Laserfiche WebLink
<br />CITY OF CENTERVILLE <br />APPLICATION FOR LICENSE TO SELL <br />TOBACCO PRODUCTS AT RETAIL <br /> <br />The undersigned, residing at 51./ClS IS] t!t SrI ,'1i. intheCityof IluhO <br /> <br />in the County of JlASNltJlhi'j),J . State of Minnesota, Residence Telephone: llJl ).!:/.D2- 7JOI HEREBY <br />~AM~ll. j'. .sA6~ <br />MAKES APPLICATION FOR LICENSE to be issued to Sfl~~ II J1i/o"rl., :;''''4 DBA 5A'.p~~ l~p-#.6Rltl <br /> <br />, <br /> <br />. to sen tobacco products at retail at 7098 CENTERVlLLE ROAD, Business Telephone: (~) 6J~ -:nJ1 <br />in the City of Centerville, Anolra County, Minnesota for the term of one (1) year beginning with the 1st day of <br /> <br />Feb,.".", ZOtJ6, subject to the laws of the State of Minnesota and the ordinances and regulations of said City of <br /> <br />CefttenJille pertaining thereto, and herewith deposit $85. Of} in payment of the fee therefore. <br /> <br />Report below details of tobacco law violations that have occurred within the last five years. (Dates, offenses, <br /> <br />fines or other penalties): <br /> <br />Report below details involving any license rejections or revocations: <br /> <br />By signing this renewal appliclllioll, applictmt certifies tlud there IuJs bee" 110 clulnge ill owllelShip, <br />corportlte officers, or ptl1'tllers. q cluuages hll1'e occ"wed durill' the pllSt12 mollths, complete ill its entirety the <br />~hed Tax CleartUlCe Illfot7lllltioll, sign below. <br /> <br />Date: )- 16"'06 <br /> <br />~/~ <br />Si . e / <br />1tUAArlll 1: 5A6{/( <br />Name (Print) <br /> <br />FOR OmCE USE ONLY (Do Dot write below this line) <br /> <br />Report by Po6ce 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 of federal, state or local law, ordinance provision, or other regulation relating to tobacco or tobacco products, or tobacco <br /> <br />relateddevice:-7.~./ .~.. 'the ~~6 <br />Sigaature~t1~ Title ch,rP aP Poh'cl/-/ <br /> <br />~~ <br />