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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 4J~ 2 C'''4n~c.t ~ e in the City of LA i -I&; ~ <br /> <br />in the County of WA~rf';\t6 rOil, State of Minnesota, Residence Telephone: rtfl )17g- - f~7l <br /> <br />HEREBY <br /> <br />MAKES APPLICATION FOR LICENSE to be issued to MICHAEL WAL~R, GNAW INC. DBA <br /> <br />CENTERVILLE LIQUOR BARRE~ to sell tobacco products at retail at 7093 20TH AVENUE SOUTH, <br /> <br />Business Telephone: (jf;;) '-it(; -(IlK in the City ofCenterville, Anoka County, Minnesota for the term of one (1) <br /> <br />year beginning with the 1st day of January, 2007, subject to the laws of the State of Minnesota and the ordinances <br /> <br />and regulations of said Oty of Centerville pertaining thereto, and herewith deposit $85.00 in payment of the fee <br /> <br />therefore. <br /> <br />Report below details of tobacco law violations that have occurred within the last five years. (Dates, offenses, <br /> <br />fines or other penalties): <br /> <br />Report below details involving any license rejections or revocations: <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 occu"ed during the past 12 months, complete in its entirety the <br />attached Tax Qearance Information, sign below. <br /> <br />Date: /1- I)" O,b <br /> <br /> <br />J1e CI/.-tft.. 7Jfrl.l1.lft~ ~At-~-<- <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 deVl <br /> <br />Signature <br /> <br />~., I I ,l~,V: <br /> <br /> <br />- - <br /> <br />Ti.t1e <br /> <br />Ch,,!l J' B/.ce <br /> <br />&1~ <br />