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r <br /> j"L,, tell)ter-0 <br /> CITY OF MOUNDS VIEW <br /> 2401 HIGHWAY 10 <br /> MOUNDS VIEW, MN 55112 <br /> LICENSE APPLICATION FORM �ry <br /> Date of Application 11(86 kf <br /> BUSINESS NAME e'a typo/ P'O/V O7-1D4 S Phone 3741.--, 36. <br /> BUSINESS ADDRESS '1?( Z. �' _ 5-1 IV, s1 <br /> P/1 I) 15 575'4 8 <br /> (city) (state) (zip code) <br /> OWNERS/CORPORATE OFFICERS/ASSOCIATES/PARTNERS (name and title: ) <br /> 6-ret- /'tic A fib/ PioA. 046'10,7iii?e/- <br /> 7`(0`'1 al/► Pro <br /> Pva toiv P 'r'f i er -08°3 <br /> t7 ". ^/ <br /> HAVE YOU EVER HAD A LICENSE REVOKED? h 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 /> 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 <br /> this application. <br /> Applicant's name / 7/CX dI40 (tie t- <br /> (please print) r , / <br /> Last� First Full Middle <br /> Date of birth 3 / / - <br /> mo day year /7 <br /> Applicant's signature / 61A/://'/ <br />