HomeMy WebLinkAbout2004-11-23 Handouts
Handouts Be~~., u. ~u
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TO: Honorable Mayor and Counci1 Members
FROM: Teresa Bender, City Clerk
SUBJECT: Items to be Added to Agenda in RED
CONSENT AGENDA
.:. Claims - To Date
NEW BUSINESS
.:. Lynn Proposa1- WIth Memo and City Attorney Recommendations
(. Lynn Proposal- Staff Development
.:. City of Hugo Correspondence - Judicial Ditch #2
(. Liquortrobacco License Renewals - WIth Memo and Attachments
.:. Centennial Lakes Police Department - Tobacco Compliance Check Failw'e (Trio
Inn)
OLD BUSINESS
.:. Mr. Tom Peterson Email- Okan Driveway Flares
ANNOUNCEMBNTSlUPDATES
.:. Anoka County Invitation - CDBG Program & HOME Investment Partnership
Program (December 1,2004 Room 715 @ 1:00 p.m.)
e,rviffe
T.stafiisfittl1857
UPDATE
CITY OF CENTERVILLE
*Check Summary Register@)
11123104 8:38 AM
Page 1
Check Date
NOVEMBER 2004
Check Amt
Name
10100 IIIAIN STREET BANK
Paid Chk# 019758 BARD ADVERTISING
Paid Chk# 019759 FORTIS BENEFITS
Paid Chk# 019760 INSTRUMENTAL RESEARCH
Paid Chk# 019761 KRIS SWEENEYIPETTY CASH
Paid Chk# 019762 LORMAN EDUCATION SERVICE
Paid Chk# 019763 MCLEOD USA
PaId Chk# 019764 MINNEGASCO*
PaId Chk# 019765 MN DEPARTMENT OF HEALTH
PaId Chk# 019766 QWEST
PaId Chk# 019767 TIME SAVER
11/2312004
11/23J2004
11/23J2004
11/23J2004
11I23l2OO4
11I23l2OO4
11I23l2OO4
11/23J2004
11I23l2OO4
11/23J2004
Total Checks
$400.00 COUGAR CASH GIFT CERTIFICATES
$121.50 DEC 2004 VOLUNTARY SHORT TERM
$34.00 OCTOBER 2004 WATER TESTING
$58.25 REIMBURSE PETTY CASH DRAWER
$329.00 T. WOOD -ADVANCED ZONING & LA
$824.01 PHONE SERYTHRU 11-15-04
$10.54 7073 CENTERVlLLE RD - SERY THR
$1.147.50 4TH QTR 10-1-04 THRU 12-31-04
$60.19 651-762-9261 SERVTHRU 12-12-0
$217.00 CITY COUNCIL MEETING -11-10-0
$3.201.99
1:-
Lynn & Associates
November 22.2004
Mr. Terry SWeeneY. Mayor
City of CenterviIIe
1880 MaIn Street
Cerd8rv111e. MN 55038
Dear Mayor SWeeney and CouncIl MembelS:
SUBJECT: Proposal for ServIces - Facilitating The Search and Sele*" Process
1NTR0DUCn0N:
The City of Centervllle has requested a proposal to help ensure that the City has an
eftIcIent and effeclIve process In place to aItract and hire a new City Administrator. A
new City Administrator needs to be recruited and the Council wants to do everything
possible 'to find the best possible candidate for this key position. As consulting
psychologists with experience In assisting cities ftnd the right leaders. Lynn &
Associates Is well equipped to work with the CIty, on this important objective.
GOALS AND OBJECTIVES:
The general goal of this proposal Is to help the CouncIl profile. screen. Interview.
assess. and select the best candidate for the position of City Admlnlstlator.
Speclftc objectives of this project Include:
> Work with the Council to profile the requirements wanted In a new City
AdmInIstrator and use that proftIe for recruiting and hiring.
> Assist the City In the recruitment, interviewing. assessment, and selection of a
new City AdmInIstrator.
> Work closely with the Mayor and a selected team (Search CommIttee) to
coordinate this whole selection process to ensure that It Is done fairly and legally.
5435 Wedgewood DrIve, Shorewood, MN 55331
(952) 474-2193
METHOD OF IMPLEMENTATION:
Dr. James Lynn, and Usa Lynn, MA, LP, both consulllng psychologists, will perfonn the
services In this proposal. The Implementation steps are as follows.
1. Review this proposal, sign It, and send or fax a signed copy back to Lynn &
Associates (Fax 952.474.3738).
2. Lynn & Assocfates reviews existing Infonnation the Council has from previous City
Administrator searches end prepares a new packet for the current search. A Search
Conn.dttee Is fonned to coordinate the whole process The Search COhulllttee may
be the whole CouncIlor a part of the Council with one or two staff menabers
depending on the wishes of the Council. The members of the Search Commitlee
would be expected to spend more time on this process.
3. Jim and Usa meet with the CouncIl members, to review the recruitment - hiring
process for the City Admirrlsbator, showing a draft schedule with steps and who
would do what. A Draft Recrufting Schedule Is attached Is this proposal as
Appendix A deta8ing the tasks Lynn & AssocIates and the Search Committee would
be doing with estimated timing.
I 4. ~__~~__~~~~~__~~L~~__~nl?!~~_~~__~~~__~~_J~~:__.~~L...-.-{ DeIeIIId:
candidates Would send their resumes and IetteIs of Interest to Lynn & AssocIates.
5. Jim Lynn and lisa Lynn will meet every two weeks with the Search Commitlee to
review findings.
6. Lynn & AssocIates would create the Structured Interview Guide and other
assessment protocols for the screening to help evaluate the candidates.
7. Jim and Usa would facilitate the psychological assessment and interviews with
candidates.
8. Jim and Usa would assist with the hiring process, working with candidates, the
Council and staff.
I i__~~__~_~~~__~~,_~_~~J~_~~~_~__~'--~_~_~!!t___-_.---{ Delellld:8
that the work of the City Is getting done and this team Is developed during this critical
period for the CIty.
1 O.lf the candidate selected is no lonaer emDloved by the CitY of CentelVille (for anv
reason. cause or otherwise) within one (1) vear of the date of the hire. Lvnn &
Associates will reoDen the search at no additional fee exceDt exoenses. and will
conduct the search Dursuant to the same conditions and tenns herein (exceDt as
otherwise noted).
5435Wedgewood DrIve, ShonIwood, MN 55331
(962) 474-2193
BENEFIts OF THIS APPROACH:
The following benefiIs should accrue as a ....It of this Initiative.
. The Council wiD have an opportunity to define and share in the process of seIecIIng
a new CIty AdmIIdsbator with assistance of a consulting psychological firm to help
ensure that the procedure Is legal and the best qualified candidate Is selected.
. The Search CommiItee wID be a link with Council and staff to ensure their Input In
this whole process (If the Search CommIttee Is not the whole Council).
. The CIty will be assured of doing the right things In going through the search In a
careful and deliberate manner.
11MELINE AND FEES:
This work described In this proposal can begin Immediately upon signing this Letter of
Agreement The Investment for facilitate the recruItfng, assessment and hiring process
of the CIty Administrator would be In the range of $7,000 - $10,000 depending on the
specific objectives identified and work completed. The special local government rate of
$125/hr. for Jim Lynn and Usa Lynn will apply for this work. invoices will be sent at the
end of each month for services deBvered during that month. Direct expenses for the
consulting and any recruiting ads are billed In addition, at cost.
Respectfully submitted,
Accepted by,
JAMES J. LYNN, Ed.D.
President
Mr. Teny SWeeney
Mayor .
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I . u _ u _ _ _ u _ _ _ u _ _ _ _ u_.. _ _ _ _..... u _ _ _. u _ _ _ _. _ u _u _ _ _ _ _ u u _ _. _ _ __. _ _ _. _. _ u _ _ _ _ _ _ _ _ _ __ _ _ __ _ _ __ _ _ _ ___ __ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ __ _ _ _ _ _ _ _ __./
5435Wedgewood Drive,Shorewood, MN55331 (952)474-2193
Lynn & Associates - Draft Recruiting 8cbedule - Centervllle CIty AdmInistrator
Time Table for the Process
Rnding and SelectIng the City of CentervllIe Adrnlnistralor
Proftle Development
The City Description
A draft Position ProfIle
Council retreatto review (sticky dots)
FInal Approval of ProftIe
EstImated TIming
December 1
December 1
December 8
December 8
Launch Recruiting Campaign
Target II8t of potential candidates
Council suggestions
Advet1i8e
December 9
December 9
December 15
Sourcing CaDs to SelBcl8d CancIIdat8s
Initial screening caII8 (telephone)
Screening aU leads
Creating flr8t list of potential candidates
Rrst Progress Report and meeting with Council
Showtarget II8t8 and blo sketches of candidates
Show -must vs. want" screening criteria
January 7
January 20
January 21
January 29
January 29
SteerIng Committee Screening Interviews
Interview Guide Developed
Selected candidates InterYIewed who pass screen
are scheduled for face-to-face Interviews
Write ups on candidates who pass first screen
January 29
February 4
February 7
Second progress Report with CouncIl
Present narrative summaries of selected candidates
DIscuss .candidates and chooss final group for
CouncIIIntervIew8
February 9
February 9
5436Wedgewood DrIve, Shorewood, MN 56331
(952) 474-21SD
.
CouncIl interviews - First Round
Make Interview arrangements
Prepare Counctl and candidates for interviews
Conduct interviews (group Interviews)
DebrIef and evaluate candidates
Referance chacking on flnaI2-3 candidates
Psychological assessment of final 2-3 cancftdates
third Pragress MlltIng WIth CouncD
Summary Reports Presented on Top Candidates
Select new candldate81f nee III Bryl8elect final
candidates for second round of interviews and
meeting with saIacted community groups and staff
Council and Community interviews final Round
Schadule fInaIlntervIew8 with a1aff and Council
Conduct final interviews and hOBt reception for all candidates
and community leaders
Select final candidate and make offer
Negotiate offer and terms - 81Brtlng date
5436 Wedgewood DrIve, Shorewood, MN 55331
Feb 13
Feb 23
Feb 23
Feb 25
Mar 1
Mar 1
Mar 9
Mar 9
Mar 11
Mar 18
Mar 21
Apr 4-11
(962) 474-21~
\'11
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Lynn & Associates
November 22, 2004
Mr. Terry SWeeney, Mayor
City of Centervilte
1880 Main Street
Centerville, MN 55038
Dear Mayor S\veeney and Council Members:
SUBJECT: Proposal fOr Servlces_":" Staff Team Building and leadership Training
INTRODUCTION:
The City of Centerville has requested a proposal to help ensure that the City staff has the necessary training
and consulting help to ensure a smooth transition of leadership with the departure of the City Administrator.
With the. departure of the City Administrator, the staff is in a position to start with a neW slate and begin to
function together as a high petforming team to get the work of the city done effectively and efficiently. The
twalnterim Co-Administrators will need both direction and sUpport during this time of change. As
. consulting psychologists, Dr. James Lynn and Usa Lynn of Lynn & Associates are well equipped to assist
. the Co-Administrators with these issues and is already familiar with the City and the statr members.
GOALS AND OBJECTIVES:
The general goal of this proposal is to help. the Council and Staff Members of the City of Centervllle to
function as a high performing team during the next few months, focusing on Issues that matter during the
transition period.
SpecifIc objectives of this project Include:
> Work with the Co-Administrators during the transition period to establish a set of goals and objectives to
focus on during the next few months. A part of this work will Include developing and delivering specific
training on "l-eadership. and "Healthy Work EnvIronments".
> Assist in the facilitation of Staff Department Meetings twice a month during the transition period to
ensure that the work of the City is getting done, projects are prioritized, and the team continues to work
together effectively. Training In "Effective Teams and Promoting Effective Work Environments. will be
delivered by Lynn & Associates.
5435 Wedgewood Drive, Shorewood, . 55331
/
(952) 474-2193
1
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METHOD OF IMPLEMENTATION:.
Dr. James Lynn, and Usa Lynn, MS, LP, will perform the services in this proposal. The implementation
steps are as. follows.
1. Review this proposal, sign it, and send or fax a signed copy back to Lynn & Associates (Fax
. 952.474.3738).' . .' . .
. ". . . .
2. Lynn & Associates will begin this. assignment by meeting with City staff members the day after this
Agreement is formally approved by th8 Council (Wednesday - November 24th). At this meeting we will
go over the report we prepared for the Council and create a short term operations plan for how we wiD
work together during the interim time period until a new City Administrator is hired and on board. A
schedule of meetings will be developed at this November 24th meeting and communicated to the
Council and City Attorney. .
3 Once a month, Lynn & Associates will attend a Council meeting to keep Council members informed as
to the status of work being performed.
4. Lynn & Associates 'will meet with staff twice a month, on the day following Council fJlE)etings to review
Council actions, discuss other City issues and develop and deliver training in "Promoting Effective Work
Environments" and "Situational Leadership.. . .
5. Jim Lynn and Usa Lynn will meet monthly with the . Mayor to review findings and discuss future actions
and plans in terms of staff development and work progress.
BENEFITS OF THIS APPROACH:
The foUowing benefits should accrue as a result of this initiative.
> The Council will have an opportunity to define and share in the process of selecting broad goals for
the Staff to address.
> Staff will have a clearer-sense of their respective roles and responsibilities with feedback from-the
first Report and participation in Department Meetings professionally facilitated by Lynn & Associates.
> The training the staff receives will send a clear message that the Council values them and - is willing
to invest in their growth and development
> The City will be well managed and run during this transition period.
TIMEUNE AND FEES:
This work described in this proposal can begin immediately upon signing this Letter of Agreement The
investment for help in working with staff will include two half':'days a month to be on site and facilitating staff
. meetings, and another half-day a month for meeting with Council and preparing training materials. The
special local government rate of$125.00lhr will apply for both Jim Lynn and Usa Lynn. Invoices will be
sent at the end of each month for services delivered during that month. Direct expenSes for the consulting
are bDled in addition, at cost
ResPectfully submitted,
Accepted by,
JAMES J. LYNN, Ed.D.
President
Mr. Terry Sweeney
Mayor
5435 Wedgewood DrIve, Shorewood, _MN 55331
(952) 414-2193
2
l
Teresa Bender
Page 10ft
From: LynnConslt@aol.com
Sent: SUnday, November 21, 2004 10:09 PM
. . .
To: Dnda@coxlns.net; netfalcon.@comcast.net; TomLee@nol-tec.com; IndyJp1@aotcom;
terry(lsYieneyconstruction.biz' . .
Cc: TBender@centelvillemn.com
Subject: Staff proposal
Hi. attached Is the second proposal for staff leadership development and training. Jim
James J. Lynn, Ed.D. LP
Lynn & AssocIates
5435 Wedgewood Dr.
Shorewood. MN 55331
T 952.474.2193
F 952.474.3738
Ceo 612.751.6000
Iynnconslt@aol.com
11/2212004
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,,'
City of Hugo
14669 Fitzgerald Avenue North
Hugo,MN 55038-9367.
PHONE: (651) 762-6300 FAX: (651) 426-2859 EMAIL: info@Ci.hugo.mn.us .
Fran MIron, Mayor
Beck;yPetryk. CouncUMember Wanll
FrankPuleo. CoundlMemberWanl2
ChuckHQQS. Coundl Member Wanl3
Ml1aJ Granger. Coundl Member at Large
November 19, 2004
Attn: Teresa Bender
Honorable Mayor and City Council
City of Centerville
1880 Main Street
Centerville, MN 55038-9794
Dear Teresa:
At its meeting of November 15, 2004 meeting, the Hugo City Council adopted a
resolution endorsing the selection of the traditional repair for the Hardwood CreeklJD#2
Repair and Corridor ReStoration Report.
You are aware that the Rice Creek Watershed District held a public hearing on November
10, 2004 in order to take public comment on the proposed four options. The City of
Hugo believes the traditional repair option provides the best plan.
Please contact me at 651-762-6312 if your have any questions. Thank you.
..
MAE/mac
Enclosures
c: Honorable Mayor and Hugo City Council
./
t
.City of Hugo
14669 Fitzgerald Avenue North
, Hugo, MN 55038-9367.
,PRONE: (651) 762-6300 FAX: (651) 426-2859 EMAlL: info@ci.hugo.mn.us .
Fnm MIron. MflJIOT
Becly petryk. Corme/l Member Ward 1
FronlcPuletl. Corme/lMember Ward 2
Chuck Haos, Corme/l Member Ward 3
MIke Granger. Council Member at Lorge
November 15, 2004
Mr. Steve Hobbs
Administrator
Rice Creek Watershed District
4325 Pheasant Ridge Drive, Suite 611
Blaine,MN 55449 "
Re: Review of Washington County 102 Repair Report dated October 29, 2004
Dear Mr. Hobbs:
Outlined below please find comments regarding the City of Hugo's review of the draft
Judicial Ditch No.2 (JD2) Repair Report dated October 29,2004. It should be noted that
this review letter is not meant as a comprehensive review by the City of the merits of the
technical analysis in the repair r~ but simply outlines the City's ,general ongoing
position regarding the project.
It continues to be the City's position that the draft repair report dated October 29, 2004, is
inconsistent with previous correspondence provided to the Rice Creek Watershed District
relating to a proposed repair project along the Hardwood Creek! 102 ditch corridor.
As preViously stated, it is the City Council's position that it would support a Hardwood
Creek! 102 repair and corridor restoration report that:
1. Includes a restoration project that returns the ditch to its official profile along
its entire reach from Rice Lake downstream to Highway 61;
2. Provides an outlet from Rice Lake at an elevation no higher than the official
protile; and
c:\Documents and SetlinS'\mary llDJl\1..oca1 SettinS'\Temporary Jotemet Files\OLK497\H
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3. Clearly states i~ for any reason, the project does not result in the return of the
ditch to the official profile, (i.e., regulatory considerations, etc); thereby,
. denying the basic drainage rights to the residents benefited, property owners '
would be fully compenSated for the loss of those drainage rights.
. 'The City of Hugo believes that the "stable stream restoration design option" as
recommended in the October 29,2004, Repair Report, is inconsistent with the above-
. mentioned project expectations. The Hugo City Council :further believes that the .
recommended stable stream option is not consistent with the City's previously defined
position throughout the development of the Hardwood Creek lID 2 Repair and Corridor
Restoration Project Report and the mediated outcomes from the 2001 ID 2 Blue R1obon
Task Force. The recommended option is also inconsistent with the February 25, 2004
letter (attached) from Administrator Hobbs to Pete Willenbring regarding RCWD staff
position on JD 2 Repair Project.
Given the previously defined position, the City of Hugo would urge that the RCWD to .
adopt Option 1 - Traditional Repair. It is the City's position that additional geotechnical
information is necessary to conclude that Option 1 is not the cost-effective and
technically feastole alternative. The City believes that a portion of the ID 2 corridor
would not experience the same type of undercutting and slumping of the lower zones of
well-decomposed peat'as concluded in the Report. The City would request that the
RCWD schedule a joint workshop between the City and RCWD to further investigate all
I:1.vai18ble sOils information related to depth of peat within the study area and discuss the
conclusions defined in the October 29, 2004 Report.
The City would also recommend that the RCWD consider incorporating water quality
treatment ponds located west offfighway 61 into the Option 1 - Traditional Repair design
to ensure that discharge to downstream waterbodies is treated to City, District, and
Federal water quality requirements. The City supports the Water Management
Implementation, "Lower Hardwood Creek Treatment Basin I Impoundment Project" as
defined on page 7-5 of the 1997 RCWD Watershed Management Plan. The City would
recommend that the District utilize a portion of the LCMR funding to construct this water
quality treatment impoundment project and not recommend formal amendment to the
RCWD Watershed Plan.
Lastly, the City would recommend an aggressive minor ditch maintenance program to
relieve remaining flooding issues and maintain the system capacity to its official
conditions. .
The City of Hugo fully understands that successful implementation of the Hardwood
Creek lID 2 Repair and Corridor Restoration Project requires a significant balance of the
various stakeholder positions, and appreciates that the RCWD Board of Mangers has
voluntary allowed the City of Hugo to be provide input into this important RCWD
project. In the spirit of attempting to provide a balanced project, the City looks forward to
continuing to work with the RCWD and other relevant agencies to address the above-
C:\Documents and Settinp\mary 8DD\Local Seltinp\Temporary Jntemet F'Iles\OLK.497\H
mentioned issues and find a solution that ensures the rights of the City's residents. If
you have any questions, please feel free to contact me at 651-762-6312.
. .
Michael Ericson
City Adn1inistrator
Attachments:
. City of Hugo Resolution 2004-83 defining the City Council position on the
October 29, 2004 JD 2 Repair Report.
. February 25, 2004 letter from Administrator Hobbs to Pete Willenbring regarding
recommendation on JD 2 Repair Project
c:\Documents and Settinp\mary ann\Local Settinp\Temporary Internet Files\OLK.497\H
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COUNTY OF WASHINGTON
CITY OF HUGO
~OLUTION 2004 - ~
A RESOLUTION IN SUPPORT FOR STREAM REHABILITATION OF
JD2lHARDWOOD CREEKlRICE CREEK WATERSHED DISTRICf
WHEREAS, The Rice Creek Watershed petitioneditselfto repair Judicial Ditch 2 (JD2)
in order to balance the District's diverse needs in the JD2 system;
WHEREAS, The needs of JD2 are given to provide drainage for adjacent property
owners, storm water conveyance to the cities of Hugo and Forest Lake, and protection of
the resources of the Ctistrict, in ~ce with the goals stated in the Water Resources
Plan; .
WHEREAS, The goals of the JD2 Rehabili~on Project with water quality initiatives
provides the dishict with a fiscally prudent repair design of JD2 that will mitigate
flooding, improve the biological condition of Hardwood Creek, and improve water
quality downstream in the Rice Creek Chain of Lakes;
WHEREAS, The traditional repair alternative provides for a fisca1ly sound alternative
with neutral to good flood mitigation, storm conveyance, good expectations for biologic
condition improvements, good expectations for downstream water quality, and lower
impacts to wetlands;
WHEREAS, Peltier Lake is the direct recipient for waters flowing :from Hardwood
Cteek and Peltier Lake is an impaired waters. The City supports the water quality
initiative for protection of downstream water bodies, as defined on Page 7-5 in the
approved RCWD Watershed Management Plan;
NOW, THEREFORE, BE IT RESOLVED that the City Council of the City of Hugo
hereby supports the implementation of the traditional repair for Hardwood CreeklJD2.
Adopted by the Hugo Cl1y Council this Is"' day OfN~ ~ '
~or
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432S Pheasant RIdge Dr. NE #611 · BJalne, MN 5544~539
Phone:7S~39&-3070. Fax: 76~9g...3088
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www.ricecree~d.com
February 25,2004
Mr. Pete Willenbring
Vice President
W.S.B. and Associates
4150 Olson Highway
Suite 300
. Minneapolis, MN 55422
Dear Pete:
In ~DSe to yout letter dated January 26.2004 and to om conversation ofyesteIday, I
would like to put forth 1J1yrecomm.endations to the Rice Creek: Watershed District
(R.CWD) Board.
As yon know. the RCWD is very intent upon arriving at a solution to the issues of
JD2IH.ardwood Creek and we have been working dDigentlyto put together a proposal
that would satisfy tb.o interests of the landownm adjacent to ID2, the landowners
downstream of JD2 onHatdwood Creek, the landowners along Peltier Lake, the myriad
offed~ state and local agencies who have been involved in this. the various
environmental groups who are ~cerned about this area, and the citizens residing in the
RCWD at large. After our conveJ:Sation ofyesteJday, I would propose the following as a
solulion that may appease the varlety ofintotestsat JD2/Haidwood. CtCelc
.:. The RCWD, workiDg'ttllh its engineers at BOR, will develop anEngineer's
Report that restores JP2 to the official profile while ensuring a complete and
comprehensive resloration of the ecologioal functions ofJD2/Hardwood Creek.
This report will be soheduled to appear before the RCWD board at their March
24, 2004 meeting.
.:. All restoration costs will be financed through ad volorum or grants in co~ with
other agenoies and Otgl'n1'7.ations as long as the RCWD can substantiate that ~e
actions taken on JD2IHardwood Creek ate in the best interests of improving water
quality for the awn ofl'..aUB and nab.1ra1 habitat for the region.
80ARD OF >- A.j. CardInal, Sr. Roger I<. Aiken James A Leroux Barbara A. Haake Harvey F~ Kanh
MANAGERS Anoka Coumy RamsRyCaunty Washington Couraq RamseyCaunty AnotcaeoUmy
* PrIIIuld lID~""'" _lIOII 81l"ll8I8fl!lill!t~"""
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.-) TheRCWD can complete th" earthmoving work involving the establishment of
the official profile and the earth wotk necessary for the restoration of the wetland
. areas along 1he main chalm~ by the end ofwinter ZOO4-200S, as wen as .
prelim1nA1}'Vegetatlve restomtion, recbgJ';7ing that some wo:dc will need tp be
done during the winter months.
. . ~.
.}. TheRCWD will implement the other phases involving vegetative restoration
S'UbsequeJlt to the c;otnpletion of the eatthmoving wodc..
.
'. (+ The RCWD position, Q part of the U'COIOInendations of the Blue Ribbon T8$k
Force, is an elevation of920.4 for the outlet ofRioe Lake. Any deviation from
.ft1at ~et1t t1iat is tower wDlneed to come with thoconco:n:mce of the DNa
and the RCWD is happy to work with all pattirJI to resolve 'Ibis issue.
(+ It Is.the intention of the RCWD to accomplish this restoration through a
C01.UJ:aeh~ve system ofvoludtatyupl~ w~ ~ water quality
improvement under the auspices of tho Exceptional Natutal Resourco ValUe
(BNRV) desigmdion for the entire JD2IHardwood Creek system. The RCWD
will also seek any other natuta1 resource designation that helps furtbettb.e goals of
the rehabilitation project.
These are the recommendations I intend to make to our board lIS soon as possible. lfyou
have any questions or concems, please feel fi:eo to call me.
Sincerely,
Steve Hobbs
Administrator
Co: RCWD Boaid of Managers
Mike BIicson. City of Hugo
Brett Emmons, BOR
Louis Smith, Smith Parker
Chuck Holtman, Smith Parleer
I'
}d_o,,~
TO:
Honorable Mayor and Council Members
FROM:
Teresa Bender, City Clerk
SUBJECT: . Liquor License Renewals - 2ooS/Tobacco License Renewals - 2006
DATE:
November 23, 2004
Attache4, please find the submitted 2005 Liquortrobacco License Renewal Applications.
First, please consider the 2005 Liquor Renewals:
Centerville Liquors
Off-Sale &. Tobacco
Trio Inn
Off Sale
On Sale
Sunday
Tobacco
WISegUyS Pizza Inc.
On S~e
Sunday
Center Mart
Tobacco
Corner Express
Tobacco
Kelly's Korner
Off Sale
On Sale
Sunday
"
Tobacco
We have one (1) establishment that has outstandi1)g property tax owed.
. .
Plea:se consider in yo'Qf mo~on the inclusion. of language regarding subject to the
submission of certificates of insurance with coverage d8tes for the entire year of2005 and
payment of all outstanding property taxes.
Second, please consider the 2005 Tobacco Renewals:
Also attached, please find a copy of Ordinance #66, Section 66.05, B. In years' past, the
Centennial Lake Police Department has provided the services ofback:ground checks only
to the extent of their records and local police department records. The previous Police
Chief has urged Council to consider language allowing a Criminal History Data check
(Felony Level Crimes) and Council has declined. Interim Chief Makela is again
requesting that Council consider adding l&nguage to the City's Ordinance #66 similar to
that of the City of Circle Pines Ordinance (Copy attached) allowing such checks or
considering the CityofPlymoutb's TobaccolBest Practices Ordinance with the inclusion
of the recommended language by Chief Makela. The previous Council desired the City
of Plymouth's TobaccolBest Practices Ordinance due to the tact that the City of
Centerville's Liquor/Best Practices is an adaptation of the City of Plymouth's
LiquorlBest Practices ordinance. However, The City of Plymm;tth does not currently
require a Criminal ffistory Data check.
Council may consider approving the tobacco license renewals for 2005 if you desire
without the Criminal History Data check. Council may desire to consider the licenses
after an Ordinance Amendment and Background Check or consider amending the current
ordinance or reviewing the City of Plymouth's tobaccolbest practices ordinance and
adopting same for 2005's retlewal.
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CITY or CENTER~
4NOKAC01JNTYt~A
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,ORDINANCE,. 66, .
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An Ordinanee.Adopting City'Code # 66
The Sale ofT0bacc9 "
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. The City Coimcil of the City ofCenteNill~does ordain as fonows: .\ .
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. Sec:EOD 1. The City Code of the City ofcCntervme is hereby adopting City Code #66
mns eJJ.ti1;~y. .
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SedioD '6'6' .. The Sale of'i'obaeeo
U.81 . ~. 'PI- ~.reco' +1.-.' " ".":..J:- 4;';' . <<10, ears .
,. . ...~'9..,....J ....gn1Zes.~matW~.~~agt? t~Y~ .
.............T..~...... or ~ o~.M-. and.' . to-r-:~ tobaGOO'~~..K:if"'and ~......:.-;..., ~..4.~
. . .tf~~.. '.. ,. '''~ PQSSeSS, use '~, .l".&~~ . ~ ~~
. ~'and siJch' $lies, ~SsesSion, and use are vioJatiotm ofbotli State.atu1 Federal "ws;:..
~se .studie$, ).Vbjch the city hereJ;Jy ~ts arid adopt$, have shown that 'mOst ~ begin
. .~~tb.ey ~reached the ~of18 years ~ that tito:se persOJ1s.wJio' ~ ~..
of 18 years withoUt ~ started smoking are sigDificantbr less likelY to begin ~ aDd '
.~ SD10kinjhasbeen shown te bethe,cause ofsevera1 ~ health FObl~~
sub~ p~ a f'ina.uQallmr-den on aU levels of gover-lIlte1_I; This Ordiii.imce sbaIl be .
intended to regUlate the sale, posseSsion, and use of tobacco, tobaCco pioducts~. 8:D.d ~
re1ated deW.ces fOr tile ~ of enforcing mi iutherlng ~ Jaws. to pllOt~ ~
~ ~ serious effects associated with illegal use oftObaceo, ~ ~ ,and tbba9co
devices, and to ~ the official public policy oftb.e State of Minnesota in Rgard to preveDtmg
young pqJle ttom starting to smoke as stated in Minn. Stat. fl44.391.
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".02 . Defimti~JIS..As used in this section, the fanowing tenns are deJmed as ibnows:
Subd. 1 Toba.cq) or Tooaem Products. "Tobacco" or "Tobacco prpducts'" sba1l
mean substance or item 001\tmnm' tobacco 1-"" ~...~...t:-_ but not limited to .. etteS:
any ,. g .-.., ~. :& CJ:g8J1 . ,
C?igars; pjpetobaQCo; snua; fine cut or o1:her chewing tobaccQ;cheroots; stogies;'perlque; '. .
~ plUg CUt, epmp CUt, ~-robbed, and other smoking tobacco; snufFflowers;' ....
~ shorts; plug and twist tobaccos; dipping tobacqos; refbse scraps; clippings; ~
.and sw~~gs of tobacco; and Qther ~dS a1i4 formS of tobacco leaf~ m:~~~ as .
to be. suitable for chewing, sttiffil:\& or smoking. . '. ~ . "
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Subd.2 Tobadoo Dalttted :QJM.ces. -Tobacco related devices" shall ~ any
. . .tobacco pnl(hwt as well ~ a pipe, roiling papers, or other dev.iqe 1nt~onaly designed
or intended to be useditt a mf3m1fl!t'wmCh enables the chewin& 'mriffin& or snio~ of
tobacco or tob8.CCQ products. . .
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Subd. 3, SeIt:.Se.r;dce ~erchj)ndising. "Self..Service Mercl1andising" shall mea,n ,
open displays oftobacoo:r"tobaooo' products, or tob.acco related deVices in any manner.'
.where any person shall have access to the tobacco, tobacco products, or tobacco related
devices, without the assistance or inteiven1ion of the lioonsee or the licensee's emplOyee.
,The issistance or intervention shall entail the actual physi~ exchange 'of the tobacco,
tobacco ~ Or tobacco related device between the ~omer and the licensee or
employee. Self-service mercha\)ili~ sba.1l not include vending macmnes.
Subd.4 VendU:W Machines. ''Ven~ Machine" s.ba.U. mean ~:mechanical,
eledJic or electronic, or Qthe.r'type of device which ~ tobacco, tobaccO .pro4u~
or tomwco related devices upon the inserliolt of money, tokens, or other fonn ofpa.y.ment
~ into the machine by the person seeking to purchase the tobac90~ tObacco product,
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or tobacco related device. .
Subel 5 Individnally ~br!, "IndividuaBy packaged" shall mean the practice
of se1ting any tQ~ <<tobacco ~ wrapped individually fur sale.,' IndividuaUy '.'
"~'~,~Q~ ~~~ sba1l~ but not be limited to, sing1e'cigar~.., ~,; (
,p~.siDg1e bass. 9.f~, of loose tobacco in any form, and single cans or other ~1ring' ';' ',;', ','
Of snuff or chewing'tObacco. Cart.ons or other p~~ng co11t~i14in8 more than a single .:.
.. pack or ot4er container as descrtbed in this subdivision sbali not be conSidered individually
~hged.
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Subd. -6 toosies. "LQosies" s.ba.1l mean the oomtnon term used to refer to a single
..or~ ~ed cigarette. .
, Subd. 7 ' MiBm:. "Minor" ~ mean any natural person who 'has 00t yet reached
the . of eighteen (18) years. l
Subd. 8 ReqW Rv.ahliWnent ~etail estabHsbmen.t" shall mean any place of
buiDness ~tobacco, tobacco products; or.tobaecorelated devices are available fur
sale to the general public. Retail establishment shaU include, but not be limited to,
grocery stores, C9.ttVenience stores and ~
Subd. 9 , Moveable ~Iace t?fBllmn~q. "Moveable Place of Business" shall refer.to
any form ofbusiness operated out of a truck, van, automobile, or other type ofvebic1e or
~le shelter minot a fixed address, store front or other perrmtn.ent type of
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Subd. 10 ~. A "sale" shall mean any transfer of ~ for money, trade, ~,
or other consideration.
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, Subd.. 11 ' CompliBtIr.A C~.1c~."CompJiance ~ sbaJt tnean the system the city .
uses to inve$tigate and "ensure that those authorized to ~ tobacco, tobacco products, and
. " ,tol?aceo r~ devbs are following and cOmplying with1he requirements of this
Oilli1,afWe. .CompJianee checks shalt involve the use ofri1inprs as authorized by this
'o~1J1ance. Comp1iance checks sha11 also mean the use of minors who attemPt to .
purchaSe-tobacco:> tobacco ~ 'or tobacco related devices for educatiofia1, ,research
and training purposes as authorized by State and Federal ~Ws. Other units of
goV'etJD.iteDt for the purpose of enfurcing -appropiwe Federal, State,. or local taws may
also conduct compliance checb and regulations rtP.iS\1i1'\g to tobacco, tobacco products
and tobacco related devi~.
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"-03 J~ R~. No person sbaJl Sell orOfthr to sell any tobaCco, tobacco .
products, or tobacco te1ated dtwice without first haying obt8ined a license to do so from the.citY.
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Subd. ~ . . Aw1!~~~ for.Uceme. ~ apptication for a ~ to ~.to~~
. tobacco productS,. cr'tOb~ related devICeS shall be made on'a fom;l proVided by the
eity. 'ne applicatiob. sJudt contain the fun name of tile appli~ the app1i~'s residAntW
and l)1Jslness addresses and telephone~, the Daftle of the busine$s for Which the
kense is -"......... and additi6.ba1 mfoi'inatiott 401.-. Mm deemS n~aAn7 Ui . . ~
. . ,"""~ any. , ~-"'.1 ----J. .poDA--Y.
of a comp1etedappJication, the city clem: sba1i bward the applicatiq~ to the .
~ for actim,. during a regularly ~ed council meeting. Jfthe ~
QbaIl deterniine that an appJication -is inoomplete, he or she sbaJI'return the appficatiOtt
to the ~Hcantwith notice dfthe ~ ~to inake the ~cation complete.
Sub4. 2 Action. The eou.ncil may ~ approve or deny the license, or it may
delay action for a r~le amOlJDt of time to complete -.ny ..estigatio~:' of the
appliQttion or the applicant it deems necessary. 'Jfthe council sbaJl ~ve the license,
the derk Shan.issue the license to. the ~ If the council denies the' license, notice
of the deaia1 sbaU be given to the applicant ~ with ~ of the appHcaut's right'to
appeal the ~'s decision.
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Subd. 3 Dmn. .AllliceD$eS is$ued under this ordirnvlce will expire December 31,
of the year the license was ~., . ' , .
. . Subd. 4 ~enmon or Revoca.tioa Any Jicelme ooder this ordinance may be
revoked ot SUspended as deemed neceisaiy bY'the CounCil.' .
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.Subd. s' . Tntri~Em4..All licenSes ~ wider this ordinance shall be valid ~
. on the premises fQr which the license was issued imd only f9r the PersOD (sl to whom the . ,
license was isSued. No ~er- of ariy license to another location,or persori ~r entity shaJl
be valid withOllt the prior approval of the coui1clL The licenseesball not be entitled to
a refund of~e license fee upon IWocatio~i or vo1untar.ily ceasing the licensed activity. .
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Subd~ 6 'Di$,pJv. AU licenses shall be posted and displayed in plain view of the
'general public on the HceDsed. premise. '
"Subd. 7 . RenewAl~. The renewal of a license issued. under this "section shall be
~ed in the same mamier as the original appiicatiori. The request for anm.ewal . ,
shall be :Q1ade at least thirty days but no~e than sixty days before the expiration of
the current license. The issuance of a license issued un4er this ordina.1ice sha1I be
considered a privilege and not an absolUte right of the appIicant,and "sba.1l not entitle
the holder to an automatic renewal of the license.
66..04 lm. No license sbaJI be iSsued under this ordinance until the appropriate
licenSe fee is paid in full. The fee for a license under this ordinancesball be determined by
resolution orthe City Council. .
"'"OS' Basis for .ni.. of' ~~. The fonowing shaD be grounds for denying the
issuance or renewal of a ~ under this ordinance; however~ eXcept as may othe.rWise be
proVided by' JawIO the existence of any particular ground f9r.denial does not mean that th~ city
.' mUst cJeny the license. If a license is mim-.akooly issued or renewed to a person, it sbal1 be
. ',;' '. ~ltm.~ upon the discovery that the person was inelit,Jibl~fur the li~~:tbis section:
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. . ',A. The applicant is.undertb.e age of 18 yeatS. .
B. The appJicam has been convicted witbit1 the past five years of any Violation of a
llederal, State or 1ocalJaw, ordirnwce prQVisioD, <<other regulation iALmng to
tobacco or tobacco products or tobacco related devices.
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C. The appiiamt has had a license to se11 tobacco, tobacco produCts, or tobacco
related devices revoked within the preceding twelve ~ of the date of
application. "
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The a,ppliamt lit.Us to provide any itl:fo.n:nation required on the application, or
provides 1).lse or misl~ information.
The applicant is prohibited by Federal, State~ or other 1ocallaw, ordinance. or
. other regulation, from holding such a license.
66.0(& Prohibited Sales. It shall.be a. violation oftbis ordinance ro.r any person to
sell or offer to sell-any tobacco, tobacco pr~ or ~ related device:
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. A to any person under the age of eighteen (18) years.
B. By meaDS o~ any type ofvending machine, except as may ()th~ be
provided in this Ontinance.
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c. By means of seIf...service methods whereby the customer does not need to malte
a verbal or written ~ to an employee Of the licensed ~ in oid~ to. :
~e tire tobacco, tobacco products, or tobacco related devices and.wherebj ,
there ill not a physieaI mreh~ of tobacco,. tobacco pmducts, or tobacce mlated '
device between tlJe..1icensee or ~ licensee's ~Ioyee, and the ~.
:Q. By means ofloosies as defined fa Section 66.02 Subd. 6 oftbis ordinance.
B. COntaining opium, morp~ jmpson weed, :aeua ~ stryclmos,. eooame,
marijuana, or other deleterious, haJIOOnogeniC, toxic, or oontro1led substances .
~ nicotine and other substattces f~und naturally in tobacc"o or added as part
oiatt otherwise JawfW ~process.
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. F. By any other Jnea1)1l) to any other peisml, or in any other manner ofform
prohibited by Fedem1, Stat~ or other Ioeat Jaw, ~ provision, or other
regulation.
, '~o07 . 'i(e)ll,UiDf 1W~,.hmeil. It sJd be unlawful for my person liceDsed lWder this
or6anee to allow the ~e ~ftobaeco, tobaccO produCts, or tOOacoo.related devkes by the
~ pia, ~ ~ unless minors ate at all times. prohibited ftom entering the
licensed estabJisbment .
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"..08 'SteII-..~ 1flA~. It ~ be unJawfuImr"a licensee ~ this ordi.~n~ to
aJIowtbe sale of~ tobacco products, or tobacco related devices by.any means whereby
the ~~may,haye ~ to such items witJlout bav.ing to ~ ~item ft'om the lieensee
or the licensee's employee and whereby there is :not a physica1.eJtChm,ge of tile tobaooo-,. tobacco
products, or the ~ related devi,Cesbctween.the licensee or his or her clerk and the qutomer.
AU tObacCo, tobacco products, and tobacco related devices sbaU either be stored behind a
couitter or 0_ ~ not freely accessible to customers. or In a case or other stOrage unit not
left open and accessible to the general publir;. Any retailer selling tobacoo, tobacoo ~
or tobaCco ~ devices at the _ this ordinsttlte is adopted shaJl Comply Wi1;h this Section
Within 9Q days. Self..service sales restt1ction shall not apply to retail stores which deriw 'at
least rooA of~ revenue ftom tobacco and tobaccO related products and which _ot be
entered. anytime by a ~n(s) y~ than 18 years ofage.
"-09 . . ~~. An Jicensees under tbis ordinance shall be respOnsible for the
aCtio. of their employees in regard to the _ bftobaooo:o tobacco products.:or t~ related
devices 'on the licensed pre.mses and the sale of such lJD. item by an employee shall be cOnsidered
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a,$al,"1>Y..the~ holder. :Nothing ill this section shall be constmed as prohibiting the City
ftom also S1ibjectmg the cledc to whatever~eS are appropriate under this OrdinanOO:o State
Or Federal Jaw, or other applicable law,or r~lation. ' '
66.10 . . <ColTItp&nllrA'l ChtP.lia.D and ''P~~1IJ. AU licensed preinises shaD be 'open to
. inspectiOn by ~ city police or other authorized city officla1.durii1g regular business hours~
From time'to ,time, but at least once per year, the city shall conduct CQmpJia:nce checb bY
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~", with die written CODSe.Qt ofthe.ir parents or guardians, minors over the age offifteen
(15) y~ but l~ than eighteen (18) years, to enter the licensed premise to attempt to purchase
tobaccO, tobacco products, or toba.coo.reJated devices. Minors Used for the purpose of
compli8nce CheekS. shall be supervised by city demgnated laW enforcement officers or other
~ed citypersonnet. Minors used for compliance checks shall not be guilty ofunIawfuI
posses$iOn oftobaceo, ~ products, or tobacco related devices wb.~ ~ items are
~ as a. part of the compliance check. No minor used in oomp~ checb Shall attempt .
to use a fi1se identi:fiqation misrepresenting the mioor~s age, and all minors law.fuU:y engaged
in a compliance .cbA;dr shall answer all questions about the minor's age asked by the licensee or his
or her empl~a.nd slutll produce any identification, if any exists, for Which .he or she is asked.
Nothing in this Section shall prohibit compliance checks authorized by State orFederallaws
fur educatio.nal, r~ or training purposes, or required for the enforcement of a particular.
Stato or Fed.erallaw.
,",oIl Other ~ A.. Unless otherwise prOvided, the fonowing rwts Shall be a
violation of ibis ordinance.
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Subd. 1 lDqW. 8~. It sha.U be a violatioo'ofthis ordinance for any person to
seD.. or otherw:ise.provide any tobacco, tobacco product, Of tobaooo rdated deviee to
any minor. " i.. ..
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Subd. 2 m.. Possession. It sha1l be.a violation of this or~:for any mit10r
to have in his or her possession any to~ tobacco product, or tobaooo related~.
This subdivision shan not apply to minors JawfuUy involved in a COOlpliance eheck.
Subd. 3 ~1 V~. Jt sha1l be a violation oftJris or~ of any ~ to smoke,
chew, snift; or otherwise use any tobacco product, or tobacco related 4evice
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Subd. 4 mept ~eIJ;J.ent. It shall be a violation oftbis ordinance for any minor
to purchase or attempt to purd1ase or otherwise obtain any tobacco, tobacco product, or
tobacCo related deVice, aud it sba11 be a violation oftbis ordinance for any person to
purobase or otherwise obtain such items .on bebaJf of a minor. It sba11 :further be a
~olatioo fur any person to coerce or attetnpt to coerce a minor to illegally purchase or
otherwise obtain or use any tobacco, tcbacoo product, or tobacco related device. ~
subdivision shaJl not apply to minors lawfully involvec:t in a compIian.ce check. . .
Subd. 5 Vse ofF~ JdAntifir.atinn It sba11 be a violation of this ordinanCe for any
minor to attempt to disguise hiS or her'true age by the use of a: ~ form.ofidentification,
whether the identification is that of another ~ or one on which the age of the person
,. " .'. ~ ~~ or ~ed wid.1 to .represent an ag~ o~ than the. aGtual. age of the .
person.
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66..12 V'1OIati9Ds.
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Noti~. Upon discovery of a suspected violation, the a11eged violator shall
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be issued, either persona11y or by ~ ~ citation that sets :tbrth tbe aJl~ violation and.
which .slWl inform t1ie alleged violator ofhis or her right .:to be heard Qn the accusation. "
"Subd. 2 " Hemingtl. "Ira person accused ofvioIatfng this ordinance so ~ a
. hearing sball be scheduled, the time and place ofwhich wn be determined bY:Ano1Q1
CountY.
Subd. 3,
~Mti. Officer. Anoka County shall serve as the hearing officer.
Subd. 4' DetisioJl. If the hearing otijcer detenniaes that a. violation of this
~ did'occur, the deQsion, alo~ with tho heating officer's reasons for find1ng .
a violatiOn and the penalty to be imposed under'SectiOn 66.13 oftbis ordiuattoe or as the
. oomt rules. shall be recorded in wrltin& a copy ofwhidi shall be provided to the aCcused
violator, their parent or legal guar4ian... :r..ibWise, if the hearing officer finds that no
vioJa1;ioii OCCUrred or finds' grounds fur not imposing any penalty, such find1ngt1 shall J>e
recorded and a 00py provided to the acquittOO accused violator, 1heir pare1lt or legal
guardian.
Subd 5 ~~. Appeals of any ~ made by tOO Jiearing officer iman be',
mediA the district court for the city m which the a11eged viohi1:iQn 0CWiT<<1. -
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Subd. 6 MWI~ Prosecution. Nothing.in this Section sba1l prohibit the City
, :from ~ prosecution as a misdemeanor for any alleged violation oftbis ordina.nr.e.
If the City eleets to seek misdemeanor proseeution" no administrative penalty shalt be
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subd. 7 ('.n1\tim!M Violation. Each violation, and every day in which a violation
~ or c:onti~ shall constitute a separate offimse.
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" sl,lbd. 1 Jlqmsees and R~IQyees. Any Jkensee, aDd 8J;lY employee of a licensee,
found to have violated this ordinance sJWl be dtarged an administrativafq1e whieh sbaIl be
de1,amined by ~ of the City Cowici1 for a first violation oftbis ordina11ce; for a
second.ofRmse at the same Hcensed pr:emises withJn a twe.oty..four'montJ:t. per;Uxt and/or
a tbird or ~ offe.ase at the same location within a twenty-four month penoo. A
fine s1m11 ~.det~Pd by ~Iution of the City CounciL In additiOD, after the third
offense,.the ~ ~ be suspended for not less than seven days.
Subd. 2. . Oifaer':rnm-whl"~A" Oth<< ~ otherthan.minors ~ by
. subdivision 3 of this SUbsection, found to be in violation Of this.ordinance man be
cha1:ged . adininistrative fee set by resolution of the City CounciL
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. , Subd. 3 Misdemeanor. Nothing in this Section shall prohibit the City from seeking
prosecution as a ~or for any violation o1this onii:wm.ce.
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66..14 Exceptions and. DefeDRSo . N~ in tJ:iis 'ordinance sha11 prevent the providing
oftobacco~ tobacco products~ o~tobaoCo related.devices to a minor as partofa.law.fu]1y
recognized religious, spiritual; or cuJ.tura1 ceremony. It sba1l be an affirniative defense to the
. violation oftbis oi~ for.a person to have reasonably relied on proof of age as ~
by State laW.. '
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66.:.15 . ' Severability.aDd Sa~ Clause.. If any section or portion oftbis ordinJtl1OO
shaJI be' found un<<;onstitutional or otherwise invalid or ~o(ceable by a court of competent
jurisdiction, that flndirtg sba1l not serve as a inWlidation or effeet the validity m1d enforceability
of any other section or provision oftbis ordinance.
.,(j~16 . 1C~tite :Qate. 'rbis ordinance shall take effect the day following
publication in ~ city's official n~. .
, '-/~ \.. ~-~
Mayor Tom Wilharbet
Attest:
&it:!:/J<lJ'-11WFL ..
R ~' I"'...:....m-~ .CMC City Oe!k" .
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~~/ ~8/.,4 JIlU1~ ,u.. ~u rAA. O~l: 104 UUO:ii:
\,.tiN.I..t.roUAL. LAA.t::I l'U
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CI1Y OF ClRCLBPINES
COUNTY OF ANOKA
STATE OF MlNNBSOTA
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ORDINANCE NO. T1
(Se<:ond Series)
AN ORDINANCE AMENDING mE CITY OF CIRCLE PINBS CITY CODE, BY
ADDINGSBCTION 270 CRlMINAL HISTORY CHECKS.
The City Council of the City of Citcle Pines ordains:
SECTION 1. The City Council of Circle Pines hereby adds Section 270,
to read as follows:
SECTXON 270 AUTHORIZING quMINAL mSTORY CHECKS
270.01. . Applicants for Employment with the Cit)' sba11 be subject to a Criminal History
Check.
270.02. Criminal History Checks shall be performed by a Records Specialist at the .
. direction of the P~1ice Chief or His or her designee.. .
270.03. An Applicant for employment shall be advised of the need for a criminal
historY check and the rights of the Applicant for Employment under law, if and, with
respect to such checks. A copy of such rights sball be executed by the Applicant for
Employment and forwarded to the Records Specialist with tJ;u, requ,est for a Criminal
H'lStoIy Cheek.
270.04. The City will not disqualify an Applicant for Employment solely or In part
because of Ii prior conviction of a crlme. ~ch is not directly relat~ to the position of
employment, the.City shall consider:
A. The natUre ana seriousness of the crime for which the Applicant for
~ploym~ was convicted;
B. The relationship of the crime'to the purpose ofregulating employment with
~C~; .
C. The relationship oCme crime to the ability. capacity. Qld fimess required to
perform the duti~ and di.'Ir.'harge the respoDSibilities of the position or
employment. . ,
27,0.05. lf1be City determines that the crime for wlilch an Applfcant for Bmployment
was convicted i$ directly related to the posi~on for employment sought pursuant to
270.04 above. the Applicant for Employment will not be disqualified. ffthe Applicant for
Employment sho~'S competent evidence of sufficient rehabilitation and present fitness to
perform the duties ofman position, as set forth in Minn. Stat. 364.03. Subd. 3.
~UU/U4 ltlU~ lZ:ZU JoM 6lZ 784 UU8Z
(;.HNl~N!AL .l...AK.HS PD
~~~ (;v Cll~ HALL
IgJ 003
270.06~ If the Ci1;y determines. that an Applicant for Employment is disqualified :from
the position solely or in part because of the prior conviction., the City shall notify the
A~licant for Employment in 'writing of the following:
A. The reasons.for disqualification;
B. . that the City will initiate a contested case hearing under the Administrative
Procedure Act. Minn. State. 14.57, upon the request of the Applicant for
employment.
C .Tbeearliest date the person may reapply for a position with the C~ty
270.07. Pursuant to Minn. Stat. 364,09(a), parts 4,5, and (; above sball not apply to the
practice of iaw enforcement arto fire protection agencies.
'270.08. . The provisions of this section shall not be deemed to be a limitation on the
sCope ofbackgIOuod checks and such checks may be as broad as the City deems
reasonable and prudent in a given circumstance within the limits of state and federa11aws
and regulations.
SECTION 2. This ordi;oance shall be effec:tive upon passag~ and official publication.
. Adopted this 28th Day of January 2003, by the Circle Pln~ City Council.
ATIEST,: //J ~~
~ ~~
~ .
am~ W. K~ City Adm.inistre.tor
First Readjng:
Second Reading:
Published:
(SEAL)
January 14,2003
Januaxy 2~ 2003
February 11,2003
0'
Section 1150 - Tobacco and Re~d Products
. Page lof3
Section 1150 - Tobacco and Related Products
1150.01. Li~Required. No person.shall directly, by coin machine, or otherwise, keep for
retail sale, sell at retail,' or otherWise dispose of, any cigarette, cigarette wrapper, tobacco, or Tobacco
'. " Products at any place in the City unless they have obtained aUcense therefor as provided herein.
1150.03. . .t\pplication for License; Grantinf of License by Council; Issuance of License by Clerk.
Application for such license shall be made to the City Clerk and shall state the full name and address of
the appli_ the location of the building to be occupied by the applicant in the co~uct 9fthe business,
the kind of business to be conducted, and such other information as the City Clerk may require. The
license shall be granted,by the City Council and issued by the City Clerk upon payment of the required
fee. .' .
1150.05. License Fee; Term; Date. The fee for a license is set by Chapter X. The license expires
. on December 31st. (Ord 96-4,02/21/96)
1150.07. Prohibited Acts.
(a) No person shall sell, give away, or otherwise furnish any cigarette, cigarette paper,
tobacco, ~r Tobacco Products to any person under the age of eighteen years. .
(b) No person shall keep for sale, sell, or dispose. of any ~igarette or other Tobacco Product
containing opium, morphin~, jimson weed, bella donna, strychnia, cocaine, marijuana, or
any other deleterious or poisonous drug, except niCotine.
(c) No person shall sell or dispense any Tobacco Producttbrough the use ofa vending
machine, unless the vending machine is ,in a nonpublic area with no minor access as
verified by a premises survey conducted by the Police Department. (Ord. 97-15; Ord
2001-08,02/27/2001)
(d) No person shall offer for sale any Tobacco Product by means of Self-Service
Merchandising, unless the display is in a nonpublic area with no minor access as verified
by'a premises survey conducted by the Police Department. (Ord 97-15; Ord 2001-08,
02/27/2001)
.( e) Every licensee shall be responsible for the conduct of its employees whfle on the licensed
premises and any sale or other disposition of tobacco products by an employee to a
person under 18 years of age shall be considered an act of the
http://www2.ci.plym.outhunn.us/plslcop/docs/FOLDERlCITY_GOV/CO_CODE/CODE_m.11/23/2004
Section 1150 ~ Tobacco and Related Products
Pa.ge 2 of3
Plymouth City Code
1150.07(e) .
licensee for pmposes of imposing an administrative fine, license suspension, or .
revocation.
(Ord 96-4. Oi/21/96)
1150.09. . Dis,play of License on Premises. Every such license shall be openly displayed in the,
, place of business to which it has been issued.
1150.10. Violations.
(a) Misdemeanors. Any person who violates this ordinance shall be guilty ofa
Misdemeanor unless the violation has a Specific penalty designated by state taw. (Ord
97-15.07/23/97)
(b) Administrative Civil Penalties; IndiViduals. An individuat who sells Tobacco to a'person
under the age of 18 years shall be subject to an administrative penalty of $50. No penalty
may be imposed until the individual has received notice, served personaIly or by mail, of
~e alleged violation and an opportunity for a hearing before the Chief of Police or his/her
designee. A decision that a violation has occurred must be in writing. (Ord 2001-29.
08/14/2001) , "
. ,
'(c) Administrative Civil Penalties; Licensee. If a licensee or an employee of a licensee is
found to have sold tobacco to a person under the age of 18 years, the licensee shall be
subject to an administrative penalty as follows:
NON-BEST PRACTICE GRID:
OffeJ;lSe Minimum (State) Presumptive Penalty Maximum (City/State)
, (Citv) ,
1 st Violation $75 and/or 0 days susp $500 fine and 5-day susp $2,000 and/or 60-days susp
2nd Violation $200 and/or 0 days susp $750 fine and 15-day $2,000 and/or 60-days susp
(within 24 mos) susp . ,
3m Violation $250 and/or 1 days susp $1,000 fine and 25~day $2,000 and/or 60 days susp
(within 24 mos) susp
41h Violation None listed :Revocation Revocation
, (within 24 mos) ,
Best Practices Establishments. Establishments entering into an agreement with Police
Department as a Best Practice Establishment will use the Best Practices violation grid:
http://www2.ci.plymouth.mn.us/pls/cop/docslFOLDER/CITY_GOV/CG_CODE/CODE_u.l1/23/2004
~ecti()n 1150 - Tobacco and Related Products
Page 3of3
..
Plymouth City Code
1150.10 (c)
,1st Vi6lation
~ Violation
within 24 mos
3rd Violation .
(within 24 mos)
4th Violation
within 24 mos
(d)
(e)
(f)
$75 and/or 0 days susp
$200 and/or 0 days susp
Presumptive Penalty
C. .
$500
$750 fine and 7-day
suspension stayed
Return to regular penalty
grid and off Best Practice
for 1 ear
Revocation
. Revocanon
Maximum (City/State)
$2,000 and/or 60-days susp .
$2,000 and/or 60-days susp
$250 and/or 1 days susp'
$2,000 and/or 60 days susp
None listed
First violations would be handled by an administrative hearing with the Police Chief or
hislher designee with the presUmptive penalty given to license holders. For Best .
Practices establishments, first and second violations would.be handled by an
adminis1rative hearing with the Police Chief or hislher designee. License holders have
the right to request a hearing before the City COlmcil if not in agreement with the
presumptive penalty. The Police Chief also has the right to request a hearing before the
Cout)Cil ifhe/she beli~ves there exists .substantial reason maldng it more appropriate ,to .
deviate from the presumptive penalty. If the Police Chief and licensee agree on the
presumptive penalty, th~ will be reported to the City Council in a staff report. (Ord 99-
16, 6/01/99; Ord 2001-08,02/27/2001; Ord 2001-29, 08/14/2001)
Defense. It is a defense to the charge of selling tobacco to a person under the age of 18
, years; that the licensee or individual, in making the sale, reasonably and in good faith .
relied upon representation of proOf of age described in State Statute section 340A.503,
subdivision 6, paragraph (a).
Exemption. A person, no younger than 1~ and no older 1:han 17, may be enlisted to assist
in the tests of compliance, provided that written consent from the person's parent or
guardian has been obtairied and that the person shall at all times act only under the direct
supervision of a law enforcement officer or an employee of the licensing deparbnent, or
in conjunction with an in-house program that has been pre-approved by the Police
Department A person who purchases or attempts to pmchase tobacco-related products
while in this capacity is exempt from the penalties imposed by subdivisions a and b
above. (Ord 2001-08,02/27/2001)
.
Revocation. The City Council has the authority to revoke any license as noted in Section
l005~21.
Penalty for minors. Although it will remain a Petty Misdemeanor for a minor to use or
. possess tobacco, the City, after consulting with interested educators and/or parents, may
. use an alternative penalty system (diversion program). (Ord 97-15, 07/23/97)
(Ord 96-4, 02/21/96) .
(g)
http://www2.ci.plyroouth.mn.uslplslcop/docs/FOLDERlCITY_GOV/CG_CODE/CODE_m.II/23/2004
Targeting underage drinking
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Last update: November 2S, 2004 at 11:15 AM
Targeting underage drinking
, Ben Stevennan, Star Tribune
Novernber24, 2004 WLIQUOR1124
. _.._____~~____, '.__~ _~. ___._._~_.._.._..____"_'.' ...__....._..____.H_.__.____
Age 21 or 99, everyone soon may need to bring their IDs to buy alcohol
at Hopkins restamants and liquor stores.
One-tbird of HopkinsJ liquor stores and'restaUrants . sold alCohol to minors
during the most recent round of police checks, leading police to propose
a change to liquor laws.
But instead of tightening laws by increasing fines and pena1ties,the
police department wants to give businesses incentives to provide better
1raining for employees so they can help prevent underage drinking, And
one of the outcomes could be carding for everyone.
The program is modeled on one Plymouth started in 2001 after 40
percent of its businesses failed compliance checks during 1999. Since it
started its new program, Plymouth's failure rate has steadily fallen; it was
6.2 perCent last year.
Hopkins Police Chief Craig Reid was convinced that Hopkins needed to
try Plymouth's approach after a recent visit to a restaurant in Plymouth.
Reid and his wife ordered wine with their meals, but his wife hadn't
brought identification, so the waitress politely told them that they
couldn't be served alcohol.
Reid said he was impressed that the young waitress, thanks to her
training, felt confident enough to enforce strict rules even when the
buyers were clearly over 21. "It sounds silly ,but it gave them the tools
they needed, R he said of the program.
Training employees is the key to preventing liquor sales to underage
buyers, Reid said. "You can't expect a police officer to be there every
time a minor tries to make a purchase."
In Plymouth, businesses that want to participate in the program must
have 75 percent of their employees trained by police officers on liquor
laws and how to detect fake IDs. Businesses.also must take other steps,
such as rewarding employees who catch underage buyers.
If they participate in the voluntary program., restaurants, bars and liquor
stores face less severe penalties when liquor violations do occur. If a
participating business fails a compliance check in Plymouth, it gets a
$500 fine for a:first offense. But unlike businesses that dQD.'t participate
in the program, it doesn't have its license suspended for five days.
Participating businesses with clean records also can get a discount on
their liquor license, which can cost thousands of dollars.
http://www.startribune.comIstories/1405/5099215.html
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11/23/2004
Targeting underage drinking
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However, participating businesses are only allowed two violations within
three years before they start receiving the same fines and suspensions as
other liquor liCCD:SC holders.
Mark Bevins, the Plymouth officer who administers the ~ said
one of its main benefits is giving.employees contact with the police
department It's a constant reminder of the fact that police are keeping an
eye on whether the business is selling to minors, he said.
The Hopkins plan
A few of the details are different in Hopkins - for example, the city ,
won't give a discount on liquor liCenses - but officials have proposed a
similar approach to Plymouth's program. The City Council will consider
the plan at its Dec. 7 meeting.
One big difference between the Hopkins and Plymouth programs is that
Hopkins would require participating businesses to check the IDs of all
people buying alcohol, no matter how old they lOOk. At participating
businesses in Plymouth" carding is required for customers who appear to
be younger t\1an 45.
That requirement rms sought by business owners who feared their
employees would have to make subjective judgments about when to ask
for someone's ID, said Kathy Magdal, a police employee who helped put
together Hopkins' proposal. '
A uniform policy of checking all IDs would take the burden off young
employ~ she said. Because liquor stores can simply post a sign
explaining the city rule, customers who forget their IDs can blame the
city, not employees. RThey won't have to have someone screaming at
them, R Magdal said.
Andrea StackeD, 18, a senior at Hopkins Ingh School, serves on the city's
Chemical Health Commission and helped the city decide on the details of
~ proposal.
She said the program would help if employees receive better training.
RJ think that if they were trained on how to identify fake IDs, it would
probably cut down on a lot of minors buying liquor, R Stacken said.
But it would do little, she said, to combat the other way that many young
people get alcohol- by convincing older adults to buy it for them.
Ben Stevermtln is tlJ
b~bune.co1l&
http://www.startribune.comIstorieSll405I5099215.htm1
Page2of3
11/23/2004
Targeting underage drinking
Page 3 of3
.
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Florida Liquor License
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.''1
Minnesota Department of Public Safety
Alcohol and GambUng Enforcement
444 Cedar Street, Suite 133
St. Paul, MN 55101-5133
651-296-6979 · TrY 651-282-6555 · Fax 651-297-5259
LJl"aI_: Please verify your license information contained below. Make corrections if necessary and sign. City
Clerk/County Auditor should submit this signed renewal with completed license and licensee liquor liability for the new
license period. City Oerk/County Auditor are also required by M.S. 340A.404 S. 3 to report any Jiceuse
canceDation.
License Code n~j::lI License Period Ending 1 :=> I ~ 1 1:=>flJf1I!iD#
City/County where license approved. Cent eY'v i 11 e
1!=iflJAq
Licensee Name
GNAW Inc.
1i'ade Name
CenteY'vil1e LiauoY's
Licensed Location address *712193 2121th Ave S
City, State, Zip Code
CenteY'yil1e. MN 5512138
Business Phone
651/426-6674
LICENSE 1i'ilR~: Off Sale $ 10.121.121121 On Sale $ 121.121121 Sunday $ 121.121121
By sigDJng this renewal application, al'l'Hcant certifies that there has been no change in ownership on the above
named Heensee.For changes In ownersbip, the Hcensee named above, or for new Hc:ensees, foB 81'l'Hcations should
be used. See back of this appHcation for further information needed to complete this renewal.
AppHeant's ~pflltn~ on this renewal mnflnnR the following: FaDure to re.port any of the following will reso1t in fhu>JL
1. Licensee confirms it has no'interest whatsoever, directly or indirectly in any other liquor establishments in
Minnesota. If so, give details on back of this application.
2. Licensee confirms that it has never had a liquor license rejected by any cityltownshiplcounty in the state of
Minnesota. If ever rejected, please give details on the back of this renewal, then sign below.
3. Licensee confirms that for the past five years it has not had a liquor license revoked for any liquor law violation
(state or local). If a revocation has occurred, please give details on the back of this renewal, then sign below.
4. Licensee confirms that during the past five years it or its employees have not been cited for any civil or criminal
liquor law violations. If violations have occurred, please give details on back of this renewal, then sip below.
S. Licensee confirms that during the past license year, a summons has not been issued under the Liquor Liability
Law (Dram Shop) MS 340A802. If yes, attach a copy of the summons, then sign below.
6. Licensee confirms that Workers Compensation insmance is in effect for the full license period.
Licensee has attached a Dquor HabDity bisurance certificate that corresponds with the Hcense period In city/county
where license is issued. $100,000 in cash or securities or $100,000 surety bond may be submitted in Heu ofliquor
DabDity.
Licensee Signature "71/1..-";-I>.I;r W~ . Date /0 -U-D.'I
(Signature certifies all :oo"Z ~~n 'to be correct and license has been approved by city/county.)
City Clerk/County Auditor Signature Date
(Signature certifies that renewal of a liquor, wine or club license ,has been approved by the city/county as stated above.)
County Attorney Signatll1'e Date
County Board issued licenses on!
Police/Sheriff Signature
(Signature certifies lice or associates have not been cited during the past five years for any state/l
(crimina1Icivil). Report violations on back, then sign here.
PS 9093-98
,
Indicate below l!hangP.-CI of cOl:porate ofiicers. partners. home addresses or telephon~ nnmhen;:
.~
. .
Indicate below any ~terest whatsoever. directly or indirectly in other liquor establishments:
Report below details of liquor law violations (civil or crfminal) that have occurred within the last five years. (Dates. offenses.
ftnP.-CI or other pP.Da1ties. includinr Liquor Control Penalties):
. . .
........":" 00
Report below details involving any liCense ~ections or revocations:
City/County Comments:
\1
't
-'
NOTIFICATION FOR ,LICENSE INVOLVING PRIVATE
OR CONFIDENTIAL INFORMATION
(b1cludes Tennesse.. Wa~g)
. . . .
In connection with your request for a license, the City has asked that
y~u provide information about yourself which is classitiedas private,
confidential, nonpublic, or protected nonpublic under the Minnesota
Govern....ent Data Practices Act. This means that, this data is not
ordinarily available to the generill' public. Accordingly, . the City is
required to inform you of the following:
1. The pmpose and intended use of the information requested is to determine if you
are eligible for a license from the City of Centerville.
2. You are not legally obligated to supply the requested information.
, 3. The known consequence of supplying the requested information is that'the
information of finther investigation could disclose information which could
cause your application to be denied.
4. The known consequence of refusing to supply the requested information is that
your request fora license cannot be processed.
s. A criminal charge, arrest, or conviction will not necessarily bar you ftom
obtaining a license with the City, unless the conviction is related to the matter
for which the license is sought, according to Minnesota Statute 364.03.
However, failure to reveal the requested criminal information will be considered
falsification of the application and may be used as grounds for the denial ofth.e
application.
6. Other governmental agencies necessary to process your application are
authorized by law to receive the information provided.
7. The City is required by law to furnish some of the information to the
Deparbnent of Labor and Industry and the Minnesota Commissioner of
Revenue.
8. During the application process, your name and address may be released to the
public. If the license is granted, all the data supplied will be available for
inspection by the public.
The undersigned, by signing this notice, acknowledges that he/she has read and
understood the contents of this notice and has received a copy of this notice.
/O-2-8-t/~,
Date
?:J::.U:;- tv~
CERlllfICATE.OF COMPLIANCE
MINNESOTA WORKERS' COMPENSATION LAW
.
Minnesota Statute, Section 176.182 requires every state and local licensing agency to withhold
the.issuance or renewal of a license or permit to opemte a business or engage in an ~ in
. :Minnesota until the applican1: presents acceptable evi~ce of compliance with the wmkers'
compensation insurance coverage requirements ofMSS Chapter 176. The information required
. is: the name of the ilisurance company, the policy number, and dates of coverage, or the perinit
to self-insore. This information will be collected by the City and rWtined in the files.
This information is required by law, and licenses and pCimitsto operate a business may not be
issued or renewed if it is not provided and/or is falsely reported.. FU1'thepnore, if this
information is not provided or falsely stated, it may result in a $1,000 penalty assessed against
the applicant by the Commissioner of the Department of Labor and Industry..
~ /: T !J,w.tr SUt1eP I}K.,.
Insurance Company Name: dCf-fC('o JnSIIVlu;e:I!. ...
(NOT the insurance agent)
Policy Number:
. Dates of Coverage:
02'" ~P-l3tj79()-IO
17/fli/O'l TO 67/n/dr
/
(OR)
I am not required to have workers' compensation liability coverage because:
D
I have no employees
D
D
I am self-insured (include permit to self-insure)
I have no employees who are covered by the workers' compensation law
(these include: spouse, parents, children and certain farm employees)
5'17) J ~
[Zip]
/6 - 'J-f'-oY
Date
,
i
(:)
n
""""f
N
W
I':t
c=
c:::a
....
CERTIFICATE OF COMPLIANCE
DEPARTMENT OF REVENUE
Pursuant to Minnesota Statute 270.72 Tax Clearance; Issuance. of Licenses, the Iicensmg
authority is required to provide to the Minnesota Commissioner of Revenue your Minnesota
Business Tax Identification Number and the soeialseeuritv number of each license
8Dolicant (oerson sifmm2 the 8Dolication).
Under the Minnesota Government Data PIactices Act and the Federal Privacy Act of 1974, we
are required to advise you of the following regaIding the use oftbis wonnation:
1. This information may be used to deny the issuance; renewal, or tlahsfuI of your
license In the event you owe the Minnesota Department of Revenue delinquent
taxes, penalties, or mterest;
2. Upon receiving this information, the license authority will supply it only to the
Minnesota Department of Revenue. However, under the Federal Exchange of
Information .Agreement, the DepartmeDt of Revenue may supply this
information to the Intemal Revenue Service;
3. Failure to supply this information may jeopardize or delay the processing of
your license issuance. .
Please supply the following irformation and return along with J1UI.l1' application:
. TYPE OF UCENSEBEING APPLIED FOR OR RENEWED: "'~/l.-I 'fi ba-c&t:'
PERSONAL INFORMATION:
Applicant's Name:/L1, C ft.oe,/ I1)PI I Wth-
Applicant's Address: 'Iff 1. 6' n:l ,.,.pell/ A-w
~4U V /IAN
[City] [State]
5$1) 38
[Zip]
Social Security Number:
BUSINESS INFORMATION:
Business Name:
64~ hilJc.
1113 A1~
c",*"&47ft
[city]
A/{))
[State]
6"'6101>>
f3-0g?~t{6r .,.
Business Address:
7)&4 Ct'1-16",'",~ /I~ Lt '1 f/IlteJ
,
,4., s.",1f.
S1138'
[Zip]
Minnesota Tax Identification Number:
Federal Tax Identification Number:
If a Minnesota. Tax Identification Number Is not required, please explain on the reverse side.
/g--)..[j,:..pl/ . .:r ~.".~: ()b/A.V
Date and Position (Officer, Owner, Partner)
...
TAX CLEARANCE. INFORMATION
.
TO LICENSE APPLICANT:
Pursuant to Minnesota Statute 270.72 Tax Clearance: Issuance of Licenses, the licensing authority is
required to provide to the. Minnesota ConuniSsioner of. Revenue your Minnesota Business Tax
Identification Number and 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 this' inf~on:' .
. .
1. This information may be used to deny the issuance, renewal or transfer of your
licei1se in the. event you owe the Minnesota Deparbnent of Revenue delinquent
taxes, penalties or interest;
2. Upon receiving this information, the licensing authority will supply it only to the
Minnesota Deparbnent of Revenue. However, under the Federal Exchange of
Information A~~ the Departm.eirt ofRevenue may supply this information
to the Internal Revenue Service.
3. Failure to supply this information may jeopardize or delay the processing of
your licensing issuance or renewal application.
Please supply the following information and return. along with your application to the agency issuing the
license. DO NOT RETURN TO THE DEPARTMENT OFREVENlJE. .
IJCENSE TYPE: ",,,,Il. / --n D4e€e? NEW [] RENEWAL [.v("
IJCENSING AUTIIORITY:
City of Centerville
IJCENSE RENEWAL DATE: I'" /-6~
BUSINESS INFORMATION:
ausinessName: Cen~tlJlk .lJ1t1~/L~
BusinessA~: 7~fJ ~ 'PI .k-. clw1?
~~etl.IIIUI" A,fAJ.
[City] [State]
Bu,siness Telq>hone Number: 6'71 - '{71 -6.6 "7Y
sn; -S K'
[Zip]
List of Officers or Partners (full name, title, and social security number):
Full Name: A4e.tltPe,/ '11td/ll1P5' WIll f ffltJY
Title: OW I)l,Y Social Security Nmnber:
Full Name:
Title:
Social Security Nmnber:
Full:Name:
Title:
Social Security Nmnber:
Full Name:
Ti,tle:
Social Security Nmnber:
.IF A CORPORATION:
Corporation Name: b f14W J'i?,.
Business Address: 7 tJf.; 2CJ p,
dba {;'4Itr-//,lIe tfl/i1~5
Ate dW'/1" {'~~7~ tVtAl SSo ~R
..
'iI
, Incorporation Date:
List of~rs:
List ofStockhol4ers:
. .
PERSONAL INFORMATION (if sole proprietor):
Applicant's Name:, ~
Applicant's A~:
[City]
[State]
[Zip]
Home Telephone Nmnber:
Social SecurityNmnber:
.ALL APPLICANTS:
List all persons or entities with either a direct or indirect interest in the applicant or the applicant's business
to be ~ under the license for which this application is made and describe their interest in detail
below.
M~t:/1a1 r~~-I'tSw~
Addresses: t{(f:J- [~'l Aw.. tf4U~ .IAIIJ .N"'12.-f'
Asswned or Trade Names, if any:
f9~/-..fU-667f
Business Telephone Nmnber:
6~/- 530 -<< 00
Home Telephone Nmnber:
Has any person named in the application ever been convicted of a felony? D Yes ~ No
If yes, set forth the offense, date, county and stated of conviction:
Applicant, agrees that any manager employed in the licensed premises will have all qualifications of a
licensee and that the manager will D.ot violate any city or state laws. .
Minnesota Tax Identification Number: 6' f'1lJ 1~(
Federal Tax Identification Number: 83 - 0 b 8' 7'16 g
. If a Minnesota Tax Identification Number is not required, please explain on the reverse side.
Signature:~1f vJ.-- Position (Office, Partner, etc.): ~"'~"
. PrintName:/11~Gfwt,f., fdtllf1tV Date: 10'" J/-tJI.{
.
STATE OF MINNESOTA
CITY OF CENTERVILLE
COUNTY OF ANOKA
AppHcation No.
RENEWAL APPLICATION FOR LICENSE TO SELL
TOBA<':CO PRODUCTS AT RETAIL
. . . /liflZ ?~ 4'e. . . . ,tla~~/~.,
The undersigned, resIding at ' ," ", . ,- m the City of -=:" ,,~; , .:.
in the CoUnty of .!l4)If.IIJl.~1) ~ State of Minnesota, Residence Telephone: (b$/) ~30.::,,16. ~o HEREBY
MAKES APPLICATION FOR UCENSE to be issued to MICHAEL WALMER. GNAW INC. DBA
CENTERVILLE LIQUOR, to seJI tobacco products at retail at 7093 20TH AVENUE: SOUTH, Business
Telephone: (/;S7 ).!:Ol.- JI1II in the City ofCenterville. Anoka County. Minnesota for the term of one (1) yea.,
beginning with the 1st dIly of Jtl1UUII'1, 2fJfJS, subject to the laws of the State ofMinnesota and the ordinances and
regulations of said at)' of Centenille pertaining thereto, and herewith deposit $75. fJfJ in payment of the fee
therefore.
By signing this nmewtil tlJlP1icotion, tlJlPlictmt certifies t1ult there has been 110 clumge in 0WfIeI'S1dp,
corporate officers, or ptl1'tllen. If changes have OCCll17'eiltblring the post 12 months, complete in its entirety the
fltttu:hetl TIa CIetmmce Info7mation, then sign below.
Date: / 0- ~i'-()l1
~~
.ItJahral I W9/tn4tr
Name (Print)
FOR OFFICE USE ONLY (Do not write below this line)
Report by Police Department
This is to certify that the applicant and the associates, named herein have not been. convicted within the past five years of any ".
violation offtXtera1,state or local law, ordinance provision, or other regulation relating to tobacco or tobacco products, ortobacco
related devices, or any felony within the last ten years.
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:AC08Lt CERTIFICATE OF LIABILITY INSURANCE I DATI!(MMIDDIYYYV)
10/29/2004
PRODUCER. . (651)644-0311 FAX (651)641-8981 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
plulet/Slater, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
2610 University Ave., '200 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR.
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. .
.-" ,p'aul,. ~$5114
:. . ,. . INSURERS AFFORDING COVERAGE NAtC f# . .
....... -
.. '0 .
. iN8u~ c;en~~~ne~iqu~rs . .. '" .. . .... '. ., ~ . ... . '.- . ..... IN~A: Safeco Xnsurance
DBA: GNAW. lilc . INSURER B: .. 0 ..
7093 20th Ave INSURER C:
. Ceriterv111e, MN 55038 INSURER D:
INSURER e:
CO
THE POUCIES OF INSURANCE USTED Baow HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POUCY PERIOD INDICATED. NOTWITHSTANDINI
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIACATE MAY BE ISSUED OR .
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POUCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
p()UCIES..AGGREGATE UMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. .
~~~~ TYPE OF INSURANCE POUCY NUMBER POUCY EFFECTIVE POUCY EXPIRATION LIMIT8
GENERAL LIABILlTY EACH OCCURRENCE $
- DAMAGE TO RENTED
COMMERCIAl. GENERAL LIABILITY $
I ClAIMS MADED OCCUR MED EXP (Any one person) $
PERSONAL & ADV INJURY $
-;
GENERAL AGGREGATE $
-
GEN'LAGGREGATE LIMIT APPLIES PER: PRODUCTS. COMPIOP AGG $.
.... l~nm9r nLOC
. AUTOMOBILE LIABILlTY . .. COMBINED SINGLE LlMl'i . ,
r-- (Ea accident) $
Att( Al1fO .. . . .
~ . .
ALL OWNED AUTOS BODILY INJURY
r-- $
SCHEDULED AUTOS (Per person) ;
'--
HIRED AUTOS BODILY INJURY
r-- (Per accident) $
NON-owNED AUTOS
.r- . ..
" PROPERlY DAMAGE $
)' (per accident)
-
GARAGE LIABILlTY AUTO ONLY. EAACeIDENT $
q ANY AUTO OTHER THAN EA ACe $
AUTO ONLY: AGG $
EXCE8SIUMBRELLA LIABILlTY EACH OCCURRENCE $
:=JoccuR DClAIMSMADE AGGREGATE $
~:=: $
$
$ $
WORKERS COMPENSATION AND WC STATU- I IO.w-
EMPLOYERS'LIABIUTY E.L EACH ACCIDENT $
ANY PROPRlETORIPARTNERIEXECUTIV
OFFlCERlMEMBER EXCLUDED? E.L. DISEASE. EA EMPLOYEE $
~ describe under
IAl. PROVISIONS below E.L DISEASE. POUCY LIMIT $
~r Liability 02BP2397901 01/01/2005 01/01/2006 $2.000,000/$4,000,000
A
..
DE8CRIPTION OF OPERATIONS / LOCATIONS/VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT /SPECIAL PROVISIONS ~:;f1 ~ 11~ I V IJU
'rovides evidence of insurance. NOV 0 1 2004
Ci ty of Centervill e
1880 Main St
Centerville, MN 55038
SHOULD ANY OF THEABOVE DESCRIBED POUC1E8 BE CANCELLED BEPORE THE
EXPIRAnON DATE THEREOF, THE ISSUING INSURER WD.L ENDEAVOR TO MAIL
J!-DAYSWRITTEN Nonce TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
BUT FAILURE TO MAIL SUCH NoncE SHALL IMPOSE NO OBLIGATION OR LJABiury
OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES.
.AIJl'HORIZED REPRESENTATIVE
ACORD 25 (21)01108)
@ACORD CORPORATION 1988
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Minnesota Department of Public Safety .
Alcohol and GambUng Enforcement
444 Cedar Street, Suite 133
St. Paul, MN 55101-5133
651-296-6979. TIY 651-282-6555. Fax 651-297-5259
RENEWAL OF LIQUOa, WINE, OR CLUB LiCENSE'
T .flWl~: Please verify yoW' license information contained below. Make corrections if necessary and sign. City
ClerklCounty Auditor should submit this signed renewal with completed license and licensee liquor liability for the new
license period. City Clerk/County Auditor are also required by M.S. 340A.404 S. 3 to report any BceDSI!
cancellation.
License Code r.M'R~ License Period Ending 1 ;::./ A j /:=-OIl7tlID#
City/County where license approved. Cent erv i 11 e
1q!=iB
Licensee Name
Mountain Enterorises InCa
Trade Name
Trio Inn
Licensed Location address 7082 Cent e 1''' v i 11 e Rd
City, State. Zip Code
HuClo.. MN 55038
Business Phone
651/426-2956
LICENSE FEES: Off Sale $ 100a 00 On Sale $ 2500.00 Sunday $ 200... 00
By sigoiDg tbis renewal appBcation, appHcant certifies that there bas been no change in ownersbip on the above
named Ii~ For clumgesin ownership, the Bcensee named above, or for new lieeusees, foB applications should
be used. See baek of tbis appHcation for further information needed to complete tbis renewaL
Apglieant's ldr~ on tbis ~ewal confirms the following: FaDnftlj to ~port any of the following will resuIt in fines.
1. Licensee confirms it has no interest whatsoever. directly or indirectly in any other liquor estabIishments in
Minnesota. If so, give details on back of this application.
2. Licensee confirms that it has never had a liquor license rejected by any cityltownship/county in the state of
Minnesota. If ever rejected, please give detaiIs on the back of this renewal, then sign below.
3. Licensee confirms that for the past five years it has not had a liquor license revoked for any liquor law violation
(state or local). If a revocation has occurred, please give details on the back of this renewal. then sign below.
4. . Licensee confirms that during the past five years it or its employees have not been cited for any civil or criminal
liquor law violations. If violations have occurred, please give details on back of this renewal, then sign below.
S. Licensee confirms that during the past license year, a summons has not been issued under the Liquor Liability
Law (Dram Shop) MS 340A.802. If yes, attach a copy of the summons, then sign below.
6. LiceDsee confirms that Workers Compensation insurance is in effect for the full license period.
Licensee bas attached a Hquor IiabDity Insurance certificate that corresponds with the Heense period in city/county
where Heense Is Issued. $100,000 in cash or seeur.lties or $100,000 surety bond may be snbmitted in Heu ofHquor
HabDity. ~ /) YJ1~
Licensee Signature . k 1/ I ' t'j ~r Date / () ;;C; -t1 L/
(Signabae c..:.me. aD aOO"- iDiODiiition to be c:a:rect and ~ """" bas beeo ~ by c:l1y/couDly.) / .
City Clerk/County Auditor Signature Date
(Signature certifies that ~ewal of a liquor, wine or club license has been approved by the city/county as stated above.)
County Attorlley Signature
County Board issued licenses only (Signature certifies licensee is eliglole for license).
Police/Sheriff Signature
(Signature 4'~"- -- --88E)~ba.e BG't ~ during
(criminallcivil) violations on then sign here: .
. .
Date
Date
liquor law violations .
PS 9093-98
Indicate below ehll~es of col1)Orate officers. partners. home addresses or teI~phone numbers:
/ff
'"
fO~
Indicate below any interest whatsoev~ directly or ~directly in other liquor estabJiRhments:
/!./~
I .
','
. ,
. to...
..... .
Report below details of liquor law, ~oIati9~ (~ or eriminan that have occurred within the'.~!fve y~ ~~ m:r~
. fines or other penaIti~ inclndbt~ Liqlior COntrol Penalties): . '
'. I'
'I .~.. .' ~
/YJ?7-.. ~/)t)
- ':. . (,', ,.
. .
l".
Re.:port below detA~ involvtJIg any license rej~ons or revocations: .
, , ':N~" 'L
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City/County P.nmments:'
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"
CEKl'I}lCATE OF COMPLIANCE
MINNESOTA WORKERS' COMPENSATION LAW
Minnesota S~ Section 176.182 requires every state and local liCAnlUttg agency to withhold
the ,issuan~ or renewal of a license or permit to opeflIte a,bnmneB or engage in an ~ in
~esota until the applicant presents acceptable evidence of compliance with the wmkers'
compensation insurance covemge requirements ofMSS Ch8pter 176. The information 'required
is: the name of the insmance company, the policy number, and dates of coverage, or the permit
to self-insure. This information will be collectecl'by the City and retBined in the files.
This information is required by law, and licenses and permits to operate a businP.!L~ may not be
issued or renewed if it is not provided and/or is fi1lsely reported. Futtbermore, if this
information is not provided or falsely stated, it may result in a $1,000 penalty assessed against
the applicant by the Coinmissioner oftbe Deparbnent of Labor and Industry.
Insurance Company Name:
amI the insurance agent)
Policy Number: .
Dates of Coverage:
~J )1l6 TO IJ' -:J{lJ,)
(OR)
I am not required to have workers' compensation liability coverage because:
o
I have no employees
I am self-ins1.n-ed (include permit to self-insure)
o
o
I have no employees who are covered by the workers' compensation law
(these include: spouse, parents, children and certain farm. employees)
1 certify that the iTiformation provilkd above is accurate and complete and that a valid
workers' compensation pOlicy will be kept in tiffect at all times a$ required by law.
Name:
[First]
[Middle]
[Last]
Name of Business:
Business Address:
[city]
[State]
[Zip]
Business Phone:
Date
Sig11ature
TAX CLEARANCE INFORMATION
. RECEIVED
NOV 0 1 2004
'.,
" ..
TO LICENSE APPLICANT:
Pmsuant to Minnesota Statute 270.72 Tax Clearance: Issuance of Licenses, the licensing authori1;y is
required to. provide to the Minnesota Commissioner of Revenue your Minnesota Business Tax
Identification Number and 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 of1:he following tegarding the use of this infQrJD.ation: .
1. This information may be used to deny the issuance, renewal or transfer of your
license in the event you owe the Minnesota Depar1ment of Revenue delinquent
tax~ penalties or interest;
2. Upon receiving this information, the licensing authority will !fIlPPly it only to the
Minnesota Depar1mentof Revenue. However, under the Federal Exchange of .
Information Agreement the Department of Revenue may supply this information
to the Internal Revenue Service.
3. Failure to supply this information may jeopardize or delay the processing of
your licensing issuance or renewal application.
Please supply the following information and ~ along with your application to the agency issuing the
license. DO NOT RETURN TO THE DEPARTMENT OF REVENUE.
UCllNSll1YPll: r . NEW [] RENEWAL?<
LICENSING AUTIlO : . City ofCenterville
LICENSE RENEWAL DATE: / -1- (;. ~
B~Address:
~)t) . J;
Business Name:
w
[City] [State]
Business Telephone Number: ~S 1- If ~ , ,. ;) rs. t
[Zip]
~, ?-~/' ;;, /.. :l/Yf
,..
List of Ofticers or Partners (full name, title, and social security number): _ J
Full Name:. /141/ ~ /ll 0/1) f/:///V
Title: ~.f4L Social Security Number: _
Full Name:
Title:
Social Security Number:
Full Name:
Title:
Social Security Number:
Full Name:
Title:
Social Security Number:
IF A CORPORATION-
Corporation Name: 7>1 0l/Jt.11'A-1,v
Business Address: 7 0 ~.. i
~~k
~4I
~..
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6:(Sb?~
Incorporation Date:
List of Directors:
~d
fJeUi.
,
Ifit
/Il ~ /l.J -ptJ JAJ
'\
. '" ,_. f:
. ;J!JeVL ../J1t1)A) TA/N
, ~ .
'. List of Stockholders:
'. . . .
PERSONAL INFORMATION (lfso1e proprietor):
=:::: p:};~ PJ:~ q' .
~. ~..~ /I!/Ll. SS03~
. . [City] [SUIte]. [Zip]
HomeTelephoneNmnber:II~ ~)I.- U3-' Og~ 'C: bSi ;)6/-;)1<1;
Socia1 Secmity Number:
ALL APPLICANTS:
List all persons or entities with either a direct or indirect interest in the awJ.cant or the apPlicant's business
to be conducted 1.mder the license for which this application is made and desctibe then' interest in detail
below.
4
Addresses:
Assumed or Trade Names, if any:
Business Telephone Nmnber: Home TelephoneNU1Ilber:
Has an;y p<IllODllllIlIlld in the applicalion ewr been - of. fOIooy'I D Yes f No
If yes, set forth the offense, date, county and stated of conviction:
Applicant agrees that any JIl8I18F1' employed in the licensed premises will have all qualifications of a
licensee and that the manager will not violate any city or state laws.
Minnesota Tax Identification Nmnber: .3 6 (, :J... ~ J 9'
Federal Tax Identification Number: LJ I J '- ~ '"- )( t. '7.r
~.~~~~plesseexpain...the.......aido. /J .
Signature: ~~_ Position (Office, Partner, etc.): r ~,.
Print Name: {?4.UL fHf)N7~J~: / /) ... ~'~--Or .
NOTIFICATION FOR LICENSE INVOLVING PRIVATE
, OR'CONFIDENTIAL INFORMATION
(Includes ,Tennessen Wa~g)
. . . .
In connection with your request for a licens~, the City has asked that
you provide information about yourself which is classified ,as private,
confidential, nonpublic, or protected nonpublic under the Minnesota
GovemmentData Practices Act. This means that this data is, not
ordinarily avallable to the generalpublie. Accordingly, the City is
required to inform you of the 'following:
1. The pmpose and intended use ~fthe ii1formatiQn~ested is to determine if you
are eIigJ.ole for a license from the City of Centerville. '
2. You are not legally obligated to supply the requested information.
3. The known coJllltlqUeIlce of supplying the requested information is that the
information of further investigation could disclose information which could
cause your application to be denied.
4. The known consequence of refusing to supply the requested information is that
your request for a license cannot be processed.
5. A criminal charge, arrest, or conviction will not necessarily bar you from
obtaining a license with the City, unless the conviction is related to the matter
for which the license is sought, according to Minnesota Statute 364.03.
, However, fidlure to revea1the requested criminal information will be considered
falsification of the application and may be used as grounds for the denial of the
application.
6. Other governmental agencies necessary to process your application are
authorized by law to receive the information provided.
7. The City is required by law to furnish some of the information to the .
Deparbnent of Labor and Industry and the Minnesota Commissioner of
Revenue. "
8. During the application process, your name and address may be released to the
public. If the license is granted, all the data supplied will be available for
inspection by the public.
The undersigned, by signing this notice, acknowledges that he/she has read and
understood the contents of this notice and has received a copy of this notice.
f1-/J~
SigDamre .
CJ c::r J- if '0 <{
Date
.'
..
STATE OF MINNESOTA
COUNTY OF ANOn
CITY OF CENTERVILLE
Application No.
RENEWAL APPlICATION FOR LICENSE TO SELL
TOBACCO PRODUCTS AT RETAIL .
Theundersigned, residing at ~() ~tfmtheCityof ~ / ~
intheCountyof ~ . . State of Minnesota, Residence Telephone: (~ k$'3 t!>8Sf HEREBY
a
MAKES APPLICATION FOR LICENSE to be issued to PAUL MONTAIN, MOUNTAIN ENTERPRISES,
INC. DBA TRIO INN, to sell tObacco products at retail at 7082 CENTE:RVlL.L.E ROAD, Business Telephone: (
~"o1) IQlt ~~mthe~qfCenterville,AnokaCounty,.Minnesotafor thetermofone(l)yearbqVnningwiththe
1st dJq of JIlfIlUIrJ, 1H5, subject to the laws of the State of Minnesota and the ordinances and regulations of said
~ of CentenilIe pertainiDg thereto, and herewith ~ $75.H in payment of the fee therefore.
BJ signing this renewaltlpJJlicatlon, tIJ1Plicat certifies t1uIt there 1uIs been fUJ clumge in ownership,
. corportlIe of.Iicers, orJ.1lll11let'& If clumges IItIve oeetm'etl tlurhIg the ptlSt 11111Onths, complete in its entirety the
tlttIIChetl TIlX Uetmuu:e Inf017lUltion, then sign below.
~d~/i i?~~~
SlgJtitore Ar<< /II(J~ ~/N
Name (Print)
Date:
FOR OFFICE USE ONLY (Do not write below this line)
Report by Pollce DepartmeDt
.This is to certify that the applicant and the associates, named herein have not been convicted within the past five years of any
:iolation offedera1, state or local law, ordinanMprovision, or otherregolation relating to tobacco or tobacco products, ortobacco
le1ated devices, or any felony within the last ten years. .
SigJISltore
Title
,-
CERI'DICATE OF COMPLIANCE
DEPARTMENT OF REVENUE
Pursuant to Minnesota Statute 270.72 Tax CleaIance; Issuance of Licenses,.-the licensing
atttb.ority is required to provide to the Minnesota. CommiA.4lioner of Revenue your M"lIlnesota
Business Tax' Identification Number and the social seemitv Dumber of each license.
amDlieant (nerson mtmine: the amDJication).
Under the Minnesota Government Da1B-Practices Act and the Fedeml Privacy Act of 1974, we
are required to advise you of the following regaIding the use of1his information:-
1. This information may be used to deny the issuanoo, renewal, or trans:feJ: of your
license in the event you owe the Minnesota Department of Revenue delinquent
taxes, penalties, or interest;
2. Upon receiving this information, the license authority will supply it only to the
Minnesota Department of Revenue. However, under the Federal Exchange of
Information Agreement, the Department of Revenue may supply 1his
information to the InteImi1 Revenue Service;
3. Failure to supply this infOImation may jeopardize or delay the pror~ing of
your license issuance.
Please gupply the following irifonnation and return along with JI(JU1' application:
1YPE OF UCI!NSB BBING APPIJJlD FOR ORRJlNEWllD: ~
PERSONAL INFORMATION: IJ
Applicant's Name: lJ2rL) /IltJ /LIlA IN
~ >;~ ~/UJ
1. 1/01) LA;(77 5 /JI/U
[City] rStatel 1ZiP! 55oJ/
Applicant's Address:
Social 8,curity Number:
BUSINESS INFORMATION:
Federal Tax Identiflcation Number:
;1!Ol//I/TA(,v ~ &
7oi2 ~~
~ ~JfI)- Jll/A/ 5,-)0
[City] [S1ate] [Zip]
3~U2/y
'-II /,-)Sl697
.
Business Name:
Business Address:
Minnesota Tax ldentijicationNumber:
l/a- TQ%~onNumberI8 not~~_ F.[Jlain on the reverse side.
&cT-;;fl(JU ..fJad
Date -, Si~ and Position (O:fticer, Owner, ~)
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ACORDTfI CERTIFICATE OF LIABILITY INSURANCE I DATE(MM/DDIYYYY)
11/1512004
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMA110N
MN01-Bums & Wilcox, lid - Minnesota ONL YAND CONFEItS NO RIGHTS UPON THE CER11FICATE
60 Plato Blvd East HOLDER. THISCER11FICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POUCIES BELOW~
St Paul MN 55107 '.
" " INSURERS AFFORDING CO~~~ _
i ...... " .., NAlC ., , ,-
INSURED THE TRIO 'INN INSURERA: SCOTTSDALE INSURAN.C.E CQ,I\I1PANY ,
..~ ','-', .. . ,
, ,MOU'NTAIN ENTERPRISES INC, DBA: INSURER B: ,. " ....
6510 CENTERVlLLE ROAD INSURER c: "
UNO lAKES MN 55038 INSURER D: "
f INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOlWlTHSTANDlNG
ANY REQUIREMENT, TERM OR CONDmON OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDmoNS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ,
~~~ POUC\' NUMBER POUC\' EFFEC11VE POUC\' EXPIRATION LIMITS
, .!!NERAL UABI1JTY EACH OCCURRENc"E $
1:8 tEa occurence\ ..
COMMERCIAL GENERAl UABIlITV $
I ClAIMS MADE D OCCUR MED EXP (Any one P8/SOIl) $ -
PERSONAL & ADV INJURY $
GENERAL AGGREGATE $
~AGGREn LlMrT APrJ' PER: PRODUCiS. COMPlOP AGG $
POUCY :.cg: LOC
~OBILE L/ABlUTY COMBINED SINGLE LlMrT $
.~ ANY AUTO (Ea~)
,
- ALL OWNED AUTOS BODILY INJURY
';... ..,- (Per person) $'
SCHEDULED AUTOS -,
---:c ...;')..'1\'../, ..~...!;-~Jt-t.........l:"J t:_'~ . t:::;...... ! .!......::'.. ;' ;... .. ' .
'HIREt)'AOrOS . ,L. , . , - BODILY INJURY ,
7 .... , "'.~.', ..... ' .. $-
; ~p ~ON..o~ AUTOS - , . '" " " .(peraccldelil), , ; ; .~.
..... .
- '" . ....-. ~. .-. ~.. .... .. .' .. -, ..
. .' . . " ' " " >0 .
. ' : PR<>PEiUv DAMAGE
- $
: " (Per~
, .. :
=rEUAmUTY AUTO ONLY. EAACCIDENT $
ANY AUTO OTHER 1liAN EAACC $
AUTO ONLY: AGG $
EXCSS8IUMBRELLA LIABIUTY EACH OCCURRENCE $
::J -OCCUR 0 CLAIMS MADE AGGREGATE $
$
~ DEDUCTIBLE $
RETENTION $ $
woRKERs COMPENSATION ~ l~sr~1 10Jt
EMPLOYERS'LIABIUTY E.1.. EACH ACCIDENT $
ANY PROPRlETORIPARTNERIEXECUTIV
OFFICERIMEMBER EXCLUDED? E.L DISEASE. EA EMPLOYEE $
~ descrlbe under $
IAL PROVISIONS below EoL DISEASE. POUCY LIMIT
A OTHER CLS1053n8 12/3112004 12/3112005 EACH COMMON CAUSE 300,000
LIQUOR lIABILITY
GENERAL AGGREGATE 300,000
"'--'; -
DESCRIPTION OF OPERA11ON8/ LOCATIONS/VEHICLES/ EXCWSIONS ADDED BY ENDORSEMENT 'SPECIAL PROVISIONS .KE CE.IVEfi
LOCATION:
7082 CENTERVlLLE ROAD NDV f 6 2004
CENTERVlLLE, MN 55038
CERTIFICATE HOLDER
CANCELLA110N
CITY OF CENTERVlLLE
1880 MAIN ST
CENTERVlLLE
MN 55038
SHOULD ANY OFTHEABOVE DESCRIBED POUClES BE CANCEUI!D BI!FORETHE EXPIRATION
DATETHEREOF, THEISSUINGINSURERWlLLENDEAVORTO~ ~ DAYSWRlT
NOTI.CE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO 80 SHALL '
IMPOSE NO OBUGATION OR LIABIUTY OF ANY KIND UPON THE INSURER, ITSAGENTS OR
REP "T1YE8.
REP
ACORD 25 (2001/08)
@ACORD CORPORA110N 1988
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Minnesota. Department of Public Safety
Alcohol and' GambliDg Enforcement
444 Cedar Street, Suite 133
St. Paul, MN 55101-5133
651-296-6979 · TrY 651-282-6S55 · Fax 651-297-5259
T .v.m-' Pl~ verlfy your license infOrmation contai!1ed below. Make corrections if necessary and sign. City ,
Clerk/Count.y Auditor should submit this signed renewal with completed licenSe ,and liceDseQ liquor liability for the new
license period. City Clerk/County Auditor are also required by M.S. 340A.404 S. 3 to report any JiceDse
cancellation.
License Code , nN!=lR License Period Ending 'I ~ /3 'I /~t1ItlJlID#
City/County where license approve4- Cent erv i 11 e
1=.:?73
Licensee Name
Wiseauvs Pizza Inc.
Trade Name
Wiseauvs Pizza
Licensed Location address 7095 20t,h Ave S
City. State. Zip Code
Centervil1e. MN 55038
Business Phone
651/653-1077
LICENSE 1i'R1i'_~: Off Sale $ 0. 00 On Sale $ 2500. 00 Sunday $ 21Z!0. 00
By signing t1ds renewal application; 'applicant certifies that there hfIS been nO clumge In oWnership on the above .
nam.ed B.censee. For cbanges In ownership, theHcensee named above, or for.new Hcensees,.foII appHcatio~ ~~:aId
be USed. See back: of this application for further information needed to '*Dplete this renewal. . .
A,ppHcant's ~AftrrP. on this renewal confirms the fonowing: Faflnftl! to ~port ~ of the followinlJ will result In t'InAL
1. Licensee confirms it bas no interest whatsoever. directly or indirectly in 8!1Y other liquor esta],l~Ahm~ in
Minnesota. If so. give &taiIs on back of this applicatiOn. .' .
2. Licensee confirms that it has never had a liquor license rejected by any cityltownsbiplcounty in the state of
. Minnesota. If ever rejected. please give details on the back of thiS renewat.. then sign bel<;>w.
3. Licensee confirms that for the past five years it has not had a liquor license revoked for any liquor law violation
(state or local). If a revocation has occorred. please give details on the b~k of this renewal. then sign below.
4. Licensee confi:t.ms that during the' past five years it or its employees ~venot been cited for any civil or rniTninlll
liquor law violations. If violations have 0CCll1'I'ed. please give details on b!lCk of this renewal. then sign below.
S. Licensee confirms that during the past license year. a summons bas not ~ issued under the Liquor LiabiIity
Law (Dram Shop) MS 340A.802. If yes. attach a copy of the summons. then sign below.
6. Licensee confirms that Workers Compensation insurance is in effect for the fall license period.
LiceDSee has attached a liquor IiabDity insurance certificate that corresponds with the HcenSe period In city/county
where license Is Issued. $100, In cash or securities 100,000 surety bond may be submitted in Heu of Hquor
Uability. .
, ".
'()~ z5- 0
Licensee Si Date
(Signature above information to be coriect and license bas been approved by city/county:)
" .
City Clerk/County Auditoi Signature Date
(Signature certifies that renewal of a liquor. wine or club license has been approved bj the city/county as stated above.)
County A.ttorI)ey Signature Date
County Board issued licenses 0
PoliceJSperlff Signature Date
(Signature certifies licensee or associates have not been cited during the past five years for any stateI1
(criminal/civil). Report-violations on back, then sign here.
PS 9093-98
(
~.
Indicate below ~lumges of col:porate nmce~ parln~ home addresses or ~hone numbers:
.....
n.'"
.
;)
Indicate below anY interest whatsoev~ directly or indirectly in other liqp.or estabH!lbments:
Rqmrt below detaillil of IiQJlor law Violations (ctriI or crimfnAn that have N'.M11"I'Pd within the last ~e years. O>a~ o:ff~
fines or other penRlti~ inclniHn~ LiQJlor Control Penalties):
J.. Z 7 - D3
fA JL~-O
(),IY'J.o4A N~ r e,hec/C
I'
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Report below deta& involving' any license rejections or revoc8.tio~:
City/County Comments:
.:..... .v.- .:;:.....~ _ _ . o. .
.
CERTIFICATE OF COMPLIANCE
MINNESOTA WORKERS' COMPENSATION LAW
, ,
Mirm.esota Statute, Section 176.182 requires every state and loca1licensing agency to withhold
:the issuance or renewal of a license or permit to opeIate a business or engage in an activity in
,Mirm.esota until the appliqurt presents acceptable evic;lence of compliance with 1:he workers'
compensation insurance coverage requirements ofMSS Chapter 176. The .infonnation required
is: the name of the insurance company, the policy number, and dates of coverage, Or the permit
to self-insure. This information will be collected by the City and retained in the files.
, ,
This information is required by law, and licenses and permits to operate a business may not be
issued or renewed if it is not provided and/or is fillsely reported. Furthermore, if this
information is not provided or :falsely stated, it may result in a $1,000 penalty assessed against
the applicant by the CommiASioner of the Department of Labor and Industry.
Insurance Company Name:
(NOT the insurance agent)
F,lls.,- DAKorn rlllll1l.JtlAJl1
W (,20 - (J 00 ();).ILJ.. () 0
-l-I- ~ '1- 0) TO-L1- "Lt/ -0 vi
(OR)
Policy Number:
Dates of Coverage:
1 am not required to have workers' compensation liability coverage because:
o
I have no employees
o
o
I am self-insured (inclutk permit to self-insure)
I have no employees who are covered by the workers' compensation law
(these include: spouse, parents, children and Certain farm employees)
1 certify that the irformation provitkd above is accurate and complete and that a valid
workers' compensation policy will be kept in effect- at all times as required by law.
Name: 1!-~t1.eTl4 F~C!-lS VItl-fnD (l (?~l~
[First] [Middle] [Last]-
Name of Business: WI> e G lJ '\., ~ R"'l.. 'Z..~
I
Business Address: 70 i s ~ qH J91/E' S
Ce1'JTeO dJ ~U- m", 55033'
[City] [State] [Zip]
Business Phone.:. .. Cs /-{S7-~
;0- 25'-0'-/ . __ _ _
Date ' Signature
CER'ID'ICATE OF COMPLIANCE
DEPARTMENT OF REVENUE
Pursuant to Minnesota Statute 270.72 Tax Clearance; Issuance of Licenses, the licensing .
authority is required to provide to the ~ Commissioner of Revenue your Minnesota
Business Tax Identification' Number and the social' secmitv number of each license
apolicant (uerson sUrniDt! the 8Dulieation).
Under the Minne$ofa Government Data PIactices Act and the Federal Privacy Act of 1974, we
are required to adVise you of the following regarding the use of this iofonnauon:
1. This information may be used to deny the issuance, renewal, or tnmsfer of your
license in the event you owe the Minnesota Department of Revenue delinquent
taxes, penalties, or interest;
2. Upon receiving this information, the license authority will supply it only to the
Minnesota Department; of Revenue. However, under the Federal Exchange of
Information Agreement, the Department; of Revenue may supply this
information to the Internal Revenue Service;
3. Failure to supply this information may jeopardize or delay the processing of
your license issuance. .
Please supply the following iriformation and return along with ymu application:
TYPE OF LICm~SEBE1NG APPLIED FOR OR RENEWED:. ~ ~.
PERSONAL INFORMATION:
Applicant's Name:
Applicant's Address:
~tl(?11-/ f flA#JD~.e.~
b89~ CenteR. Ull.LK' ~-o
~TCfl"'~LtE tnN' . 5'So:JY
[City] [State] [Zip]
Social Security Number: _
BUSINESS INFORMATION:
Business Name: M.s tE (; u y S RtZ z,A-
Business Address: 7 () q S' ;;'oqrJ ~ S
C'en1trV/~ rn'" SSo3Y
[City] [State] [Zip]
Minnesota Tax ldentijJcatton Number: '-/S Od} 9 7 0
Federal Tax ldentljJcation Number: L/ 1- I <1S 0 1.3 Y
If a Minnesota Tax ldentiftcationNumber is no
/(J-;;;S - 0'1
.
Date
Incorporation Date:
List of Directors:
/99~
~J')~e.1VI E-VA~/)~tJ~/<-
ListofStockho1deJ:s: -.-}<MIl.e 17f~f' VPnJ oJiP.,"BJi/L\l
JUt..I~ m fJ/t,J/J..ef2a~
. .
PEBSONAL INJ'OR.MATION (If sole proprietor):
App1ic:aDt's Name:
Applic:ant's Address:
[City]
[State]
[Zip]
Home Telephone Number:
Social Secorl1y Number:
ALLAPPUCANTS:
List an peISODS or entities with either a ctirect or indirect interest in the applic:ant or the app1ic:ant's bnmness
to be conducted under the liceDse for which this appli<:ation is made and descn'be their interest in detail
below.
. ~/lJ)Jlr
Addresses:
Assumed or Tmde Names, if any:
Business Telephone Number: Home Telephone Number:
Has any personmunedin the appli<:ation ever been convicted of a fe1ony? 0 Yes 9J{ No
Jfyes. set forth the offense, date, c:ounty and stated of conviction:
I
Applic:ant agrees that any Dl8II8geI" employed in the liceDSed premises will bave an qualifications of a
liceDsee and that the manager will not violate any city or state Jaws.
MinnesotaTaxl~Number: '-Is 0:2, q 7 0
Federal Tax Identification Number: t..j I ~ I <; ~ 0 7:1 Y
Jfa~ ~_islllll~ pkasoczplaia..,1he_sidc.
Si8"81~ --"" Position (Office, Partner. etc.): ~~eg 1 D ~1"\tJ" .
PriDtName:'~ Date: J()- 25-0'-/ I
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TAX CLEARANCE INFORMATION
TO LICENSEAPPUCANT:
PwSll8l1t to Minnesota Statute 270.72 Tax aearance: Issuance of Li~ the licensiTlg authority is
lQJ.uUtd to 'provide to the Minnesota Commissioner of Revenue your Minnesota Business Tax
l~on Number and social secu1.itJ number of each license applic:aot.
Under the Minnesota Govemmeut Data P.racti<:es Act and the Federal P.rivacy Act of 1974, we are fequh~
, to advise you of the fonOwingl~diu.g the use oftbis information:
, ,
1. This .inf01mation may be used to deny the ~ nmewal or b:ansfel of your
license in the event you owe the Minnesota DepaJ:tmeDt of Revenue cIeliDquent
taxes, penalties or interest;
2. Upon receiving tbis illfoll1latOt. the licenRing authori1y w.iJl supply it only to the
MiDnesota Department of Revenue. However, under the Federal Exc~ of
TlIfol numon Agreement the Department of Revenue may supply tbis h.thnmlti()n
to the Internal Revenue Service.
3. Faihue to supply this lofo.tmation may jeopardize or delay the ~ng of
your lic:ensing issuance or renewal appJiaItion.
Please supply the foJ1owing j..thr~QD and return aIoDg with your application to the agency issuing the
license. 'DO NOT RET1JRN TO THE DEPARTMENT OF REVENUE.
LICENSE TYPE: ~ cnrn- NEW [] RENEWAL ~
LlCENSlNG AtITHORITY: City ofOmterville
LlCENSERENBWALDATB: 1- I-I) ~
BUSINESS INJ'OBMATION:
Bush1essName: Wl5 € ().U ys ~-Z 'Z;it
Business Address: '70 q 5 :2 () rH fJ-tIlr: S
(lpA?,erVlt.,.r /J1rJ
[City] [State]
Business Telephone Number: 6~<; 1- '53-1077
P03~
[Zip]
List ofOJlicers or Partners (full name, 1it1e, and social security nmn1,er):
FoB~: ~Il/U>JtJ--F~C4r VIblDe.fl, 6.ee....
TItle: J ~e. ~ J t:1-t"''''' Social Security Number: ~
FoB Name: JUL/€"" ;1IJltfltiG lIA-JIUI/Oee.K
Title: ~ ~"'rA ~ Social Secority Number:
FoB Name:
Social Security Number:
Title:
FoB Name:
TItle:
Social Secority Number:
D A COBPOBATION:
Cmpura/imName: J1j1k G~ y' f(l.t.n I ~ (. I!!!II. Wis.fE. G <41 r. ~'t"'t,q.
Business Address:
Time: 02:32 PM To: 651-429-8629
651-641-8981
CERTIFICATE OF LIABILITY INSURANCE
DUCER (651)644-0311 FAX (651)641-8981
ulet/Slater, Inc.
2610 University Ave., #200
St. Paul, MN 55114
Page: 001..002
DATE (MMIDDIYY'tY)
11/01/2004
. THIS CERTlRCATE IS ISSUED ASA MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
. HOLDER. THIS CERTIFICATE DOES NOT AMENDJ .EXTEND OR
AL TERTHE COVERAGE AFFORDED BY THE POuCIES BELOW.
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVJ; FOR THE POLICY PERIOD INDICATED. N01Wl1HSTANDING
AN( REQUIREMENT, TERM OR CONDmON OF ANf CONTRACT OR OTHER DOCUMENTWI11i RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN, THE INSURANCE AFFORDED BYTHE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDmoNS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID ClAIMS.
If: ~ 1YPE OF INSURANCE POUCYNUMBER POUCYEFFEC11VE . POUCYEXPIRAnON
, GENERAL L/AB1l..l1Y
-
COMMERCIAl GENERALI.IABII.ITY
I CLAIMS MADE D OccuR
COMaNED SINGLE UMT $
(Ea actIdenI)
BODILY INJURY $
(Per person)
BODILY INJURY $
(Per actIdenl)
PROPERlY DAMAGE $
(Per acddenl) ,
$
$
$
$
$
$
$
$
I WCSTA'fU. I IOJr,
EL. EACH ACCIDENT $ 1000
EL.DISEASE-EAEMPlOYEE $ lOOOl
EL.DISEASE-POUCYUMT $ 5000
$1,000,000 Ea Conunon Cause
$2,000,000 Aggregate
CANCELLATION
SHOULD ANf OF THE ABOVE DESCRIBED POUCIES BE CANCB.LED BEFORE THE
. .
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAD..
....1Jl.DAYSWRrTTENNOTICETO THE CERTIFICAlE HOLDER NAMED TO THE LEFT,
BUT FAI1.URE TO MAt1. SUCH NOnCE SHALL IMPOSE NO OBUGA'nON OR L/ABn.nY
OF ANfKIND UPON THE INSURER, ITS AGENTS ORREPRESENTA11VES.
AUTHORIZED REPRESENTATIVE 4'~ J
@ACORDCORPORATlON1~
INSURED Wi seguys P zza Inc
,7095 20th Avenue S
Centervil1e, MN 55038-0000
INSURERS AFFOR()ING COVERAGE
INSURERA: First Dakota
INSURERS: Safeco Insurance
INSURERC:,
INSURER D:
INSURER E:
EACH OCCURRENCE
DAMAGETO~II:D
GEN'l. AGGREGAlE UMT'APPUES PER:
I POUCY n ~ nlOC
MED EXP (Anyone person)
PERSONAl & ADVJNJURY
GENERAlAGGREGAlE
PRODUCTS- COMPIOP AGG
.
AUTOMOBD..E L/ABn.nY
-
ANYAUTO
All OWNED AUTOS
SCHEDUlED AUTOS
HIRED AUTOS
NON-OWNED AUTOS
-
-
-
-
-
i::~
EXCESSlUMBREi.L.A LlABn.nY
:=J OCCUR D Cl.AIMSMAoE
I D~LE
"I RETENTION $
WORKERS COMPENSATIONANO
EMPLOYERS' LIABILITY
,~ ~~~CUTIVE
Wyes, describe under
SPECIAL PROVISIONS below
L~or Liability
B
AUTO ONlY - EA ACCIDENT
EA ACC
AGG
OTHERlHAN
AUTOONlY:
EACH OCCURRENCE
AGGREGAlE
WC20000221400 11/24/2003 11/24/2004
02BP240321 01/01/2004 01/01/2005
..pESCRJP1]ON OF OPE,MTIONS ILOCAJ'lONS IVEHlCLESI EXCWSlONSADDED BYENOORSEMENT I SPECIAL PROVISIONS
~rov1des Evidence or Insurance
CERTlRCATE HOLDER
City of Centerville
1880 Main Street
Centerville, Mt1I 55038,
ACORD 25 (2001/08) FAX: (651)429-8629
NAlC#
LIMITS
$
$
$
$
$
$
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. .
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.
NOlll1:CATION FOR LICENSE INVOLVING PRIVATE
OR CONFIDENTIAL INFORMATION
(Inclnd~ Te~essen Wa~g)
. . . . .' .
In, connection With your request for a license, the City has asked that
you provide'information about yourself which is ~Iassified as private,
confidential, nonpublic, or proteeted nonpublic under the Minnesota
Government Data Practices Act. This means that thiS data is not
,ordinarily available to the general public. Accordingly, t~e City ,is
required to inform you of the following:
1. The p1lq)OSe and intended use of the information requested is to determine if you
are eligible for a license from the City ofCenterville.
2. You are not legaJly obligated to supply the requested information.
3. The known consequence of supplying the requested information is that the
information of further investigation could "disClose information which could
cause your application to be denied.
4. The known consequence of refusing to supply the requested information is that
your request for a license cannot be processed.
S. A criminal charge, mest, or conviction will not necessarily b8:r you from
obtaining a license with the City, unless the conviction is related to the matter
for which the license is sought, according to, Minnesota' Statute 364.03. '
However, failure to reveal the requested criminal information will be considered
fBlsification of the application and may be used as grounds for the denial of the
application.
6. Other governmental agencies necessary to process your application are
authorized by law to receive the information provided.
7. The City is required by law to :furnish some of the information to the
Deparbnent of Labor and Industry and the Minnesota Commissioner of
Revenue.
8. During the application process, your name and address may be released to the
public. If the license is granted, all the data. supplied will be available for
inspection by the public.
The undersigned, by signing this notice, acknowledges that he/she has read and
understood the contents of this notice and has received a copy of this notice.
. . . .
Itll /(/~.
~n~
Signatme
Date
. .
'.
STATE OF MINNESOTA
COUNTY OF ANOKA
CITY OF CENTERVILLE
Application No.
RENEWAL APPLICATION FOR LICENSE TO SELL,
TOBACCO PRODUCTS AT RETAIL
The undersigned, residing at Jd'87 hI~7.J-; in the City of CO--1::r~-
-
in the County of ~tate of Minnesota, Residence Telephone: fG/) 7~ -; U"b HEREBY
MAKES APPLICATION FOR LICENSE to be issued to CARL BUECHLER, DBA CENTER MART, tose1l
tobacco products at retail at 1801 MAIN STREET, Business Telephone: (Jo/ ~- ~ the City of.-
Centerville, AnDira County, Minnesota for the term of one (1) year beginning with the 1st day of JIl1IUII'IY, ZtHJS,
subject to the laws of the State ofMinnesota and the ordinances and regulations of said O(v ofCentetvi1le pertaining
thereto, and herewith deposit $75.00 in payment of the fee therefore.
By signing this renewal fJ]1JIlication, tIJIplictlnt certifies t1uIt there 1uIs been no chimge in ownership,
cotp01'llte offken, or]Jfl1'lnen. If cbtmges 1uwe OCClU'I'etl during the post 1Z'montlls, complete in its entirety the
tltttJched Ta CIeartmce InfOl'llUlJion, then Sign below.
Date: II/I /Po/
&~~
Signature
e~; J.. P. 8k6e:f!.h'.LSAL.
Name (Print) ,
FOR OFFICE USE ONLY (J)o not write below this line)
Report by PoJiceDepartment
This is to certiJY that the applicant and the ~ named herein have not been convicted within the past five years of any
violation offederal, state or local law, ordinance provision, or other regulation reJ.ating to tobacco or tobacco products, ortobaoo
related devices, or any felonywitbin the last ten years.
Signature
Title
. ~
'1
CERTIFICATE OF COMPLIANCE
DEPART:MENT OF REVENUE'
I
, ,
Pmsuant to Minnesota St.a:tute 270.72 Tax 'Clearance; Isswmce of Licenses,: the licensing
authority is reqoiredto provide to the Minnesota Commi~oner of Revenue your Minnesota
Business Tax Identification Number and the social seCuritv number of ea.eh license
aDuHcant (uerson monm2' the aouHcation).
Under the Mfunesota Government Data. Practices Act and the Federal Privacy Act of 1974, we
are required to advise you of the following regarding the use of this .uauulIi:atlon:
1. This informa1ion may be ~ed to deny the ~, renewal, ortlaosfbr of your
license in the event you owe the Minnesota Department of Revenue delinquent
taxes, penalties, or interest; ,
2. Upon receiv.ing this information, the license authority will supply it only to the
Minnesota Department of Rcveme. However, under the FedeJ:al Jl"l'l"~ of
Info.unation Agreement, the Department of Revem1e may supply' this
information to the 'fntP.mal Rcveme Semce;
3. Failure to supply this information may j~ or delay the ~g of
your license issuance.
Please supply the joliowtng irif01'1(lation and retuni along with your application:
lYPH OF UCBNSBBHlNG APPLIED FORORRBNBWIID: ~
PERSONAL INFORMATION:
~licant's Name:
Applicant's Address:
e.JJII- BI/,.C,H,l.p!l
I~ 87 /f!4U AJ.b TA/
CslJr~ V/t-./,.e . m)J .15"9$8"
[City]" [State] [Zip]
Soclal SeCurIty Number: _
:"BUSlNESS INFORMATION:
Business Name:
c'6P T GL AI/JA! r
/ ~t:I / AlII/AI S7",
Business Address:
D6NT6tv/u,.E' {r/)./ ~.:JK
[City] [State] [Zip].
Minnesota Tax ldentiftCation Number: '}CJ' /750- I
Federal Tax ldentiflcation Number: dO-II L/ IS.5~
If a Minnesota Tax Identtflcation Number is not required. please erplain on the reverse side.
11;'10'1 . ~'~~
Date Sigoatore and Position (Officer, Owner. Partner)
.'
TAX CL.EARANCE INFORMATION
TO LICENSE APPLICANT:
Pw:suautto Minnesota Statute 270.72 Tax Oearance: Issuance of Licenses, the JiCP.nRillg authority is
required to provide to the Minnesota CommiRonet' of Revenue your Minnesota Business Tax
,J~ Nmnberand ~ secmitynmnberofeachJi~ appJicaut. .
~ {-
Under the Minnesota Govemment~ P.ractic:es Act and the Federal Privacy Act of 1974, we are lQ{uh~
to advise you of the fo1lowingregardingthe use oftbis infulmahon'. .
1. This .information may be used to deny the issuance, renewal or ttansfer of yom
license 1n the event you owe the).finnesota Department of ReVenue de1inquent
taxes, penalties or.interest; .
2. Upon n=iving tbis int(\r1nmiOJl,. the til"P-mling ....fl.....lty wiJ1 supply it oiJ1y to the
Minnesota Department of Revenue. However, under the Federal Exchange of
'nm. ,~ Agreement the Department ofRevenne may sopplythis iofurmation
to the Tntei-rml Revenue Service.
3. Failure to supply tbis information may jeopatdize or. delay the process"lg of
yout Ji~~ or renewal. application.
Please supply the fo1lowing 1nfonn3tion and retum along with your appJic:a1ion to the agency issuing the
licxmse. DO NOT DTUBN TOTIU DEPARTMENT OF REVENUE.
LICENSE TYPE:
T~
NEW! ]
RENEWAL J>4:-
I~A/~s-
. .
LICENSING AUIHORITY:
LICBNSBRBNBWALDAm:
. CitY of C'..enterville
1/, /(Jff"
. .
. '~,
b.g~
[Zip]
Business Telephone Number:
my
[S.l
"~/- 1{ ~~ - 'IYI'&)
ListofOJJroers or Partners (full name, tit:k; and social security number):
FoIl Name: t:Jlfll L- .BUlPtJlli..E~
-
Title: ~ Social ~Number:
FoIl Name: t.u T 11 tl'l RulE & Hi..$"A...
TItle: ~
FoIl Name: r.~.
Title: V.. P ..
FoIlName: ~ ~
Title: ~.
D A CORPORATION:
Corpo1ationName: ('D~ nUll. T LLi!. dba 1'14..,.~ /J1~.
Business Address: J~P I /J1~ S::/. ~
Social ~Number:
~~
Social Secority NumbeI
~
Social Secority Number:
".. . .'" co
List of Directors:
7// /d~
~ of Jf3wlX ~'-
?~l.~~
~- '
.. lnoorpomtionDate:
..
List of Stock:holders:
'~:OSONAL INFORMATION (1.f sole proprietor):
AppJicaot's ~
AppJicanf.s Address:
/
./
[atyl [State]
HomeTe1q>>ho.neNmnber: q S I 7~ ;2 / ~b
Sacia1 Sclcurit}r Nu:mber:: .-
[Zip]
ALL ~LICAlft'S:
~.. -:r. 'ol ~. ' ",
List aU persOns 01' entitieS with el1he..- a direct or iodirect hJteJest in tbe appliamtortbe appJicant"s ~
to be conducted. under the license for which this application is made and desc.tibe their intereSt in del3il
below. . ..;
. .
eAJ."'~ ~,
./t1e7 /fI~ 'r~
,. .
, ~~.Fn '8
~ 'J ~
~t/ &.- ~,/t/~
, "
/H~~
~ ..
.. . . /II#(~
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~ .~.
~'Or'nodoNaaloi,if~ . ' ,~ ~
- y
~Te1ephone:Nunmer.I$'-~.- /fBtfo ~T~Number: /'6-/-: 71 ;;. ../~
HasanypelS01l~inthe~1iatti~~beenconvictedofa:fetony.1:, D Yes l( No
Jfyes. ~forth the ~ ~: COUDty and stated ~ COIl'riction:
'/
/',
. .
AppJiamt agrees tbat any maoager Cmployed m'the JiceJRd ptemises wilI':have an cpm'Hficatioos of a
licensee and that tbe manager wiD DOt vioJate any city or state laws: .. , .
Minnesota Tax:Td~catUmNmnber. ',' 7'0 17 S.5 I
Fedexal Tax ldentificationNomber: :l () - II t/ IS 5' ~
If a Minnesota Tax TdP.ntificmiQJl Number is not requhed, please explain on the reveISC side.
Signatuie:
PrintName:
Position (Office, PaItner. etc.):
Date:
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CEKrfii'1CATE OF COMPLIANCE
MINNESOTA WORKERS' COMPENSATION LAW
Minnesota statute,' Section 176.182 requires eVery state and local licensmg agency to withhold
the.~ or renewal of a license. or permit to QpC1'8te a business or engage in an activity in
~esota. . until the applicant presents acceptable evidence of compliance with the workers'
compenSation ~ covemge rCquiremen:ts ofMSSChapt.ei 176. The information required
is: the DalIie of the irisurance company, the policy number, ana dates of covemge, or the permit
to self-insure. This information.will be collected by the City and retained in the files.
This information is required by law, and licenses and permits to opemte a business may not be
iSsued or renewed if it is not provided and/or is :6dsely reported. Fu:rthermore,if this
information is not provided or :fidsely stated, it may result in a $1,000 penalty assessed agaiDSt
the applicant by the CommiRSioner of the DeparIment of Labor and InduStry.
Insurance Company Name:
(NOT the inslU'ance agent)
~~44Iwt.
Policy Number: we ~~-I)l/...ls.G8S5-(JJt:)
Dates of Coverage: ~~ l/fP'/()5' TO 12h/~.r
b....... 1.::1 a*7/3,h~- ,'I~J6
I"""" (OR)
I am not required to have workers' compensation liability coverage because:
o
I have no employees
D
D
I am self-insured (incI1.Ide permit to self-insure)
I have no employees who are covered by the WO!kers' compensation law
(these include: spouse, pareiJ.ts, children and certain fium employees)
.
I certify that the itiformation provided above is accurate and complete and that a valid
workers' compensation policy will be kept in effect at all times as required by law.
Name of Business:
/)/EAJ J.J is
[Middle]
CE prE f{ ftlj}R./
J&'o I In~ st.
eu..l&cHL.E~
[Last]
Name: C/fl. L
[First]
Business Address:
~ l:G;.A:JJ!..t- . hIh,- S>o:3 E
[City] / [State] [Zip]
.., ..' 'B1iSiiieSsPhone:' . IP51- 1;6,... LfB'~ "
J//) ItJit COA~~~
Date Signature
,"
'~
,
RECEIVED
NOY 0 2 2004
NOTIFICATION FOR LICENSE. INVOLVING PRIVATE
OR CONFIDENTIAL INFORMATION
(Includes Tennessen Warning)
. .
lB. conneetion with your' request for a license, the City has asked that
. you provide information about yourself which is dassified as private,
confidential, nonpubHc, or protected. nonpubHc under the Minnesota
Government Data Practices Ad. This means that this data is not
ordinarily available to the general public. Accordingly, the City is
required to inform you of the foRowing:
.1. The purpose and ~ use of the .infurmation requested is to detemrine if you
are eligible for a Jic:ense from the City of 0mterviJle.
2. You are not lega1J.y obligated to supply the JeqUeSted .ha<aaoation.
3. The known ~ of supplying the requested iDlbrmation is 1bat the
information of further ~on could disclose information wbich could
cause your applica1ion to be denied.
4. The,known consequenc:e ofrefusiDg to supply the requested infomIation is that
your request for a license amnot be processed
S. A crimiDa1 cbarge. arrest, or conviction wiJl not ~ bar you from
obtaioiDg a Jicense with the City. UD1ess the c:o.nviction is m1ated to the matter
for which the license is sought. according to Minnesota Statute 364.03.
However. failure to reveal the requested crimimtl io~n mAfion wiJl be CODSideted
fidsification of the application aDd may be used as grounds for the denial of the
applica1ion.
6. Other 8OyC,...laenta1 agencies l1eOO!JSary to process your application are
a.,t1h)o i7IXJ by Jaw to m:eive the information provided.
7. The Ci1J is' .u;qu.iRd by Jaw to furnish some of the information to the
Department of Labor and Industry and the Minnesota Q)mmiMiooer of
Revenue.
8. During the applicat:ioo process. your mune and addJ:as may be Id.eased to the
public. If the li<:eDse is gmnted, an the data supplied will be available for
inspection by the public.
'Jheundersigne4 by signing this notice, acknowledges th(lt belshe hils real and
understood the contents o/this notice and has received a Copy o/this notice.
\\\,\~
.~ \ ~6&>
S\prture
Date
~
r
.
STATE OF MINNESOTA
COUNTY OF ANOKA
CITY OFCENTERVILLE
Appliedon No. .
RENEWAL APPLICATION FOR LICENSE TO SELL
TOBACCO PRODUCTS AT RETAIL
,
The undersigned, residing at ~ l.t> ~~ J)e... in the City of C.CtJr'UW\ \...U;
intheCountyof-AM}~ . StateofMinneso~ResidenceTelephone: (~)1~1..- 1SS'2- HEREBY
MAKES APPUCATIONFOR UCENSE to be issued. to TODD STEFFAN. DBA CORNER ExPRESS, to
sell tobacco productS at retail at 1990 MAIN STREET, Business Telephone: (It:b\)~ ~in the City oj
Centerville, A.nolra County, Minnesota for the term of one (1) year ~nni11g with the 1st tltq of JIl1IlUlI'.1, 2fJfJS.
subject to the laws of the State ofMinnesota and the ordinances and regulations of said City ofCentenille pertaining
thereto, and herewith deposit $75.tJ' in payment of the fee therefore.
By slgnlng t1ds renewal flJ'pliclltioll, tlpplicllld certifies t1uIt there IuIS been BO clumge in 0WIIeI'Ship,
corpOl'tlte officers, OI'pll1'l1u!r& If elumges 1uwe ocetm'etl"gthe pllSt 12 mollth, complete in its entret.1 the
tJtttIeheil Tu CletJmnee InfOl'llUltion, then sign 1Jelow.
Date: " \ , \ o&.\:
~~
'1:0;0 S~
Name (Print)
FOR O~CE USEOl'iLY (Do not write below this fine)
Report by Police Department
This is to cert.iJY that the applicant and the associates~ named herein have not been eonv:icted within the past five years of any
violation offederal..state or local law, ordinance provision, or otherregulatiOllre1atingto tobacco or tobacco products, ortobacr'
related devices, or any felony within the last ten years. .
~~
TItle
'=Y~~~
,~
,~
CERTIFICATE OF COMPLIANCE
MINNESOTA WORKERS' COMPENSATION LAW
" '
MDm.esot8.,Statute,.Section 176.182 requires every state and loCalliceiJsing agency to withhold,
the issuance or'renewal of a license or permit to operate a business or engage in an ~ in
Minnesota until the applicant ~ acceptable eviden~ of compliance with the workers'
coriJ.pensation insuIaBCe cOverage requirements ofMSS Chapter 176. The information iequired
is: the name of the insmance company, the policy number, and dates of coverage, Or the permit
to self-insure. This information will be collected by the City and retained in the files. '
This information is recpiired by law, and licenses and permits to operate a business may not be
issued or renewed if it is not provided and/or is :fi11sely reported. Furthermore, if this
iDformati.on is not provided or fidsely stated, it may result in a $1,000 penalty asSessed against
the applicant by the Commissioner of the Department of Labor and Industly.
--
InsuranceC01IIfJ01IYName: .;p-~ .v~~a-.
(NOT the insurance agent)
Dates of Coverage:
-, ~'3"2. t
<2-\ \ \ 0'+ 2..1 & los
TO.
Policy Number:
(OR)
I am not required to have wQ1'kers' compensation liability coverage because:
o
o
0'
I have no employees
I am self-insured (include permit to self-insure)
I have no employees who are covered by the wmkers' compensation law
(these include: spouse, parents, children and certain farm employees)
I certify that the irformation provided above is DCC'III'ate and complete and that a valid
workers' compensation policy will be kept in effect at all times as required by law.
Name:
,--\ o~
[First]
K,C:~,,-
[Middle]
~~ '6c~s
\'1~o M~, ~-
~\)Jo.
[City]
1dS\ ~ 'U.,
~
[Last]
Name of Business:
Business Address:
Business Phone:
\\\,\d-\
Date
M~,
[State]
(,,(,OB
S'SD 1>5
. [Zip]
~
I
CEKrD1CATE OF COMPLIANCE
DEPARTMENT OF REVENUE
I
I
~
Pm:swmt to Mitinesota Statute 270.12 TaX Clea.nU1ce; Jssuance of Licenses, the licensing
authority is required to provide to the Minnesota Commissioner of Revenue your MiDnesota
Business Tax Identification NUmber and. the social setoritv number of each Hcense
aDuHCaIIt (nerSon sioninl! the aD'OHcation).
Under the Minnesota Government Data Pmctices Act and the Fede.ral Privacy Act of 1974, we
are required to advise you of the followlng regarding the use oftbis iofor.manon:
1. This infonnation may be used to deny the issnatme, renewa.t, or 1:IaDsfer of your
license in the event you owe the Minnesota Department of Revenue delinquent
taxes, penalties, or interest;
2. Upon receiving this information, -the license authority will supply it only to the
Minnesota Department of Revenue. However, under the Federal. EYl".Jun,ge of
Information Agreement, the Departm.ent of Revenue may supply this
information to the Internal Revenue Service;
3. Failure to supply this information may jeopardize or delay the pl"OCCS$i1l8,'Of .
your license issuance.
Please supply the following iriformtition and return along with your application:
1YPE OF LICENSE BEING APPLIED FOR OR RENEWED: ~A~
PERSONAL INFORMATION:
Appltcant's Address:
~no S~
. (o'rl \0 t (l,\AA
e.~I2>>~\\t ~
[City] rStatel
,.
nfl,\ v~
5So~
fZjpl
Applicant's Name:
Social Security Number:
BUSINESS INFORMATION:
BustnessName: "0 'S\c.~ ;~,. J>M Corua~~ sS'
Business Address: \~t) M~ S~...
~\'f(l.V~ \LQ lV\.tJ SS03 B
. [City] [State] [Zip]
Minnesota Tax Identification Number: S 10 '5ltJ () S
Federal Tax Identification Number: Ifl- an..1 (." S ,
If a Minnesota Tax Identification Number 'Is not required, please explain on the reverse side.
.~~ .L
\ o. ~ ttl...::t"
. . (0J1icer, OwneI;Partner)
~
TAX CLEARANCE INFORMATION
TO LICENSE APPLICANT:
Pmsuant to Minnesota Statute 270.72 Tax Clearance: Issuance of Licenses, 1he licensing authority is
required'. to. . provide to 1he Minnesota 'Commissioner of Revenue your }4innesota Business Tax
IdentifiCation Number.and social secmity number.of each license applicant.
Pnder the Minnesota Government Data Practices Act and 1he Federal Privacy Act of 1974, we are required
to advise you of the folloWing regardbJ.g the use oftbis ~on: .
This information may be used to deny the issuance, renewal or transfer of your
license in the event you owe the Minnesota Department of Revenue delinquent
taxes, penalties or interest; .
Upon receiving this information, the licensing authority will supply it only to the
Minnesota Department of Revenue. However, under the Federal Exc~ of
Information Agreement the Department of Revenue may supply this information
to the Internal Revenue service.
Failure to supply this information may jeopardize or delay the processing of
your licensing issuance or renewal application.
(
Please supply the following information and retorn..along with your application to 1he agency issuing the
license. DO NOT RETURN TO THE DEPARTMENT OF.REVENUE. .
c.\\P~
1.
'2.
3.
IJCBNSB TYPE:
NEW[]
RENEWAL [~
IJCBNSING A.unIORITY:
IJCBNSB RENEWAL DATE:
City of Centerville
\ I vOoS
BUSINESS INFORMATION:
Business Name: ~i\~ ~p~S
Business Address: \,Cb~' tV c:;rr-
~-~..,,, \e.
[City]
('-\~
[State]
'-\1...\, lo (, Of::> -
~~o 38
[Zip]
Business. Telephone Number:
to~\
List of Officers or Partners (full name, title, and social security number):
Full Name: ~~ M\~ S,.,,~
Title: ~~~ Social SecmityNumber: .
Full Name:
Title:
Social Secmity Number:
Full Name:
Title:
Social Secmity Number:
Full Name:
Title: .
Social Secmity Number:
IF A CORPORATION:
eorporationName:..:tD ~--" '!:-nC,.. - dba ~Q)IL ~)tI'~~S
Business Address:
,~""o """,-J'nl'> b"T ..
List .ofDirectors:
l'2'\O\
~OO ~~~
~~\~
~
'Incorporation Date:
ListofStQckb.9IderS:
'. f\l A
. PERSONAL INFORMATION (if sole proprietor):
Applicant's Name:
~ppUcant's Address:
[City]
[State]
[Zip]
Home Telephone Number:
Social Security Number:
ALL APPLICANTS:
List ~ persons or ~es with either a direct or indirect interest in the applicant or the applicant's business
to be conducted under the license for which this application is made and describe their.interest in detail
below.
~QO N\~ ~.Ae-
Addresses:
U\1 \0 'e,,^,,~
f'
~(l>.~
..
~J..J\\.A~
Assumed or Trade Names, if any:
TD ~~'^ \ ~t'\c:.-
Business Telephone Number: l,6\ ~'U;, \ti~ Ofb Home Telephone Number: \0 ~, -Z l., 1. Ur 2-
Has any person named in the ~lication ever been convicted of a felony? 0 Yes ~ No
If yes, set forth the offense, date, county and stated of conviction:
Applicant agrees that any manager employed in the licensed premises will have all qualifications of a
licensee and that the lIl8J1&ger will not violate any city or state laws.
Minnesota.Tax Identification Number:
. Federal Tax Identification Number:
S tCSloOC;
,
4.( -"U>"l.ll.oS 1
If a Minnesota Tax Identification Number is not required, please explain on the reverse side.
SignaIore: ~~ PosiIion (Offico. _. etc.): ~IO.:t
. PrintName: ~~ Date: \\l (l 04
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Minnesota Department of Public Safety
Alcohol and GambUng Enforcement
444 Cedar Street, Suite 133
St. Paul. MN 55101-5133
651-296-6979 · TIY 651-282-6555 · Fax 651-297-5259
'-,
l,itBIsee: Please verify your license information contained below. Make corrections if necessary and sign. City
ClerldCounty Auditor should submit this signed renewal with completed license and licensee liquor liability for the new
license period. City OerklCounty Auditor are also required by M.S. 340A.404 S. 3 to report any license
caneellation.
License Cod~ GIYI'j::\~ License Period Ending 1 ;::&/::?1/?L7JfJI@# 1=.111
City/County where license approved. Cent erv ill e
Licensee Name
Kel1v's Korner Inc.
1Iade Name
Kellv' 5 Kor"ner"
Licensed Location address " 709B Cent e'rv i 11 e Rd
City, State, Zip Code
Hutl.9.. MN 5503B
"
Business Phone
651/653-1469
LICENSE ~: Off Sale $ 100.. 00 On Sale $ 2500. 00 Sunday $ 200: 00
By signing thiS renewal appUeation, appHeant certifies that there has been no cIumge In ownership on the above
named Dcensee.; For changes In ownership, the Dcensee ~ed above, or for new Hceusees, foB appDeations should
be used. See back of this appDeation for further Information needed to complete this renewal
AppHcant's lligPatnre 'on this renewal confirms the fnnnwing: FaDnre to nwort any of the following wDl result in fines.
1. Licensee confirms it has no interest whatsoever, directly or indirectly in any other liquor establishments in
Minnesota. If so, give details on back of this application.
2. Licensee confirms that it has never had a liquor license rejected by any cityltownship/county in the state of
Minnesota. If ever rejected. please give details on the back of this renewal, then sign below.
3. Licensee confirms that for the past five years it has not had a liquor license revoked for any liquor law violation
(state or local), If a revocation has occurred. please give details on the back of this renewal, then sign below.
4. Licensee confirms that during the past five years it or its employees have not been cited for any civil or criminal
liquor law ,violations. If violations have occurred, please give details on back of this renewal, then sign below.
S. Licensee confirms that during the past license year, a summons has not been issued under the Liquor Liability
Law (Dram Shop) MS 340A.802. If yes, attach a copy of the summons, then sign below.
6. Licensee confirms that Workers Compensation insurance is in effect for the full license period.
Licensee has attached a Dquor IiabDity insnrance certificate that corresponds with the license period In city/county
where 6cense Is issued. $100,000 In cash or seeurltfes or $100,000 surety bond may be submitted In Dea of Hquor
UabDity.
Licensee Si Date
(Si~ certifies all above information correct ~ license has been approved by city/county.)
City Clerk/County Auditor Signature Date
(Signature certifies that renewal of a liquor, Wine or club license has been approved by the city/county as stated above.)
County Attorney Signature Date
County Board issued licenses only (Signature certifies licensee is eligible for license).
Police/Sheriff Signature Date
(Signatufe certifies licensee or associates have not been cited d
(r.riminallcivil). Report violations on back, then sign here.
9093-98
I. I
,t "
Indicate below ~hangP.!l of col1lorate officers. partners. home addresses or te1~phone numbers:
. , . .'
Indicate below any interest whatsoever. directly or"indirectly in other liqnor estabHJlhments:
. .: 'J" ..... ' - .
S~t"l1l W ZO()'! J~~t ""NJ€(,~QA>
:S-l'_9. ~, 141..;' ~ I/~tf - Setrl~ """"""-7
. r.~~i~~' ~~~,J!~~y~ s.k~ flloJo&
1~,Qo
ReDPrt below detailJl involving any license rejections or revocations:
'eB,,'Cmmf,. Comments:
~.(, IlL.. htJ I,. l ,
. tJ€#!-/c. of ';J() if.
.
. \
hc,/ael ~s
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NOTD1CATION FOR LICENSE INVOLVING PRIVATE
OR CONFIDENTlAL INFORMATION
(lnclu~es Tennessen Wa~g)
. . . .
In connection with your request for a license, the City has asked that
you provide information about yourself which is classified as private,
confidential, nonpublic, or protected nonpublic under the Minnesota'
Government Data Practices Act. This means that this data is Dot
ordinarily avaUable to the general public. Accordingly, the CitY is
required to inform you of the following: .
1. The pmpose and intended use of the information requested is to determine ifyo'il
are eligible for a license from the City of Centerville.
2. You are not legally obligated to supply the requested information.
3. The known consequence of supplying the requested information is that the
information of further investigation could disclose information which could
cause your application to be denied.
4. The known consequence of refusing to supply the requested information is that
your request for a license cannot be processed.
5. A criminal charge, arrest, or conviction will not necessarily bar you from
obtaining a license with the City, unless the conviction is related to the matter
for which the license is sought, according to Minnesota Statute 364.03.
However, failure to reveal the requested criminal information will becoi1sidered
fillsification of the application and may be used as grounds for the denial of the
application.
6. Other governmental agencies necessary to process your application are
authorized by law to receive the information provided.
7. The City is required by law to fmnish some of the information to the
Department of Labor and Industry' - -li1id the Minnesota COmmissioner of
Revenue.
8. During the application process, your name and address may be released to the
public. If the license is granted, all the data supplied will be available for
inspection by the public.
The undersigned, by signing this notice, acknowledges thpt he/she has read and
understood the contents of this notice and has received a copy of this notice.
~A.p~
Signature
't9~
Date
31
;
I)~
STATE OF MINNESOTA
COUNTY OF ANOn
CITY QF CENTERVILLE
Application No.
RENEWAL APPLICATION FOR LICENSE TO SELL
TOBACCO PRODUCTS AT RETAIL
Theundersigned, residing at 15 g 8 () .. 't ~t) ,,::;J. in the City of !9-JIIJ (J 0 ,) t. t2
in the County of.J4~()#{A . state ofMinneso~ Residence Telephone: (9/13) //311- liIP g HEREBY
MAKES APPLICATION FOR LICENSE to be issued to BIU.. BISEK, KELLY'S KORNER INC. DBA
KELLY'S KORNER BAR, to sell tobacco products at retail at 7098 CENTERVII.J...E ROAD, Business Telephone:
(UI) '5J - ')P'II in the City ofCenterville, Anolra County, Minnesota for the term of one (1) year beginning with .
the 1st iItly of Jtl1I1U.I1Y, 2tHJ5 , subject to the laws of the State of Minnesota and the ordinances and regulations 0
said Oty of Centerville pertaining thereto, and herewith deposit $75. (J(J in payment of the fee therefore.
By signing t1ds renewtIl flJIl11ie11tion, tIJlPlictmt certifles tIutt there IuIs been 110 c1umge in ownen1dp,
COI'JHlIYlIe ojjicers, or pll11ners. If changes 1uJve OCCil,.,.etl d1lring the pllSt 12 months, complete in its entirety the
tltttIchet1 Tta Cleartmce lnfOl7llll1ion, then sign 11e'Iow.
Date: ()~,.. 3/ I).J/
.,
~?~
w,i/(~ ~,;e~
Name (Print)
FOR OFFICE USE ONLY (Do not write below thls line)
",
/!
Report by Police Department
This is to certify that the applicant and the associates, named herein have not been convicted within the past:five years of any
. violation offederal, state or local law, ordinance provision, or otherregolation re1atingto tobacco or tobacco products, ortobacx:o
related devices, or any felony within the last ten years.
Signature
Title
-:-
.CEKfD1CATEOF COMPLIANCE
MINNESOTA WORKERS' COMPENSATION LAW
Minnesota Statute, Section 176.182 requires every state and local licensing agency to withhold
the isswu1ce or renewal of a license. or permit to operate a business or engage in an activity in
Minnesota until the applicant. presents acceptable evidence of compliance with the. workers'
cOmpensation insurance covemge requirements ofMSS Chapter 176. The information required
is: the:name of the insurance company, the policy number, and dates of covemge, or the permit
to self-insure. This information will be collected by the City and fehainM in the files.
This information is required by law, and licenses and permits to operate a business may not be
issued or renewed if it is not provided and/or is :fidse1y reported. Furthermore, if this
information is not provided or fi1lsely stated, it may result in a $1,000 penalty assessed against
the applicant by the Commissioner of the Department of Labor and Industry.
Insurance Company Name: ].:Sf.. r Il ( & y J1J. V/1l f ,J 161'-11- t D~!r.
(NQI the insurance agent)
Dates of Coverage:
01.( - 13 f>3 3:$ - 02.-
6 J, J () 1I To;f / 9 / #S
, # , ."
(OR)
Policy Number:
I am not required to ht:ive workers' compensation liability coverage because:
D
I have no employees
D
I am self-insured (include permit to self-insure)
D I have no employees who are covered by the workers' compensation law
(these include: spouse, parents, children and certain farm. employees)
1 certify that the itiformation provided above is accurate and complete and that a valid
workers' compensation policy will be kept in effect at all times as required by law.
Name: JA1j I, ~ ;:(i./ltnn t 13-J.$~k
[First] [Middle] [Last]
Name of Business: 1&//" S )~~~f/', J:'/II~.
~
Business Address: I)/) '/3.. c;.", If /'tJ; I ~ fJJ
c''''fEY"tll/h /11,.) d~/)53
[City] [State] [Zip]
Business Phone: UI-t-5~-?~9~ .
IP/31/tW _-_- .-. a~:.1
Date Signatu11
CEKl'D1CATE OF COMPLIANCE
DEPARTMENT OF REVENUE
PurswmttoMinnesota Statute 270.72 Tax Clea.rance; Issuan.ce of Licenses, the licensmg
~ is required to provide to the Minnesota Commissi~ of Revenue your Minnesota
Business Tax Identification Number and the soci81 securitv number of. eilehlicense
'aDDlieant (Berson mmunl! the aDDlication).
Under the Minnesota Government DataPracti.ces Act and the FedeIal Privacy Act of 1974, we
are required to advise you of the following regarding the use oftbiS information:
1. This information may be used to. deny the issuance, renewal, or transfer of your
license in the event you owe the Minnesota Department of Revenue dC1inquent
taxes, penalties, or interest;
2. Upon receiving this information, the license authority will supply it only to the
Minnesota Department of Revenue. However, under the Federal Exchange of
Information. Agreement,; the Department of Revenue may supply this
information to the Internal Revenue Service;
3. Failure to supply this information may jeopardize or delay the processing of
your license issuance.
Please supply the following iriformation and ,:etum along with your application:
TYPE OF liCENSE BEING APPLIED FOR OR RENEWED: /)11!-;/ :lP4 f /8. I: / ~AI
PERSONAL INFORMATION:
~licont'sName: iA)ll~
~licont's Address:
l~fI at) ...
j/.yd IJ~VfA
[City]
;:3';f.K
j(, e~N ~I.
f/1w
[State]
;'51:1'1
[Zip]
Social Security Number:
BUSINESS INFORMATION:
)/t I ~ ~ J~"''''fl'' I .t4Jtt..
?~? B w Ce ",1&1",,;/4 b
(;,,; k/*II//h /1/ ~
[City] [State]
Minnesota Tax Identification Number: J 7'/ j / 41)
Federal Tax Identification Number: 'i / - I} ~ f ;f ~ f
/f~ ;7f1
[Zip]
Business Name:
Business Address:
If a Mime. 'SOfa Tax Identification Number is not re~ IjeDS. e explain on the reverse side.
~J~~f ~~
Date Signature ~ . (Officer, Owner, Partner)
/..
/'
TAX CLEARANCE INFORMATION
TO LICENSE APPLICANT:
. Pursuant toMbmesota Statute 270.72 Tax Clearance: Issuance of Licenses, the licensing authority is
required. u.>"Provide to the Minnesota Commissioner of Revenue your Minnesota, Business Tax
Identification Number and 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 oftJrls information: .
1. This information may be used to deny the issuance, renewal or transfer of your
license in the event you owe the Minnesota Department of Revenue delinqueirt
taxeS, penalties or b1terest;
2. Upon receiving this information, the licensing authority will supply it only to the .
Minne.sota Department of Revenue. . However, under the Federal Exchange of
Information Agreement the Department of Revenue may supply.this information
to the Jnternal Revenue Service.
3. Failure to supply this information may jeopardize or delay the processing of
your licensing issuance or renewal awlicai:ion.
Please supply the following information and retmn along with your application to the agency issuing the
license. DO NOT RETURN TO THE DEPARTMENT OF REVENUE.
. LICENSE TYPE: ()"/~JI' S'8t1! S.Z/SAJI'U'l NEW [] RENEWAL l><l
LICENSJNG AUTHORITY: City ofC'..entervt11e
LICENSE RENEWAL DAm: ;{;",,/ . / b 5
,
BUSINESS INFORMATION:
Business Name: JCI., l!y ~ ~r,J~t< I he.
Business Address: ?Pf8'- (f,/nrt//tk ,;~
C~ 11,.1/; II! . ;11,,;
.
[City] [State]
Business T~lephone Number: ~1 / - &, S;3 .. /) P 9'/
55'~J 8'
[Zip]
List of Officers or Partners (full name, title, and social ~ number):
Full Name: W,I/I/"'~ 13ISl,"k '.
Title: I~,.$. ,
Social Security Number:
Full Name:
Title:
Social Security Number:
Full Name:
Title:
Social Security Number:
Full ~ame:
Title:
Social Security Number: .
IF A CORPORATION:
Corporation Name: li,ll,! $ .IC~/'''rt; f~c, dba it, fly ~ }6;rltlt".
Business Address: ?#f8'.. a~h"'tI//I~ IV. Ce~/f;'II,Jlc
.
Incorporatimi Date:' /1 'II
List of Directors: . W , l ( ,~ 'B. s i ~
..
List of Stockholders: _W I \ l, t:c...-.. B J ~i /C
. .
PERSONAL INFORMATION (if sole proprietor):
AppliCant's Name:
Applicant's Address:
[City]
[State]
[Zi? J
Home Telephone Number:
Socia18ecuritY Number:
ALL APPLICANTS:
List all persons or entities with either a direct or indirect interest in the applicant or the applicant's business
to be conducted under the license for which this aPPlication is made and describe their interest in detail
below.
WII/,~ D/$t/~
Addresses: I If 8 ff 0.. Xi./},.J -> I
AJf1do,)Y'! 141 #I 5' f )' :J ~
Assumed or Trade Names, if any:
BusinessTelephoneNumber: (P11 "'~SJ- 'J?'/ HomeTelephoneNwnber: ~6J - '/,//f.../pl. i'
Has any person named in the application ever been convicted of a felony? 0 Yes Ii No
If yes, set forth the offense, date, county and stated of conviction:
Applicant agrees 1hat any manager employed in the licensed premises will have all qualifications of a
licensee and that the manager will not violate any city or state laws.
Minnesota Tax Identification Number: 151 9 J ~ I)
Federal Tax Identification Number: if / ... I , /) f '$1) <;
Si
. on Nwnber is not required, please explain on the reverse side.
14' :>
Position (Office, Partner; etc.):
Date: {Jot. ':1/, ~ r
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1880 !Main sn-, ~ 'M.'1f 55038
(651)429-3232 ' fax (651)429-8629
i
i
RECEIVED OF , ,AMOUNT
KeIIv's Kormir 12754.00
FOR:
JauorITobacoo I..Jcense ~fI 6094
Renewal 2005
"
i
BY TIII'_IJetukr
November 9 2004 ~
'.
Thank you for your business.
R~lpt# 1278
Officer Jason Corlew
Centennial Lakes Police Deparlment
200 civic Heights Circle
Circle Pines MN 55014
763-784-2501
November 22, 2004
Centerville City Administration
1880 Main St
Centervi1le, MN 55038
Centerville City Adininistration,
The Police Department conducted Tobacco Compliance checks on November 19th, 2004
for the Cities of Circle Pines, Lexington, and Centerville. One of the businesses in your
city that are licensed to sell tobacco failed the check. I directed an underage buyer into
these businesses for the purposes of ensuring that they are taking the appropriate
measures to sell their tobacco products only to adults. The businesses that failed the
compliance check are listed below.
Trio Inn
7082 Centerville Rd.
The employee that sold the tobacco to the underage buyer was cited for the violation
under state statue 609.685. This violation is a Misdemeanor. I am advising you of the
violation since this sale to the underage buyer is also a violation of your city ordinance.
Because of this, there may be civil sanctions that you can impose on the tobacco license
holder for this business. Please feel free to contact me if you have any questions regarding
this matter.
S' oereIY~
.Corlew #124
CLPD
Tobacco Compliance Officer
Paul Pa~er
From:
Sent:
To:
Subject:
Peterson, Tom W [tpeterson@bonestroo.com]
Monday, November 22, 2004 3:22 PM.
Paul Palzer
North Country ConCrete
,fI
FaxS1512.tIf (481<8)
Hi Paul,
The cost shown ($1,029.73) is for doing the Okan driveway this year. I would recommend we .
wait till 2005.
Tom Peterson
Bonestroo Rosene Anderlik
-----Original Message-----
From: Goodman, Ryan J
Sent: Friday, November 19, 2004 1:38 PM
To: Peterson, Tom W
Cc: Schluender, Dan S
Subject: FW: Fax Received from CSID: 651 257 1169 Pages: 2 page(s)
Tom,
Here is the quote North Country gave Dresel to come in and install the concrete flared
ends this year on 1841 Center Street.
Thanks,
Ryan Goodman
-----Original Message-----
From: Fax Status
Sent: Friday, November 19, 2004 1:28 PM
To: Goodman, Ryan J
Subject: FW: Fax Received from CSID: 651 257 1169 Pages: 2 page(s)
-----Original Message-----
From: LightningFAX server [FAX:LightningFAX server]
Sent:. Friday, November 19, 2004 1:02 PM
To: .Fax Status
Subject: Fax Received from CSID: 651 257 1169 Pages: 2 page(s)
Status
MessageID
Pages Received
Time Received.
Duration
Remote CSID
,
New
51512 (c938)
~ page (s) .
Fti, 19 Nov2004 13:02:25 -0600
00': 54
651 257 1169
1
~
COUNTY OF ANOKA
GO?Je1'fJmentaJ Servim Division / COfllf)'JunZ!1 l)e'/Jelopment Departm8fJt
GOVERNM::ENr CENTER, 71h-Floor
2100 3rd Avenue. Anoka, Minnesota 55303-2265
(763) 323-5700
Karen Skepper
Community Development Manager
DD# 763-323-5709
MEMO
TO: _ Cities- and Townshlp.s wf~ Anon County .
FROM:
DATE:
Karen Skepper, Comttlunity Development Manager #-
November 19, 2004
SUBJECT: Anoka County Consolidated Plan - Goals and Priorities of 2005-2009
The Consolidated Plan is a document provided by Anoka County to the Department of Housing
and Urban Development every five years. This document provides a framework for the planning
process used by -the County when identifying housing, homeless, community and economic
development needs and resources and is used extensively in the funding process for the
Community Development Block Grant (CDBG) program and the HOME Investment Partnership
program.
Please accept this invitation to participate in the process of determining the 2005-2009 needs and
priorities related to housing and non-housing issues in Anoka County. A short presentation has
been scheduled for Wednesday, December 1,2004 in room 715 at 1:00 p.m. in theAnoka County
Government Center. During the presentation we will begin the process of identifying the needs
and priorities in the county. Your input and insight into your communities and pr~ will be
very beneficial as we begin this process. Please review the ~hed 2000-2004 Needs and
Priorities Chart and determine whether any of the priority rankings should be modified. If you
feel there is a need to change a priority ranking, now is the time to share your comments.
Public input will be received from users of'the CDBG and HOME programs, elected officials.
and local advocacy groups before a public hearing on the Consolidated Planls held in early
2005. If you have questions, please feel free to contact me at 763-323-5709. Your participation
in this process is very important. - If you are unable to attend, feel free to send another
representative from your organization. -
EncloSure
1S).
EQUAL- HOUSDlG
OPPORTUKIn FAX: 763-323-5682 Affitmative Action / Equal Opportuni1;y Employer 'IDD/TTY: 763-323-5289
.~,
Needs and PrIorities Chart - 2000 Con Plan
Plannl H
. *We assumed that Other Youth Programs were the same as YoiJth Services.
**We assumed that Other Senior Programs were the same as Senior ServiC9$.
e.
RECEIVED
Nav 2 2 200~
Housing Goals and Priorities Chart
2000 - 2004
Priority Need Level
Priority Housing Needs rom ~ Medium - Low
(households) Income Priority
0-30% H
Small Related .31-50% H
51-80% M
0-30% H
Large Related 31-50% H
Renter 51-80% H
0-30% H
Elderly 31-50% H
51-80% L
0-30% H
All Other 31-50% H
51-80% L
0-30% H
Owner 31-50% M
51-80% M
S -~... Populations 0-80% H
'.
,,". ". '. ..
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.... 'I ....
".
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Register today for the Leade~hlp
Confer~nce for ~r1enced OffIcial
Leadership In Q Challenging .
Political Environment
to learn how to:
. Identify' and positively respond
, to (:onflict '
, · Address discontent and
dysfunction . ,
. Strike a balance at work
and home
, League of MinneSota CItIes
14S'Un!venityAve.West .
St.Paul,MN 55103-2044
(651) ~1-12O!l
Registration fee Is $175.
Register onUne "
at wwvir.lmnc.org.
'- f!
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1cI,I,JJ,Ua""JIt'; ,J..ItII.J.,JItl,..J"Il.,.,l"J",aiIIU
TERESA BENDJm '
Cler~ . ,
GITY OF CENl,rERVILLE .
1889 MAIN' 81'
CENT.ERVrLLE ~ 5S0~~-9794
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,s.'tAll~l1is TRAI'N'~N~ OPP6RTUNITY' WITH ELEC1ED Ol=F~CIALS
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)AN...28-29, 20~5
ST.I,.OUIS P,\RK
FEB. 25-26, 2005
GRAND RAPIDS
"
. Craig Rapp has
2Syearsexperlence
In thepubllcond
-prWate sectors, ,
~tfg'lt$'fori!1er
BiookIyn'MdtY
managerunder .
formerniayor
Jesse ventUra.
.,...
~r1ell~~ city officials !<OOW ~ha~ after heat~
el,ectlons, the cJ1al!eflges conttmi~.Dlfflcult and. ,
demahdlng ~ltIo...s-lnsld!! and outside city lJall.,...
can make leadership a tough bal(!ndng act.
Come to the leadership CO,nference for ExP.erlenced
Offlclais Leadership iil a Challenging political.
E.n'lllronni~tto ~ani ways to addresS dlscont~nt .
... and Tand ~resjxMId!O cOrII11ii.
,.
REGISTER O~LlNE ANYTIME::WWw~lmnc.or~'
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