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<br /> <br />o~_1-~.-z,~ <br /> <br />ocr 2.~ 2003 <br /> <br />ervi{{e <br />'ESta6{iSftit{ 1857 . " <br /> <br />1880 :Main Street it Centervilt:e,:M9.L 55038 <br />,.~ "(651)429-32;32' . riJe'(651)'429--8629 <br /> <br />. ' , <br />STATE OF MINNESOTA <br /> <br />CITY OF CENTERVILLE <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 7fJm ;Iu( ml #d'/ ~ - in the City of & /J-J JPJ//'J IE <br />in the County of IJ/l~f H . State of Minnesota, Residence Telephone: ClPs/)!IiZ- 9tJd.3 HEREBY <br /> <br />MAKES APPLICATION FOR LICENSE to be issued to DBA TOM THUMB FOOD MARKETS, to sell <br />tobacco products at'retail at/80l MAIN STREET, Business Telephone: (~J ~-!fMl in the City of <br />Centerville, AnokQ County, Minnesota for the term of one (1) year beginning with the 1st day of January, 2004, <br /> <br />subject to the laws of the State of Minnesota and the ordinances and regulations of said City ofCenterville pertaining <br /> <br />thereto, and herewith deposit $75.00 in payment of the fee therefore. <br /> <br />By signing this renewal applicotion, applicant certifies that there has been no change in ownership, <br />corporate officers, or partners. If changes have occurred during the post 12 months, complete in its entirety the <br />attached Tax Clearance InformoJion, then sign below. <br /> <br />Date: /tJhl/113 <br />, ( <br /> <br /> <br />-' <br /> <br />FOR OFFICE USE ONLY (Do not write below this line) <br /> <br />Report by Police Departmen~ AfAN~7d SflII4'~'Ph/J,--No <br />This is to certify that the .appliHftt 4tid. the associates, named herein mwe-not been convicted within the past five years of any <br />violation offederal, state or local law, ordinance provision, or other regulation relating to tobacco or tobacco products, ortobacco <br /> <br /> <br />:=..-'~~W;~. . _~ ad/f~~ <br />>fi~1U /,_p..-~~ ~;/AI ~~~ a~er1~ <br />./ dL/a--. "'~.fJ~ In r~ Utrle-, ~ <br />