2005-11-09 CC Packet - Laserfiche WebLink

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CITY OF CENTERVILLE RENEWAL APPLICATION FOR LICENSE TO SELL TOBACCOPRODUCTSATRETML The undersigned, residing at Vi1 t::. ~ f.\ ~ 1)fL .. in the City-of c,~ 'LV I \...L'f in the County of .JtM>v..~ . State ofMinnesoui,"Residence Telephone: ("5\)7"1-" CSS"L HEREBY MAKES APPLICATION FOR LICENSE to be issued to TODD STEFFAN, DBA CORNER EXPRESS, to sell tobacco products at retail at 1990 MAIN STREET, Business Telephone: (Co~ I )tft{.. - 'G.~ in the City of Centervil/e, Anoka County, Minnesota for the term of one (1) year beginning with the 1st day of January, 2006, subject to the laws of the State of Minnesota and the ordinances and regulations of said City ofCenterville pertaining thereto, and herewith deposit $85.00 in payment of the fee therefore. _______~ __~q>_<?!:t_!>.C?l<?~~~@~_~i~~!>~~ !~~~_~~~~<?~~_~t_~y~~~~_~t~!!'_ !!i~_!~_~~_y.~~ Q?~~ <?f!'~____~ fines or other penalties): fj [ Pr Report below details involving any license rejections or revocations: (0/4_ By signing this renewal application, applicant certifies that there has been no change in ownership, corporate officers, or partners. If changes have occun-ed during the past 12 months, complete in its entirety the attached Tax Oearance Information, sign below. Date: to f-z I \u S Si~ lifts ~t;O ~ Name (print) FOR OmCE USE ONLY (Do not write below this line) Report by Police Department . This is to certify that the applicant and the associates, named herein have not been convicted within the past five years of any violation of federal, state or local law, ordinance provision, or other regulation relating to tobacco or tobacco products, ortobacco related devices, or any felony within the last ten years. Signature Title tf;9