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98-17Council File # R�-�� ordinance # Green Sheet # 50240 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 Presented By Re£erred To RESOLUTION CITY OF SAINT PAUL, MINNESOTA d� --� Yeas NaYS sent Requested by Department of: Adopted by council: Date Adoption Certified by Cou By: Approved by a o at By: Secretary Off�ce of L�cense rnsgections and n ie r BY: � it� Form Approved by City Attorney Bye � Approved by Dayor for Submission to Council By: RESOLVED: That application, ZD #32086, for a Restaurant (B) and On-Sale Malt (3.2) Licenses by Chiang Rai Restaurant DBA Chiang Rai Restaurant, (Allison Vang, Mgr.), located at 432 University Avenue W., be and the same is hereby approved. �° 50240 a�_,-, OEPPRTMENTqFFICEICOUNGL � DATE INITIATED I a I J LIEP GREEN SHEE COMACT PERSON 8 PHONE INITIAUDATE INITIAVDATE O DEPAPTMENT DIRECTOR O CIiV COUNQL Christine A. Rozek - 266-9108 0.55tGN O CITV ATiORNEY O qSV CLERK MUST BE ON CAUNCR AGENDA BY (DATE) NVMBER FOR � BUDGET OIRECTOfl Q FIN & MGT SERVICES DIR. NOUTING Hearin : % 'j � OROEP � MAYOR (OR ASS�STANTJ � TOTAL # Of SIGNATURE PAGES (CIIP AI.L LOCASIONS FOR SIGPIASURE) AGTION fiEOUESTE�: Chiang Rai Restaurant DBA Chiang Rai Restaurant, (Allison Vang, Mgr.) requests Council approval of their application for a Restaurant (B) and On-Sale Malt (3.2) Licenses, ID �i32086„located at 432 University Avenue W. RECOMMENDAnONS: Approve (A) or Rejeet (R) pERSONAL SERVICE CONTRACTS MUST ANSWER THE FOLLOWING QUESTIONS: _. PLANNING GOMMISSION _ CIVIL SEpVICE COMMISSION 1. Has ffiis person/firm ever wakeA under a cortrect tor this departmentl __ CIB COMMITTEE _ �'ES � NO 2. Has this personHirm ever been a city em0loyee? _ STAFF — VES NO _ DISiRICT COURT _ 3. Does Nis perSOnRirm Qossess a skill not nortnalty possessed 6y any curzent ciry employee? SUPPOBTS WHICH COUNCII O&IECTIVE? YES NO Ezplaln all yes answers on seperete sheet end ettach to green sheel MRIATING PROBLEM.ISSUE.O�PORTUNITY(Who. Whap Wnen. Where. Why) ADVANTAGES IF APPROVED. DISADVANTAGES IFAPPROVEO: DISADVANTAGES IF NOTAPPROVED' �r01i[1CIi I'��it�3 l;�li��f DEC 11 1�97 TOTAL AMOUNT OF TRANSACTION $ COST/REVENUE BUDGETED (CIRCLE ONE) VES NO FUNDItiG SOURCE ACTIVITY NUMBER FINpNCIAL INFORfhAT10N: (EXPLAIN) . � � � � �'L� 9f�-l� CLASS III LICENSE APPLICATION THIS APPLICATION IS SUBJECT TO REVIEW BY T!HE PiJBLIC Type of License(s) being PLEASE TYPE OR PRINT IN II�'K CITY OF SAINT PAUL �cz of Licnsz, Inspzctions and Emvonme.rtai Protection 350 5:?,.c 5: S�^�=300 Szsv Pz�.J, �!^a;�.^x 55101 (6II) 3669JJJ !u Cb121266-oq3< � - � r �i ` � Company Nazne: � �t � g�� (�� l� ) (ZF��T Colpolation / Pertnaxhip / Sole Proprietrnship If business is incorporated, give date of incorporation: Doing Business As: C� f tnv�5 Z.Pi I ��T�l S� ft'�� Business Phone: a�� "�,g �7 BusinessAddress: �� i�1. ��Il)F�Si'1'\' (TSUP . ST.�(�t� R"1t� ' Street Address ciTy stete Zip Behveen u�hat cross streets is the business located? �} Y L? tti �� Which side of the street? ��( Are the premises now occupied7 Mail To Address: s� f,da� Applicant Information: What Type of Business? � Ciry State Zip Name and TiUe: A I� i Sp� ��U R- ��-R�JZ�, ��}��, �, F�rsc :�tiadl� � (Maiden) I.ast Title Home Address: ��i�1 C,�� 5� ��l,l� � E.� �� StratAddtess CiTy � S�ate Zip Date of Bir[h: CY� -, b- �. Place of Birth: �C 1 e�.SC� �' �d �?tk _ L f� � Home Phone: G I� - RSS� Have you ever been convicted of any felony, crime or ��iolation of any city ordutance other than traffic? YES NO �_ Date of arrest: Chazge: _ Conviction: Where? Sentence: List the naznes and residences of three persons of good moral chazacter, living within the Twin Cities Metro Area, not related to the applicznt or financially interested in the premises or business, who may be refeired to as to the applicanPs chazacter: NAME ADDRESS PHONE � � 2f18(97 `� t�-pa, � t� a�u a�a� �T fi��1, M��1 �S��S� �1,-1..��— List licenses which you currently hold, formerly held, or may have an interest in: CH1�� RRt R��TRZ)2�tiF'�( � c�.(1Sf Ha��e any of the above named licenses eva been revoked? YES � NO If yes, list the dates and reasons for revocation: 9� I� Are }�ou going to operate this business personallyY �_ YES F�t �� .Vi'iddle Initial (�faidrnj HomeAddzas: Strec.\auc Cirv Are gou going to have a sanzga or usistzat in this business? X YES please complete the folloning i*ifonnztion: � F��:�� HomeAddras: SfreetN�e waa�� tNa� p�,an,� C;Ty Please list } our employment history for the p: evious 5ve (5) } ear period: BusinesslEmplovment Add�ess NO If not, who will operate it? Lasc Sfate Date of BiAn T.�p Pnone VrmUer NO If the manager is not the szsne as the operator, r °� Siafc Datc of Birth Z�p Phone \'immber �{-f�f.�� t-}A-1 1 h l.flt� �'�,� 1<n�� i Ce Sr S �H-�, i �1 �Sf { 7 List all other officers of the corporation: OFFICER TITLE HOME HOME BUSINESS DATE OF NAME (Office Held) ADDRESS PHONE PHONE BTRTH i' — (�� r�or�-S�NU�+ °;R� C�i�ta�� A�e �I�� 8�� aa_� �R��t � �a �� If business is a parhtership, please include the following information for each paztner (vse additional pages if necessary): FirstNamc Hame Addrtss; Stree[ h'ame Fintl�amc Home Add�sss: $tne( Ivame Middle Lutiel ?vtiddlc Initial CiTy (.Maidrn) C�Ty State state 1-%tt DateafBirth Zip Phone \umber � DateofBirth Zip Phone Number M3IQNESOTA TAX IDEN'IIFICATION NUMBER - Pursuant to the Laws of Minnesota, I 984, Chapter 502, Article 8, Section 2(270.72) (Tax Clearance; Issuance of Licenses), licensing authorities are required to provide to the State of Minnesota Commissioner of Revenue, the Minnesota business tax identificatson number and the social security number of each license applicant Under the Minnesota Govemment Data Practices Act and the Federai Privacy Act of 1974, we aze required to ad�dse 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 u�tYiholding or motor vehicle excise taxes; - Upon receiving this infoimation, the licensing au'thority will supply it only to the Minnesota Departinent of Revenue. However, under the Federal Exchange of Infozmation Av., jeement, the Department of Recenue may supply this information to the Internal Revenue Service. Mumesota TaY Idenlification Numbers (Sales & Use Tax Number) may be obtained frnm the State of Minnesota, Business Records Department, 10 River Park Plaza (612-296-6181). Social Security Number: �g�r� - l�." �ag� 5 Minnesota Tax Identification Number: _ ff a Minnesota Tax Idzntification Number is not requuzd for the business being operated, indicate so by placing an"X" in the box. __ � 2/18/97 9�-/? CERiIFICATION OF WORKERS' CO'vIPENSATION COVERAGE PURSUlu'v 1' TO MR��TIESOTA STATUTE 1%6.182 I haeby certif}� that � or my company, am in compliance with the workers' compensation i�surance coverage requirements of �nesota S+riute 176.182, subdivision 2. I aLso undeistznd that provision of false information in this certi5czlion constitutes sufiicient groLS for zd� erse zc�ion zeainst all licenses hzld, including recocation and suspension of said l;censes. (� ?vazne ofInsurance Company: �.l��T � (Z-�; L r�l � (� (�)(` � �� I (7 � U�A� �� Policy Number: Coc�zrage frozn C'. -��l �`f 7 to Sti S L� r�� -� I hace no emplo}'ezs coverzd under uorkers compensation insw-ance �(I\'ITL4LS) G/� �� AR`Y FALSIFICATION OF AIvSWERS GIVEN OR MATERLAL SUBMITTED WILL RESULT LN DEN7AL OF THIS APPLICATION I hereby state that I hatie z�swered all of the preceding questions, and that the infomiation contained herein is hue and co�rect to the bes[ of my kno�i�ledge and belief. I hereby staie further that I hzve received no money or othzt consideration, by way of loan �+ft, conhibutioq or otherv,�ise, other than ��readp disclosed in thz application k I hereuith submittzd. I also understand this premise ma} be :nspected by po1_ice, fire, health and other city omcials at any and all times when Lhe business is in operation. ��— Signature (REQUIRED for all We wtilI accept pa}'ment by cash, check (made payable to City of Saint Paul) or credit card (M/C or Visa). 3 =� Date� IFPAYINGBYCREDITCARDPLEASECOMPLETETHEFOLLOWINGINFORMATION: �MasterCard �Visa EXPII2ATION DATE: ACCOUNT NUMBER: ❑�/C1❑ ❑�0❑ ❑��❑ ❑��❑ ❑�❑❑ x� af of Cazd all Date ""Note: If this applicalion is Food/Liquor related, glease contact a Ciry of Saint Paul Health Inspector, Steve Olson (266-9139), to re�iew plans. If any substantial changes to structure are anticipated, please contact a City of Saint Paul Plan Exanuner at 265-9007 to apply for building pemuts. Ifthere aze any ct�anges 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 foltoR�ng documents. Please artach these documents R�hen submitting ?•our application: I. A detai]ed description of the design, location and square footage of the preauses to be licensed (site plan). The following data should be on the site plan (preferably on an 8 I I2" x 11" or 8 1/2" x 14" paper): - Name, address, and phone number. - The scale should be stated such as 1"= 20'. ^N shauld be indicated toward the top. - Placement of a11 pertinent features of the interior of the licensed faciliTy' such as seating areas, kitchens, offices, repair azea, parking, rest rooms, etc. - If a request is for an addiuon or expansion of the licensed facility, indicate both the current area and the proposed eapansion. 2. A copy of your ]ease a�eement or proof of ow�nership of the properry. SPECIFIC LICENSE APPLICATIONS REQUIl2E ADDTTIOl\'AL INFORMATION. PLEASE SEE REVERSE FOR DETAII�S >>>> �; 2/18/97 Council File # R�-�� ordinance # Green Sheet # 50240 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 Presented By Re£erred To RESOLUTION CITY OF SAINT PAUL, MINNESOTA d� --� Yeas NaYS sent Requested by Department of: Adopted by council: Date Adoption Certified by Cou By: Approved by a o at By: Secretary Off�ce of L�cense rnsgections and n ie r BY: � it� Form Approved by City Attorney Bye � Approved by Dayor for Submission to Council By: RESOLVED: That application, ZD #32086, for a Restaurant (B) and On-Sale Malt (3.2) Licenses by Chiang Rai Restaurant DBA Chiang Rai Restaurant, (Allison Vang, Mgr.), located at 432 University Avenue W., be and the same is hereby approved. �° 50240 a�_,-, OEPPRTMENTqFFICEICOUNGL � DATE INITIATED I a I J LIEP GREEN SHEE COMACT PERSON 8 PHONE INITIAUDATE INITIAVDATE O DEPAPTMENT DIRECTOR O CIiV COUNQL Christine A. Rozek - 266-9108 0.55tGN O CITV ATiORNEY O qSV CLERK MUST BE ON CAUNCR AGENDA BY (DATE) NVMBER FOR � BUDGET OIRECTOfl Q FIN & MGT SERVICES DIR. NOUTING Hearin : % 'j � OROEP � MAYOR (OR ASS�STANTJ � TOTAL # Of SIGNATURE PAGES (CIIP AI.L LOCASIONS FOR SIGPIASURE) AGTION fiEOUESTE�: Chiang Rai Restaurant DBA Chiang Rai Restaurant, (Allison Vang, Mgr.) requests Council approval of their application for a Restaurant (B) and On-Sale Malt (3.2) Licenses, ID �i32086„located at 432 University Avenue W. RECOMMENDAnONS: Approve (A) or Rejeet (R) pERSONAL SERVICE CONTRACTS MUST ANSWER THE FOLLOWING QUESTIONS: _. PLANNING GOMMISSION _ CIVIL SEpVICE COMMISSION 1. Has ffiis person/firm ever wakeA under a cortrect tor this departmentl __ CIB COMMITTEE _ �'ES � NO 2. Has this personHirm ever been a city em0loyee? _ STAFF — VES NO _ DISiRICT COURT _ 3. Does Nis perSOnRirm Qossess a skill not nortnalty possessed 6y any curzent ciry employee? SUPPOBTS WHICH COUNCII O&IECTIVE? YES NO Ezplaln all yes answers on seperete sheet end ettach to green sheel MRIATING PROBLEM.ISSUE.O�PORTUNITY(Who. Whap Wnen. Where. Why) ADVANTAGES IF APPROVED. DISADVANTAGES IFAPPROVEO: DISADVANTAGES IF NOTAPPROVED' �r01i[1CIi I'��it�3 l;�li��f DEC 11 1�97 TOTAL AMOUNT OF TRANSACTION $ COST/REVENUE BUDGETED (CIRCLE ONE) VES NO FUNDItiG SOURCE ACTIVITY NUMBER FINpNCIAL INFORfhAT10N: (EXPLAIN) . � � � � �'L� 9f�-l� CLASS III LICENSE APPLICATION THIS APPLICATION IS SUBJECT TO REVIEW BY T!HE PiJBLIC Type of License(s) being PLEASE TYPE OR PRINT IN II�'K CITY OF SAINT PAUL �cz of Licnsz, Inspzctions and Emvonme.rtai Protection 350 5:?,.c 5: S�^�=300 Szsv Pz�.J, �!^a;�.^x 55101 (6II) 3669JJJ !u Cb121266-oq3< � - � r �i ` � Company Nazne: � �t � g�� (�� l� ) (ZF��T Colpolation / Pertnaxhip / Sole Proprietrnship If business is incorporated, give date of incorporation: Doing Business As: C� f tnv�5 Z.Pi I ��T�l S� ft'�� Business Phone: a�� "�,g �7 BusinessAddress: �� i�1. ��Il)F�Si'1'\' (TSUP . ST.�(�t� R"1t� ' Street Address ciTy stete Zip Behveen u�hat cross streets is the business located? �} Y L? tti �� Which side of the street? ��( Are the premises now occupied7 Mail To Address: s� f,da� Applicant Information: What Type of Business? � Ciry State Zip Name and TiUe: A I� i Sp� ��U R- ��-R�JZ�, ��}��, �, F�rsc :�tiadl� � (Maiden) I.ast Title Home Address: ��i�1 C,�� 5� ��l,l� � E.� �� StratAddtess CiTy � S�ate Zip Date of Bir[h: CY� -, b- �. Place of Birth: �C 1 e�.SC� �' �d �?tk _ L f� � Home Phone: G I� - RSS� Have you ever been convicted of any felony, crime or ��iolation of any city ordutance other than traffic? YES NO �_ Date of arrest: Chazge: _ Conviction: Where? Sentence: List the naznes and residences of three persons of good moral chazacter, living within the Twin Cities Metro Area, not related to the applicznt or financially interested in the premises or business, who may be refeired to as to the applicanPs chazacter: NAME ADDRESS PHONE � � 2f18(97 `� t�-pa, � t� a�u a�a� �T fi��1, M��1 �S��S� �1,-1..��— List licenses which you currently hold, formerly held, or may have an interest in: CH1�� RRt R��TRZ)2�tiF'�( � c�.(1Sf Ha��e any of the above named licenses eva been revoked? YES � NO If yes, list the dates and reasons for revocation: 9� I� Are }�ou going to operate this business personallyY �_ YES F�t �� .Vi'iddle Initial (�faidrnj HomeAddzas: Strec.\auc Cirv Are gou going to have a sanzga or usistzat in this business? X YES please complete the folloning i*ifonnztion: � F��:�� HomeAddras: SfreetN�e waa�� tNa� p�,an,� C;Ty Please list } our employment history for the p: evious 5ve (5) } ear period: BusinesslEmplovment Add�ess NO If not, who will operate it? Lasc Sfate Date of BiAn T.�p Pnone VrmUer NO If the manager is not the szsne as the operator, r °� Siafc Datc of Birth Z�p Phone \'immber �{-f�f.�� t-}A-1 1 h l.flt� �'�,� 1<n�� i Ce Sr S �H-�, i �1 �Sf { 7 List all other officers of the corporation: OFFICER TITLE HOME HOME BUSINESS DATE OF NAME (Office Held) ADDRESS PHONE PHONE BTRTH i' — (�� r�or�-S�NU�+ °;R� C�i�ta�� A�e �I�� 8�� aa_� �R��t � �a �� If business is a parhtership, please include the following information for each paztner (vse additional pages if necessary): FirstNamc Hame Addrtss; Stree[ h'ame Fintl�amc Home Add�sss: $tne( Ivame Middle Lutiel ?vtiddlc Initial CiTy (.Maidrn) C�Ty State state 1-%tt DateafBirth Zip Phone \umber � DateofBirth Zip Phone Number M3IQNESOTA TAX IDEN'IIFICATION NUMBER - Pursuant to the Laws of Minnesota, I 984, Chapter 502, Article 8, Section 2(270.72) (Tax Clearance; Issuance of Licenses), licensing authorities are required to provide to the State of Minnesota Commissioner of Revenue, the Minnesota business tax identificatson number and the social security number of each license applicant Under the Minnesota Govemment Data Practices Act and the Federai Privacy Act of 1974, we aze required to ad�dse 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 u�tYiholding or motor vehicle excise taxes; - Upon receiving this infoimation, the licensing au'thority will supply it only to the Minnesota Departinent of Revenue. However, under the Federal Exchange of Infozmation Av., jeement, the Department of Recenue may supply this information to the Internal Revenue Service. Mumesota TaY Idenlification Numbers (Sales & Use Tax Number) may be obtained frnm the State of Minnesota, Business Records Department, 10 River Park Plaza (612-296-6181). Social Security Number: �g�r� - l�." �ag� 5 Minnesota Tax Identification Number: _ ff a Minnesota Tax Idzntification Number is not requuzd for the business being operated, indicate so by placing an"X" in the box. __ � 2/18/97 9�-/? CERiIFICATION OF WORKERS' CO'vIPENSATION COVERAGE PURSUlu'v 1' TO MR��TIESOTA STATUTE 1%6.182 I haeby certif}� that � or my company, am in compliance with the workers' compensation i�surance coverage requirements of �nesota S+riute 176.182, subdivision 2. I aLso undeistznd that provision of false information in this certi5czlion constitutes sufiicient groLS for zd� erse zc�ion zeainst all licenses hzld, including recocation and suspension of said l;censes. (� ?vazne ofInsurance Company: �.l��T � (Z-�; L r�l � (� (�)(` � �� I (7 � U�A� �� Policy Number: Coc�zrage frozn C'. -��l �`f 7 to Sti S L� r�� -� I hace no emplo}'ezs coverzd under uorkers compensation insw-ance �(I\'ITL4LS) G/� �� AR`Y FALSIFICATION OF AIvSWERS GIVEN OR MATERLAL SUBMITTED WILL RESULT LN DEN7AL OF THIS APPLICATION I hereby state that I hatie z�swered all of the preceding questions, and that the infomiation contained herein is hue and co�rect to the bes[ of my kno�i�ledge and belief. I hereby staie further that I hzve received no money or othzt consideration, by way of loan �+ft, conhibutioq or otherv,�ise, other than ��readp disclosed in thz application k I hereuith submittzd. I also understand this premise ma} be :nspected by po1_ice, fire, health and other city omcials at any and all times when Lhe business is in operation. ��— Signature (REQUIRED for all We wtilI accept pa}'ment by cash, check (made payable to City of Saint Paul) or credit card (M/C or Visa). 3 =� Date� IFPAYINGBYCREDITCARDPLEASECOMPLETETHEFOLLOWINGINFORMATION: �MasterCard �Visa EXPII2ATION DATE: ACCOUNT NUMBER: ❑�/C1❑ ❑�0❑ ❑��❑ ❑��❑ ❑�❑❑ x� af of Cazd all Date ""Note: If this applicalion is Food/Liquor related, glease contact a Ciry of Saint Paul Health Inspector, Steve Olson (266-9139), to re�iew plans. If any substantial changes to structure are anticipated, please contact a City of Saint Paul Plan Exanuner at 265-9007 to apply for building pemuts. Ifthere aze any ct�anges 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 foltoR�ng documents. Please artach these documents R�hen submitting ?•our application: I. A detai]ed description of the design, location and square footage of the preauses to be licensed (site plan). The following data should be on the site plan (preferably on an 8 I I2" x 11" or 8 1/2" x 14" paper): - Name, address, and phone number. - The scale should be stated such as 1"= 20'. ^N shauld be indicated toward the top. - Placement of a11 pertinent features of the interior of the licensed faciliTy' such as seating areas, kitchens, offices, repair azea, parking, rest rooms, etc. - If a request is for an addiuon or expansion of the licensed facility, indicate both the current area and the proposed eapansion. 2. A copy of your ]ease a�eement or proof of ow�nership of the properry. SPECIFIC LICENSE APPLICATIONS REQUIl2E ADDTTIOl\'AL INFORMATION. PLEASE SEE REVERSE FOR DETAII�S >>>> �; 2/18/97 Council File # R�-�� ordinance # Green Sheet # 50240 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 Presented By Re£erred To RESOLUTION CITY OF SAINT PAUL, MINNESOTA d� --� Yeas NaYS sent Requested by Department of: Adopted by council: Date Adoption Certified by Cou By: Approved by a o at By: Secretary Off�ce of L�cense rnsgections and n ie r BY: � it� Form Approved by City Attorney Bye � Approved by Dayor for Submission to Council By: RESOLVED: That application, ZD #32086, for a Restaurant (B) and On-Sale Malt (3.2) Licenses by Chiang Rai Restaurant DBA Chiang Rai Restaurant, (Allison Vang, Mgr.), located at 432 University Avenue W., be and the same is hereby approved. �° 50240 a�_,-, OEPPRTMENTqFFICEICOUNGL � DATE INITIATED I a I J LIEP GREEN SHEE COMACT PERSON 8 PHONE INITIAUDATE INITIAVDATE O DEPAPTMENT DIRECTOR O CIiV COUNQL Christine A. Rozek - 266-9108 0.55tGN O CITV ATiORNEY O qSV CLERK MUST BE ON CAUNCR AGENDA BY (DATE) NVMBER FOR � BUDGET OIRECTOfl Q FIN & MGT SERVICES DIR. NOUTING Hearin : % 'j � OROEP � MAYOR (OR ASS�STANTJ � TOTAL # Of SIGNATURE PAGES (CIIP AI.L LOCASIONS FOR SIGPIASURE) AGTION fiEOUESTE�: Chiang Rai Restaurant DBA Chiang Rai Restaurant, (Allison Vang, Mgr.) requests Council approval of their application for a Restaurant (B) and On-Sale Malt (3.2) Licenses, ID �i32086„located at 432 University Avenue W. RECOMMENDAnONS: Approve (A) or Rejeet (R) pERSONAL SERVICE CONTRACTS MUST ANSWER THE FOLLOWING QUESTIONS: _. PLANNING GOMMISSION _ CIVIL SEpVICE COMMISSION 1. Has ffiis person/firm ever wakeA under a cortrect tor this departmentl __ CIB COMMITTEE _ �'ES � NO 2. Has this personHirm ever been a city em0loyee? _ STAFF — VES NO _ DISiRICT COURT _ 3. Does Nis perSOnRirm Qossess a skill not nortnalty possessed 6y any curzent ciry employee? SUPPOBTS WHICH COUNCII O&IECTIVE? YES NO Ezplaln all yes answers on seperete sheet end ettach to green sheel MRIATING PROBLEM.ISSUE.O�PORTUNITY(Who. Whap Wnen. Where. Why) ADVANTAGES IF APPROVED. DISADVANTAGES IFAPPROVEO: DISADVANTAGES IF NOTAPPROVED' �r01i[1CIi I'��it�3 l;�li��f DEC 11 1�97 TOTAL AMOUNT OF TRANSACTION $ COST/REVENUE BUDGETED (CIRCLE ONE) VES NO FUNDItiG SOURCE ACTIVITY NUMBER FINpNCIAL INFORfhAT10N: (EXPLAIN) . � � � � �'L� 9f�-l� CLASS III LICENSE APPLICATION THIS APPLICATION IS SUBJECT TO REVIEW BY T!HE PiJBLIC Type of License(s) being PLEASE TYPE OR PRINT IN II�'K CITY OF SAINT PAUL �cz of Licnsz, Inspzctions and Emvonme.rtai Protection 350 5:?,.c 5: S�^�=300 Szsv Pz�.J, �!^a;�.^x 55101 (6II) 3669JJJ !u Cb121266-oq3< � - � r �i ` � Company Nazne: � �t � g�� (�� l� ) (ZF��T Colpolation / Pertnaxhip / Sole Proprietrnship If business is incorporated, give date of incorporation: Doing Business As: C� f tnv�5 Z.Pi I ��T�l S� ft'�� Business Phone: a�� "�,g �7 BusinessAddress: �� i�1. ��Il)F�Si'1'\' (TSUP . ST.�(�t� R"1t� ' Street Address ciTy stete Zip Behveen u�hat cross streets is the business located? �} Y L? tti �� Which side of the street? ��( Are the premises now occupied7 Mail To Address: s� f,da� Applicant Information: What Type of Business? � Ciry State Zip Name and TiUe: A I� i Sp� ��U R- ��-R�JZ�, ��}��, �, F�rsc :�tiadl� � (Maiden) I.ast Title Home Address: ��i�1 C,�� 5� ��l,l� � E.� �� StratAddtess CiTy � S�ate Zip Date of Bir[h: CY� -, b- �. Place of Birth: �C 1 e�.SC� �' �d �?tk _ L f� � Home Phone: G I� - RSS� Have you ever been convicted of any felony, crime or ��iolation of any city ordutance other than traffic? YES NO �_ Date of arrest: Chazge: _ Conviction: Where? Sentence: List the naznes and residences of three persons of good moral chazacter, living within the Twin Cities Metro Area, not related to the applicznt or financially interested in the premises or business, who may be refeired to as to the applicanPs chazacter: NAME ADDRESS PHONE � � 2f18(97 `� t�-pa, � t� a�u a�a� �T fi��1, M��1 �S��S� �1,-1..��— List licenses which you currently hold, formerly held, or may have an interest in: CH1�� RRt R��TRZ)2�tiF'�( � c�.(1Sf Ha��e any of the above named licenses eva been revoked? YES � NO If yes, list the dates and reasons for revocation: 9� I� Are }�ou going to operate this business personallyY �_ YES F�t �� .Vi'iddle Initial (�faidrnj HomeAddzas: Strec.\auc Cirv Are gou going to have a sanzga or usistzat in this business? X YES please complete the folloning i*ifonnztion: � F��:�� HomeAddras: SfreetN�e waa�� tNa� p�,an,� C;Ty Please list } our employment history for the p: evious 5ve (5) } ear period: BusinesslEmplovment Add�ess NO If not, who will operate it? Lasc Sfate Date of BiAn T.�p Pnone VrmUer NO If the manager is not the szsne as the operator, r °� Siafc Datc of Birth Z�p Phone \'immber �{-f�f.�� t-}A-1 1 h l.flt� �'�,� 1<n�� i Ce Sr S �H-�, i �1 �Sf { 7 List all other officers of the corporation: OFFICER TITLE HOME HOME BUSINESS DATE OF NAME (Office Held) ADDRESS PHONE PHONE BTRTH i' — (�� r�or�-S�NU�+ °;R� C�i�ta�� A�e �I�� 8�� aa_� �R��t � �a �� If business is a parhtership, please include the following information for each paztner (vse additional pages if necessary): FirstNamc Hame Addrtss; Stree[ h'ame Fintl�amc Home Add�sss: $tne( Ivame Middle Lutiel ?vtiddlc Initial CiTy (.Maidrn) C�Ty State state 1-%tt DateafBirth Zip Phone \umber � DateofBirth Zip Phone Number M3IQNESOTA TAX IDEN'IIFICATION NUMBER - Pursuant to the Laws of Minnesota, I 984, Chapter 502, Article 8, Section 2(270.72) (Tax Clearance; Issuance of Licenses), licensing authorities are required to provide to the State of Minnesota Commissioner of Revenue, the Minnesota business tax identificatson number and the social security number of each license applicant Under the Minnesota Govemment Data Practices Act and the Federai Privacy Act of 1974, we aze required to ad�dse 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 u�tYiholding or motor vehicle excise taxes; - Upon receiving this infoimation, the licensing au'thority will supply it only to the Minnesota Departinent of Revenue. However, under the Federal Exchange of Infozmation Av., jeement, the Department of Recenue may supply this information to the Internal Revenue Service. Mumesota TaY Idenlification Numbers (Sales & Use Tax Number) may be obtained frnm the State of Minnesota, Business Records Department, 10 River Park Plaza (612-296-6181). Social Security Number: �g�r� - l�." �ag� 5 Minnesota Tax Identification Number: _ ff a Minnesota Tax Idzntification Number is not requuzd for the business being operated, indicate so by placing an"X" in the box. __ � 2/18/97 9�-/? CERiIFICATION OF WORKERS' CO'vIPENSATION COVERAGE PURSUlu'v 1' TO MR��TIESOTA STATUTE 1%6.182 I haeby certif}� that � or my company, am in compliance with the workers' compensation i�surance coverage requirements of �nesota S+riute 176.182, subdivision 2. I aLso undeistznd that provision of false information in this certi5czlion constitutes sufiicient groLS for zd� erse zc�ion zeainst all licenses hzld, including recocation and suspension of said l;censes. (� ?vazne ofInsurance Company: �.l��T � (Z-�; L r�l � (� (�)(` � �� I (7 � U�A� �� Policy Number: Coc�zrage frozn C'. -��l �`f 7 to Sti S L� r�� -� I hace no emplo}'ezs coverzd under uorkers compensation insw-ance �(I\'ITL4LS) G/� �� AR`Y FALSIFICATION OF AIvSWERS GIVEN OR MATERLAL SUBMITTED WILL RESULT LN DEN7AL OF THIS APPLICATION I hereby state that I hatie z�swered all of the preceding questions, and that the infomiation contained herein is hue and co�rect to the bes[ of my kno�i�ledge and belief. I hereby staie further that I hzve received no money or othzt consideration, by way of loan �+ft, conhibutioq or otherv,�ise, other than ��readp disclosed in thz application k I hereuith submittzd. I also understand this premise ma} be :nspected by po1_ice, fire, health and other city omcials at any and all times when Lhe business is in operation. ��— Signature (REQUIRED for all We wtilI accept pa}'ment by cash, check (made payable to City of Saint Paul) or credit card (M/C or Visa). 3 =� Date� IFPAYINGBYCREDITCARDPLEASECOMPLETETHEFOLLOWINGINFORMATION: �MasterCard �Visa EXPII2ATION DATE: ACCOUNT NUMBER: ❑�/C1❑ ❑�0❑ ❑��❑ ❑��❑ ❑�❑❑ x� af of Cazd all Date ""Note: If this applicalion is Food/Liquor related, glease contact a Ciry of Saint Paul Health Inspector, Steve Olson (266-9139), to re�iew plans. If any substantial changes to structure are anticipated, please contact a City of Saint Paul Plan Exanuner at 265-9007 to apply for building pemuts. Ifthere aze any ct�anges 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 foltoR�ng documents. Please artach these documents R�hen submitting ?•our application: I. A detai]ed description of the design, location and square footage of the preauses to be licensed (site plan). The following data should be on the site plan (preferably on an 8 I I2" x 11" or 8 1/2" x 14" paper): - Name, address, and phone number. - The scale should be stated such as 1"= 20'. ^N shauld be indicated toward the top. - Placement of a11 pertinent features of the interior of the licensed faciliTy' such as seating areas, kitchens, offices, repair azea, parking, rest rooms, etc. - If a request is for an addiuon or expansion of the licensed facility, indicate both the current area and the proposed eapansion. 2. A copy of your ]ease a�eement or proof of ow�nership of the properry. SPECIFIC LICENSE APPLICATIONS REQUIl2E ADDTTIOl\'AL INFORMATION. PLEASE SEE REVERSE FOR DETAII�S >>>> �; 2/18/97