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• <br /> CITY OF MOUNDS VIEW <br /> 2401 HIGHWAY 10 <br /> MOUNDS VIEW, MN 55112 <br /> LICENSE APPLICATION FORM <br /> Date of Application , 12/2/./7./ <br /> BUSINESS NAME (150404c4/ C.--- o6)-6S- <br /> .- - o L'L S Phone 75-27- <br /> BUSINESS <br /> 5' -BUSINESS ADDRESS -2-3/ //3 -1.7 ,9e•L- 'f,/ <br /> (street) <br /> 0 7v' }7,#/'/D5 AA,/ <br /> (city) (state) (zip code) <br /> OWNERS/CORPORATE OFFICERS/ASSOCIATES/PARTNERS (name and title: ) <br /> /147451,,4V 7 Se,-v <br /> 4' /i4.t/D l�iozccfz/� <br /> HAVE YOU EVER HAD A LICENSE REVOKED? /VGA 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 /> '25 No&fl- °' oti' :: ., ,4 <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 /> uollection, gasp-line 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/4/744)/Z7 <br /> (p-lease pr--int) Last First-- Full Middle <br /> Date of birth 7 / 7 / <br /> mo day year <br /> )47 <br /> Applicant's signature �e2 <br /> /J D X //v5- 57/o L0 ,5 L- 4 �A A/ 2/, / <br />