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1. <br />2. <br />3. <br />4. <br />APPLICATION FOR LICENSE TO <br />SELL TOBACCO PRODUCTS AND <br />TOBACCO RELATED DEVICES <br />(OrUiiuncc Nu. 164. Second Srricf - Adopted 12 08.^>7) <br />Make check payable to: City of Orbno <br />Mailing address: <br />FEE: $100.00 (February 1-January 31) <br />P.O. Box 66 2 p <br />Crystal Bay, MN 5532^,|^^ * <br />/- <br />o <br />DATE <br />Applicant's Full Name <br />HRSr MiOULc:LAST <br />Applicant's Home Address <br />CLn sQ.<i ______ <br />HOUSff h*STREET <br />7^3 ¥79-6,^79 <br />HOME PHONE <br />IV7 <br />STATE ZIP <br />Applicant's Business <br />c:rt»TipK/ <br />TYPE OF BUSINESS BUSINESS PHONE <br />4/^//^iei2tg- <br />BUSINESS NAME <br />MAILINO ADDRESS <br />\ Of O /-/fj ^ <br />STREET ADDRESS <br />ZIP <br />Describe how the actual physical exchange of the tobacco, tobacco product, or <br />tobacco related device between the customer and the licensee or employee takes <br />place.___________________________________________________________ <br />I HEREBY MAKE APPLICATION FOR LICENSE TO SELL TOBACCO. TOBACCO <br />PRODUCTS. OR TOBACCO RELATED DEVICES AT THE ABOVE LOCATION SUBJECT <br />TO THE LAWS OF THE STATE OF MINNESOTA AND THE ORDINANCES OF THE CITY <br />Dale <br />Dm ifivancc or# Nevnsa unOif (Ml onMnanca aAaff M consfttorad a prM*t0a and nor an aftsoTuM (liOftr ortfw aPP<*canr <br />and $hMtnol9rMltth» holder to »n automatic i9f»ynl of th»Sc»ns9.