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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 {1,V/" fJ1~ in the City of ~ ~ <br />, /t01 <br />in the County of 4JJW ' State of Minnesota, Residence Telephone: ( ). /,.0 01-S1 HEREBY <br /> <br />MAKES APPLICATION FOR LICENSE to be issued to"PAuL. Mer ff.AdN, MOUNTAIN ENTERPRISES, <br /> <br />INC. DBA TRIO INN, to sell tobacco products at retail at 7082 CENTERVlLLE ROAD, Business Telephone: ( <br />eS' <br />) '1).1, - J9 SLin the City ofCenterville, Anoia County, Minnesota for the term of one (1) year beginning with the <br /> <br />1st day of JlUIllary, 2008, subject to the laws of the State of Minnesota and the ordinances and regulations of said <br /> <br />City of Centenrilk pertaining thereto, and herewith deposit $IS. 01# 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 />/ /-/9~ Jf}tJ 1 <br /> <br />~ <br /> <br />~ <br /> <br />~ <br /> <br />fines or other penalties): <br /> <br />~~ <br /> <br />Report below details involving any license rejections or revocations: <br /> <br />By sirlOlJg this renewalllpplicatioll, applicant certifies tiull there hIlS b<<n 110 change ill tMlUftldp, <br />corporate officers, or plll11lers. 1/ changes Iune occlln'ed dll.ring the past 12 months, complete in its entirety the <br />IJttacltetl Tu Cktmutce lnformtllioll, sign Wow. <br />Date: (tf., )).r () 7 <br /> <br /> <br />FOR OFFICE USE ONLY (Do not write below this line) <br /> <br />Report by PoUce 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 1ocallaw, ordinaoce provision, or other reguJation relating to tobac:eo or tobacco products, C1l tOOacco <br />related devices, or any felony within the last ten years. <br /> <br />Title <br /> <br />S....ture <br />* Vj,,14n~vt 011 JI/'P~' <br /> <br />