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ak1 )4 id 7 t <br /> CITY OF MOUNDS VIEW it 0 <br /> 2401 HIGHWAY 10 <br /> MOUNDS VIEW, MN 55112 <br /> LICENSE APPLICATION FORM <br /> Date of Application //-17-/- <br /> BUSINESS <br /> 'BUSINESS NAME j)/74=-) /1)Pwl-` tp�/ifE/ 6/v U' Phone 7SS- 6 <br /> BUSINESS ADDRESS0'13/1 //3 � v <br /> (street) <br /> ec cx /?/7 /J 1'/l,t/ <br /> (city) (state) (zip code) <br /> OWNERS/CORPORATE OFFICERS/ASSOCIATES/PARTNERS (name and title: ) <br /> A4412. 544 <br /> v(0y /%1FS ''e v7`/� 7 ,��=t <br /> �/z.�--.4 5 ve.E <br /> HAVE YOU EVER HAD A LICENSE REVOKED? 100 If yes, attach <br /> explanation. <br /> REFERENCES: CITIES WHERE PREVIOUSLY OR CURRENTLY LICENSED FOR <br /> SAME ACTIVITY� (name of city and year(s) licensed) <br /> Mea,V1S !/!�'"J !�c<3-* 4///74/ 1 rs' eoo/12 Py/L5 / s f4 <br /> A4,04 AfiY/4,9 /”j- 5-77041o4 l fRs- <br /> Applicants for the following license(s) must complete the <br /> applicable section on the reverse side of this form: <br /> amusement devices, bowling alleys, dance halls, garbage <br /> collection, gasoline stations, kennels, and restaurants. <br /> * * * * * *. * * . * * * * * * * * * * _* * * * * * * * * * * * * * * <br /> I hereby certify that information provided on this application is <br /> true and correct and understand that any misrepresentation made <br /> herein may be grounds for denial of this application. , <br /> Applicant's name A)CPL4 .v/7 Cd yo � 'iv t/) S <br /> (please print) Last First Full Middle <br /> Date of birth 7 / 7 /2s' <br /> mo day year <br /> Applicant's signature <br />