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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 'Mrz Cr-~~ -in the City of a.JlJa'; I!f, <br />WASJh:~fD'" <br />in the County of ~ , State of Minnesota, Residence Telephone: (v7i- )11K...- Kg?? HEREBY <br /> <br />MAKES APPLICATION FOR LICENSE to be issued to MICHAEL WA~R, GNAW INC. DBA <br /> <br />CENTERVILLE LIQUOR, to sell tobacco products at retail at 7093 20TH AVENUE SOUTH, Business <br />Telephone: ,,, )'1 U; -"11 in the City ofCenterville, Anoka County, Minnesota for the term of one (1) year <br /> <br />beginning with the 1st doy of January, 2006, subject to the laws of the State of Minnesota and the ordinances and <br /> <br />regulations of said Oty of CenterviUe pertaining thereto, and herewith deposit $85.00 in payment of the fee <br /> <br />therefore. <br /> <br />Report below details of tobacco law violations that have occurred within the last five years. (Dates, offenses, <br /> <br />fines or other penalties): <br /> <br />Report below details involving any license rejections or revocations: <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 occu"ed during the past 12 months, complete in its entirety the <br />attached Tax Oearance Information, sign below. <br /> <br />Date: <br /> <br />10- f/-f} { <br /> <br />~-&v~ <br />Signa re. . /'1 <br /> <br />f1V0~ r T W.A(...M~ ~ <br />Name (print) <br /> <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 />55 <br />