98-16Council File # ` O � `�
ordinance #
1
2
3
4
5
6
7
8
9
10
11
12
13
ia
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
RESOLUTION
CITY O�
Presented
Referred To
Green Sheet # 50241
�
��
RESOLVED: That application, ID #15480, for a Wine On-Sale and On-Sale Malt (3.2)
License by Muzit Rubrom & Lemlem Libsu DBA Asmara East A£rica Restaurant,
(Muzit Belay Rubrom, Mgr.), located at 854 University Avenue W., be and the
same is hereby approved.
Committee: Date
Requested by Department of:
O� of •� na . rnsgections and
Env�rorLmenta Protection
BY� l L�.1.tim�t,L..r � N-���
Form Approved by City Attorney
B y : __- �-��� �'�`t ^
Approved by ayor for Submission to
:il
By:
App�
By:
Adopted by Council: Date
Adoption Certified by Council Secretary
N° .50241
G G _1/
DEM�NiYENL4FFICEIGOUNCII �ATE INIi1ATE0 � p � �
LIEP i GREEN SHEE
CON7AGTPERS�N&PHONE � INITIAVDATE INfTIAVDATE
� DEPAR'TMENi DIREGTOR � CITY COUNqL
Christine A. Rozek - 266-9108 assior+ CIiVATTORNEY CIT'CLERK
NUMBEH FOq O a
MVST BE ON CpUNqI AGENDA eY (DATE) pp�ING O 9UDGET DIRECTOR Q GIN. & MGT SEAVICES OVR.
Hearing: ` f g� ORDER O MAYOR (OR ASSISTANT) �
TOTAL # OF SIGNATURE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE)
ACTION REQUESTED:
Muzit Rubrom 5 Lemlem I.ibsu DBA Asmara East Africa Restaurant, (Muzit Belay
Kubrom, Mgr.), requests Council approval of their application for a Wine On-Sale and
On-Sale Malt (3.2) Licenses, ID ��18480, located at 854 University Avenue W.
RECOMMENDA710NS� AvProve (A) or Reject (R) PERSONAL SERVICE CONTRACTS MUST ANSWER THE POLLOWINCa QUESTIONS:
_ PLANNMG COMMISSION _ CIVIL SERVICE COMMISSION �� Has this person�rm ¢ver wOfked untler a ContraCt for this department?
_ CIB COMMITfEE _ YES NO
_ SiAFF Z. Has ihis perSOnRirm e�er been a city employee?
— YES NO
_ DiSiRiCrCOUai _ 3. Does this person/fi�m possess a skill not no�maily posse55etl by any current ciry employee?
SUPPORTS WHICH CAUNCIL OBJECTIVE'+ YES NO
Explaln all yes anawers on separate aheet p�tl attech to green sheet
INITIATING PROBLEM, ISSUE. OPPORTUNITV (Who. NTat. When, Whare. Why)
ADVANTA('iES IFAPPROVED:
DISADVANTAGE$ IFAPPROVED'
DISADVANTAGES IF NOTAPPROVED:
trvaa'�S� I"��°vo7 As�[L�w
DEC 11 1997
TOiAL AMOUNT OF TRANSAGTION S COST/REVENUE BUUGETED (CIRCLE ONE) YES NO
FUNDIWG SOURCE ACTIVITY NUMBER
F�NANCIAL INFOflAFATION (EXPLpIN)
sw�xr I
PAUL
�I
AAAII
CLASS III
LICENSE APPLICATION
THIS APPLICATION IS SLTB7ECT TO REVIEW BY TI� PL7BLIC
PLEASE ?YPE OR PRINT IN IIQIC
Type ofLicense(s) being applied for: '��FC � t �\� t14
CITY OF SAINT PALJL
�]CC Of LiCCpSC, �CCllOriS
zr�d EnvironmmW Protectioa
3Y1 SC Pec SL Sline 300
��L�sos SS101
(613)2669090 �(6I])26G91]a
Company Nazne: �SCYIFY'� FAg� (�c oAS� Q,E���
Corpomtion / Partnerzhip / Sole Ptopiieforship
If business is incoiporated, give date of incorporation:
DoingBusinzssAs: _ �Lx)(1FC BusinessPhone: �1
Business Address: _°�51.� 11ht�'��k-�e n J�' Q$�l� �� Pi�i��
street Addicss CiTy state Zip
� Between what aoss streets is the business located4
T
Arethepremisesnowoccupied? WhatTypeofBusiness? f-bmc�ra �'r��e �4'r=[��n 9��,��R�
—
MailToAddress: �i�� l)l���)FC� y �} �j� ��� ���
• sa«� naaK� crtr srar� z,
=Applicant Information:
Name and Title: ��'
��
F� �aa�� ��arn) i.aa
HomeAddress: �l � C�F`L' �s� � �,�`
s�c naa� c s � u Z;r
DateofBirth: II'�i'71 PlaceofBirth: �'.('�}pCF} HomePhone: `M�
--- _ - . _ °..�r `�°:z com:c±u.? �F �;; ��z;:�._ �r :ie , - ,z �:olat;ea nf an5• ei?y ^: dir.ar.�e ^:her thea t-�`fic? - �S ?"' �_
Date of arrest:
Chuge: _
Conviction:
S a"1; �� cg.� i n,y�(� ti� ri,�r� n Which side of the street�
Sentence:
Lisi tha names and residences of thtee persons of good moral chazacter, living within the Twin Cities IvSetro Area, not related to the applicant
or financially interested in the premises or business, who may be refeired to as to the applicanPs character:
N� ADDRESS
PHONE
cS�C:�F l4`��7-`� �"l4�'l�O �
_ \R�h(1 '] R�R�A `l'l\ 84 � l
:
licenses which you currently hoic� formerly held, ar may have
s�.
Have any of the above named licenses ever been revoked7 YES
\� ��
�_ NO If yes, list the dates aud reasons for revocation:
2/I S/97
Where?
.;re you going to operafe this business personally? � YES
F� ���
x�� naa�s: sc«; �:�c
�t;aat� L,;s�t �!.�,a��
Are you going to have a manager ar assis`�ant in ttus business?
please completz ihe following information:
Fvz[ Namc
fiomeAddms: Strcet:�amc
csry
� YES
Mv�)
City
Please list your employment history for the pre��ious five (5) }-e2r period:
NO ffnot, who will operate it?
�
s�
�1�-/�0 . h _�
D� ofa�nn
z;P rb�� �.*��
NO If the manager is not the same zs the operator,
I,ast
Statc Zip
Dxte ofBi+th
Phone I3umber
���, - ��� M 'sS�o z
List all other o�cers of the corporation:
OFFICER TITLE HOME
NAME (Office Held) ADDRESS
HOME BUSTNESS
PHONE PHONE
If business is a parmership, please include the following infoimation for each partner (use additional pages if necessary):
DATE OF
BII2I'Fi
�iID
Fuatl�'ame MiddlcLritini (Maidcu) Last DattofHiith
Sfate Zin Phone
��rYl1-Q 'M� �' L-t ��.( 1 �' � � S �
Firat t�Tame - 7vLdAe Initinl _ (Maidcn) .. Las[ Datc of Birth
a .., r- l Z"1 "\ . . � ,-�
HomeP.ddresr. SheetN�= - City Statc Zip Pk�onel3�mmber
MINNESOTA TAX IDENTIFICATION NUMI3ER - Pwsuant to the Laws of Minnesot� 1984, Chapier 502, futicle 8, Section 2(270J2)
(T� Clearance; Issuance of Licenses), licensing authorities aze requiral to provide to the State of Minnesota Commissioner of Revenue, the
Ivlinnesota business tax identification number and the social security numba ofeach license applicant
Under fhe 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 Tax Identification Number:
- This information may be used to deny the issuance or renewal of your license in the event you owe Minnesota sales, employer's
withholding or motor velricle excise taxes;
- Upon receiving this infoimation, ihe licensing authority will supply ii only to the Minnesota Deparmient of Reaenue. However,
under the Federal Exchange of Information Agreement, the Deputment of Revenue may supply this infozmation ta the Intemal
Revenue Service.
Ivfnmmesota Tax IdentificalionNiunbecs (Sales & iise Tax Number) may be obtained &vm tbe State of Minnesota, Business Records Department,
10 River Park Plaza (612-296-6181).
Social Security Number. ��" U"�"1 �� Minnesota Tax Identification Number: �
� If a Minnesota Tax Idrntification Numba is not required for the business being operated, indicate so by placing an "X" in the box
2/18/9�
CERTIFICATION OF WORKERS' COMPENSATION COVERAGE PURSUANT TO MINNESOTA STANTE 176.182 � 3
i hereby certify tl�at I, cx my company, aw in compliance with the workers' compensation insurance coverage requirements of Minnesota Sfatute
176.182, subdivision 2. I also undetstand that provisian offalse infozmation in this ceRification constitutes sufficient gnunds for adverse action
againsc all licenses held, including revocation and suspension of said licenses.
I�ame of Insurance Company:
Policy Number: �e �� ��.� � Coz�erage from
� �
I have no emplo}�ees covered under u�orkers' compensation insurance �i _(INII'IALS)
to
ANY FALSIFICATTON OF ANSWERS GIVEN OR MATERIAL SUBMITTED
WII.L RESULT IN DENIAL OF TFIIS riPPLICATION
I hereby state that I have ans�n'ered all of the preceding questions, and that the infoimation contained herein is true and cozrect to the best of
my Imowledge and belief. I hereby state further that I have received no money or other consideration, by way of loan, gift, conhibution, or
othernise, other than akeady disclosed in the application v�'nich I herewith subnutted I also understand tkris premise may be in�ected by police,
fire, health and other ciry o�cials at any and all times when the business is in operation.
�
for all applications)
We ezll accept payment by cash, check (made payable to City of Saint Paun or credit card (M/C or Visa).
Date
PAYING BY CREDIT CARD PLEASE COMPLETE THE FOLLOWING INFOl?MATIOK � MasterCard � Visa
EXPIl2ATION DATE:
� 1 �
ACCOUNT NtIMBER:
f�f��ife�ei�iv ■ ■ ■ ■ �7iiiT;7
.��
*•Note: If this applicauon is Food/Liquor relater� please contact a City of Saint Paul Health Inspector, Steve Olson (266-9139), to review
plans.
If any substantial changes to structure are anticipate,� please contact a City of Saint Paul Plan Bxaminer at 266-9007 to apply for
builQing permits.
�there are a�� cl�anges to the pazking lot, floor space, or for new operations, please contact a City of Saint Paul Zoning Inspector at
266-4�08.
A11 applications mquim the following documents. Please attach these documents when submirting your application:
1. A detailed description of the design, location and square footage of the premises to 6e liceused (site plan).
The following data should be on the site plan (preferably on an S 1/2" x 11" 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.
- Placement of all pertinent features of the interior of the licensed facility such as seating areas, kitchens, offices, repair azea,
parlang, rest rooms, etc.
- If a request is for an addition or expansion of the licensed facility, indicate both the cwrent area and the proposed expansion.
2. A copy of your lease agreement or proof of owneiship of the properry.
SPECIFIC LICENSE APPLICATIONS REQUIRE ADDTTIONAL LNFOIiMATION.
PLEASE SEE REVERSE FOR DETAII,S >>>>
2118l97
Council File # ` O � `�
ordinance #
1
2
3
4
5
6
7
8
9
10
11
12
13
ia
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
RESOLUTION
CITY O�
Presented
Referred To
Green Sheet # 50241
�
��
RESOLVED: That application, ID #15480, for a Wine On-Sale and On-Sale Malt (3.2)
License by Muzit Rubrom & Lemlem Libsu DBA Asmara East A£rica Restaurant,
(Muzit Belay Rubrom, Mgr.), located at 854 University Avenue W., be and the
same is hereby approved.
Committee: Date
Requested by Department of:
O� of •� na . rnsgections and
Env�rorLmenta Protection
BY� l L�.1.tim�t,L..r � N-���
Form Approved by City Attorney
B y : __- �-��� �'�`t ^
Approved by ayor for Submission to
:il
By:
App�
By:
Adopted by Council: Date
Adoption Certified by Council Secretary
N° .50241
G G _1/
DEM�NiYENL4FFICEIGOUNCII �ATE INIi1ATE0 � p � �
LIEP i GREEN SHEE
CON7AGTPERS�N&PHONE � INITIAVDATE INfTIAVDATE
� DEPAR'TMENi DIREGTOR � CITY COUNqL
Christine A. Rozek - 266-9108 assior+ CIiVATTORNEY CIT'CLERK
NUMBEH FOq O a
MVST BE ON CpUNqI AGENDA eY (DATE) pp�ING O 9UDGET DIRECTOR Q GIN. & MGT SEAVICES OVR.
Hearing: ` f g� ORDER O MAYOR (OR ASSISTANT) �
TOTAL # OF SIGNATURE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE)
ACTION REQUESTED:
Muzit Rubrom 5 Lemlem I.ibsu DBA Asmara East Africa Restaurant, (Muzit Belay
Kubrom, Mgr.), requests Council approval of their application for a Wine On-Sale and
On-Sale Malt (3.2) Licenses, ID ��18480, located at 854 University Avenue W.
RECOMMENDA710NS� AvProve (A) or Reject (R) PERSONAL SERVICE CONTRACTS MUST ANSWER THE POLLOWINCa QUESTIONS:
_ PLANNMG COMMISSION _ CIVIL SERVICE COMMISSION �� Has this person�rm ¢ver wOfked untler a ContraCt for this department?
_ CIB COMMITfEE _ YES NO
_ SiAFF Z. Has ihis perSOnRirm e�er been a city employee?
— YES NO
_ DiSiRiCrCOUai _ 3. Does this person/fi�m possess a skill not no�maily posse55etl by any current ciry employee?
SUPPORTS WHICH CAUNCIL OBJECTIVE'+ YES NO
Explaln all yes anawers on separate aheet p�tl attech to green sheet
INITIATING PROBLEM, ISSUE. OPPORTUNITV (Who. NTat. When, Whare. Why)
ADVANTA('iES IFAPPROVED:
DISADVANTAGE$ IFAPPROVED'
DISADVANTAGES IF NOTAPPROVED:
trvaa'�S� I"��°vo7 As�[L�w
DEC 11 1997
TOiAL AMOUNT OF TRANSAGTION S COST/REVENUE BUUGETED (CIRCLE ONE) YES NO
FUNDIWG SOURCE ACTIVITY NUMBER
F�NANCIAL INFOflAFATION (EXPLpIN)
sw�xr I
PAUL
�I
AAAII
CLASS III
LICENSE APPLICATION
THIS APPLICATION IS SLTB7ECT TO REVIEW BY TI� PL7BLIC
PLEASE ?YPE OR PRINT IN IIQIC
Type ofLicense(s) being applied for: '��FC � t �\� t14
CITY OF SAINT PALJL
�]CC Of LiCCpSC, �CCllOriS
zr�d EnvironmmW Protectioa
3Y1 SC Pec SL Sline 300
��L�sos SS101
(613)2669090 �(6I])26G91]a
Company Nazne: �SCYIFY'� FAg� (�c oAS� Q,E���
Corpomtion / Partnerzhip / Sole Ptopiieforship
If business is incoiporated, give date of incorporation:
DoingBusinzssAs: _ �Lx)(1FC BusinessPhone: �1
Business Address: _°�51.� 11ht�'��k-�e n J�' Q$�l� �� Pi�i��
street Addicss CiTy state Zip
� Between what aoss streets is the business located4
T
Arethepremisesnowoccupied? WhatTypeofBusiness? f-bmc�ra �'r��e �4'r=[��n 9��,��R�
—
MailToAddress: �i�� l)l���)FC� y �} �j� ��� ���
• sa«� naaK� crtr srar� z,
=Applicant Information:
Name and Title: ��'
��
F� �aa�� ��arn) i.aa
HomeAddress: �l � C�F`L' �s� � �,�`
s�c naa� c s � u Z;r
DateofBirth: II'�i'71 PlaceofBirth: �'.('�}pCF} HomePhone: `M�
--- _ - . _ °..�r `�°:z com:c±u.? �F �;; ��z;:�._ �r :ie , - ,z �:olat;ea nf an5• ei?y ^: dir.ar.�e ^:her thea t-�`fic? - �S ?"' �_
Date of arrest:
Chuge: _
Conviction:
S a"1; �� cg.� i n,y�(� ti� ri,�r� n Which side of the street�
Sentence:
Lisi tha names and residences of thtee persons of good moral chazacter, living within the Twin Cities IvSetro Area, not related to the applicant
or financially interested in the premises or business, who may be refeired to as to the applicanPs character:
N� ADDRESS
PHONE
cS�C:�F l4`��7-`� �"l4�'l�O �
_ \R�h(1 '] R�R�A `l'l\ 84 � l
:
licenses which you currently hoic� formerly held, ar may have
s�.
Have any of the above named licenses ever been revoked7 YES
\� ��
�_ NO If yes, list the dates aud reasons for revocation:
2/I S/97
Where?
.;re you going to operafe this business personally? � YES
F� ���
x�� naa�s: sc«; �:�c
�t;aat� L,;s�t �!.�,a��
Are you going to have a manager ar assis`�ant in ttus business?
please completz ihe following information:
Fvz[ Namc
fiomeAddms: Strcet:�amc
csry
� YES
Mv�)
City
Please list your employment history for the pre��ious five (5) }-e2r period:
NO ffnot, who will operate it?
�
s�
�1�-/�0 . h _�
D� ofa�nn
z;P rb�� �.*��
NO If the manager is not the same zs the operator,
I,ast
Statc Zip
Dxte ofBi+th
Phone I3umber
���, - ��� M 'sS�o z
List all other o�cers of the corporation:
OFFICER TITLE HOME
NAME (Office Held) ADDRESS
HOME BUSTNESS
PHONE PHONE
If business is a parmership, please include the following infoimation for each partner (use additional pages if necessary):
DATE OF
BII2I'Fi
�iID
Fuatl�'ame MiddlcLritini (Maidcu) Last DattofHiith
Sfate Zin Phone
��rYl1-Q 'M� �' L-t ��.( 1 �' � � S �
Firat t�Tame - 7vLdAe Initinl _ (Maidcn) .. Las[ Datc of Birth
a .., r- l Z"1 "\ . . � ,-�
HomeP.ddresr. SheetN�= - City Statc Zip Pk�onel3�mmber
MINNESOTA TAX IDENTIFICATION NUMI3ER - Pwsuant to the Laws of Minnesot� 1984, Chapier 502, futicle 8, Section 2(270J2)
(T� Clearance; Issuance of Licenses), licensing authorities aze requiral to provide to the State of Minnesota Commissioner of Revenue, the
Ivlinnesota business tax identification number and the social security numba ofeach license applicant
Under fhe 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 Tax Identification Number:
- This information may be used to deny the issuance or renewal of your license in the event you owe Minnesota sales, employer's
withholding or motor velricle excise taxes;
- Upon receiving this infoimation, ihe licensing authority will supply ii only to the Minnesota Deparmient of Reaenue. However,
under the Federal Exchange of Information Agreement, the Deputment of Revenue may supply this infozmation ta the Intemal
Revenue Service.
Ivfnmmesota Tax IdentificalionNiunbecs (Sales & iise Tax Number) may be obtained &vm tbe State of Minnesota, Business Records Department,
10 River Park Plaza (612-296-6181).
Social Security Number. ��" U"�"1 �� Minnesota Tax Identification Number: �
� If a Minnesota Tax Idrntification Numba is not required for the business being operated, indicate so by placing an "X" in the box
2/18/9�
CERTIFICATION OF WORKERS' COMPENSATION COVERAGE PURSUANT TO MINNESOTA STANTE 176.182 � 3
i hereby certify tl�at I, cx my company, aw in compliance with the workers' compensation insurance coverage requirements of Minnesota Sfatute
176.182, subdivision 2. I also undetstand that provisian offalse infozmation in this ceRification constitutes sufficient gnunds for adverse action
againsc all licenses held, including revocation and suspension of said licenses.
I�ame of Insurance Company:
Policy Number: �e �� ��.� � Coz�erage from
� �
I have no emplo}�ees covered under u�orkers' compensation insurance �i _(INII'IALS)
to
ANY FALSIFICATTON OF ANSWERS GIVEN OR MATERIAL SUBMITTED
WII.L RESULT IN DENIAL OF TFIIS riPPLICATION
I hereby state that I have ans�n'ered all of the preceding questions, and that the infoimation contained herein is true and cozrect to the best of
my Imowledge and belief. I hereby state further that I have received no money or other consideration, by way of loan, gift, conhibution, or
othernise, other than akeady disclosed in the application v�'nich I herewith subnutted I also understand tkris premise may be in�ected by police,
fire, health and other ciry o�cials at any and all times when the business is in operation.
�
for all applications)
We ezll accept payment by cash, check (made payable to City of Saint Paun or credit card (M/C or Visa).
Date
PAYING BY CREDIT CARD PLEASE COMPLETE THE FOLLOWING INFOl?MATIOK � MasterCard � Visa
EXPIl2ATION DATE:
� 1 �
ACCOUNT NtIMBER:
f�f��ife�ei�iv ■ ■ ■ ■ �7iiiT;7
.��
*•Note: If this applicauon is Food/Liquor relater� please contact a City of Saint Paul Health Inspector, Steve Olson (266-9139), to review
plans.
If any substantial changes to structure are anticipate,� please contact a City of Saint Paul Plan Bxaminer at 266-9007 to apply for
builQing permits.
�there are a�� cl�anges to the pazking lot, floor space, or for new operations, please contact a City of Saint Paul Zoning Inspector at
266-4�08.
A11 applications mquim the following documents. Please attach these documents when submirting your application:
1. A detailed description of the design, location and square footage of the premises to 6e liceused (site plan).
The following data should be on the site plan (preferably on an S 1/2" x 11" 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.
- Placement of all pertinent features of the interior of the licensed facility such as seating areas, kitchens, offices, repair azea,
parlang, rest rooms, etc.
- If a request is for an addition or expansion of the licensed facility, indicate both the cwrent area and the proposed expansion.
2. A copy of your lease agreement or proof of owneiship of the properry.
SPECIFIC LICENSE APPLICATIONS REQUIRE ADDTTIONAL LNFOIiMATION.
PLEASE SEE REVERSE FOR DETAII,S >>>>
2118l97
Council File # ` O � `�
ordinance #
1
2
3
4
5
6
7
8
9
10
11
12
13
ia
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
RESOLUTION
CITY O�
Presented
Referred To
Green Sheet # 50241
�
��
RESOLVED: That application, ID #15480, for a Wine On-Sale and On-Sale Malt (3.2)
License by Muzit Rubrom & Lemlem Libsu DBA Asmara East A£rica Restaurant,
(Muzit Belay Rubrom, Mgr.), located at 854 University Avenue W., be and the
same is hereby approved.
Committee: Date
Requested by Department of:
O� of •� na . rnsgections and
Env�rorLmenta Protection
BY� l L�.1.tim�t,L..r � N-���
Form Approved by City Attorney
B y : __- �-��� �'�`t ^
Approved by ayor for Submission to
:il
By:
App�
By:
Adopted by Council: Date
Adoption Certified by Council Secretary
N° .50241
G G _1/
DEM�NiYENL4FFICEIGOUNCII �ATE INIi1ATE0 � p � �
LIEP i GREEN SHEE
CON7AGTPERS�N&PHONE � INITIAVDATE INfTIAVDATE
� DEPAR'TMENi DIREGTOR � CITY COUNqL
Christine A. Rozek - 266-9108 assior+ CIiVATTORNEY CIT'CLERK
NUMBEH FOq O a
MVST BE ON CpUNqI AGENDA eY (DATE) pp�ING O 9UDGET DIRECTOR Q GIN. & MGT SEAVICES OVR.
Hearing: ` f g� ORDER O MAYOR (OR ASSISTANT) �
TOTAL # OF SIGNATURE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE)
ACTION REQUESTED:
Muzit Rubrom 5 Lemlem I.ibsu DBA Asmara East Africa Restaurant, (Muzit Belay
Kubrom, Mgr.), requests Council approval of their application for a Wine On-Sale and
On-Sale Malt (3.2) Licenses, ID ��18480, located at 854 University Avenue W.
RECOMMENDA710NS� AvProve (A) or Reject (R) PERSONAL SERVICE CONTRACTS MUST ANSWER THE POLLOWINCa QUESTIONS:
_ PLANNMG COMMISSION _ CIVIL SERVICE COMMISSION �� Has this person�rm ¢ver wOfked untler a ContraCt for this department?
_ CIB COMMITfEE _ YES NO
_ SiAFF Z. Has ihis perSOnRirm e�er been a city employee?
— YES NO
_ DiSiRiCrCOUai _ 3. Does this person/fi�m possess a skill not no�maily posse55etl by any current ciry employee?
SUPPORTS WHICH CAUNCIL OBJECTIVE'+ YES NO
Explaln all yes anawers on separate aheet p�tl attech to green sheet
INITIATING PROBLEM, ISSUE. OPPORTUNITV (Who. NTat. When, Whare. Why)
ADVANTA('iES IFAPPROVED:
DISADVANTAGE$ IFAPPROVED'
DISADVANTAGES IF NOTAPPROVED:
trvaa'�S� I"��°vo7 As�[L�w
DEC 11 1997
TOiAL AMOUNT OF TRANSAGTION S COST/REVENUE BUUGETED (CIRCLE ONE) YES NO
FUNDIWG SOURCE ACTIVITY NUMBER
F�NANCIAL INFOflAFATION (EXPLpIN)
sw�xr I
PAUL
�I
AAAII
CLASS III
LICENSE APPLICATION
THIS APPLICATION IS SLTB7ECT TO REVIEW BY TI� PL7BLIC
PLEASE ?YPE OR PRINT IN IIQIC
Type ofLicense(s) being applied for: '��FC � t �\� t14
CITY OF SAINT PALJL
�]CC Of LiCCpSC, �CCllOriS
zr�d EnvironmmW Protectioa
3Y1 SC Pec SL Sline 300
��L�sos SS101
(613)2669090 �(6I])26G91]a
Company Nazne: �SCYIFY'� FAg� (�c oAS� Q,E���
Corpomtion / Partnerzhip / Sole Ptopiieforship
If business is incoiporated, give date of incorporation:
DoingBusinzssAs: _ �Lx)(1FC BusinessPhone: �1
Business Address: _°�51.� 11ht�'��k-�e n J�' Q$�l� �� Pi�i��
street Addicss CiTy state Zip
� Between what aoss streets is the business located4
T
Arethepremisesnowoccupied? WhatTypeofBusiness? f-bmc�ra �'r��e �4'r=[��n 9��,��R�
—
MailToAddress: �i�� l)l���)FC� y �} �j� ��� ���
• sa«� naaK� crtr srar� z,
=Applicant Information:
Name and Title: ��'
��
F� �aa�� ��arn) i.aa
HomeAddress: �l � C�F`L' �s� � �,�`
s�c naa� c s � u Z;r
DateofBirth: II'�i'71 PlaceofBirth: �'.('�}pCF} HomePhone: `M�
--- _ - . _ °..�r `�°:z com:c±u.? �F �;; ��z;:�._ �r :ie , - ,z �:olat;ea nf an5• ei?y ^: dir.ar.�e ^:her thea t-�`fic? - �S ?"' �_
Date of arrest:
Chuge: _
Conviction:
S a"1; �� cg.� i n,y�(� ti� ri,�r� n Which side of the street�
Sentence:
Lisi tha names and residences of thtee persons of good moral chazacter, living within the Twin Cities IvSetro Area, not related to the applicant
or financially interested in the premises or business, who may be refeired to as to the applicanPs character:
N� ADDRESS
PHONE
cS�C:�F l4`��7-`� �"l4�'l�O �
_ \R�h(1 '] R�R�A `l'l\ 84 � l
:
licenses which you currently hoic� formerly held, ar may have
s�.
Have any of the above named licenses ever been revoked7 YES
\� ��
�_ NO If yes, list the dates aud reasons for revocation:
2/I S/97
Where?
.;re you going to operafe this business personally? � YES
F� ���
x�� naa�s: sc«; �:�c
�t;aat� L,;s�t �!.�,a��
Are you going to have a manager ar assis`�ant in ttus business?
please completz ihe following information:
Fvz[ Namc
fiomeAddms: Strcet:�amc
csry
� YES
Mv�)
City
Please list your employment history for the pre��ious five (5) }-e2r period:
NO ffnot, who will operate it?
�
s�
�1�-/�0 . h _�
D� ofa�nn
z;P rb�� �.*��
NO If the manager is not the same zs the operator,
I,ast
Statc Zip
Dxte ofBi+th
Phone I3umber
���, - ��� M 'sS�o z
List all other o�cers of the corporation:
OFFICER TITLE HOME
NAME (Office Held) ADDRESS
HOME BUSTNESS
PHONE PHONE
If business is a parmership, please include the following infoimation for each partner (use additional pages if necessary):
DATE OF
BII2I'Fi
�iID
Fuatl�'ame MiddlcLritini (Maidcu) Last DattofHiith
Sfate Zin Phone
��rYl1-Q 'M� �' L-t ��.( 1 �' � � S �
Firat t�Tame - 7vLdAe Initinl _ (Maidcn) .. Las[ Datc of Birth
a .., r- l Z"1 "\ . . � ,-�
HomeP.ddresr. SheetN�= - City Statc Zip Pk�onel3�mmber
MINNESOTA TAX IDENTIFICATION NUMI3ER - Pwsuant to the Laws of Minnesot� 1984, Chapier 502, futicle 8, Section 2(270J2)
(T� Clearance; Issuance of Licenses), licensing authorities aze requiral to provide to the State of Minnesota Commissioner of Revenue, the
Ivlinnesota business tax identification number and the social security numba ofeach license applicant
Under fhe 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 Tax Identification Number:
- This information may be used to deny the issuance or renewal of your license in the event you owe Minnesota sales, employer's
withholding or motor velricle excise taxes;
- Upon receiving this infoimation, ihe licensing authority will supply ii only to the Minnesota Deparmient of Reaenue. However,
under the Federal Exchange of Information Agreement, the Deputment of Revenue may supply this infozmation ta the Intemal
Revenue Service.
Ivfnmmesota Tax IdentificalionNiunbecs (Sales & iise Tax Number) may be obtained &vm tbe State of Minnesota, Business Records Department,
10 River Park Plaza (612-296-6181).
Social Security Number. ��" U"�"1 �� Minnesota Tax Identification Number: �
� If a Minnesota Tax Idrntification Numba is not required for the business being operated, indicate so by placing an "X" in the box
2/18/9�
CERTIFICATION OF WORKERS' COMPENSATION COVERAGE PURSUANT TO MINNESOTA STANTE 176.182 � 3
i hereby certify tl�at I, cx my company, aw in compliance with the workers' compensation insurance coverage requirements of Minnesota Sfatute
176.182, subdivision 2. I also undetstand that provisian offalse infozmation in this ceRification constitutes sufficient gnunds for adverse action
againsc all licenses held, including revocation and suspension of said licenses.
I�ame of Insurance Company:
Policy Number: �e �� ��.� � Coz�erage from
� �
I have no emplo}�ees covered under u�orkers' compensation insurance �i _(INII'IALS)
to
ANY FALSIFICATTON OF ANSWERS GIVEN OR MATERIAL SUBMITTED
WII.L RESULT IN DENIAL OF TFIIS riPPLICATION
I hereby state that I have ans�n'ered all of the preceding questions, and that the infoimation contained herein is true and cozrect to the best of
my Imowledge and belief. I hereby state further that I have received no money or other consideration, by way of loan, gift, conhibution, or
othernise, other than akeady disclosed in the application v�'nich I herewith subnutted I also understand tkris premise may be in�ected by police,
fire, health and other ciry o�cials at any and all times when the business is in operation.
�
for all applications)
We ezll accept payment by cash, check (made payable to City of Saint Paun or credit card (M/C or Visa).
Date
PAYING BY CREDIT CARD PLEASE COMPLETE THE FOLLOWING INFOl?MATIOK � MasterCard � Visa
EXPIl2ATION DATE:
� 1 �
ACCOUNT NtIMBER:
f�f��ife�ei�iv ■ ■ ■ ■ �7iiiT;7
.��
*•Note: If this applicauon is Food/Liquor relater� please contact a City of Saint Paul Health Inspector, Steve Olson (266-9139), to review
plans.
If any substantial changes to structure are anticipate,� please contact a City of Saint Paul Plan Bxaminer at 266-9007 to apply for
builQing permits.
�there are a�� cl�anges to the pazking lot, floor space, or for new operations, please contact a City of Saint Paul Zoning Inspector at
266-4�08.
A11 applications mquim the following documents. Please attach these documents when submirting your application:
1. A detailed description of the design, location and square footage of the premises to 6e liceused (site plan).
The following data should be on the site plan (preferably on an S 1/2" x 11" 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.
- Placement of all pertinent features of the interior of the licensed facility such as seating areas, kitchens, offices, repair azea,
parlang, rest rooms, etc.
- If a request is for an addition or expansion of the licensed facility, indicate both the cwrent area and the proposed expansion.
2. A copy of your lease agreement or proof of owneiship of the properry.
SPECIFIC LICENSE APPLICATIONS REQUIRE ADDTTIONAL LNFOIiMATION.
PLEASE SEE REVERSE FOR DETAII,S >>>>
2118l97