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APPLICATION/RENEW AL <br />AMUSEMENT CENTER LICENSE <br />Fee - $15.00 Per Site <br />AMUSEMENT DEVICE LICENSE <br />Fee - 515.00 Per Machine ~" ~' ``~ // <br />Co L/~C"Ct yh ~ `~i ~-~2 a(.S, ~/t/C , `Lcr>,+YC-~~ ~~~ C7 C7 <br />Trade Na99me Date of Application <br />d~ ~ <br />Number of Machines License Period MN Business ID No. <br />I. Type of Application: ~_ New Renewal Transfer <br />i. ~i/i;~rr~-c L /r' . ~~ Loy ~~~ . goo,. dC~/0 <br /> f <br />A <br />Na <br />pplicant~ <br />m-e o Phone /,~i <br />3. ` <br />c <br />~ <br />{ <br />Q <br />d 0 0 ~ duJUfQ~L~ ~~ ~j~~,~ f"~ I/ <br /> State <br />City <br />Hom <br />Address <br />e <br />4. // <br />/ <br />~ <br />T ' ~ ~ Z" ~ /// C~ / <br />T `~ (". ~Co ~~`lc~ <br /> Date of Birth Social Security Number <br />s. ~ ~'G~Zj /~ii~ ~r2e~-7~ T~e /~l~~~e~~l~' <br /> Address of Business Location `~ <br />6. List owners of building r premise to be li <br />~ <br />t <br />~ ce sed: ~~°Ofwit~.~/'V ~~ <br />~' sp <br />~ <br /> - <br />~ <br />~ e ~- ~ r ~ <br />, a <br />r <br />~. <br /> te or Partnership Title <br />Corpora <br /> // <br />C~-~,2~ <br />~7~~ ~`yj7L~ ~] <br />~'~iL' <br />~C/~• Gc1/~ ~19 <br />~ <br />' <br />/ <br />8. j , <br />~ <br />i <br />i <br />Corporate or Partnership Address <br />9. List all partners, officers or directors, if corporation: <br />ame <br />A dress <br />Date of Birth <br />10. If this is a transfer application, give name, address, persons, partnership or <br />corporation holding the license for the past year. <br />Page 25 <br />