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-"""' t'1 t NIRANGE A-2116, .._ :. x,2.:2-94 <br /> ^ ►uAfl R OF INFORMATION ONLY AND CONFERS <br /> "�e CERTIFICATE DOES NOf MEND, <br /> sib" 9 <br /> CITY OF MOUNDSAVIEW 10 <br /> MOUNDS VIEW, MN 55112 <br /> LICENSE APPLICATION FORM <br /> BUSINESS NAME �4Date of Application 42' /5- ',e. <br /> 4/b�u Cr- <br /> BUSINESS ADDRESS.?,, ‘7,.3. _ �o. y .1,40d4-5 Phone <br /> _________-75-S-- � ��_ <br /> (street)J �V cc1 <br /> (cit ) PO/ 5 s�3_3 <br /> OWNERS/CORPORATEASOFFICERS/ (state) <br /> SOCIATES/p (zip code) <br /> Jo �Sh4 ASSOCIATES/PARTNERS (name and title: <br /> .Q,14- �otibc'rt/ ) <br /> L(c /.8C—'C7e, <br /> HAVE YOU <br /> explanation.ER HAD A LICENSE REVOKED? �a If yes, attach <br /> QACTIVITY CITIES ARE PREVIOUSLY OR cA, <br /> (name of city and year(s) CURRENTLY LICENSED FOR <br /> Mo v c%as licensed) <br /> 4 �, - S ' u� i <br /> � s- ,. rs <br /> A .' a� d� Y ..5— <br /> — <br /> caO.t/ in 96!�� Iceui <br /> PPcants for r ;HEMP <br /> aPP abie the following license <br /> section on the reverse license(s) must <br /> casement side of this complete the , <br /> devices, bowfin : <br /> * * * lection gasoline g alleys, dance <br /> * * *, * * * * stations, kennelshalls, garbage <br /> I hereby �, thatinformation <br /> * * * * * * * * *, and*r* * *r*n*s. <br /> true an �rtif info * * * * * * * * * <br /> herein marrect and understand a on provided on this a <br /> Applicants grounds for denial of that any application. <br /> is <br /> lease this aPP kation. made ED BEFO <br /> (P priDe A t-p:S 4ti/ e <br /> Last �� �''� U1-:= <br /> )EAVOR- <br /> Date o f birth First ��` v/'�' .S4 <br /> AED TO Tt <br /> m/da/ Z� Full Middle ESN oR <br /> Y year <br /> Applicant's sigi� L'- <br />