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<br /> <br />ervi{{e <br />'Estabfislieti 1857 <br /> <br />1880 !Main Street ,. Centeroif{eJ M9.[.55038 <br />(651) 429-3232 .!fa7( (651) 429-8629 <br /> <br />STATE OF MINNESOTA <br /> <br />CITY OF CENTERVILLE <br /> <br />, <br /> <br />COUNTY OF ANOKA <br /> <br />Application No. <br /> <br />RENEWAL APPLICATION FOR LICENSE TO SELL <br />TOBACCO PRODUCTS AT RETAIL <br /> <br />The undersigned, residing at t)!IJ ~ ~j in the City of ~ ~ <br />in the County of lI/lJu;l1- . State of Minnesota, Residence Telephone: isl )G6:~ - Og,0( HEREBY <br />MAKES APPLICATION FOR LICENSE to be issued to PAUL MONTAIN, MOUNTAIN ENTERPRISES, <br /> <br />INC. DBA TRIO INN, to sell tobacco products at retail at 7082 CENTERVILLE ROAD, Business Telephone: ( <br /> <br /> <br />GSl ) r-u., - 'J..t5~ in the City of Centerville, Anoka County, Minnesota for the term of one (1) year beginning with the <br /> <br />1st day of January, 2004 , subject to the laws of the State of Minnesota and the ordinances and regulations of said <br /> <br />City of Centerville pertaining thereto, and herewith deposit $75.00 in payment of the fee therefore. <br /> <br />By signing this renewal application, applicant certifies thot there hos been no change in ownership, <br />corporate officers, or partners. If changes have occurred during the past 12 months, complete in its entirety the <br />oJ:tached Tox Clearance Inf0171Ultion, then sign below. <br /> <br />Date: 10 -; 7-~ 3 <br /> <br />~P!d <br />signature A <br />'.~t/J... At)1V7fJ,)~ <br />Name (Prim) <br /> <br />FOR OFFICE USE ONLY (Do not write below this line) <br /> <br /> <br />Report by Police Dep..- 4 <br />This is to certify that the applicant ~, named herein have not been convicted within the past five years of any <br />violation of federal, state or local law, ordinance provision, or other regulation relating to tobacco or tobacco products, ortobacco <br /> <br /> <br />=-~~T. ~ at'ff4" <br />