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<br /> <br />I, . <br /> <br />OCT 2 3 200J <br /> <br />etvi{{e' <br />" 'PdQ6fisnet{ 1857 .,~ . ." <br /> <br />1880 Main Street. 8 Centeroi1le, 9vf!J( 55038 , <br />';' '-(65i) 429-32,ji . !Fa;c'(651) 429-862.9 <br /> <br />.' . .,' J I : ~ '... _, . I <br /> <br />STATE OF MINNESOTA <br /> <br />CITY OF CENTERVILLE <br /> <br />, " <br />COUNTY OF ANOn <br /> <br />Application No. <br /> <br />RENEWAL APPLICATION FOR LICENSE TO SELL <br />TOBACCO'PRODUCTS AT RETAIL <br />The undersigned, residing at /iim ~ ml#d~ ~ - in the City of & 11* IPI/~'J k <br />in the County of 1l/7~119- -.. State ofMimiesota, Residence Telephone: ClP5I)1IZ- 9tJE HEREBY <br /> <br />MAKES APPLICATION FOR LICENSE to be issued to DBA TOM THUMB FOOD MARKETS, to sell <br />tobacco producls at '~etail at ISO 1 MAIN STREET, Business Telephone: ({fi.l ~;.!lMi in the City of <br /> <br />. ~ _, ~ ,~ 1" :' ",', ...:.... <br /> <br />Centerville, AriolcQ Coimty, 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 ofMinnesota and the ordinances and regulations of said Ci(J1 ofCentervi1le pertaining <br /> <br />thereto, and herewith deposit $75.00 in payment of the fee therefore. <br /> <br />By signing this renewal applicoJion, 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 Information, then sign below. <br /> <br />Date: /o~/;llLS <br />f , <br /> <br /> <br />FOR OFFICE USE ONLY (Do not write below this line) <br /> <br />Report by Police Department <br />This is to certify that the applicant and the associates, named herein have not been convicted within the past five years of any <br />violation offedera1, state or local law, ordinance provision, or other regulation relating to tobacco or tobacco products, or tobacco <br />related devices, or any felony within the last ten years. <br /> <br />Signature . <br /> <br />Title <br />