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<br />STATE OF MINNESOTA <br />COUNTY OF ANOn <br /> <br />CITY QF CENTERVILLE <br /> <br />Application No. <br /> <br />RENEWAL APPLICATION FOR LICENSE TO SELL <br />TOBACCO PRODUCTS AT RETAIL <br /> <br />Theundersigned, residing at 15 g 8 () .. 't ~t) ,,::;J. in the City of !9-JIIJ (J 0 ,) t. t2 <br /> <br /> <br />in the County of.J4~()#{A . state ofMinneso~ Residence Telephone: (9/13) //311- liIP g HEREBY <br /> <br />MAKES APPLICATION FOR LICENSE to be issued to BIU.. BISEK, KELLY'S KORNER INC. DBA <br /> <br />KELLY'S KORNER BAR, to sell tobacco products at retail at 7098 CENTERVII.J...E ROAD, Business Telephone: <br />(UI) '5J - ')P'II in the City ofCenterville, Anolra County, Minnesota for the term of one (1) year beginning with . <br />the 1st iItly of Jtl1I1U.I1Y, 2tHJ5 , subject to the laws of the State of Minnesota and the ordinances and regulations 0 <br />said Oty of Centerville pertaining thereto, and herewith deposit $75. (J(J in payment of the fee therefore. <br /> <br />By signing t1ds renewtIl flJIl11ie11tion, tIJlPlictmt certifles tIutt there IuIs been 110 c1umge in ownen1dp, <br />COI'JHlIYlIe ojjicers, or pll11ners. If changes 1uJve OCCil,.,.etl d1lring the pllSt 12 months, complete in its entirety the <br />tltttIchet1 Tta Cleartmce lnfOl7llll1ion, then sign 11e'Iow. <br /> <br />Date: ()~,.. 3/ I).J/ <br />., <br /> <br />~?~ <br /> <br />w,i/(~ ~,;e~ <br />Name (Print) <br /> <br />FOR OFFICE USE ONLY (Do not write below thls line) <br /> <br />", <br /> <br />/! <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 otherregolation re1atingto tobacco or tobacco products, ortobacx:o <br />related devices, or any felony within the last ten years. <br /> <br />Signature <br /> <br />Title <br />