Laserfiche WebLink
<br />OCT g ll00r <br /> <br />CITY OF CENTERVILLE <br />RENEW At APPLICA nON FOR LICENSE T SB~leRVILLE; MN <br />TOBACCO PRODUCTS AT RETAIL <br /> <br />The undersigned, residing at ! 8 I'Z.. ~A I N ~ 1'P.frl in the city of ~ ~,'/I.e <br />in the County of Af\)O ~ . State of Minnesota, Residence Telephone: (ft31)~ (It", 1....", HEREBY <br /> <br />MAKESAPPUCATION FORUCENSE to be issued to KEVlNBUECHLER, DBA CENTER MART, to sell <br /> <br />tobacco products at retail at 1801 MAIN STREET; Business Telephone: ((.6\) ~'l"'_ 'tB&Oin the City 01 <br /> <br />Centervil/e, AnoIa1 County, Minnesota for the term of ODe (1) year beginning with the 1st dtly of JilIIIlIIIy, 2." <br /> <br />subject to the Jaws of the State ofMinnesota and the ordinances and regulations of said O(v ofCmtervilJe pertaining <br /> <br />thereto. and herewith deposit S1S.(JO in payment of the fee therefore. <br /> <br />Report below details of tobacco law violations ,that have occurred witbin the last five yeaIS. (Dares. ~ <br />fines or other peoaI1ies): t}h~a1Z - ~{fO (~~e -/i,.~kYe: "!Jf!: <br /> <br />Report below details involving any license rejections or revocations: <br /> <br />By rig.", '"is I'eIIeWtlI tq1p1ictztion, appliellllt certifies that ~ Iuu bee" 110 c1ulnge ;" OWIlel'SIUp, <br />corporaJe officers, or pflt'tnen. q cluznges Iuzve occurred during the pllSt 12 months, complete in its entirety the <br />IItttIclled Tu ~ 111{0I7IUlIi0n, sig,. below. <br /> <br />Date: i D /1/ I t3T <br />{ I <br /> <br /> <br />I <br />I <br />I ' <br /> <br />Name (Print) <br /> <br />FOR. OFFICE USE ONLY (Do not write below this line) <br /> <br />Report by Ponce IlepartmeDt <br />This is to certi1Y 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 produas, ortobacco <br />related devices. or any &Iony within the last ten years. <br /> <br />Signature <br /> <br />TItle <br />