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Date of application <br />BUSINESS NAME -5*,9RWG 4AKE A.AK, Qwy <br />BUSINESS ADDRESS Po q3 E,FI'F �LSonl S f . NL. <br />(street) <br />SP. AIL PK py/y. <br />city) V (state) <br />PHONE 2S-4. yS3(. <br />OWNIiRS/CORPORATE OFF ICERS/ASSOC IATF-S/PARTNE RS (name L title): <br />AIZM KELtedl3aRe /mod/Ce iortts. <br />KE&� S -IgIEs Z dreE Plus. <br />eA <br />HAVE YOU EVER HAD A LICENSEREVOKED? !J Q If yes, attach explanation. <br />TYPE OF LICENSE REQUESTED: L/'L- t L71 <br />PROC¢COS }0 6a 1 p PeNMA-L CENfE fJR FA�(ILy /��5og1tcC4 2 4, <br />REFERENCES: CITIES WHERE PREVIOUSLY OR CURRENTLY LICENSED FOR SAME %Ef <br />AC'TIVI'TY (name of city and year(s) licensed) .9?*CNM4t <br />REV104sLY — 6Pkj4G L,AKz /7APe". <br />LOCATION FOR WHICH LICENSE' IS REQUESTED (if applicable) <br />OWNER OF PREMISES (if applicable) �J(T ito `rtt ITL('1 <br />Applicants for the following license must complete the applicable section <br />on the revers_ side of this form: <br />amusement devices/bingo/bowling-alleys/dance halls/ garbage <br />collection/gasoline stations/kennels/peddlers/solicitors/ <br />restaurants. <br />I hereby certify that information provided on this application is true <br />and correct and understand that any misrepresentation made herein may <br />be grounds for denial of this application. <br />/0,4,R4/N ti1&4- dws i d/tT/3j <br />Applicant's name S6MoRE AlklSoA.) Date of birth8/t t <br />.(please print) <br />Applicant's signatures <br />—1 Datc of Council approval <br />License number <br />New Renewal_ <br />(rev. 5/77) <br />