The URL can be used to link to this page

98-192RESOLUTION OF Presented By Re£erred To Committee: Date RSSOLVED: 1 That application (ID #19980000054) for a Gas Station, Cigarette/Tobacco 2 License(s) by SEAPORT INC DBA TOTAL at 281 SNELLING AVE N be 3 and the same is hereby approved. Requested by Department of: Office of License, Ins ections and Environmental Protection By: �i�� T�T ��?� X _ `� Adoption Certified by Council Secretary By: Appx Bp: PAl7t, MINNESOTA Council Fi1e# \ — � � ordinance � Green Sheet # LP60025 �Z Form Approved by city Attorney s _�� dl,c� 3 � Z —�� Approved by Mayor for Submission to Council By: Adopted by Council: Date ��,i�,�q�S' lsrf lan DEPARTMENT/OFFICE/COUNCIL DAiewrtuieo V IQ `I �� IIEP/Lice�irg GREEN SkiEET No. LP60025 ON7ACT PERSON & PHONE InAaVOafe mNauDa2 LOOM JAMES (JIA� (61� 2669073 � C �, Aaa UST BE ON COUNCIL AGENDA BY (DATE) A � 3rttr5s � �; c �'retr r: �rg M1N�Ht WR � Counul Researcn ROUTR�G ORD6t TOTAL # OF SIGNATURE PAGES (CLJP ALL LOCATIONS FOR SIGNANRE) ACTION REQUESTED: Counwl approy8l o(the fdbwitg license applieafron: License # 199600000r.�4, fw SEAPORT W C, Doing Business As TOTAL, at 281 SNELUNG AVE N, including the fdlwring bUSiness type(s): Gas StaGon� CigareGeJTobaceo. RECOMMENDATIONS: Approve(A) Reject(R) ERSONAL SERVICE CON7RACTS MUST ANSwER THE FOLLOwING �UESTIONS: 1. Has this perso�rtn ever �wrked under a conhact for this depahmeM? PLANNING COMMISSION yES NO CIB COMMITTEE 2. Has ihis persoMirtn ever been a city emplryeeT CIVIL SVC CINN, YES NO 3. Does this perso�rm possess a skili not normalN possessed by arry curteM city employee? YES NO . Is this pe�rtn a targefed vendolt —"' YES NO Erzplain all yes ansvers on uparate sheet antl attach to green aheet INITIATING PROBLEM, �SSUE, OPPORTUNITY (Who, What, When, Where, Why): Requesting CounciV approval for a Gas Station 8 Cigarette License by Seaport Inc. DBA Total at 281 Snelling Ave. N. ADVANTAGES IF APPROVED: ISADVANTAGES lF APPftOVED: DISADVANTAGES IF NOT APPROVED: TOTAL AMOUNT OP TRANSACTION $ COST/REVENUE BUDGETfD (CIRCLE ONE) YES NO FUNDING SOURCE ACTIVITY NUMBER FINANCIAL INFORMATION: (EXPLAIN) . a�c�� 1 �� -19 a- cLass lii LICENSE APPLICATION THIS APPLICATION IS SUS7ECT TO REVIEW BY TT� PUBLIC Type of License(s) being applied for: PLEASE TYPE OR PRINT IN INK CTTY OF SAINT PAUL osce etL;crnu, Inspect;«ss and Enviromnttrtat Profection 350 S� Pnu St Svte 300 SanrRU7,.N�vncso4 55101 (612)1665090 fz<(61])366913C �� d� - I/1/ /I _ ' Company Nazne: �<% � P� u.� �_ . Cmporetion / Pertnenhip / Solc Propxietonhip If business is incorporated, give date of incorporation: Doing Business As: T'r.! ,� ) Business Phone: �� Business Address: ��! a� .� i w`t : K.� C_��.. L_ _ M tv . �S'Qt� LI Street Addrcsa CiTy Sfete Zip Between what cross streets is the business located? �� 1� � c��- l�c� h��r �- Which side of the streei7 �_ Are the premises now occupied9 �_ What Type of Business? G' o� ,�n � i c; ;� Mail To Address: �'iA� � n �.r��'P s� naa�, ctry sr�m Z�p Applicant Information: 77 ��`�n'� �( � k�/ PG� Na-ne and Title: �E�g� �'4 W�Cl� ��i�/Prj r�iC�YI � Y Firet Middle (Maiden) Last Title Home Address: Sizoct Addrcss City State Zip DatcofBirth: �-'7.�j- h� PlaccofBirlh: �r�;q(-XGn[ih±CY IiomePhone�(s�1�2� (�`Z,�.�i Have you ever been convicted of any felony, crime or violation of any city ordinance other than tr�c? YES NO ,�_ Date of arrest: Where? Chazge: Conviction: �-�'^" Sentence: List the naznes and residences of three penons of good moral character, living within the Twin Cities Metro Area, not related to the applicant or financially intaested in the premises or business, who may be referred to as to the applicanPs character: �� ADDRESS List Iicenses which you currrntly hold, formerly held, or may have an interest in: PHONE Have any of the above named licenses ever been tevoked? YES NO If yes, list the dates and reasons for revocation: 2/18/97 Are you going to operate this business personally? �/ YES Fusl \eme Home Addrev: C�'Inidcn7 City Are you going to have a manager or assistant in this business? _ j�YES please complete the following information: First'�ame Home P.ddicss: Streef \amc ?vtiddleInitisl (.Naidrn) City Please lisc your employmem history for the previous five (5) year period: IR� Sfetc Zip PhrncNimber NO If the manager is not the sazne as the operator, Last Stau Zip Dnte Phmw N�mbtt Business/Emplovment Address - - S e�� P m��r� � ara ��,y -11� +� .r��-1 I ci tr I� S List all other officers of the coiporation: OFFICER TITLE HOME NAME (OfficeHeld) ADDRESS HOME BUSINESS PHONE PHONE If business is a partnership, please include the following infoimation for each partner (use additional pages if neeessary): F�i x�� ?.tiaa�� ie� �--- Home Add�css: Street Nemc ^—� Fint Neme Middle Initia —'_. Home Address: S[rcet Nms (!�naiaa,) City (.Ylaidrn) City �n Stetc Zip Lsst Stnte Zip DATE OF BIItTH Phoue Number Date ofBirth Phone N�mba MINNESOTA TAX IDENTIFICATION NUMBER - Pursuant to the Laws of Minnesota, 1984, 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 ident�cation number and the social security number of each license applicant. Under the Minnesota Government Data Practices Act and the Federal Privacy Act of 1974, we aze requ'ued to advise you of the following regazding the use of the Minnesota Tar ldentification Number: - This infoimation may be used to deny the issuance or renewal of your license in the event you owe Minnesota sales, employer'S withholding or motor vehicle excise taxes; - Upon receiving this information, the licensing authority wil] supply it only to the Minnesota Department of Revenue. Howeve{ under the Federal Eschange of Jnformation Agreement, the Department of Revenue may supply Uus information to the Internal Revenue Service. Minnesota TaY Identification Numbers (Sales & Use Tax Number) may be obtained from the State of Minnesota, Business Records Depar4nen� 10 RiverPark Plua (612-296-6181). Social Security Number: I �l� �j�'9 k�� rl Minnesota Tan Identification Number: �� q��i � If a Minnesota Tax Identification Number is no[ required for the business being operated, indicate so by placing an"X" in the box. NO If not, who will operate it? °��-1��- 2/18/97 q8 -1q �-- CER'1'IFICATION OF WORKERS' COMPENSATION CO VERAGE PURSUANT TO MINNESOTA STATUTE 176.182 I haeby certify that I, or my company, azn in compliance ��ith the workers' compensalion insurance coverage requirements of Minnesota Statvte 176.182, subdic�ision 2. I also understand that provision of false informalion in this cert�cation constitutes suflicient grounds for adverse action against all licenses held, including revocation and suspension of said licrnses. Name of Insurance Company: Policy Number: ' Coverage I have no employees covered i:nder workers compensation insurance _ �ru�.s� (-1. A to ANY FALSIFICATION OF ANSWERS GIVEI�T OR MATERIAL SUBiSITTED WILL RESULT IN DENIAL OF THIS APPLICATION I hereby state that I have answered all of the preceding questions, and that the infonnation contained herein is true and cotrect to the best of my ]mowledge and belief. I hereby state fiuther that I have received no money or other consideratioq by way of loan, gift, conhibution, or otherwise, othet than already disclosed in the application which I herewith submitted I also understand this premise may be inspected by police, fire, health and othzr city officials at any and all times when the business is in operation. �� for all applications) We will accept payment by cash, check (made payable to City of Saint Paun or credit card (N7lC or Visa). �� Date PAYING BY CREDIT CARD PLEASE COMPLETE THE FOLLOWING INFORMATION: � MasterCard � Visa EXPII2ATION DATE: � � � � �- Name of Car�older of Card Holder(required for all Date '�*Note: If this application is Food/Liquor related, please contact a Ciry of Saint Paul Health Inspector, Steve Olson (266AI39), to review plans. If any substantial changes to structure aze anticipated, please contact a City of Saint Paul Plan Examiner at 266-9007 to apply for building pemvts. Ifthere are any changes to the pazking 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. Piease attach these documents when submitting your application: 1. A detailed description of the design, location and square footage of the premises to be licensed (site plan). The following data should be on the site plan (preferably on an 8 I/2" x I 1" or 8 1/2" x 14" paper): - Name, address, and phone number. - The scale should be stated such as 1" = 20'. ^N should 6e indicated towazd the top. - Placement of all pertinent features of the interior of the licensed facility such as seating areas, }dtchrns, offices, repair area, pazking, rest rooms, etc. - 7f a request is for an addilion or e�pansion of the ]icensed facility, indicate both the cturent azea and the proposed expansion. 2. A copy of your lease agreement or proof of ownership of the property. SPECIFIC LICENSE APPLICATIONS REQUII2E ADDTTIONAL INFORMATION. PLEASE SEE REVERSE FOR DETAILS >>>> ACCOUNT I�SLJMBER: � � � � � � � � � � � � � � � � 2/18/97 RESOLUTION OF Presented By Re£erred To Committee: Date RSSOLVED: 1 That application (ID #19980000054) for a Gas Station, Cigarette/Tobacco 2 License(s) by SEAPORT INC DBA TOTAL at 281 SNELLING AVE N be 3 and the same is hereby approved. Requested by Department of: Office of License, Ins ections and Environmental Protection By: �i�� T�T ��?� X _ `� Adoption Certified by Council Secretary By: Appx Bp: PAl7t, MINNESOTA Council Fi1e# \ — � � ordinance � Green Sheet # LP60025 �Z Form Approved by city Attorney s _�� dl,c� 3 � Z —�� Approved by Mayor for Submission to Council By: Adopted by Council: Date ��,i�,�q�S' lsrf lan DEPARTMENT/OFFICE/COUNCIL DAiewrtuieo V IQ `I �� IIEP/Lice�irg GREEN SkiEET No. LP60025 ON7ACT PERSON & PHONE InAaVOafe mNauDa2 LOOM JAMES (JIA� (61� 2669073 � C �, Aaa UST BE ON COUNCIL AGENDA BY (DATE) A � 3rttr5s � �; c �'retr r: �rg M1N�Ht WR � Counul Researcn ROUTR�G ORD6t TOTAL # OF SIGNATURE PAGES (CLJP ALL LOCATIONS FOR SIGNANRE) ACTION REQUESTED: Counwl approy8l o(the fdbwitg license applieafron: License # 199600000r.�4, fw SEAPORT W C, Doing Business As TOTAL, at 281 SNELUNG AVE N, including the fdlwring bUSiness type(s): Gas StaGon� CigareGeJTobaceo. RECOMMENDATIONS: Approve(A) Reject(R) ERSONAL SERVICE CON7RACTS MUST ANSwER THE FOLLOwING �UESTIONS: 1. Has this perso�rtn ever �wrked under a conhact for this depahmeM? PLANNING COMMISSION yES NO CIB COMMITTEE 2. Has ihis persoMirtn ever been a city emplryeeT CIVIL SVC CINN, YES NO 3. Does this perso�rm possess a skili not normalN possessed by arry curteM city employee? YES NO . Is this pe�rtn a targefed vendolt —"' YES NO Erzplain all yes ansvers on uparate sheet antl attach to green aheet INITIATING PROBLEM, �SSUE, OPPORTUNITY (Who, What, When, Where, Why): Requesting CounciV approval for a Gas Station 8 Cigarette License by Seaport Inc. DBA Total at 281 Snelling Ave. N. ADVANTAGES IF APPROVED: ISADVANTAGES lF APPftOVED: DISADVANTAGES IF NOT APPROVED: TOTAL AMOUNT OP TRANSACTION $ COST/REVENUE BUDGETfD (CIRCLE ONE) YES NO FUNDING SOURCE ACTIVITY NUMBER FINANCIAL INFORMATION: (EXPLAIN) . a�c�� 1 �� -19 a- cLass lii LICENSE APPLICATION THIS APPLICATION IS SUS7ECT TO REVIEW BY TT� PUBLIC Type of License(s) being applied for: PLEASE TYPE OR PRINT IN INK CTTY OF SAINT PAUL osce etL;crnu, Inspect;«ss and Enviromnttrtat Profection 350 S� Pnu St Svte 300 SanrRU7,.N�vncso4 55101 (612)1665090 fz<(61])366913C �� d� - I/1/ /I _ ' Company Nazne: �<% � P� u.� �_ . Cmporetion / Pertnenhip / Solc Propxietonhip If business is incorporated, give date of incorporation: Doing Business As: T'r.! ,� ) Business Phone: �� Business Address: ��! a� .� i w`t : K.� C_��.. L_ _ M tv . �S'Qt� LI Street Addrcsa CiTy Sfete Zip Between what cross streets is the business located? �� 1� � c��- l�c� h��r �- Which side of the streei7 �_ Are the premises now occupied9 �_ What Type of Business? G' o� ,�n � i c; ;� Mail To Address: �'iA� � n �.r��'P s� naa�, ctry sr�m Z�p Applicant Information: 77 ��`�n'� �( � k�/ PG� Na-ne and Title: �E�g� �'4 W�Cl� ��i�/Prj r�iC�YI � Y Firet Middle (Maiden) Last Title Home Address: Sizoct Addrcss City State Zip DatcofBirth: �-'7.�j- h� PlaccofBirlh: �r�;q(-XGn[ih±CY IiomePhone�(s�1�2� (�`Z,�.�i Have you ever been convicted of any felony, crime or violation of any city ordinance other than tr�c? YES NO ,�_ Date of arrest: Where? Chazge: Conviction: �-�'^" Sentence: List the naznes and residences of three penons of good moral character, living within the Twin Cities Metro Area, not related to the applicant or financially intaested in the premises or business, who may be referred to as to the applicanPs character: �� ADDRESS List Iicenses which you currrntly hold, formerly held, or may have an interest in: PHONE Have any of the above named licenses ever been tevoked? YES NO If yes, list the dates and reasons for revocation: 2/18/97 Are you going to operate this business personally? �/ YES Fusl \eme Home Addrev: C�'Inidcn7 City Are you going to have a manager or assistant in this business? _ j�YES please complete the following information: First'�ame Home P.ddicss: Streef \amc ?vtiddleInitisl (.Naidrn) City Please lisc your employmem history for the previous five (5) year period: IR� Sfetc Zip PhrncNimber NO If the manager is not the sazne as the operator, Last Stau Zip Dnte Phmw N�mbtt Business/Emplovment Address - - S e�� P m��r� � ara ��,y -11� +� .r��-1 I ci tr I� S List all other officers of the coiporation: OFFICER TITLE HOME NAME (OfficeHeld) ADDRESS HOME BUSINESS PHONE PHONE If business is a partnership, please include the following infoimation for each partner (use additional pages if neeessary): F�i x�� ?.tiaa�� ie� �--- Home Add�css: Street Nemc ^—� Fint Neme Middle Initia —'_. Home Address: S[rcet Nms (!�naiaa,) City (.Ylaidrn) City �n Stetc Zip Lsst Stnte Zip DATE OF BIItTH Phoue Number Date ofBirth Phone N�mba MINNESOTA TAX IDENTIFICATION NUMBER - Pursuant to the Laws of Minnesota, 1984, 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 ident�cation number and the social security number of each license applicant. Under the Minnesota Government Data Practices Act and the Federal Privacy Act of 1974, we aze requ'ued to advise you of the following regazding the use of the Minnesota Tar ldentification Number: - This infoimation may be used to deny the issuance or renewal of your license in the event you owe Minnesota sales, employer'S withholding or motor vehicle excise taxes; - Upon receiving this information, the licensing authority wil] supply it only to the Minnesota Department of Revenue. Howeve{ under the Federal Eschange of Jnformation Agreement, the Department of Revenue may supply Uus information to the Internal Revenue Service. Minnesota TaY Identification Numbers (Sales & Use Tax Number) may be obtained from the State of Minnesota, Business Records Depar4nen� 10 RiverPark Plua (612-296-6181). Social Security Number: I �l� �j�'9 k�� rl Minnesota Tan Identification Number: �� q��i � If a Minnesota Tax Identification Number is no[ required for the business being operated, indicate so by placing an"X" in the box. NO If not, who will operate it? °��-1��- 2/18/97 q8 -1q �-- CER'1'IFICATION OF WORKERS' COMPENSATION CO VERAGE PURSUANT TO MINNESOTA STATUTE 176.182 I haeby certify that I, or my company, azn in compliance ��ith the workers' compensalion insurance coverage requirements of Minnesota Statvte 176.182, subdic�ision 2. I also understand that provision of false informalion in this cert�cation constitutes suflicient grounds for adverse action against all licenses held, including revocation and suspension of said licrnses. Name of Insurance Company: Policy Number: ' Coverage I have no employees covered i:nder workers compensation insurance _ �ru�.s� (-1. A to ANY FALSIFICATION OF ANSWERS GIVEI�T OR MATERIAL SUBiSITTED WILL RESULT IN DENIAL OF THIS APPLICATION I hereby state that I have answered all of the preceding questions, and that the infonnation contained herein is true and cotrect to the best of my ]mowledge and belief. I hereby state fiuther that I have received no money or other consideratioq by way of loan, gift, conhibution, or otherwise, othet than already disclosed in the application which I herewith submitted I also understand this premise may be inspected by police, fire, health and othzr city officials at any and all times when the business is in operation. �� for all applications) We will accept payment by cash, check (made payable to City of Saint Paun or credit card (N7lC or Visa). �� Date PAYING BY CREDIT CARD PLEASE COMPLETE THE FOLLOWING INFORMATION: � MasterCard � Visa EXPII2ATION DATE: � � � � �- Name of Car�older of Card Holder(required for all Date '�*Note: If this application is Food/Liquor related, please contact a Ciry of Saint Paul Health Inspector, Steve Olson (266AI39), to review plans. If any substantial changes to structure aze anticipated, please contact a City of Saint Paul Plan Examiner at 266-9007 to apply for building pemvts. Ifthere are any changes to the pazking 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. Piease attach these documents when submitting your application: 1. A detailed description of the design, location and square footage of the premises to be licensed (site plan). The following data should be on the site plan (preferably on an 8 I/2" x I 1" or 8 1/2" x 14" paper): - Name, address, and phone number. - The scale should be stated such as 1" = 20'. ^N should 6e indicated towazd the top. - Placement of all pertinent features of the interior of the licensed facility such as seating areas, }dtchrns, offices, repair area, pazking, rest rooms, etc. - 7f a request is for an addilion or e�pansion of the ]icensed facility, indicate both the cturent azea and the proposed expansion. 2. A copy of your lease agreement or proof of ownership of the property. SPECIFIC LICENSE APPLICATIONS REQUII2E ADDTTIONAL INFORMATION. PLEASE SEE REVERSE FOR DETAILS >>>> ACCOUNT I�SLJMBER: � � � � � � � � � � � � � � � � 2/18/97 RESOLUTION OF Presented By Re£erred To Committee: Date RSSOLVED: 1 That application (ID #19980000054) for a Gas Station, Cigarette/Tobacco 2 License(s) by SEAPORT INC DBA TOTAL at 281 SNELLING AVE N be 3 and the same is hereby approved. Requested by Department of: Office of License, Ins ections and Environmental Protection By: �i�� T�T ��?� X _ `� Adoption Certified by Council Secretary By: Appx Bp: PAl7t, MINNESOTA Council Fi1e# \ — � � ordinance � Green Sheet # LP60025 �Z Form Approved by city Attorney s _�� dl,c� 3 � Z —�� Approved by Mayor for Submission to Council By: Adopted by Council: Date ��,i�,�q�S' lsrf lan DEPARTMENT/OFFICE/COUNCIL DAiewrtuieo V IQ `I �� IIEP/Lice�irg GREEN SkiEET No. LP60025 ON7ACT PERSON & PHONE InAaVOafe mNauDa2 LOOM JAMES (JIA� (61� 2669073 � C �, Aaa UST BE ON COUNCIL AGENDA BY (DATE) A � 3rttr5s � �; c �'retr r: �rg M1N�Ht WR � Counul Researcn ROUTR�G ORD6t TOTAL # OF SIGNATURE PAGES (CLJP ALL LOCATIONS FOR SIGNANRE) ACTION REQUESTED: Counwl approy8l o(the fdbwitg license applieafron: License # 199600000r.�4, fw SEAPORT W C, Doing Business As TOTAL, at 281 SNELUNG AVE N, including the fdlwring bUSiness type(s): Gas StaGon� CigareGeJTobaceo. RECOMMENDATIONS: Approve(A) Reject(R) ERSONAL SERVICE CON7RACTS MUST ANSwER THE FOLLOwING �UESTIONS: 1. Has this perso�rtn ever �wrked under a conhact for this depahmeM? PLANNING COMMISSION yES NO CIB COMMITTEE 2. Has ihis persoMirtn ever been a city emplryeeT CIVIL SVC CINN, YES NO 3. Does this perso�rm possess a skili not normalN possessed by arry curteM city employee? YES NO . Is this pe�rtn a targefed vendolt —"' YES NO Erzplain all yes ansvers on uparate sheet antl attach to green aheet INITIATING PROBLEM, �SSUE, OPPORTUNITY (Who, What, When, Where, Why): Requesting CounciV approval for a Gas Station 8 Cigarette License by Seaport Inc. DBA Total at 281 Snelling Ave. N. ADVANTAGES IF APPROVED: ISADVANTAGES lF APPftOVED: DISADVANTAGES IF NOT APPROVED: TOTAL AMOUNT OP TRANSACTION $ COST/REVENUE BUDGETfD (CIRCLE ONE) YES NO FUNDING SOURCE ACTIVITY NUMBER FINANCIAL INFORMATION: (EXPLAIN) . a�c�� 1 �� -19 a- cLass lii LICENSE APPLICATION THIS APPLICATION IS SUS7ECT TO REVIEW BY TT� PUBLIC Type of License(s) being applied for: PLEASE TYPE OR PRINT IN INK CTTY OF SAINT PAUL osce etL;crnu, Inspect;«ss and Enviromnttrtat Profection 350 S� Pnu St Svte 300 SanrRU7,.N�vncso4 55101 (612)1665090 fz<(61])366913C �� d� - I/1/ /I _ ' Company Nazne: �<% � P� u.� �_ . Cmporetion / Pertnenhip / Solc Propxietonhip If business is incorporated, give date of incorporation: Doing Business As: T'r.! ,� ) Business Phone: �� Business Address: ��! a� .� i w`t : K.� C_��.. L_ _ M tv . �S'Qt� LI Street Addrcsa CiTy Sfete Zip Between what cross streets is the business located? �� 1� � c��- l�c� h��r �- Which side of the streei7 �_ Are the premises now occupied9 �_ What Type of Business? G' o� ,�n � i c; ;� Mail To Address: �'iA� � n �.r��'P s� naa�, ctry sr�m Z�p Applicant Information: 77 ��`�n'� �( � k�/ PG� Na-ne and Title: �E�g� �'4 W�Cl� ��i�/Prj r�iC�YI � Y Firet Middle (Maiden) Last Title Home Address: Sizoct Addrcss City State Zip DatcofBirth: �-'7.�j- h� PlaccofBirlh: �r�;q(-XGn[ih±CY IiomePhone�(s�1�2� (�`Z,�.�i Have you ever been convicted of any felony, crime or violation of any city ordinance other than tr�c? YES NO ,�_ Date of arrest: Where? Chazge: Conviction: �-�'^" Sentence: List the naznes and residences of three penons of good moral character, living within the Twin Cities Metro Area, not related to the applicant or financially intaested in the premises or business, who may be referred to as to the applicanPs character: �� ADDRESS List Iicenses which you currrntly hold, formerly held, or may have an interest in: PHONE Have any of the above named licenses ever been tevoked? YES NO If yes, list the dates and reasons for revocation: 2/18/97 Are you going to operate this business personally? �/ YES Fusl \eme Home Addrev: C�'Inidcn7 City Are you going to have a manager or assistant in this business? _ j�YES please complete the following information: First'�ame Home P.ddicss: Streef \amc ?vtiddleInitisl (.Naidrn) City Please lisc your employmem history for the previous five (5) year period: IR� Sfetc Zip PhrncNimber NO If the manager is not the sazne as the operator, Last Stau Zip Dnte Phmw N�mbtt Business/Emplovment Address - - S e�� P m��r� � ara ��,y -11� +� .r��-1 I ci tr I� S List all other officers of the coiporation: OFFICER TITLE HOME NAME (OfficeHeld) ADDRESS HOME BUSINESS PHONE PHONE If business is a partnership, please include the following infoimation for each partner (use additional pages if neeessary): F�i x�� ?.tiaa�� ie� �--- Home Add�css: Street Nemc ^—� Fint Neme Middle Initia —'_. Home Address: S[rcet Nms (!�naiaa,) City (.Ylaidrn) City �n Stetc Zip Lsst Stnte Zip DATE OF BIItTH Phoue Number Date ofBirth Phone N�mba MINNESOTA TAX IDENTIFICATION NUMBER - Pursuant to the Laws of Minnesota, 1984, 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 ident�cation number and the social security number of each license applicant. Under the Minnesota Government Data Practices Act and the Federal Privacy Act of 1974, we aze requ'ued to advise you of the following regazding the use of the Minnesota Tar ldentification Number: - This infoimation may be used to deny the issuance or renewal of your license in the event you owe Minnesota sales, employer'S withholding or motor vehicle excise taxes; - Upon receiving this information, the licensing authority wil] supply it only to the Minnesota Department of Revenue. Howeve{ under the Federal Eschange of Jnformation Agreement, the Department of Revenue may supply Uus information to the Internal Revenue Service. Minnesota TaY Identification Numbers (Sales & Use Tax Number) may be obtained from the State of Minnesota, Business Records Depar4nen� 10 RiverPark Plua (612-296-6181). Social Security Number: I �l� �j�'9 k�� rl Minnesota Tan Identification Number: �� q��i � If a Minnesota Tax Identification Number is no[ required for the business being operated, indicate so by placing an"X" in the box. NO If not, who will operate it? °��-1��- 2/18/97 q8 -1q �-- CER'1'IFICATION OF WORKERS' COMPENSATION CO VERAGE PURSUANT TO MINNESOTA STATUTE 176.182 I haeby certify that I, or my company, azn in compliance ��ith the workers' compensalion insurance coverage requirements of Minnesota Statvte 176.182, subdic�ision 2. I also understand that provision of false informalion in this cert�cation constitutes suflicient grounds for adverse action against all licenses held, including revocation and suspension of said licrnses. Name of Insurance Company: Policy Number: ' Coverage I have no employees covered i:nder workers compensation insurance _ �ru�.s� (-1. A to ANY FALSIFICATION OF ANSWERS GIVEI�T OR MATERIAL SUBiSITTED WILL RESULT IN DENIAL OF THIS APPLICATION I hereby state that I have answered all of the preceding questions, and that the infonnation contained herein is true and cotrect to the best of my ]mowledge and belief. I hereby state fiuther that I have received no money or other consideratioq by way of loan, gift, conhibution, or otherwise, othet than already disclosed in the application which I herewith submitted I also understand this premise may be inspected by police, fire, health and othzr city officials at any and all times when the business is in operation. �� for all applications) We will accept payment by cash, check (made payable to City of Saint Paun or credit card (N7lC or Visa). �� Date PAYING BY CREDIT CARD PLEASE COMPLETE THE FOLLOWING INFORMATION: � MasterCard � Visa EXPII2ATION DATE: � � � � �- Name of Car�older of Card Holder(required for all Date '�*Note: If this application is Food/Liquor related, please contact a Ciry of Saint Paul Health Inspector, Steve Olson (266AI39), to review plans. If any substantial changes to structure aze anticipated, please contact a City of Saint Paul Plan Examiner at 266-9007 to apply for building pemvts. Ifthere are any changes to the pazking 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. Piease attach these documents when submitting your application: 1. A detailed description of the design, location and square footage of the premises to be licensed (site plan). The following data should be on the site plan (preferably on an 8 I/2" x I 1" or 8 1/2" x 14" paper): - Name, address, and phone number. - The scale should be stated such as 1" = 20'. ^N should 6e indicated towazd the top. - Placement of all pertinent features of the interior of the licensed facility such as seating areas, }dtchrns, offices, repair area, pazking, rest rooms, etc. - 7f a request is for an addilion or e�pansion of the ]icensed facility, indicate both the cturent azea and the proposed expansion. 2. A copy of your lease agreement or proof of ownership of the property. SPECIFIC LICENSE APPLICATIONS REQUII2E ADDTTIONAL INFORMATION. PLEASE SEE REVERSE FOR DETAILS >>>> ACCOUNT I�SLJMBER: � � � � � � � � � � � � � � � � 2/18/97