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CC_Minutes_2013_1118
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CC_Minutes_2013_1118
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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 9 PLEASE TYPE OR PRINT ALL INFORMATION <br /> STATE ASSIGNED LICENSE NUMBER 0722 44 - 046 008 <br /> ALL APPLICANTS ANSWER THE FOLLOWING <br /> 9.1 DOES ANY INDIVIDUAL, PARTNERSHIP, CORPORATION OR ASSOCIATION OTHER THAN THE APPLICANT HAVE <br /> AN INTEREST DIRECTLY OR INDIRECTLY IN THE LICENSE APPLIED FOR OR IS THE STOCK OF ANY <br /> STOCKHOLDER HELD IN ESCROW OR PLEDGED IN ANYWAY? Yes XX No <br /> IF THE ANSWER IS"YES,"ANSWER THE FOLLOWING USING A SEPARATE PAGE 9 FOR EACH INDIVIDUAL OR <br /> CORPORATION OF INTEREST. ATTACH A SEPARATE PAGE OF EXPLANATION IF MORE SPACE IS NEEDED. <br /> Name of Individual(Last Name First)or Corporation <br /> (Last Name, First Name,Middle Initial or Corporate Name) <br /> Social Security Number - DR <br /> NJ Sales Tax Certificate of Authority Number <br /> Street Address <br /> Number Street Name <br /> P.O. Box# Municipality State <br /> Zip - <br /> Describe Nature of Interest <br /> 9.2 DOES ANY INDIVIDUAL,PARTNERSHIP,CORPORATION OR ASSOCIATION HOLD ANY CHATTEL MORTGAGE OR <br /> CONDITIONAL BILL OF SALE OR OTHER SECURITY INTEREST ON ANY FURNITURE, FIXTURES, GOODS OR <br /> EQUIPMENT TO BE USED IFONNECTION WITH THE BUSINESS TO BE OPERATED UNDER THE LICENSE <br /> APPLIED FOR? Yes No <br /> IF THE ANSWER IS'YES,"ANSWER THE FOLLOWING USING A SEPARATE PAGE 9 FOR EACH INDIVIDUAL OR <br /> CORPORATION TO BE REPORTED. ATTACH A SEPARATE PAGE OF EXPLANATION IF MORE SPACE IS NEEDED. <br /> Name of Individual(Last Name First)or Corporation <br /> (Lest Name,First Name, Middle Initial or Corporate Name) <br /> Social Security Number - - OR <br /> NJ Sales Tax Certificate of Authority Number <br /> Street Address <br /> Number Street Name <br /> P.O. Box# Municipality State <br /> Zip - <br /> Describe Nature of Interest <br /> 9.3 HAS THE APPLICANT AGREED TO PERMIT ANYONE NOT HAVING AN OWNERSHIP INTEREST IN THE LICENSE TO <br /> RECEIVE OR AGREED TO PAY ANYONE(BY WAY OF RENT,SALARY OR OTHERWISE)ALL OR ANY PERCENTAGE <br /> OF THE GROSS RECEIPTS OR NET PROFIT OR INCOME DERIVED FROM THE BUSINESS TO BE CONDUCTED <br /> UNDER THE LICENSE APPLIED FOR? Yes XX No <br /> IF THE ANSWER IS"YES,"ANSWER THE FOLLOWING USING A SEPARATE PAGE 9 FOR EACH INDIVIDUAL OR <br /> CORPORATION TO BE REPORTED. ATTACH A SEPARATE PAGE OF EXPLANATION IF MORE SPACE IS NEEDED, <br /> Name of Individual(Last Name First)or Corporation <br /> Last Name First Name Middle Initial <br /> Social Security Number - - OR <br /> NJ Sales Tax Certificate of Authority Number <br /> Street Address <br /> Number Street Name <br /> P.O. Box# Municipality State <br /> Zip - <br /> Describe Nature of Interest — <br /> APPLICANTS THAT ARE SOLE PROPRIETORS OR PARTNERSHIPS GO TO PAGE 10A. CORPORATIONS AND LIMITED LIABILITY <br /> COMPANIES COMPLETE PAGE 10. <br />
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