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2006-12-13 Packet
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2006-12-13 Packet
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1/25/2011 11:01:39 AM
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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 7V ~ J..~ In the City of ~ <br /> <br />in the County of ~A ' State of Minnesota, Residence Telephone: ( )_- HEREBY <br /> <br />MAKES APPLICATION FOR LICENSE to be issued to PAUL MONTAIN, MOUNTAIN ENTERPRISES, <br /> <br />INC. DBA TRIO INN, to sell tobacco products at retail at 7082 CENTERVILLE ROAD, Business Telephone: ( <br />~ /I)L )~ the City ofCenterville, Anoka County, Minnesota for the term of one (1) year beginning with the <br /> <br />1st day of January, 2007, subject to the laws of the State of Minnesota and the ordinances and regulations of said <br /> <br />aty ofCenterville pertaining 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 /> <br />fines or other penalties): <br /> <br />J~ <br /> <br />., <br /> <br />!}- tl- oy <br /> <br />Report below details involving any license rejections or revocations: <br /> <br />.-- <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 occun-ed during the past 12 months, complete in its entirety the <br />attached Tax Dearanee Information, sign below. <br /> <br />Date: IUI-l/ 7 I 0 ~ <br /> <br /> <br />Signature <br />~~ P /'47V7A/;V <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 />JIt <br />
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