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CC_Minutes_2013_1118
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CC_Minutes_2013_1118
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Last modified
12/17/2013 9:45:31 AM
Creation date
11/26/2013 11:00:14 AM
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Roseville City Council
Document Type
Council Minutes
Meeting Date
11/18/2013
Meeting Type
Regular
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Page 5 PLEASE TYPE OR PRINT ALL INFORMATION <br /> STATE ASSIGNED LICENSE NUMBER 0722 - 44 - 046 . 008 <br /> ALL APPLICANTS ANSWER THE FOLLOWING <br /> 5.1 IS THE APPLICANT OR ANY OTHER PERSON MENTIONED IN THIS APPLICATION A POLICE OFFICER <br /> OR HOLD ANY POSITION ENTRUSTED WITH THE ENFORCEMENT OF ANY LAWS CONCERNING <br /> ALCOHOLIC BEVERAGES IN ANY MANNER WHATSOEVER? <br /> Yes XX No <br /> If the answer is"Yes,"complete the following: <br /> Name of individual <br /> Last Name First Name Middle Initial <br /> Title of position held <br /> Name of Employing Agency <br /> 5.2 DOES THE APPLICANT OR ANY OTHER PERSON MENTIONED IN THIS APPLICATION, OR ANY <br /> PERSON HAVING A BENEFICIAL INTEREST IN THE LICENSED BUSINESS, HOLD OFFICE IN THE UNIT <br /> OF GOVERNMENT ISSUING THE LICENSE? Yes XX No <br /> IF THE ANSWER IS"YES,"COMPLETE THE FOLLOWING: <br /> Name of Individual <br /> Last Name First Name Middle Initial <br /> Title of Office <br /> Municipality <br /> 5.3 DOES THE APPLICANT OR ANY OTHER PERSON MENTIONED IN THIS LICENSE APPLICATION, OR <br /> ANYONE WITH A BENEFICIAL INTEREST IN THE LICENSED BUSINESS, DIRECTLY OR INDIRECTLY, <br /> HAVE ANY INTEREST IN ANY BREWERY,WINERY, DISTILLERY, RECTIFYING AND BLENDING PLANT, <br /> IMPORTER OR WHOLESALE ALCOHOLIC BEVERAGE BUSINESS, AS OWNER, PART OWNER, <br /> LANDLORD,TENANT, MORTGAGE HOLDER OR AS A STOCKHOLDER, OFFICER, DIRECTOR,AGENT, <br /> EMPLOYEE OR OTHERWISE? <br /> Yes XX No <br /> IF THE ANSWER IS'YES,"ATTACH AN AFFIDAVIT EXPLAINING THE RELATIONSHIP AND NATURE OF <br /> THE INTEREST AND COMPLETE THE FOLLOWING: <br /> • <br /> A. New Jersey license number, if applicable - - <br /> B. IF THE BUSINESS DOES NOT HOLD A NEW JERSEY LIQUOR LICENSE,ANSWER THE FOLLOWING <br /> QUESTIONS: <br /> Name of entity conducting business(Corporation, Partnership or Individual) <br /> (Last Name, First Name, Middle Initial or Corporate Name) <br /> Street Address <br /> Number Street Name <br /> P.O. Box# Municipality State <br /> Zip - <br /> Type of Business <br />
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