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<br />SCANNED <br /> <br />CITY OF CENTERVILLE <br />RENEWAL APPLICATION FOR LICENSE TO SE <br />TOBACCO PRODUCTS AT RETAIL <br />~1~Jfl~ pa. <br /> <br />NOV 16 2006 <br /> <br /> <br />HEREBY <br /> <br />MAKES APPLICA nON FOR LICENSE to be issued to TODD STEFF&N. DBA CORNER ExPRESS, to <br /> <br />sell tobacco products at retail at 1990 MAIN STREET, Business Telephone: (In, )~- ","o6in the City of <br /> <br />Centerville, Anoka County, Minnesota for the term of one (1) year beginning with the 1st day of January, 2007, <br /> <br />subject to the laws ofthe State of Minnesota and the ordinances and regulations of said City ofCentervillepertaining <br /> <br />thereto, and herewith deposit $85.00 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 />fines or other penaIties): );.,~ t:.;.~ -~~AI~ ~,~... 'oQ - ~,,~~ ?c1&....\.d; <br />Vt:P~~.. l ~ ,~1'.~ a.c.-Jh \) ,1a~s!.4m) <br /> <br />Report below details involving any license rejections or revocations: <br />f\l~ <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 Clearance Informalion, sign below. <br /> <br />Date: \\ ,,~ \ 0" <br /> <br /> <br />Signature <br />~~ ~1'\.~ <br />Name (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 <br /> <br />Title <br /> <br />ti1s <br />