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CITY OF GEM LAKE, i17(N <br />mi 4200 Otter Lake Road <br />Gem Lake, MN 55110-3227 <br />Telephone 651-747-2790 <br />E-mail Citv(h aemlakeMN.org <br />Application for Retail Sales of <br />Tobacco, Tobacco Products & Tobacco Related Devices <br />in Accordance with Provisions of Ordinance No. 68 <br />COMPANY: Country Lounge Inc. <br />ADDRESS: 3590 Hoffman Road West <br />White Sear Lake, MN 55110 <br />BUSINESS ® Corporation ❑ Limited Liability Corp. ❑ Partnership <br />TYPE: ❑ Sole Proprietorship ❑ Other <br />651— 55 <br />TELEPHONE: Business:484-4770 Cell:1 341-8666 Fax�51-484-0972 <br />FEDERAL TAX ID #: 41-0974557 SALES TAX #: 7756699 <br />Officers/Directors of Company: <br />NAME . , TITLE <br />IJAh 17.B,rkehhJ f CIj <br />10 n-S .r bo lanJ �%�'e�tc$Jehi <br />d tJ Cre r", <br />ke And Tur r <br />Shareholders: <br />NAME TJLE <br />'ahh li it�'tland t <br />HOME ADDRESS D/O/B <br />dS.1C idieruDr� N1hr9Gt rlt+ke, Mn1.t"SII0 <br />� � • �iJic°ra r' W � l�r��)ss � 10 ;�se <br />Zki S. gu&t- La k,;r1 <br />42203 S. eibii kA Dr; A ; gPur 1i�i'r.l`1rJ 5St stl <br />HOME ADDRESS D/O/B <br />The applicant certifies that he/she is 1) authorized to make application for this license; 2 that he/she has received a <br />complete copy of City of Gem Lake Ord. No. 68 & understands & is in compliance with all sections of the Ordinance; <br />3) that he/she has not been denied any license of any type by the City of Gem Lake in the last five years; 4) that he/she <br />is fully aware of & in compliance with all State of Minnesota Laws & Statutes regarding the sale of tobacco, tobacco <br />products & tobacco related devices; & 5) that he/she maintains a suitable liability insurance policy. <br />11)9President & Secretary 12/10/12 <br />A#plicant Signature Applicant Title Date <br />Office Use <br />Only: Fee Paid Yes ❑ No ❑ License Period: 1/1/20 (5 througli 12/31/20f <br />Look for us on the World Wide Web at gemlakenui.org <br />