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ffMTONT <br /> City of t JUL 2 7 2023 <br /> Peyoi1___LICENSE APPLICATION <br /> TOBACCO AND TOBACCO PRODUCTS <br /> License Fee: $50.00 per year I <br /> This is an application to seli tobacco and tobacco products at retail in the City ofPequot <br /> Lakes,for the term of one year beginningJuly 1, 2014 and endingJune 30,2015. <br /> I. Full name of applicant R. a, A 1 \m AA 0 0 A L Yl <br /> First Middle Last Maiden LL I M` <br /> 2. Applicant's residential address: 1 ®g I -- r1 J�, s �`( t� d s <br /> 51311 <br /> 3. Applicant's phone number: 3 2 0 _ 40NO D 4 1 <br /> 4. Name of business: E L :P S 1O j O C C <br /> 5. Address of business: `-3 l 0 't•'`' e P; 1,i pe F Dt <br /> 33 6c)6. Phone number of business: �2_4 �, 4 - 4-.Q5 641 <br /> 7. Area where tobacco products will be sold: <br /> 8. Has the applicant been convicted within the past five years of any violation of a federal, <br /> state, or local law, ordinance provision, or other regulation relating to tobacco or tobacco <br /> products, or tobacco related devices? Yes No 'x <br /> If yes, explain: <br /> (Please Complete Application on Back Side of this Page)—> <br /> 4638 County Road 11, Pequot Lakes, MN 56472 <br /> 218-568-5222, Fax 218-568-5860 <br /> www.pequotlakes-mn.gov <br />