HomeMy WebLinkAboutBusiness License Application 1986-3-19
Date Issued
,
OREXn'l LIQUOR ,-VN.l<VI.. CQMMISSIct'l
::;t'l:L.1l\L DISPENSER LICENSE APPLICATIct'l
UKJ:U)J.~ LIQUOR ,-",n<vI.. CQMMISSIct'l
P.O. BOX 22297, PORTLAND, uKJ:U)J.~ 97222
Appl:Lcatl.on 15 hereby made for a Specl.al D15peIlser Ll.cense . . . . $25.00 per day
(Appll.cant holder of D15peIlser Class A X. Class B or Class C Ll.cense.)
(Check one of the atove) -
Hours of sale are from 7:00 AM to 2:30 AM. Ll.cense may not exceed 5 days. Lnclosed
l.S a check or noney order m the anormt of $ as full payment. Fee wl.ll be
refrmded l.f l:Lcense l.S deIued, otherwl.Se l.t wl.ll not be refrmded.
1 . Appl:Lcant: US-U.) \ 'S -+ -e..... 'L \\ t: ,A ~~c....
2. Trade Narre: ~~\ > '.relephone No.
3. Ma:Llmg Address: , C; 0 <; LU L ~ f (tV: ~
(Number) (Street) (Cl.ty)
4. Event: W~ i/_k..~~ ~~ f) ~ i--k:",yL.
5. person(s) responsJ.ble: ~e-ILil:I ~ ~""C~<">-iS...:::::, ~ W '0-\ 1t,"J L
lNarre) \?' (BusmesS tele.]2.hone)
Meress: I~! C ~ L\J ( ."t:2.-- fJ7 L-<- t-.-/ ') 1<( 0"2- t., 0 (:J- I '7 <7 0
(Number) (Street) (Cl.ty) (Zl.p) (Home telephone)'
6. SYo!ct locatl.On of pr6ffiLSr for~uch l1c~se ~appl:Led: L
/7/7 ~.". / S-J..v~,~~f..,/ ~...-<.-
lNumberJs<,\i-c:. ~eet) -/ (Cl.~) iL:l.p; (cormty)
7. A'::xJve locatl.On l.S: :>L Wl.thm Cl.ty l:uruts Outsl.de Cl.ty l:uruts (Check one)
;4)('~1
f
4 -I" 7
;;L(d'lC)"32-
0"7lfO L-
(Zl.p)
8.
O)ate or dates of event:
10
/lq~G
I
10.
Who Wl.ll recel.ve the profl.ts from thl.S ll.cense:
" ExpeCted attendance:
ISw~
I~O
9. Hours of operatl.on:
'1. Ijwe rmderstand that a false answer to any of the foregomg questl.Ons Wl.ll subject
th15 appl:Lcatl.On to denl.al. Ijwe cert1.fy that all mforrnatl.On sulnutted l.S complete
and correct to the best of ~jour knowledge.
i2. Ll.censees holdmg a D15peIlser Class A, B or C Ll.cense rmderstand that saLd ll.cense 1S
S..:DJect to suspensl.on or revocatl.on l.f cause rmder ORS 47~.180~1 ar m connec-
tl.OTI W1th the specl.al l:Lcense appll.ed for.
Sl.gnature: "r?;, ,L~
. (V" .
Sl.gnature:
Date: ~ - I (( - '10
CCJMPLI:;l'tD AND W!.AJt<SED APPLICATIct'lS MUST BE RECEIVED BY OUX 10 DAYS PRIOR 'lD DATE OF EVENT
THAT APPLICATION COVERS.
Form 84545-469 (Rev. 10-79)
GeneJr.a.l SbUemen-t a 11 I n-ten-t
~~
Spec-tal Even-t uc.elU U
U -w -the -<.n-ten-t 06 -the SpJUng6-<.e1.d Cdy Cou.nc.M'. to c.olU-<.dVt the heaLth,
M.6ety, and .{.1lIpac;t an the CA.taelU 06 aWL c.ommLl.Yl.{..;ty when Jr.ev-<.e.LllU1g Jr.equuu
60Jr. -6 peCA.a1. even-t uc.elU u.
FOJr. -th.w Jr.e.a.6on, the Cou.nc.M'. w.til. addJc.U-6 [but w.til. no-t be Luru.;ted to) the.
60UoWUlg c.onc.VtIU whe.n plWc.U-6-<.ng -6uc.h UC.e.IUe. Jr.eouuu.
7. Me.a.-6WLU c.on-temptaJ:e.d 60Jr. C.On-tiUl'lIIIe.n-t 06 the. e.ve.n-t to the. -6pe.u6-<.ed
Mea .
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Z. Impac.t an the. nughboJr.hood I zoYU.ng pJr.ov-W-<'OIU, oc.c.upancy Me., paltlu,lg,
pJr.ue.nce. 06 atc.ohot, etc..).
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3. AppJr.opJUaJ:e. -6e.c~y PMV-W-<'~IU., / __ . (" f. (
f,U fi, L? ~ t<;t;.U. c-/c.a_....) &f...- ~ .-/"- ~
(/1 J;. ~ J~ tf' ; /" /'
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{/ L L' LV ....-f.....~~. lor' '" /"
l..- I ~(. d ft r-t.- &t:L- ---- .
Clty of Sprlngfleld * Flnance Depaf'tment
225 North 5th Street * Sprlngfleld, OR 97477 * 503/726-3705
'-
TIllS APPLICATION MUST BE ENOORSED BY THE At-t'lVt'rtIATE PERSONS AS INDICATED BELCW t:\UUl<l:.
REI'URNTIlG 'KJ THE Ul<l:."'-'" LIQUOR CONI'OOL COMMISSION.
()
TIllS SEcrION MUST BE COMPLEI'ED BY THE PERSON HAVTIlG ClJ::>Luui OF THE t'KUt'J:.K.Li WHERE
THE EVENT IS 'KJ BE HELD OR HIS Kt.>'1<J:BENI'ATIVE.
Th~s apphcatwn has been sub1u.tted to 4 &;/~) '7'9~-e4.-1 ,,-1.-~.~ '.
. and Ireets mth = approval.
. ~j~) /t)~/~;.,)
.." (Author~zed s~qna1:ure)
.? - .:kJ -.J11L1
(Date)
14. TIllS SECTION MUST BE COMPLEI'ED BY THE CHIEF OF POLICE FOR TIlLVKr\..Jl<ATE!) CITIES OR
THE COUNTY SHERIFF FOR UNTIlCuKr\..Jl<ATE!) AREAS OR THEIR AUlliORIZED l<l:.P1<J:.::>.t:.l'JTATIVES.
Th~s apphcatwn has been sub1u.tted to 7""A~ S;I#I/V'/';;~// a,et< ~,f A/;CL
Th:LS off~ce rc~v",,=,ds X GRANT or RmJSE*
* If recomrrendat~on ~s RmJSE, please illd~cate grounds for refusal
4kd72p~
~~~nZed s"iqnature)
.?-2.s--?6
(Date) ,
OFFICE USE ONLY
SUMMARY OF EVENT: DESCRIBE ACI'IVITY, PAST OPERATION, HCW POLICED:
Date rece~ved
I cert~fy that the at.ove lllfonnatwn has been rev~ewed by Ire.
(Narre and hUe) (Date)
Certlf~cate of Authonty to operate ~ssued. (Copy enclosed)
Forwarded re-.v,,"u",udJ.ng staff act~on. Supplerrental repJrt enclosed.
RESTRIcrIONS: