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<br />I <br /> <br /> <br />tervi{{e <br /> <br />1:staflisfiecf 1857 <br />STATE OF MINNESOTA <br /> <br />1880 !Main Street . Centervi[[eJ !M'JIf.. 55038 <br />(651) 429-3232 . ~a;( (651) 429-8629 <br />CITY OF CENTERVILLE <br /> <br />COUNTY OF ANOKA <br /> <br />Application No. <br /> <br />RENEWAL APPLICATION FOR LICENSE TO SELL <br />TOBACCO PRODUCTS AT RETAIL <br /> <br />The undersigned, residing at \ '0 \;. V\~ s.\-. <br /> <br />in the City of t\ttS~itcf <br /> <br />in the County of DI1\<t'"s\u... <br /> <br />, State of Minnesota, Residence Telephone: (lpSI )...12l- qD~ 3 <br /> <br />HEREBY <br /> <br />MAKES APPLICATION FOR LICENSE to be issued to DBA TOM THUMB FOOD MARKETS, to sell <br /> <br />tobacco products at retail at 801 MAIN STREET, Business Telephone: (~Sl )1s.3. -~ in the City of <br /> <br />Centerville, Anoka County, Minnesota for the term of one (1) year beginning with the 1st day of January, 2001 , <br /> <br />subject to the laws of the State of Minnesota and the ordinances and regulations of said City of Centerville <br /> <br />pertaining thereto, and herewith deposit $75.00 in payment of the fee therefore. <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 Information, then sign below. <br /> <br />lo~(o~oo <br /> <br />cf;oJ,\A~ <br /> <br />.')~ . -or ._~ <br />1\1 ~""-J <br /> <br />Date: <br /> <br />Signature <br /> <br />lovr:e/ KnLl--+sD'" <br />Name (Print) <br /> <br />FOR OFFICE USE ONLY (Applicant do not write below this line) <br /> <br />POLICE DEPARTMENT <br /> <br />This is to certify that the applicant aftB tftB !lI5~'" jJthil!t, 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 re lation relating to tobacco or tobacco products, or <br />tobacco related devices, or any felony Wi~l<l:;ttt;n ye<;lFS. .. /../J" ,/ <br /> <br />Police Departmritt S' nature: ~~"~'--7itle: ~/~~ <br />Date: / ;//~ t1'D ... / <br />/ ' / <br /> <br />/Itro, 'Lde*, 4'ean~ c~ dn4z- Cfi!M~'___ /.,1'/ ~..or. ~___. <br />.L C}/2/;J ~ rz; /:;1e J7455i<t11o a~w ?V~ ~ /_/ <br />L1r7 / ~ /;/./700 <br /> <br />