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<br />CITY OF CENTERVILLE <br />RENEWAL APPLICATION FOR LICENSE TO SELL <br />TOBACCO PRODUCTS AT RETAIL <br /> <br />The undersigned, residing at II" I 'hi ~ - ~ ~ . in the City of ~~ ~ t ~~ '-I .I . <br /> <br />in the County of ~ . State of Minnesota, Residence Telephone: ~)7 &;.' ~ L 5""1.. HEREBY <br /> <br />MAKES APPLICATION FOR LICENSE to be issued to CARL BUECHLER, DBA CENTER MART, to sell <br /> <br />tobacco products at retail at 1801 MAIN STREET, Business Telephone: ~I )!61.J...- ~ in the City of <br />Centerville, Anoka County, Minnesota for the tenn of one (1) year beginning with the 1st day of January, 2007, <br /> <br />subject to the laws of the State of Minnesota and the ordinances and regulations of said City ofCentervi1lepertaining <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 penalties): AJOn e.. <br /> <br />Report below details involving any license rejections or revocations: JJ n Yl ~ <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, sign below. <br /> <br />Date: 101 (/ /1.00 (., <br />, <br /> <br /> <br />Signature <br />c?d.r / V. bu..€-(' 1, \ Q r <br />Name (print) <br /> <br />FOR omCE 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 /> <br />relak:d devices, ~witbin.. ~8 ~ <br />Signature . Title C. 0" r '" <br />IJlo/.utb <br /> <br />61v <br />