2005-11-09 CC Packet - Laserfiche WebLink

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CITY OF CENTERVILLE RENEWAL APPLICATION FOR LICENSE TO SELL TOBACCO PRODUCTS AT RETAIL - The undersigned, residing at IJ~ 13.. C&~ Ie nil fk I!d in the City of - 4~ If ril J i If in the County of ftrJO It-~ , State of Minnesota, Residence Telephone: ~/~) 7f9- t:)&'c; S HEREBY MAKES APPLICATION FOR LICENSE to be issued to BILL BISEK, KELLY'S KORNER INC. DBA KELLY'S KORNER BAR, to sell tobacco products at retail at 7098 CENTERVILLE ROAD, Business Telephone: (t5/ ).kfL- 'Jf I in the City ofCenterville, 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 of Centerville pertaining thereto, and herewith deposit $85.00 in payment of the fee therefore. ~ _ ____~ __~ _~~l>.<?!!~~~!<?w 4~!~s~<?f~~~cc~}a~~yi~lat~~~~~t ~~e o~~~~_~.!!lln !!J.~ last five ~~~.!~QJ~ offenses,~~__ . fines or other penalties): Z ~ () z / CVJn-kJ!" t?~(; t G,i~ c; k / ~ ~ e- ~ {V · Report below details involving any license rejections or revocations: By signing this renewal application, applicant certifies that there has been no change in ownership, corporate officers, or partners. If changes have occu"ed during the past 12 months, complete in its entirety the attached Tax Qearance Information, sign below. Date: tI-d YI/ IJ5 ~f2~ Signature Ul//!tff~ ::r [3/;&R Name (print) FOR OFFICE 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, or tobacco related devices, or any felony within the last ten years. Signature Title k.