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<br />. . <br /> <br />'. <br /> <br />STATE OF MINNESOTA <br />COUNTY OF ANOKA <br /> <br />CITY OF CENTERVILLE <br /> <br />Application No. <br /> <br />RENEWAL APPLICATION FOR LICENSE TO SELL, <br />TOBACCO PRODUCTS AT RETAIL <br /> <br />The undersigned, residing at Jd'87 hI~7.J-; in the City of CO--1::r~- <br />- <br /> <br /> <br />in the County of ~tate of Minnesota, Residence Telephone: fG/) 7~ -; U"b HEREBY <br /> <br />MAKES APPLICATION FOR LICENSE to be issued to CARL BUECHLER, DBA CENTER MART, tose1l <br /> <br /> <br />tobacco products at retail at 1801 MAIN STREET, Business Telephone: (Jo/ ~- ~ the City of.- <br /> <br />Centerville, AnDira County, Minnesota for the term of one (1) year beginning with the 1st day of JIl1IUII'IY, ZtHJS, <br /> <br />subject to the laws of the State ofMinnesota and the ordinances and regulations of said O(v ofCentetvi1le pertaining <br /> <br />thereto, and herewith deposit $75.00 in payment of the fee therefore. <br /> <br />By signing this renewal fJ]1JIlication, tIJIplictlnt certifies t1uIt there 1uIs been no chimge in ownership, <br />cotp01'llte offken, or]Jfl1'lnen. If cbtmges 1uwe OCClU'I'etl during the post 1Z'montlls, complete in its entirety the <br />tltttJched Ta CIeartmce InfOl'llUlJion, then Sign below. <br /> <br />Date: II/I /Po/ <br /> <br />&~~ <br />Signature <br />e~; J.. P. 8k6e:f!.h'.LSAL. <br />Name (Print) , <br /> <br />FOR OFFICE USE ONLY (J)o not write below this line) <br /> <br />Report by PoJiceDepartment <br />This is to certiJY that the applicant and the ~ 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 reJ.ating to tobacco or tobacco products, ortobaoo <br />related devices, or any felonywitbin the last ten years. <br /> <br />Signature <br /> <br />Title <br />