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<br /> <br />ervi{{e <br />'Esta6Bsfiet[ 1B57 <br /> <br />1880 Main Street . CenterviUe, !JItfN.. 55038 <br />(651) 429-3232 .:Fa?( (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 />TOBACCOPRODUCTSATRETAa <br /> <br />.. <br /> <br />Th d . ed, Odin . (A~~~~ ~~ . th C. f f\~..~ .- <br />e un erSlgn rest g at ~.--....... . m e rty 0 Li\:O'..... ,.,lLV \ Ll.,iQ <br />in the County of I\tJO'l-4'\ -: State of Minnesota, Residence Telephone: (I,.~ ) 1W. - 1.. $'2.... HEREBY <br />MAKES APPLICATION FOR LICENSE to be issued to TODD STEFFAN, DBA CORNER ExPRESS, to <br /> <br />sell tobacco products at retail at 1990 MAIN STREET, Business Telephone: (b~t )~- we in the City of <br /> <br />Centerville, Anoka County, Minnesota for the term of one (1) year bef9nning 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 ofCentervillepertaining <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 post 12 months, complete in its entirety the <br />attached Tox Clearance Inf01'llU1tion, then sign below. <br /> <br />Date: '<Ie \'"1..~ \'0"3 <br /> <br />s~l~ <br /> <br />~ J;:- <;:''T''i.l'f' \iN <br />Name (Print <br /> <br />FOR OFFICE USE ONLY (Do not write below this tine) <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 offederal, state or local law, ordinance provision, or other regulation relating to tobacco or tobacco products, ortobacco <br />related devices, or any felony witbinthe last ten years. <br /> <br />Signature <br /> <br />Title <br />