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Date of application_"/7c./}';� <br />BUSINESS NAF1G_ / 1PHONE%/f S <br />BUSINESS ADDRESS "; .r/�' / %�!l•sfi:.����:__ .-_..__._.- -' <br />(sl•rue.C) <br />(city) 0,a.a11.-) - .__._—____ (rip code) <br />O;%NGI(S/COV4)RA'1'I'. OPI'ICIiIIS/ASSOCIATES/PAI(TNEItS (name 6 title) <br />HAVE YOU EVER HAD A I.ICENSI•: RKVOKED? &J If yes, attach explanation. <br />TYPE UV 1.7CENSE REQUESTED - <br />REFERENCES: CITIES WHERE•. PREVIOUSLY OR CURRENTLY LICENSED <br />ACTIVITY (name of city and ycar(s) licensed) ,. <br />SST" .A'11 AW4Y4/ -, ry, <br />LOCATION FOR WHICH LICENSE, IS RE'QUESTED (if applicable) <br />A <br />OF PREMISES (if ipplicablo) <br />FOR SAME <br />he /i'l6. <br />Applicants for the following license must comnlete the applicable section <br />on the reverse side of this form: <br />amusement devices/bingo/bowling alleys/dance halls/ garbage <br />collection/gasoline stations/keuncls/peddlers/solicitors/ <br />restaurants. <br />I hereby certify that information provided on this application is true <br />and correct and understand that any misreprosentoLion made herein may <br />be grounds for 'JZdenial of this applicat'on. nu'a :✓);glA ei' ti•�h�h �} �� E+ � .'SJ�e:/j7 <br />/:"iJ.Clrl..af Jai G:�'!S"�.Twv <br />Applicant's name ,T,'r , /�^ iyIrt✓l.0 Dote of bth PAf <br />oleo se riot) _ L <br />Applicant's signatures jy,y,,,y(�lYl. <br />lfoh"P = _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ <br />Date of Council approval <br />Nin: Renewal <br />(rov. 5/77) <br />License number <br />S1e�++��+�raS�ra::c,+aa�n.:an::tt:azaut� ::ra�r.n:�crar�n <br />