98-65Council File $ r0 � �s
ordinance #
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ORIGiNAL
Presented
Referred To
Green Sheet # 50346
RESOLUTION
CITY OF SA�NT PAUL, MINNESOTA
Committee: Date
/b
RESOLVED: That application, ZD �19970000053, for a Liquid Fuel Dealer, Gas Station
License(s) by Midway Euel Inc. DBA Midway Fuel Inc. at 543 Cleveland Avenue
N., be and the same is hereby approved.
Requested by Department of:
Office of License. Ins�ections and
/' � �nv' o
BY: 1 ��n✓ l�''
Form Approved by`Eity At �ey
Bye ' /
Approved by Mayor for Submission to
ncil
Sys
APF
By:
Adopted by Council: Date
Adoption Certified by Counc' Secretary
DEPARTMENT/OFFICEICOUNCfL DATE iN�7wTEP � � �
UEP/Licensing GREEN SHEET roo. sosas S
ONTACT PERSON & PHONE
IniEaVDate NitiaVDate
ECHMANN CaARY
(612j26S9136 � C �, Att
UST BE ON COUNCIL AGENDA BY (DATE) �
1/28196 �� � CouncilReseatch
ROIiTf�G
ORD�
TOTAL # OF SIGNATURE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE)
ACTION REQUESTED:
Caawil approval Mthe fdbwing liceree appfication: License # 1997000D053, for MIDWAY FUEL
MC, Doing Business As MIDWAY FUEL INC, at 543 CLEVELAND AVE N, and type of business(es): Liquid
Fuel D�kr, C,as Station.
RECOMMENDATIONS: Approve(A) Reject(R) RSOwLL.SERV�Ce cONiRAC751.a1ST aNSwER THE FOLLOW�MG CUES710NS:
1. FinsihispecsoMicmererwakedu+Wera wMraclfatl�depattment4
__ PLANNING COMMISSION yEg �.�p
CIB COMMITTEE 2. tlx this persoMrm ever been a city employee?
CIVIL SVC CINN, �S �
3. Does thic personrtirtn pwsess a skill nof namaiy possessed by eiry curtent ci(y employee?
YES NO
. Is ihis persor�rtn a prgeted vendoft
- YES NO
Euplain all yes answers on uparffie sheet and attach to green aheet
INITIATING PROBLEM, ISSUE, OPPORTUNITY (Who, Wha[, When, Where, Why):
Requesting Council approval fa M'idway Fuei fnc. D&4 M'idxay Fuei irc. (Robert Bentiey) for a Liquid Fuel DealedGas Station at 543 Cteveland Avenue So.
ADVANTAGESIFAPPROVED:
ISADVANTAGES IP APPROVED:
DISADVANTAGES IF NOT APPROVED:
TOTALAMOUN7 Of TRANSACTION S COST/REUENUE BUDGETED (CIRCLE ONE) YES NO
FUNDING SOURCE ACTIVITY NUMBER
FINANCIAL INFORMATION:
(EXPLAIN)
. � {
�3Q9_�C�
CLASS III
LICENSE APPLICATION
THIS APPLICATION IS SUB3ECT TO REVLW BY TF� PUBLIC
Type of License(s) being applied for:
Company tdame:
Corporation / Partncxs6ip / Solc Proprietorship
r�
ifbusiness is incorporated, give date ofincocporation: Seotember 5. 1997 __
DoingBusinessAs: Midwav Fuel. Inc. BusinessPhone: 688-20p0
BusinessAddress: 543 Cleveland Avenue N. . Pa,l mmr Sst94
Strcet Addresa City Stato Zip
Between v.�hat cross streets is the business locata3? C1eveland Ave :& Wabash GVhich side of the street?
ArethepremisesnowoccupiedT Yes WhatTypeofBusiness? Gas Station
IvIail To Address: 800 Lone Oak- Road Eagan MN 55121
svar nr�� . c�ry s,s,� z�P
Applicant Information:
NameandTitie: Garv 6eorQe Santoor�ian RPa� Fcrara t�a„ �P,-
Fust . ?tid�e (Mnidcn) Last TiUe
HomeAddress: 12885 Emmer Place Apvle Vallev MN 55124
Stroet Addrta City State Zip
DateofBirth: 7-4-61 PlaceofBirth: St. Louis Park. MN HomePhone: 4�3-44��
Have you ever been convicted of any felony, crime or violation of any city ordinance other than traffic? YES NO _�_
Date of azrest:
Charge: _
ConvicGon:
Wnerei
Sentence:
Lizt the naznes and residences of tt�ree persons of good moral chazacter, living urithin the T���in Cities Metro Area, not related to the applicant
or financially interested in the premises or business, who may be referred to as to tl�e applicanYs character:
NAME ADDRESS PHONE
Scott Daubanton 2719 W 43rd Sr �t2f74 MpIG � 55t�1n �'t� Ssz��
Steve Corcoran 4920 Dupont Ave. S. Mp1s MN 55409 825-7628
Lance Johnson 3127 F 57st Mnlc MN 55417 7�7 4459
List liceases u•hich you curtently hold, fotmerly held, or may ha��e an interest in:
Real Estate Brokers License ParkinQ 1ot license (Dart Trans�t�— Ke�logg Park;,,g t�r�_
Hat�e any of the above named licenses e>•er been revoked? YES X NfJ If yes, ]ist the dates and-reasons for revocation:
CITY OF SAINT PAt3L
�ce ofLiccnse, Inspections
znd Fnviramnental ftotection
35.1' St Pna St Sti�c 300 p
Stint PavL 1f'i'c�aoa 55101 �d i�5
j672)265-9�^74.;(6t3)166-9S1f V
::
ans��
PLEASE TYPE OR PRIIvTT IN INK
`'— c �� - 65
Are you going to operaie this businzss personally7 YES X NO If not, w$o rxill operate it?
Ro�er W. Bentlev 9-12-51
Fint\amc ?�tiddlelnitiat (�lnids�) Lvt DateofBirth
3084 Farrin¢ton Ct. = Roseville MN 55113 486-9615
Homc Address: St-cct \amc City State Zip PEone I�umber
Are you going to l�ve a manager or assistant in tlus btuivess? YES X NO If the manxger is not the sz as ihe operator,
p]ease compiete the following information:
Fust Neme
HomeAddma: Sttut\sac
r5ddle Initiai
(.�is;arn)
City
Last
Sta�e Zip
n_« arB�nn
Please list your empioyment history for the previous five (5} year period:
Business/Emnlovment Address
Pcone \�ber
• .. .. . 1 N� .
List all other officers ofthe corporation:
OFFICER TITLE HOME HOME BUSINESS DATE OF
NAME (Office Held) ADDRESS PHONE PHONE BII2IH
David D. Oren CEO 6977 Blackduck Dr., Lino Lakes, MN 55104 688-2000 8-3-58
Daniel L. Oren CFO 3150 W. Owasso Blvd., Roseville, MN 55113 688-2000 12-23-60
-- &radley S. Oren Sec. 375 S. Owasso Blvd:, Roseville,-MN-55113;688-2�00 1-26-65
if business is a partnership, please include the following uiformation for each pazxner (use additional pages if necessary):
Ficst i��e Middlc Ltitia] (Vfaidrn) Lad Date of Bixth
Home Add=sea: Sttut l�ame
Firat Name
Middlc Initial
City
���)
Statc Zip Phonc Numbct
I.as[
Dste ofBirth
Home Addicax; Strect I�ame City Stete Zip PLone Ivmmber
MINNESOTA TAX IDENTff'ICATION Nt3MSER - Pwsuant to the Laws of Minnesofa, 1984, Chapter 502, Article 8, Section 2(270.72)
(Taac Clearance; Issuance of Licenses), licensing authorities are required to provide to ihe State of Minnesota Commissioner of Revenue, the
Minnesota business tax identification 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 are required to advise you of the following
regarding the use of the Minnesota Tax Identification Number:
- This infocmation may be used to deny the issuance or renewal of your liceose in the event you owe Minnesota sales, employer's
withholding or motor velucle e�tcise taxes;
- Upon receiving this information, the licensing authority will supply it only to the Minnesota Department of Revenue. However,
under the Federai Exchange of Tnfo:mation Agreemen� the Department of Revenue may supply this information to che Intemal
Revenue Service.
Minnesota Tax Idenufication Niunb¢s (Sales & Use Tax N�snber) may be obtained fram the State o{ Minnesota, Business Records Department,
10 River Park Plaza (612-29b-6181).
Sociai Security Number. 47 7-54-1683 Ivlinnesota Tax Identification Number: 41-1885743
_ If a Minnesota Ta;c Idrntification Number is not required for the business being operated, indicate so by placing an"X' in the box.
1'i '
O/iR109
�--�� 9d�-GS
CERTffICATIO2vT OF WORKERS' COMPENSATION COVERAGE PURSUANT TO MII�TIESOTA STANTE 176.182
I hereby certify that I, or my company, am in compliance uith the workers' compensation insurance coverage requirements of Mumesota StLtuYe
176.182, subdi�-isirn 2. I al� undersT�d that provision of falsy information in this cer[ification canstitutes sufficient grounds for adversz action
zgainst all licenses held, including revocation and susprnsion of said licenses. Midway Fuel, Inc leases employees irom
re ted co anies who are covered under the following policy: Credi[ General
Name o surance �gmpany:
PolicyNumber: SWC 100 08103 Coveragefrom 1-15-97 to 1-15-98 -
I ha� e no emplo} co�ered undu �i•orkers compensation insurance (I?1ITIALS)
ANY FALSTFTCATION OF AIVSWERS GIVEN OR MATERIAL SUBMITTED
WTLL RESIILT IN DEi�'7AL OF THIS APPLICATION
I hereby state that I have answered al1 of the preceding questions, and that the information contained herein is true and coirect to the b�t of
my know]edge and belief. I hereby state further that I have received no money or other consideratioq by way of Ioan, gift, conhibutioa, or
othenvise, other thzn zLeady disclosed in the application k�hich I herewith submittzd. I also understand this premise may be inspected by police,
fire, health and other ciry officials at any znd all times when the business is in operation.
lf �-9�
applications)
We will accept pa}'meut by cash, check (made payable to City of Saint Paun or cmdit card (M/C or Visa).
Dafe
IFPAYING BYCREDIT CARD PLEASE COMPLETE THE FOLLOWING INFORMATION � MasterCard . � Visa
EXPIRATION DATE:
� � � �
\ame of CarA�oldcr
for
Date
•*Note: If this application is Food/Liquor related, please contact a City of Saint Paut Health Inspector, Steve Olson (266-9139), to reFiew
plans.
If any substantial changes to structure aze anticipatec� please contact a City of Saint Paul Plan Examiner at 266-9007 to apply for
building permits.
If there are azry changes to the parking lot, floor space, or for new operations, please contact a City of Saint Paul Zoning Inspector at
266-9008.
All applications mquire the following documents. Pleave attach these documents n•hen submitting your applicarion:
1. A detailed description of the design, location and squaze footage of the preauses 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 i"= 20'. ^N should be indicated toward the top.
- Placemrnt of all pertinent features of tbe incerior of the licensed £acility such as seating azeas, kitchens, offices, repair area,
parlang, re�t rooms, etc.
- If a request is for an addition or expansion of the licensed facility, indicate both the currrnt uea and the proposed expanrion.
2. A copy of your ]ease agreement or proof of ownership of the property.
SPECIFYC LICENSE APPLICATIONS REQUII2E ADDTTIONAL INFORMATION.
PLEASE SEE REVERSE FOR DETAII.S >>>>
ACCOLINT NUSvIBER;
� � � � � � � � � � � � � � t �
C_):
Council File $ r0 � �s
ordinance #
1
2
3
4
5
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7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
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25
26
27
28
29
ORIGiNAL
Presented
Referred To
Green Sheet # 50346
RESOLUTION
CITY OF SA�NT PAUL, MINNESOTA
Committee: Date
/b
RESOLVED: That application, ZD �19970000053, for a Liquid Fuel Dealer, Gas Station
License(s) by Midway Euel Inc. DBA Midway Fuel Inc. at 543 Cleveland Avenue
N., be and the same is hereby approved.
Requested by Department of:
Office of License. Ins�ections and
/' � �nv' o
BY: 1 ��n✓ l�''
Form Approved by`Eity At �ey
Bye ' /
Approved by Mayor for Submission to
ncil
Sys
APF
By:
Adopted by Council: Date
Adoption Certified by Counc' Secretary
DEPARTMENT/OFFICEICOUNCfL DATE iN�7wTEP � � �
UEP/Licensing GREEN SHEET roo. sosas S
ONTACT PERSON & PHONE
IniEaVDate NitiaVDate
ECHMANN CaARY
(612j26S9136 � C �, Att
UST BE ON COUNCIL AGENDA BY (DATE) �
1/28196 �� � CouncilReseatch
ROIiTf�G
ORD�
TOTAL # OF SIGNATURE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE)
ACTION REQUESTED:
Caawil approval Mthe fdbwing liceree appfication: License # 1997000D053, for MIDWAY FUEL
MC, Doing Business As MIDWAY FUEL INC, at 543 CLEVELAND AVE N, and type of business(es): Liquid
Fuel D�kr, C,as Station.
RECOMMENDATIONS: Approve(A) Reject(R) RSOwLL.SERV�Ce cONiRAC751.a1ST aNSwER THE FOLLOW�MG CUES710NS:
1. FinsihispecsoMicmererwakedu+Wera wMraclfatl�depattment4
__ PLANNING COMMISSION yEg �.�p
CIB COMMITTEE 2. tlx this persoMrm ever been a city employee?
CIVIL SVC CINN, �S �
3. Does thic personrtirtn pwsess a skill nof namaiy possessed by eiry curtent ci(y employee?
YES NO
. Is ihis persor�rtn a prgeted vendoft
- YES NO
Euplain all yes answers on uparffie sheet and attach to green aheet
INITIATING PROBLEM, ISSUE, OPPORTUNITY (Who, Wha[, When, Where, Why):
Requesting Council approval fa M'idway Fuei fnc. D&4 M'idxay Fuei irc. (Robert Bentiey) for a Liquid Fuel DealedGas Station at 543 Cteveland Avenue So.
ADVANTAGESIFAPPROVED:
ISADVANTAGES IP APPROVED:
DISADVANTAGES IF NOT APPROVED:
TOTALAMOUN7 Of TRANSACTION S COST/REUENUE BUDGETED (CIRCLE ONE) YES NO
FUNDING SOURCE ACTIVITY NUMBER
FINANCIAL INFORMATION:
(EXPLAIN)
. � {
�3Q9_�C�
CLASS III
LICENSE APPLICATION
THIS APPLICATION IS SUB3ECT TO REVLW BY TF� PUBLIC
Type of License(s) being applied for:
Company tdame:
Corporation / Partncxs6ip / Solc Proprietorship
r�
ifbusiness is incorporated, give date ofincocporation: Seotember 5. 1997 __
DoingBusinessAs: Midwav Fuel. Inc. BusinessPhone: 688-20p0
BusinessAddress: 543 Cleveland Avenue N. . Pa,l mmr Sst94
Strcet Addresa City Stato Zip
Between v.�hat cross streets is the business locata3? C1eveland Ave :& Wabash GVhich side of the street?
ArethepremisesnowoccupiedT Yes WhatTypeofBusiness? Gas Station
IvIail To Address: 800 Lone Oak- Road Eagan MN 55121
svar nr�� . c�ry s,s,� z�P
Applicant Information:
NameandTitie: Garv 6eorQe Santoor�ian RPa� Fcrara t�a„ �P,-
Fust . ?tid�e (Mnidcn) Last TiUe
HomeAddress: 12885 Emmer Place Apvle Vallev MN 55124
Stroet Addrta City State Zip
DateofBirth: 7-4-61 PlaceofBirth: St. Louis Park. MN HomePhone: 4�3-44��
Have you ever been convicted of any felony, crime or violation of any city ordinance other than traffic? YES NO _�_
Date of azrest:
Charge: _
ConvicGon:
Wnerei
Sentence:
Lizt the naznes and residences of tt�ree persons of good moral chazacter, living urithin the T���in Cities Metro Area, not related to the applicant
or financially interested in the premises or business, who may be referred to as to tl�e applicanYs character:
NAME ADDRESS PHONE
Scott Daubanton 2719 W 43rd Sr �t2f74 MpIG � 55t�1n �'t� Ssz��
Steve Corcoran 4920 Dupont Ave. S. Mp1s MN 55409 825-7628
Lance Johnson 3127 F 57st Mnlc MN 55417 7�7 4459
List liceases u•hich you curtently hold, fotmerly held, or may ha��e an interest in:
Real Estate Brokers License ParkinQ 1ot license (Dart Trans�t�— Ke�logg Park;,,g t�r�_
Hat�e any of the above named licenses e>•er been revoked? YES X NfJ If yes, ]ist the dates and-reasons for revocation:
CITY OF SAINT PAt3L
�ce ofLiccnse, Inspections
znd Fnviramnental ftotection
35.1' St Pna St Sti�c 300 p
Stint PavL 1f'i'c�aoa 55101 �d i�5
j672)265-9�^74.;(6t3)166-9S1f V
::
ans��
PLEASE TYPE OR PRIIvTT IN INK
`'— c �� - 65
Are you going to operaie this businzss personally7 YES X NO If not, w$o rxill operate it?
Ro�er W. Bentlev 9-12-51
Fint\amc ?�tiddlelnitiat (�lnids�) Lvt DateofBirth
3084 Farrin¢ton Ct. = Roseville MN 55113 486-9615
Homc Address: St-cct \amc City State Zip PEone I�umber
Are you going to l�ve a manager or assistant in tlus btuivess? YES X NO If the manxger is not the sz as ihe operator,
p]ease compiete the following information:
Fust Neme
HomeAddma: Sttut\sac
r5ddle Initiai
(.�is;arn)
City
Last
Sta�e Zip
n_« arB�nn
Please list your empioyment history for the previous five (5} year period:
Business/Emnlovment Address
Pcone \�ber
• .. .. . 1 N� .
List all other officers ofthe corporation:
OFFICER TITLE HOME HOME BUSINESS DATE OF
NAME (Office Held) ADDRESS PHONE PHONE BII2IH
David D. Oren CEO 6977 Blackduck Dr., Lino Lakes, MN 55104 688-2000 8-3-58
Daniel L. Oren CFO 3150 W. Owasso Blvd., Roseville, MN 55113 688-2000 12-23-60
-- &radley S. Oren Sec. 375 S. Owasso Blvd:, Roseville,-MN-55113;688-2�00 1-26-65
if business is a partnership, please include the following uiformation for each pazxner (use additional pages if necessary):
Ficst i��e Middlc Ltitia] (Vfaidrn) Lad Date of Bixth
Home Add=sea: Sttut l�ame
Firat Name
Middlc Initial
City
���)
Statc Zip Phonc Numbct
I.as[
Dste ofBirth
Home Addicax; Strect I�ame City Stete Zip PLone Ivmmber
MINNESOTA TAX IDENTff'ICATION Nt3MSER - Pwsuant to the Laws of Minnesofa, 1984, Chapter 502, Article 8, Section 2(270.72)
(Taac Clearance; Issuance of Licenses), licensing authorities are required to provide to ihe State of Minnesota Commissioner of Revenue, the
Minnesota business tax identification 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 are required to advise you of the following
regarding the use of the Minnesota Tax Identification Number:
- This infocmation may be used to deny the issuance or renewal of your liceose in the event you owe Minnesota sales, employer's
withholding or motor velucle e�tcise taxes;
- Upon receiving this information, the licensing authority will supply it only to the Minnesota Department of Revenue. However,
under the Federai Exchange of Tnfo:mation Agreemen� the Department of Revenue may supply this information to che Intemal
Revenue Service.
Minnesota Tax Idenufication Niunb¢s (Sales & Use Tax N�snber) may be obtained fram the State o{ Minnesota, Business Records Department,
10 River Park Plaza (612-29b-6181).
Sociai Security Number. 47 7-54-1683 Ivlinnesota Tax Identification Number: 41-1885743
_ If a Minnesota Ta;c Idrntification Number is not required for the business being operated, indicate so by placing an"X' in the box.
1'i '
O/iR109
�--�� 9d�-GS
CERTffICATIO2vT OF WORKERS' COMPENSATION COVERAGE PURSUANT TO MII�TIESOTA STANTE 176.182
I hereby certify that I, or my company, am in compliance uith the workers' compensation insurance coverage requirements of Mumesota StLtuYe
176.182, subdi�-isirn 2. I al� undersT�d that provision of falsy information in this cer[ification canstitutes sufficient grounds for adversz action
zgainst all licenses held, including revocation and susprnsion of said licenses. Midway Fuel, Inc leases employees irom
re ted co anies who are covered under the following policy: Credi[ General
Name o surance �gmpany:
PolicyNumber: SWC 100 08103 Coveragefrom 1-15-97 to 1-15-98 -
I ha� e no emplo} co�ered undu �i•orkers compensation insurance (I?1ITIALS)
ANY FALSTFTCATION OF AIVSWERS GIVEN OR MATERIAL SUBMITTED
WTLL RESIILT IN DEi�'7AL OF THIS APPLICATION
I hereby state that I have answered al1 of the preceding questions, and that the information contained herein is true and coirect to the b�t of
my know]edge and belief. I hereby state further that I have received no money or other consideratioq by way of Ioan, gift, conhibutioa, or
othenvise, other thzn zLeady disclosed in the application k�hich I herewith submittzd. I also understand this premise may be inspected by police,
fire, health and other ciry officials at any znd all times when the business is in operation.
lf �-9�
applications)
We will accept pa}'meut by cash, check (made payable to City of Saint Paun or cmdit card (M/C or Visa).
Dafe
IFPAYING BYCREDIT CARD PLEASE COMPLETE THE FOLLOWING INFORMATION � MasterCard . � Visa
EXPIRATION DATE:
� � � �
\ame of CarA�oldcr
for
Date
•*Note: If this application is Food/Liquor related, please contact a City of Saint Paut Health Inspector, Steve Olson (266-9139), to reFiew
plans.
If any substantial changes to structure aze anticipatec� please contact a City of Saint Paul Plan Examiner at 266-9007 to apply for
building permits.
If there are azry changes to the parking lot, floor space, or for new operations, please contact a City of Saint Paul Zoning Inspector at
266-9008.
All applications mquire the following documents. Pleave attach these documents n•hen submitting your applicarion:
1. A detailed description of the design, location and squaze footage of the preauses 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 i"= 20'. ^N should be indicated toward the top.
- Placemrnt of all pertinent features of tbe incerior of the licensed £acility such as seating azeas, kitchens, offices, repair area,
parlang, re�t rooms, etc.
- If a request is for an addition or expansion of the licensed facility, indicate both the currrnt uea and the proposed expanrion.
2. A copy of your ]ease agreement or proof of ownership of the property.
SPECIFYC LICENSE APPLICATIONS REQUII2E ADDTTIONAL INFORMATION.
PLEASE SEE REVERSE FOR DETAII.S >>>>
ACCOLINT NUSvIBER;
� � � � � � � � � � � � � � t �
C_):
Council File $ r0 � �s
ordinance #
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
ORIGiNAL
Presented
Referred To
Green Sheet # 50346
RESOLUTION
CITY OF SA�NT PAUL, MINNESOTA
Committee: Date
/b
RESOLVED: That application, ZD �19970000053, for a Liquid Fuel Dealer, Gas Station
License(s) by Midway Euel Inc. DBA Midway Fuel Inc. at 543 Cleveland Avenue
N., be and the same is hereby approved.
Requested by Department of:
Office of License. Ins�ections and
/' � �nv' o
BY: 1 ��n✓ l�''
Form Approved by`Eity At �ey
Bye ' /
Approved by Mayor for Submission to
ncil
Sys
APF
By:
Adopted by Council: Date
Adoption Certified by Counc' Secretary
DEPARTMENT/OFFICEICOUNCfL DATE iN�7wTEP � � �
UEP/Licensing GREEN SHEET roo. sosas S
ONTACT PERSON & PHONE
IniEaVDate NitiaVDate
ECHMANN CaARY
(612j26S9136 � C �, Att
UST BE ON COUNCIL AGENDA BY (DATE) �
1/28196 �� � CouncilReseatch
ROIiTf�G
ORD�
TOTAL # OF SIGNATURE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE)
ACTION REQUESTED:
Caawil approval Mthe fdbwing liceree appfication: License # 1997000D053, for MIDWAY FUEL
MC, Doing Business As MIDWAY FUEL INC, at 543 CLEVELAND AVE N, and type of business(es): Liquid
Fuel D�kr, C,as Station.
RECOMMENDATIONS: Approve(A) Reject(R) RSOwLL.SERV�Ce cONiRAC751.a1ST aNSwER THE FOLLOW�MG CUES710NS:
1. FinsihispecsoMicmererwakedu+Wera wMraclfatl�depattment4
__ PLANNING COMMISSION yEg �.�p
CIB COMMITTEE 2. tlx this persoMrm ever been a city employee?
CIVIL SVC CINN, �S �
3. Does thic personrtirtn pwsess a skill nof namaiy possessed by eiry curtent ci(y employee?
YES NO
. Is ihis persor�rtn a prgeted vendoft
- YES NO
Euplain all yes answers on uparffie sheet and attach to green aheet
INITIATING PROBLEM, ISSUE, OPPORTUNITY (Who, Wha[, When, Where, Why):
Requesting Council approval fa M'idway Fuei fnc. D&4 M'idxay Fuei irc. (Robert Bentiey) for a Liquid Fuel DealedGas Station at 543 Cteveland Avenue So.
ADVANTAGESIFAPPROVED:
ISADVANTAGES IP APPROVED:
DISADVANTAGES IF NOT APPROVED:
TOTALAMOUN7 Of TRANSACTION S COST/REUENUE BUDGETED (CIRCLE ONE) YES NO
FUNDING SOURCE ACTIVITY NUMBER
FINANCIAL INFORMATION:
(EXPLAIN)
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CLASS III
LICENSE APPLICATION
THIS APPLICATION IS SUB3ECT TO REVLW BY TF� PUBLIC
Type of License(s) being applied for:
Company tdame:
Corporation / Partncxs6ip / Solc Proprietorship
r�
ifbusiness is incorporated, give date ofincocporation: Seotember 5. 1997 __
DoingBusinessAs: Midwav Fuel. Inc. BusinessPhone: 688-20p0
BusinessAddress: 543 Cleveland Avenue N. . Pa,l mmr Sst94
Strcet Addresa City Stato Zip
Between v.�hat cross streets is the business locata3? C1eveland Ave :& Wabash GVhich side of the street?
ArethepremisesnowoccupiedT Yes WhatTypeofBusiness? Gas Station
IvIail To Address: 800 Lone Oak- Road Eagan MN 55121
svar nr�� . c�ry s,s,� z�P
Applicant Information:
NameandTitie: Garv 6eorQe Santoor�ian RPa� Fcrara t�a„ �P,-
Fust . ?tid�e (Mnidcn) Last TiUe
HomeAddress: 12885 Emmer Place Apvle Vallev MN 55124
Stroet Addrta City State Zip
DateofBirth: 7-4-61 PlaceofBirth: St. Louis Park. MN HomePhone: 4�3-44��
Have you ever been convicted of any felony, crime or violation of any city ordinance other than traffic? YES NO _�_
Date of azrest:
Charge: _
ConvicGon:
Wnerei
Sentence:
Lizt the naznes and residences of tt�ree persons of good moral chazacter, living urithin the T���in Cities Metro Area, not related to the applicant
or financially interested in the premises or business, who may be referred to as to tl�e applicanYs character:
NAME ADDRESS PHONE
Scott Daubanton 2719 W 43rd Sr �t2f74 MpIG � 55t�1n �'t� Ssz��
Steve Corcoran 4920 Dupont Ave. S. Mp1s MN 55409 825-7628
Lance Johnson 3127 F 57st Mnlc MN 55417 7�7 4459
List liceases u•hich you curtently hold, fotmerly held, or may ha��e an interest in:
Real Estate Brokers License ParkinQ 1ot license (Dart Trans�t�— Ke�logg Park;,,g t�r�_
Hat�e any of the above named licenses e>•er been revoked? YES X NfJ If yes, ]ist the dates and-reasons for revocation:
CITY OF SAINT PAt3L
�ce ofLiccnse, Inspections
znd Fnviramnental ftotection
35.1' St Pna St Sti�c 300 p
Stint PavL 1f'i'c�aoa 55101 �d i�5
j672)265-9�^74.;(6t3)166-9S1f V
::
ans��
PLEASE TYPE OR PRIIvTT IN INK
`'— c �� - 65
Are you going to operaie this businzss personally7 YES X NO If not, w$o rxill operate it?
Ro�er W. Bentlev 9-12-51
Fint\amc ?�tiddlelnitiat (�lnids�) Lvt DateofBirth
3084 Farrin¢ton Ct. = Roseville MN 55113 486-9615
Homc Address: St-cct \amc City State Zip PEone I�umber
Are you going to l�ve a manager or assistant in tlus btuivess? YES X NO If the manxger is not the sz as ihe operator,
p]ease compiete the following information:
Fust Neme
HomeAddma: Sttut\sac
r5ddle Initiai
(.�is;arn)
City
Last
Sta�e Zip
n_« arB�nn
Please list your empioyment history for the previous five (5} year period:
Business/Emnlovment Address
Pcone \�ber
• .. .. . 1 N� .
List all other officers ofthe corporation:
OFFICER TITLE HOME HOME BUSINESS DATE OF
NAME (Office Held) ADDRESS PHONE PHONE BII2IH
David D. Oren CEO 6977 Blackduck Dr., Lino Lakes, MN 55104 688-2000 8-3-58
Daniel L. Oren CFO 3150 W. Owasso Blvd., Roseville, MN 55113 688-2000 12-23-60
-- &radley S. Oren Sec. 375 S. Owasso Blvd:, Roseville,-MN-55113;688-2�00 1-26-65
if business is a partnership, please include the following uiformation for each pazxner (use additional pages if necessary):
Ficst i��e Middlc Ltitia] (Vfaidrn) Lad Date of Bixth
Home Add=sea: Sttut l�ame
Firat Name
Middlc Initial
City
���)
Statc Zip Phonc Numbct
I.as[
Dste ofBirth
Home Addicax; Strect I�ame City Stete Zip PLone Ivmmber
MINNESOTA TAX IDENTff'ICATION Nt3MSER - Pwsuant to the Laws of Minnesofa, 1984, Chapter 502, Article 8, Section 2(270.72)
(Taac Clearance; Issuance of Licenses), licensing authorities are required to provide to ihe State of Minnesota Commissioner of Revenue, the
Minnesota business tax identification 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 are required to advise you of the following
regarding the use of the Minnesota Tax Identification Number:
- This infocmation may be used to deny the issuance or renewal of your liceose in the event you owe Minnesota sales, employer's
withholding or motor velucle e�tcise taxes;
- Upon receiving this information, the licensing authority will supply it only to the Minnesota Department of Revenue. However,
under the Federai Exchange of Tnfo:mation Agreemen� the Department of Revenue may supply this information to che Intemal
Revenue Service.
Minnesota Tax Idenufication Niunb¢s (Sales & Use Tax N�snber) may be obtained fram the State o{ Minnesota, Business Records Department,
10 River Park Plaza (612-29b-6181).
Sociai Security Number. 47 7-54-1683 Ivlinnesota Tax Identification Number: 41-1885743
_ If a Minnesota Ta;c Idrntification Number is not required for the business being operated, indicate so by placing an"X' in the box.
1'i '
O/iR109
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CERTffICATIO2vT OF WORKERS' COMPENSATION COVERAGE PURSUANT TO MII�TIESOTA STANTE 176.182
I hereby certify that I, or my company, am in compliance uith the workers' compensation insurance coverage requirements of Mumesota StLtuYe
176.182, subdi�-isirn 2. I al� undersT�d that provision of falsy information in this cer[ification canstitutes sufficient grounds for adversz action
zgainst all licenses held, including revocation and susprnsion of said licenses. Midway Fuel, Inc leases employees irom
re ted co anies who are covered under the following policy: Credi[ General
Name o surance �gmpany:
PolicyNumber: SWC 100 08103 Coveragefrom 1-15-97 to 1-15-98 -
I ha� e no emplo} co�ered undu �i•orkers compensation insurance (I?1ITIALS)
ANY FALSTFTCATION OF AIVSWERS GIVEN OR MATERIAL SUBMITTED
WTLL RESIILT IN DEi�'7AL OF THIS APPLICATION
I hereby state that I have answered al1 of the preceding questions, and that the information contained herein is true and coirect to the b�t of
my know]edge and belief. I hereby state further that I have received no money or other consideratioq by way of Ioan, gift, conhibutioa, or
othenvise, other thzn zLeady disclosed in the application k�hich I herewith submittzd. I also understand this premise may be inspected by police,
fire, health and other ciry officials at any znd all times when the business is in operation.
lf �-9�
applications)
We will accept pa}'meut by cash, check (made payable to City of Saint Paun or cmdit card (M/C or Visa).
Dafe
IFPAYING BYCREDIT CARD PLEASE COMPLETE THE FOLLOWING INFORMATION � MasterCard . � Visa
EXPIRATION DATE:
� � � �
\ame of CarA�oldcr
for
Date
•*Note: If this application is Food/Liquor related, please contact a City of Saint Paut Health Inspector, Steve Olson (266-9139), to reFiew
plans.
If any substantial changes to structure aze anticipatec� please contact a City of Saint Paul Plan Examiner at 266-9007 to apply for
building permits.
If there are azry changes to the parking lot, floor space, or for new operations, please contact a City of Saint Paul Zoning Inspector at
266-9008.
All applications mquire the following documents. Pleave attach these documents n•hen submitting your applicarion:
1. A detailed description of the design, location and squaze footage of the preauses 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 i"= 20'. ^N should be indicated toward the top.
- Placemrnt of all pertinent features of tbe incerior of the licensed £acility such as seating azeas, kitchens, offices, repair area,
parlang, re�t rooms, etc.
- If a request is for an addition or expansion of the licensed facility, indicate both the currrnt uea and the proposed expanrion.
2. A copy of your ]ease agreement or proof of ownership of the property.
SPECIFYC LICENSE APPLICATIONS REQUII2E ADDTTIONAL INFORMATION.
PLEASE SEE REVERSE FOR DETAII.S >>>>
ACCOLINT NUSvIBER;
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