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<br /> <br />fervi{{e <br /> <br />'Estaflished 1857 <br /> <br />ocr " 5 2002 <br /> <br />1880 ~Jv{ain Street ~ Centervi[[e, ~Jv{'J\[ 55038 <br />(651) 429-3232 @> :Ja;c (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 /> <br />Theundersigned,residing~~~b;;/4::lq5 intheCityof Cf-r1 ky VI 1\0 <br />in the County of &0(:.--<1.-/ , State of Minnesota, Residence Telephone: wr}!jj:]- qD ~3 HEREBY <br /> <br />MAKES APPLICATION FOR LICENSE to be issued to DBA TOM THUMB FOOD MARKETS, to sell <br /> <br />tobacco products at retail at 801 MAIN STREET, Business Telephone: 0i )~ .l-{tptffJm the City of <br /> <br />Centerville, Anoka County, lvfinnesota for the term of one (1) year beginning with the 1st day of January, 2003, <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 past 12 months, complete in its entirety the <br />attached Tax Oearance Information, then sign below. <br /> <br />Date:Cc~bef rEf :l(XJ;)" <br /> <br />LIrluktt Il. ~~ <br /> <br />Signature . <br /> <br />&{/(J;eJIL R ;;a;-.L-c <br />ame (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 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 />related devices, or any felony within the last ten years. <br /> <br />Signature Title <br /> <br />IO/;O /rz--5A1-6 ~;c:: 7O~AccU Jr 41/~tlt€ ~~J <br />1//;010) ->A"z,e tJP YO~Aao Jb /ft/NeJ<-t- . <br /> <br />_ ~__. -" _ _ __J_A~ <br /> <br />I <br /> <br /> <br />It C4mJ1JP#I~J <br />/Jon - (elle <br />