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"AV <br />CITY OF HOUNDS VIEW <br />2401 HIGMY 10 <br />MOUNDS VIEW, MN 55112 <br />LICENSE APPLICATION FORM <br />Date of Application / <br />drpEr /�Cc�O[-n Phone 7SJ= "6 'Z <br />BUSINESS NAME <br />BUSINESS ADDRESS ( i/3 /�fvE GU <br />(street) <br />s�7 y <br />(city) (state) (zip <br />OWNERS/CORPORATE OFFICERS/ASSOCIATES/PARTNERS (name and title:) <br />Juc 5r�cnA�aNrt _ �,et-s <br />-/fLALO <br />HAVE YOU EVER HAD A LICENSE REVOKED? NC; <br />If yes, attach <br />explanation. <br />RAAY <br />NCES: CITIES tP <br />o PREVIOUSLY OR <br />CURRENTLY <br />LICENSED FOR <br />ME <br />S / i 93 <br />�.17 << <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 ad hereinn <br />nmay correct andnderstand <br />denialtoftany this pplictation made <br />ation <br />Applicant's name pull Middle <br />(please print) Last FLrst <br />Date of birth % / / / Z'5 <br />mo day year / J l <br />14 ! v' <br />Applicant's signature <br />/ j, <br />