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n,il.0 of application_/ y <br />PR rJn»tY �0,.VL)rve/'1 oN rcN 4-- ---_99 <br />141SINESS NAMENe To.,r3f_, pCrc.:,+iil/"$110m.; <br />DUSINI:^;i ADDRESS1 2.S OA-4•at y — L JL� �--^- - <br />(strout) <br />LVAIzlra CI sc - S"S3 <br />(.ip code <br />OWNERS/I:ORI'ORA'Pli Ort'ICIiIIS/ASSOCIA'I'LiS/PARTNl•:1tS (name S Litle) <br />t.L <br />IIAVE YOU IiVlik HAD A LICL'NSE REVOKED?— <br />No 1C yes, attach explanation. <br />TYPO OF LiCL••NSE <br />/N& <br />RE'PERENCES: CITII7S WIIERIi PREVIOUSLY OR CURRE TLY LICENSED FOR SAME <br />ACT1V1'I'Y huone of CiLy and ycar(s) licensed) <br />...(�. .. ,/ll luV fAfsLl1 AM C,. RJtr✓,'L L <br />Fz <br />�Pac..d (3/4 4ParC Ste, <br />LOCATION FOIL 11111('II l,ll'RWSE lti III:QIJI5'l'RD (if applicable) qT�"i TrT <br />� s <br />OW)Ililt OF I'111:M1SI.5 (il' applicabl,:) <br />2-j:u2 -e- E4ATIaP .._— I-,ct /?e aC.tJr•� _l P•kNr�i- <br />- - �--- ---- --- - <br />AppJicants for the following licrnse must: completo the applic,ible section <br />on the rvversu side of this form: <br />:nnusrmunt devices/bingo/bowlinq d1lcys/dance halls/ garbage <br />coJlrctirni/q;/,;nline sLnL•ions/kennels/prddlers/solicitors/ <br />restaurants. <br />1 heruby certify that information providrd on this application is true <br />and currect and undeastand that any misrepresentation made heruin may <br />he grounds for dunia.l of Lhis applieation. <br />Applicant's name ] µ eS A . Loe, Se n/ Date of birth 71,17130 <br />(I�.11:ase orID4 - <br />Applicant's signatures <br />Date of. Council approval- Licensc number <br />Nuw Renewal <br />