Laserfiche WebLink
an c <br /> ©UNDO CITY OF MOUNDS VIEW <br /> 2401 HIGHWAY 10 <br /> �" MOUNDS VIEW,MN 55112 <br /> �'w� OG�,+lVJ <br /> o 'St.Palet*9% <br /> LICENSE APPLICATION FORM <br /> ' Date of Application q- 11,o -9 Q <br /> Business Name 51-1 A M - 0- J E,T kE IUIv.E.LS Phone 10(2 -78g - 111 7 <br /> Business Address 77 0 O LO NI t', 1..A k.E RA M o u M 1/r e CO 1 MA) SSI I,?.62 <br /> Owners/Corporate fficers/Associates/Partners (name and title:) <br /> `A Ith,c,L4 0s Lys i <br /> G.. )&i a5 VN 0 ui/ve .5 <br /> Have you ever had a license revoked? NO If yes, attach explanation. <br /> References: Cities where previously or currently license for same activity(name of City and <br /> year(s) licensed) <br /> PO niOs Viet() • <br /> Applications for the following licenses must complete the applicable section on the reverse side <br /> of this form: <br /> ► Bowling Alleys Gasoline Stations <br /> ► Automobile Sales ► 4— Kennels <br /> ► Cigarette and Tobacco ► Restaurants <br /> ► Dance Halls <br /> • <br /> I hereby certify that information provided on this application is true and hereby correct and <br /> understand any misrepresentation made herein may be ground for denial of this application. <br /> Applicants's Full Name MAR C I A P. TOS L vAi <br /> (Please print) <br /> Date of Birth i / G2 / 55 <br /> Applicant's Signature cAZA--ok e 9n4__q_____, <br />