Cigarette Dealer Application

STATE OF CONNECTICUT
DEPARTMENT OF REVENUE SERVICES
‘Telephone: 860-297-4005
ORS Website: Portal ct. gowDRS
myconneGyt Partah fRaMtalctaowORS-myconnett
Distening Baas ar ine “ADBIRSANT section
Below has beer completed and the information in
the “Business information” Seotion is correct,
Chen presentio the tran clark ofthe munixesd 5
pohere ihe business t fea be) located. Have ihe | |
ian ster acknowledge receipt of thie rotiication.
pénce Completed, raturn to the MHCUGRECT porta
Bad complete the acknowiedgement return,
i
NOTICE OF APPLICATION FOR A CIGARETTE DEALER/RETAILER LICENSE
Department of Revenue Services, 450 Columbus Blvd, Suite 1, Hartford, CT BR7B34 837
License Case Number: 659401
Name of Applicant
«LJohn D. Andrea
(Residential Address
£r=) mz
3120 Bloebercy Cicele. Sn
Residential City. State Zip f - 22m
South Windsor CT OWO74 me
Business Information nN Ete
40 BOSTON POST ROAD OF WATERFORD LLC UG Pn
» [40 BOSTON POST AD om
& DWATERFORD ct 05385-2424 — 3
a ~~ co
&
iCerification of Receipt by Town Glee
his application has been received by the clark of the municipality for the above listed business,
Signature as Geek Z wR fe
Pua ame
The above noted applicant has applied for 8 Cigarette Dealer/Retaiter License by submitting a registration application ta
the Connections Department of Revenue Services {DRS).
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Not later than the day following the date an applicant provides notice io the clerk of the municipality, the applicant shat
alix a copy of this otice, which shat be maintained in a legible candition, Upon the outer door af the building where such
Place of business is ta be jdcated,
If an application is fled for a license for @ bull
day following the da!
ding that has not yet bern eonstructed, the applicant shail, not fater than the
fe an applicant Provides notice to the clerk of the municipality, arect and maintain ina legible
SOndition on the site where the business is to be located, 3 sign that:
(A}is not fess than Six feet by four feet,
(8) contains the ficense @pplied for and the name of th© prapdsed licensee, and
iC} is clearly visinte from the publie highway.
450 Columbus Bivel.. Suite, 1
File Your Taxes Electronicaty
Hartford, CT oes OS-aS7
Portal.ct. gowtes
Alflomative Action / Eguat Opportunity Srptover
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