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ID Number """"'r <br /> 138 KLER-A58TZQ Write ID number on check <br /> Do NOT send cash <br /> Activity Return this renewal with the <br /> Hotel-Tourist Rooming House(LTR)( WDATCP-LICENSE RENE11 <br /> Rooms) DRAWER 296 <br /> MILWAUKEE,WI 53293-0: <br /> RICHARD AND GERALDINE SLACHTA Reason Amc <br /> RICHARD&GERALDINE SLACHTA License Fee $11( <br /> 28057 S JOHNSON LAKE RD <br /> WEBSTER WI 54893 <br /> Please call (608) 224-4720 regarding any questions with this application <br /> DIf establishment is out of business check here,provide date of closure&sign below.Date <br /> THIS SECTION IS FOR CHANGES ONLY - If there are no changes please leave blank. <br /> IMPORTANT: Licenses are not transferable. New operator or new location requires a new license. If you are not the <br /> noted above or the establishment has moved, you must contact us at (608) 224-4720 to be licensed prior to operating <br /> penalty fees. <br /> Change to Establishment Name(same operator above) <br /> Change to Mailing Address(same operator above) <br /> Change in Operator Name(specify reason,e.g. marriage,death,etc) <br /> If you noted changes above, please provide a contact phone number <br /> Note:Additional fe:- ••ay be invoi =: :t your ext insp-cti. • if your establishment has a change in processes or level of of <br /> Your signature . .w will in, :te t - all oft •,v- r .0 .tion is true and rrect t your knowledge. <br /> Signature , . �jd/ A bai . i t , Date 1 �la / o/ ! <br /> f-Jk g,.._ _e-k 0 1q 4--(-Af R.....� <br /> A) ( ; C. <br /> rk � <br /> kit -3,-' <br />