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<br /> <br />01- Z5Z zZ'2- <br /> <br />ervi{{e <br />. 'Esta6{isftd 1857 <br /> <br />1880 Main Street . Centeroilfe, 9vf!J.l 55038 <br />(651) 429-3232 4I)!F0J( (651) 429-8629 <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 />_ ~t11v-~. .~~~ p~_ <br />The undersigned, residing at ~--r~ . in the City of Ce~;lLV\Ll..~ <br />in the County of (\tJo ~ , State of Minnesota. Residence Telephone: ~.Sl ) '1f..l- - 1.. c;$'L HEREBY <br />MAKES APPLICATION FOR LICENSE to be issued to TODD STEFF~, DBA CORNER ExPRESS, to <br /> <br />sell tobacco products at retail at 1990 MAIN STREET, Business Telephone: (Ic~' l~:l1k_-~ in the City of <br /> <br />Centerville, Anolra County, Minnesota for the term of one (1) year beginning with the 1st day of January, 2004, <br /> <br />\ <br /> <br />subject to the laws of the State of Minnesota and the ordinances and regulations of said City ofCent8ville pertaining <br /> <br />thereto, and herewith deposit $75.00 in payment of the fee therefore. <br /> <br />By signing this renewal application, applicant certifies that there has 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 />attached Tax Clearance InforltUltion, then sign below. <br /> <br />Date: \0 \ c.. ~ \ 0 ~ <br /> <br />"t~ <br />Signature <br /> <br />~..o ~'<<i.P~ 6.1'4 <br />Name (Print} <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 &&1 . atef., named herein have not been convicted within the past five years of any <br />violation off~w, ordinance provision, or other regulation relating to tobacco or tobacco products, or tobacco <br />reIared clevi<:e(Coc any felooy~. <br /> <br />Sigaature ,{-;0, ." : - / ."" ~ ~1' #d'~ " <br />