2005-11-30 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 I)/J r3-. Ce~ 1& f'v i fk I2J - in the City of 4r1 If rill i /~ in the County of ArJolt-tf , State of Minnesota, Residence Telephone: f,/~)5'~/f- ?)&,oS 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: (1,5/) 1,53 - JlJ.L in the City of Centerville, Anoka County, Minnesota for the tenn of one (1) year beginning with the 1st day of January, 2006 , subject to the laws ofthe State of Minnesota and the ordinances and regulations of said City of Centerville pertaining thereto, and herewith deposit $85.00 in payment of the fee therefore. Report below details of tobacco law violfltio~ that have qc~~d within the last five years. (Dates, offenses, ~ SQte.- f!F .I~b4cto 7<f.lYvt(l41" / ~ _ fl/ib.~1- #/qd,O::> fines or other penalties): Z t! t! Z C~~ /; ",.;c t c.1.. c ~ /:.".; e- s '/ ~ ~"e.- , sa R -Ii. I1a4 17 n-'wP / ' tll/kMO ~ J2j3(j/~- (d"fP4'u:CCklj F,n~ #//1 / /. /? ~et:S I Report below details involving any license rejections or revocations: By signing this renewal application, applicant certifies that there has been no change in ownership, corporate officers, or partners. If changes have occu"ed during the past 12 months, complete in its entirety the attached Tax Qearance Information, sign below. Date: ~ Y/, H ~f2~ Signature tJl/I/f'/4.. ::r D/;$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, ortobacco related devices, or any felony within the last ten years. Signature Title 21