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CITY OF CENTERVILLE <br /> RENEWAL APPLICATION FOR LICENSE TO SELL <br /> TOBACCO PRODUCTS AT RETAIL <br /> "I'lie i,,inde,rsi,gn.ed,rf,zidingat, M)t pkt"'Zj' in.thea C61i <br /> It <br /> ............................................................................................................ ................................................................... <br /> in the County of–A�t�o State of Minnesota, Residence Telephone: (6�1' SqZ,- 6615C H-EREBY <br /> ....................................... <br /> MAKES ATION FOR LICENSE to be issued to CHAD BUECHLER,DBA CENTER MART,to sell <br /> tobacco products at retail at 1801 MAIN STREET,Business Telephone: (651)426-3460 in the City of Centerville, <br /> Anoka County,Minnesota for the term of one(1)year beginning with the Ist day of January,2019,subject to the <br /> laws of the State of Minnesota and the ordinances and regulations of said City of Centerville pertaining thereto,and <br /> herewith deposit$85.00 in payment of the fee therefore. <br /> Report below details of tobacco law violations that have occurred within the last Eve years. (Dates,offenses, <br /> -fines or other penalties): <br /> Report below details involving any license rejections or revocations: —----......................................................................... ry. <br /> ............... <br /> By signing this renewal application, applicant certifies that there has been no change in ownership, <br /> corporate officers,orpartners. If changes have occurred during the past 12 months,complete in its entirety the <br /> attached Tax Clearance Information, sign below. <br /> Date: <br /> . ......... <br /> .......................- I"'. ,, I I,( <br /> Signa , — <br /> Si t4t <br /> , ire <br /> ...........��A�e��q <br /> Name(Pii-itit) <br /> ........................... <br /> FOR OFFICE USE ONLY(Do not write below this line) <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 <br /> the last ten years. <br /> tobacco related d an f I M <br /> Signature..................-0 ............... Title <br /> ——----------- <br /> 33 <br />