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<br />CITY OF CENTERVlLLE <br />RENEWAL APPLICATION FOR LICENSE TO SELL <br />TOBACCO PRODUCTS AT RETAIL <br /> <br />. <br />The undersigned, residing at ~~'ll, GQ.\~ S)Q..\U~ <br /> <br />in the City of c.~l'l"telt\J\~ <br /> <br />in the County of A..:>o\t.'" , State of Minnesota, Residence Telephone: (~~') ~1._ 1, SS2 HEREBY <br />MAKES APPLICATION FOR UCENSE to be issued to TODD SrEF'F'AN, DBA CORNER ExPRESS, to <br />sen tobacco products at retail at 1 990 MAIN STREE:r, Business Telephone: ~S\ )1.{1.(, - (,(,(16 in the City of <br /> <br />Centerville, Anola County, Minnesota for the term of one (1) year beginning with the 1st day of JtlllMlII'Y, 2008, <br /> <br />subject to the laws of the State of Minnesota and the ordinances and regulations of said aty ofCenterville pertaining <br /> <br />thereto, and herewith deposit S85.00 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 />fines or other penalties): \Q~ ~u~ ~\.r.t..o ~\...~ -t:,~ &"11~d <br /> <br />Report below details involving any license rejections or revocations: <br /> <br />r'\/Ir <br /> <br />By siglli"g tlds renewal app1klltiOll, appliclUll ct!l'tifis tlUJl tIIere IuIS bee" "0 cIuuIg~ ill l1W1Jel'S1Jip, <br />corporate offU:ers, or plll11lers. If changes htn'e occllrred .ri"g the ptlSt 12 IfWllths, complete in its entirety the <br />IIttiu:Iaed Tax QetJ1YIrICe l"formotitm, sig" below. <br /> <br />Date: ~ \ \ ~01 <br /> <br />Signature <br /> <br />~9o <br />Name (Print) <br /> <br /> <br />FOR OFFICE USE ONLY (Do not write below this line) <br /> <br />Report by Police Departmedt <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 loca1law, otdiDancc provision, or other regulation relating to tobacco or tobacco products. ortobacoo <br />related devices, or any felony within the last ten years. <br /> <br />Sipature Title <br /> <br />.- v.~lJiifn a-Vl /'/PJj'tJb ~.#/?k <br />