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J <br /> 1 <br /> e ��Jp l /3 <br /> CITY OF HIGHWAYH10 i, — /2 — <br /> 2401 10 <br /> MOUNDS VIEW, MN 55112 / '96-- <br /> LICENSE <br /> SLICENSE APPLICATION FORM <br /> Date of Application 5� <br /> BUSINESS NAME L/fl?E '2,4)4557' (5O Pi'V c2-4oQ' Phone 75s- 6, 95-2 <br /> BUSINESS ADDRESS 19tT /14` A-Ge <br /> (street) <br /> CJOoV -r,4 <a‹, t ti 5-37-Y33 <br /> (city) (state) (zip code) <br /> OWNERS/CORPORATE OFFICERS/ASSOCIATES/PARTNERS (name and title: ) <br /> J o r-L P/14_25'rid ; C; 'x.64:74/7" <br /> �v#vee 144L/=S <br /> �,r U1/yE <br /> HAVE YOU EVER HAD A LICENSE REVOKED? 4)6 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 /> MI Av,/,E- te 2 I f95 - /gAvDf460pt4/ 19 9-5" cr'oa� p, ,i5s' / ,5-- <br /> O v,v,os VI,cup 19951-1c 176/0/e/z/S >99,5— <br /> Applicants <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 onthis <br /> true and correct and understand that any misrepresent <br /> herein may be grounds for denial of this application. <br /> IUCrD/4tii CF�y,� ,J5-Ai/V14/7 ,S <br /> Applicant's name <br /> (please print) Last First Full Middle <br /> Date of birth 7 / 7 /5- <br /> mo day year <br /> Applicant's signature e-. if .. 1--/. <br />