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<br />CITY OF CENTERVILLE <br />RENEWAL APPLICATION FOR LICENSE TO SELL <br />TOBACCO PRODUCTS AT RETAIL <br /> <br />Theundersigoed, residing at .5'1S"1 Isf;!9-.N intheCityof Huqn <br />(l <br />in the County of ~ofMinnesot8, Residence Telephone: (f;6t)..m qS-qD RERJ:RY <br /> <br />MAKES A!'PUCATlON FOR UCENSE to be issued to l<ea;(c..l-(~ K,OME/f. ~efArnle'lJlllL ~ <br /> <br />. to seD tobacco products at retail at 7098 CENTERVlLLE ROAD, Rn"""- Telephone: <br /> <br />(~f)1a53.-' 7 q( in the City ofCentervil1e. Anoka County, Minnesota for the term of one (1) year beginning with <br /> <br />the 1st day of JfIIIUary, 2008, subject to the laws of the State ofMiMesota lII1d the ordinances and regulations of <br /> <br />said City of CenWVille pertaining thereto, and herewith deposit $85. 00 in payment of the fee th",d'ore. <br /> <br />Report below details oftobaceo h!w violations that have occum:d within the last five years. (Dates, om.. .. ~, <br />o . <br />fines or other penalties): ) I/J <br />, <br /> <br />Report below details involving any license rejections or revocations: <br /> <br />;1/)4 <br /> <br />By si,l""" dill reMWfIlllpplktdio,., ttppUcut cettifia tIulI,lIm 1uIs bee" IW c"""e ,,, -nenltip. <br />corporate ofjicen, or partners. If c1lflllges Aave ocel4rred dJuilfg tlle past 12 mo"tb. colllJllete ill it111!lf1irety tlle <br />attached Tc Oetl1'flllCe ,rtJomultitm, sigll below. <br />I J ;).; J 08 <br />I , <br /> <br /> <br />e <br /> <br />~A5 LJ SWAfVSoM <br />Name (Print) <br /> <br />Date: <br /> <br />FOR OFFICE USE ONLY (Do not write btJow this 1iDe) <br /> <br />",rt b1 Potice Departmeat <br />This is to certifY that the applicant 8Dd the ascnci"""', II/IlIIed bcn:in have DOt becD amvicted within the past five)'lllllB of BDY <br />. =-"__~"'_""""'_Io""''''__''''''''' <br /> <br />~ptv~ / years r* dJJ~tl:€- <br /> <br />-51- <br />