7URE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE) N° 50243 q�-�S iNfTiAVDATE � CINCOUNCII O CITY CLEFK � FIN. 8 MGT. SERVICES �IR. a Inside Sports, Inc. DBA Inside Sports, Inc. (Gerald S. Freeman, President) requests Council approval of their application for an On-Sale Malt (3.2) and Restaurant (A) License located at 1500 Rice Street. (ID �15406) _ PI.ANNING COMMISSION _ CNIL SERVICE COMMISSION _ Cf8 COMMIiTEE _ _ $TpFF _ _ DISTRICTCOURT _ SUPPoHT5 WHICH CqUNCI� O&IECTNE? ADVANTAGES IFAPPPOVED' iC�51 PERSONAL SERVICE CONTRAC75 MUST ANSWER TNE FOLLOWING QUES710NS: t. Has this person/firm ever worketl under a contrect for this department? YES NO 2. Has ihis perSOnKrm ever been a ciN employee? YES NO 3. Ooes this personlfirm possess a sitiil not normally Qossessed by any cunent ciry empioyea� YES NO Explain alt yes answers on separate shaet entl nttaeh to greon shcet TOTAL AMOUNT OF TRANSACTION COST/pEVENUE BUDGETED (CIRCLE ONE) VES NO FUNDIWG SOURCE °INANCIAL MFOflIfiA710N; (EXPIAIN) . 9�-�s _ � r's�ld � Type of License(s) being applied fot: Company Name: Coipo�atian / Paztnanhip / PLEASB TYPE OR Srntence: If business is incorporated, give date of incorporation: `�� J;?s �oing Business As: _ �n�+ S i r� �`�n� S ��,; i_ Business Phone: ��'1�/ - � 1° / Business Address: _ % SL%t� � � CE �- �'r 1�G�+� M� a``�. 1 i� Sx« aaa,� csry sr� ztp $etween what cross streets is the business located? __�1 R.L �nx� TOne �y p r,JrAn.A Which side of the street� �AS i Are the premises now occupied? � What Type of Business? �t � S �/2�Z/ZEA�ic'h� Mail To Address: IS�[? �� L'r S �: ST 1��N �� n� � 1!� so-«� nda� ctry s�u z� ApplicantInformation: NazneandTitle: Ga�A�-� �M�e'Z �'l"i� `�jt� Fint Middlc (4[aidrn) Lnst Titt< Home Address: �� i°t �.O(-FfWS� /`��uJ) �cta� �� ,�.�r: SSt 1"� Skeet Address --7 City State Zip Date of Buth: / J 1 �'� `� Place of Birth: �r �F'N � Home Phone: �4 `v' 7 � S�� Have you ever been cAnvicted of any felony, crime ar violation of any ciry ordinance other than traffic? YES NO ,�_ Date of azrest: Whete7 Chuge: _ Conviction: Lis[ the names and residences of three persons of good moral characier, living within the Twin Cities Metro Area, not related to the applicant or financially interested in the premises or business, who may be refened to as to the applicant's chuacter: � List licenses which you CLASS III LICENSE APPLICATION ADDRESS formerly held, or may have an interest in: Hace any of the above nazned licenses ever bzen revoked7 CITY OF SA1NT PAUZ o�',« oeU�a�, ��cs� and Envirocunrnta( Protectior. 3N1 SL P>c St Sw¢ 700 ti SSIO2 (612)266NA0 (612)1659131 S a�� S �- h : �iJ � � S '�'� •�1� YE5 ��NO If yes, ]ist the dates and reasons for revocation: ;�? THIS APPLICATION IS SUBJFCT TO REV3EW BY THE Pi3BLIC Are you going to operate this business personally7 � YES N�� HocicMLras: Sk-.,ettiame 0 :v7iddlc Ciry Are you going to have a manager or assistant in this business? �YES please complete the following information: raadi� �u� NO If noi, who will operate it? I.ent Ststc 9� -�S � Date af Bir,h Zip phonel�umbcr NO If the manager is not the same as the operator, �/�S �� 5� l 0�-- na� orsw, � —��' HomeAddicsc StreetName CiTy SieL- Zip Phonc\umbcr Please list your employment history for the previous five (5) year period: $usiness/Em�lo�ment ddress jN Sra�t4 S t�c�liYS /�� C� 5c', S�. {�;vi f�� ( 7 List all other officers of the corporalion: OFFICER TITLE J HOME HOME BUSINESS DATE OF NAME (Office Held) � ADDRESS PHONE PHONE BIRTH !=. S � �-�+t�� W �N�=�� (1.i', �ck,o GAi�, 64io �,03 ��;-2�, 7l*5 /�? If business is a parfnership, please include the following information for each partner (use additional pages if necessary): Fint Name Homc Address: SUeet Nnmc FintName Home Md`r.v: Shxet Name Middle Initial Middk Initial �+�) CiTy (�laidrnj City Lavt Stste Zip I.ast Siate 2ip Dau of Buth Phonc Number Da£c of Birth Phone Number MINNESOTA TAX IDENLIFICATIQN NUMBER - Pursuant to the Laws of Mianesota, 1984, Chapter 502, Article 8, Section 2(27Q.72) (TaK Cleazance; Issuance of Licenses), licensing authoritie's are required to provide to the State of Minnesota Commissioner of Revenue, the Minnesota business tax identifioatian number and the soc;al 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 the use of the Minnesota Ta� Identification Number: - This infonnafion may be used to deny the issuance or renewal of your license in the evrnt you owe Minnesota sales, employer's withholding or motor vehicle excise taxes; - Upon receiving this infomiation, the licensing �uthority will supply it only to the Minnesota Depaztment of Revenue. However, under thz Federal Exchange of Information AgFeement, the Departmznt of Revenue may supply this information to the Intemal Revenue Service. Minnesota TaY Identification Numbe� (Sales & Use Tati Number) may be obtained from the State of Minnesota, Business Records Depar[ment, 10 River Pazk Plua (612-296-6181). Social Security Number: �� '� � 5 �`� Minnesota TaY Identification Number: � �`�� _ If a Minnesota TaY Tdrnt�cation Numbzr is not iequired for the businzss being operated, indicate so by placing an "X" in thz box `^L 2/18'97 qs-�s CERTIFICATION OF WORKERS' COMPENSATION COVERAGE PURSUANT TO MINNESOTA STANTE 176.182 I tizreby ceRify that I, or rny company, am in cqmpliance with the workers' compensation insurance coverage requuements of Minnesota Statutz 176.182, subdivision 2 I also uuderst�d that provision of false infoimation in this certification constiNtes sufficient grounds for adverse action against all licenses held, including revocauon and suspension of said licenses. Name of Insurance Company: S� 1. �?v I ^�k �� . 7:u � ��t12 � i,Ry � N>, Policy Number: W��(.� � i.+_s �?�} Coverzge from 31 � 4 15 7 to I have no employees covered under workers' compensation insurance (INITIALS) �itd�51 ANY FALSIFICATION OF ANS'WERS GIVEN OR MATERIAL SUBD�IITTED WII.L RESULT IN DENIAL OF THIS APPLICATION I hereby state that I have answered all of the preceding questions, and that the infoimation contained herein is true and correct to the best of my l�owledge and belief I hereby state fiuther that I have received no money or other consideration, by way of loan, gif� contribution, or othenvise, other than alreasly disclosed in the applicalion which I herewith submitted. I also understand this premise may be inspected by police, fire, health and other ciry officials at any and all times when the business is in operation. �G (REQUIRED for all applications) We will accept payment by cash, check (made payable to City of Saint Paul) or c-tlit card (MJC or Visa). Date IF PAYING BY CREDIT CARD PLEASE COMPLETE THE FOLLOWING INFORMATION: � MasterCard ❑ Visa EXPIItATION DATE: ❑o/o❑ Name for all Date *"Note: Tf this application is Food/Liquor related, please contact a City of Saint Paul Health Inspector, Steve Olson (266-9139), to review plans. Tf any substantiai changes to shucture are anticipated, please contact a City oi Saint Paul Plan Examiner at 266-9007 to apply fo: building permits. Ifthere aze any ch�ages 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 documents when submitting your applicatioo: 1. A detailed description of the design, location and squaze footage of the premises to be licensed (site plan). The foltowing data should be on the site plan (preferably on an 8 1/2" x I 1" or 8 1/2" x 14" paper): - Name, address, and phone number. - The scale should be stated such as I"= 20'. ^N should be indicated towazd the top. - Placetnent of all pertinent features of the interior of the licensed facility such as seating areas, kitchens, offices, repair azea, puking, rest rooms, etc. - If a request is for an addition or expansion of the licensed facility, indicate both the current area and thz proposed e�pansion. 2. A copy of your lease agteement or proof of ownership of the properry'. 5PECIFIC LICENSE APPLTCATIONS REQilII2E ADDTTIONAL INFORMATION. PLEASE SEE REVERSE FQR DETAII�S >>>> ,� i ACCOUNTNUMBER: ■■■■ ■■■■ ■■■■ ■■■■ vLSro� 1 2 3 4 5 6 7 9 10 �� 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 _ �`�� ` `� �� ` � �� .$- �� . Date (3.2) and Restaurant (A) , Inc. (Gerald S. Freeman, is hereby approved. ("•. j ` i ('`� ,`• : f ,P i ` t P= E i \.! . � i ��e . r . _ , ,_. Presented Referred To Council File # r a I J ordinance # �� Green Sheet 50243 RESOLUTION CITY OF SA1NT PAUL, MINNESOTA �.��'�-- RESOLVED: That application, ID #15406, for an On-Sale License by Inside Sports, Inc. DBA Inside S President) at 1500 Rice Street, be and the � � Requested by Department of: • - - •�- •s_�-t - •: Bye Adoption C�ztified by Council Secretary By: Apgrov d by Mayor: Date By: Form Approved by City At . By : � �-� � Approved by yor for Submiasion to Council By: Adogted by C�uncil: Date GREEN SHEET INIT1AUf)ATF - a DEPARTMENT O�RECTOR — 266-9108 asacx �cmarroaroev NIJMBEp FON � BUDGET D�RECTOFl ilOUTING > Ofl�ER � MAYOR (OR ASS�STANT) TOTAL # OF SIGNA7URE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE) N° 50243 q�-�S iNfTiAVDATE � CINCOUNCII O CITY CLEFK � FIN. 8 MGT. SERVICES �IR. a Inside Sports, Inc. DBA Inside Sports, Inc. (Gerald S. Freeman, President) requests Council approval of their application for an On-Sale Malt (3.2) and Restaurant (A) License located at 1500 Rice Street. (ID �15406) _ PI.ANNING COMMISSION _ CNIL SERVICE COMMISSION _ Cf8 COMMIiTEE _ _ $TpFF _ _ DISTRICTCOURT _ SUPPoHT5 WHICH CqUNCI� O&IECTNE? ADVANTAGES IFAPPPOVED' iC�51 PERSONAL SERVICE CONTRAC75 MUST ANSWER TNE FOLLOWING QUES710NS: t. Has this person/firm ever worketl under a contrect for this department? YES NO 2. Has ihis perSOnKrm ever been a ciN employee? YES NO 3. Ooes this personlfirm possess a sitiil not normally Qossessed by any cunent ciry empioyea� YES NO Explain alt yes answers on separate shaet entl nttaeh to greon shcet TOTAL AMOUNT OF TRANSACTION COST/pEVENUE BUDGETED (CIRCLE ONE) VES NO FUNDIWG SOURCE °INANCIAL MFOflIfiA710N; (EXPIAIN) . 9�-�s _ � r's�ld � Type of License(s) being applied fot: Company Name: Coipo�atian / Paztnanhip / PLEASB TYPE OR Srntence: If business is incorporated, give date of incorporation: `�� J;?s �oing Business As: _ �n�+ S i r� �`�n� S ��,; i_ Business Phone: ��'1�/ - � 1° / Business Address: _ % SL%t� � � CE �- �'r 1�G�+� M� a``�. 1 i� Sx« aaa,� csry sr� ztp $etween what cross streets is the business located? __�1 R.L �nx� TOne �y p r,JrAn.A Which side of the street� �AS i Are the premises now occupied? � What Type of Business? �t � S �/2�Z/ZEA�ic'h� Mail To Address: IS�[? �� L'r S �: ST 1��N �� n� � 1!� so-«� nda� ctry s�u z� ApplicantInformation: NazneandTitle: Ga�A�-� �M�e'Z �'l"i� `�jt� Fint Middlc (4[aidrn) Lnst Titt< Home Address: �� i°t �.O(-FfWS� /`��uJ) �cta� �� ,�.�r: SSt 1"� Skeet Address --7 City State Zip Date of Buth: / J 1 �'� `� Place of Birth: �r �F'N � Home Phone: �4 `v' 7 � S�� Have you ever been cAnvicted of any felony, crime ar violation of any ciry ordinance other than traffic? YES NO ,�_ Date of azrest: Whete7 Chuge: _ Conviction: Lis[ the names and residences of three persons of good moral characier, living within the Twin Cities Metro Area, not related to the applicant or financially interested in the premises or business, who may be refened to as to the applicant's chuacter: � List licenses which you CLASS III LICENSE APPLICATION ADDRESS formerly held, or may have an interest in: Hace any of the above nazned licenses ever bzen revoked7 CITY OF SA1NT PAUZ o�',« oeU�a�, ��cs� and Envirocunrnta( Protectior. 3N1 SL P>c St Sw¢ 700 ti SSIO2 (612)266NA0 (612)1659131 S a�� S �- h : �iJ � � S '�'� •�1� YE5 ��NO If yes, ]ist the dates and reasons for revocation: ;�? THIS APPLICATION IS SUBJFCT TO REV3EW BY THE Pi3BLIC Are you going to operate this business personally7 � YES N�� HocicMLras: Sk-.,ettiame 0 :v7iddlc Ciry Are you going to have a manager or assistant in this business? �YES please complete the following information: raadi� �u� NO If noi, who will operate it? I.ent Ststc 9� -�S � Date af Bir,h Zip phonel�umbcr NO If the manager is not the same as the operator, �/�S �� 5� l 0�-- na� orsw, � —��' HomeAddicsc StreetName CiTy SieL- Zip Phonc\umbcr Please list your employment history for the previous five (5) year period: $usiness/Em�lo�ment ddress jN Sra�t4 S t�c�liYS /�� C� 5c', S�. {�;vi f�� ( 7 List all other officers of the corporalion: OFFICER TITLE J HOME HOME BUSINESS DATE OF NAME (Office Held) � ADDRESS PHONE PHONE BIRTH !=. S � �-�+t�� W �N�=�� (1.i', �ck,o GAi�, 64io �,03 ��;-2�, 7l*5 /�? If business is a parfnership, please include the following information for each partner (use additional pages if necessary): Fint Name Homc Address: SUeet Nnmc FintName Home Md`r.v: Shxet Name Middle Initial Middk Initial �+�) CiTy (�laidrnj City Lavt Stste Zip I.ast Siate 2ip Dau of Buth Phonc Number Da£c of Birth Phone Number MINNESOTA TAX IDENLIFICATIQN NUMBER - Pursuant to the Laws of Mianesota, 1984, Chapter 502, Article 8, Section 2(27Q.72) (TaK Cleazance; Issuance of Licenses), licensing authoritie's are required to provide to the State of Minnesota Commissioner of Revenue, the Minnesota business tax identifioatian number and the soc;al 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 the use of the Minnesota Ta� Identification Number: - This infonnafion may be used to deny the issuance or renewal of your license in the evrnt you owe Minnesota sales, employer's withholding or motor vehicle excise taxes; - Upon receiving this infomiation, the licensing �uthority will supply it only to the Minnesota Depaztment of Revenue. However, under thz Federal Exchange of Information AgFeement, the Departmznt of Revenue may supply this information to the Intemal Revenue Service. Minnesota TaY Identification Numbe� (Sales & Use Tati Number) may be obtained from the State of Minnesota, Business Records Depar[ment, 10 River Pazk Plua (612-296-6181). Social Security Number: �� '� � 5 �`� Minnesota TaY Identification Number: � �`�� _ If a Minnesota TaY Tdrnt�cation Numbzr is not iequired for the businzss being operated, indicate so by placing an "X" in thz box `^L 2/18'97 qs-�s CERTIFICATION OF WORKERS' COMPENSATION COVERAGE PURSUANT TO MINNESOTA STANTE 176.182 I tizreby ceRify that I, or rny company, am in cqmpliance with the workers' compensation insurance coverage requuements of Minnesota Statutz 176.182, subdivision 2 I also uuderst�d that provision of false infoimation in this certification constiNtes sufficient grounds for adverse action against all licenses held, including revocauon and suspension of said licenses. Name of Insurance Company: S� 1. �?v I ^�k �� . 7:u � ��t12 � i,Ry � N>, Policy Number: W��(.� � i.+_s �?�} Coverzge from 31 � 4 15 7 to I have no employees covered under workers' compensation insurance (INITIALS) �itd�51 ANY FALSIFICATION OF ANS'WERS GIVEN OR MATERIAL SUBD�IITTED WII.L RESULT IN DENIAL OF THIS APPLICATION I hereby state that I have answered all of the preceding questions, and that the infoimation contained herein is true and correct to the best of my l�owledge and belief I hereby state fiuther that I have received no money or other consideration, by way of loan, gif� contribution, or othenvise, other than alreasly disclosed in the applicalion which I herewith submitted. I also understand this premise may be inspected by police, fire, health and other ciry officials at any and all times when the business is in operation. �G (REQUIRED for all applications) We will accept payment by cash, check (made payable to City of Saint Paul) or c-tlit card (MJC or Visa). Date IF PAYING BY CREDIT CARD PLEASE COMPLETE THE FOLLOWING INFORMATION: � MasterCard ❑ Visa EXPIItATION DATE: ❑o/o❑ Name for all Date *"Note: Tf this application is Food/Liquor related, please contact a City of Saint Paul Health Inspector, Steve Olson (266-9139), to review plans. Tf any substantiai changes to shucture are anticipated, please contact a City oi Saint Paul Plan Examiner at 266-9007 to apply fo: building permits. Ifthere aze any ch�ages 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 documents when submitting your applicatioo: 1. A detailed description of the design, location and squaze footage of the premises to be licensed (site plan). The foltowing data should be on the site plan (preferably on an 8 1/2" x I 1" or 8 1/2" x 14" paper): - Name, address, and phone number. - The scale should be stated such as I"= 20'. ^N should be indicated towazd the top. - Placetnent of all pertinent features of the interior of the licensed facility such as seating areas, kitchens, offices, repair azea, puking, rest rooms, etc. - If a request is for an addition or expansion of the licensed facility, indicate both the current area and thz proposed e�pansion. 2. A copy of your lease agteement or proof of ownership of the properry'. 5PECIFIC LICENSE APPLTCATIONS REQilII2E ADDTTIONAL INFORMATION. PLEASE SEE REVERSE FQR DETAII�S >>>> ,� i ACCOUNTNUMBER: ■■■■ ■■■■ ■■■■ ■■■■ vLSro�