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<br />CITY OF CENTERVILLE <br />RENEWAL APPLICATION FOR LICENSE TO SELL <br />TOBACCO PRODUCTS AT RETAIL <br /> <br />The iindersigned, residing at - J :; 8'7 J)1tJtt/t//) TA 1. I in the City of ~~ <br />:-J ~ /61 -7~;J- I J6-c." <br />in the County of ~~ . State of Minnesota, Residence Telephone: rJ5/).I/':;t,. . 1/88'" HEREBY <br /> <br />MAKES APPLICATION FOR LICENSE to be issued to CARL BUECHLER. DBA CENTER MART, to sell <br /> <br />tobacco products at retail at 1801 MAIN STREET, Business Telephone: (t~7 {1~~~(Jin the City of <br /> <br />Centerville, Anoka County, Minnesota for the term of one (1) year beginning with the 1st day of January, 2006, <br /> <br />subject to the laws of the State of Minnesota and the ordinances and regulations of said Dty of Centervil1e pertaining <br /> <br />thereto, and herewith deposit $85.00 in payment of the fee therefore. <br /> <br />_ _ _ RepQrt J>~low_d_t~bllls ()f t()1?~~cQIClw violati()Ils ~t!t~ye occurred within the last five years. Q?at~s, ()~~ <br /> <br />Report below details involving any license r . <br /> <br /> <br />fines or other penalties): <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 Qearance Information, sign below. <br /> <br />Date: <br /> <br />lofr/o!5 <br /> <br />Catt~ <br />Signature <br /> <br />Olf~ L Bl1"EeH-Lt=/C <br />Name (print) <br />Ct=fJTclC fJ1f}trr <br />FOR OFFICE USE ONLY (Do not write below this line) <br /> <br />Report by Police 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 local law, ordinance provision, or other regulation relating to tobacco or tobacco products, or tobacco <br />related devices, or any felony within the last ten years. <br /> <br />Signature ~ r((}f3~~ Title ~ f <br /> <br />39 <br />