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<br />, <br /> <br />.(/ <br /> <br /> <br />~ <br /> <br />1 <br /> <br />STATE OF MINNESOTA <br /> <br />#Plop <br />dw,d YIIf' <br /> <br />APR 2 9 2U02 <br /> <br />CITY OF CENTERVILLE <br /> <br />COUNTY OF ANOKA <br /> <br />Apptication No. <br /> <br />APPLICATION FOR LICENSE TO SELL <br />TOBACCO PRODUCTS AT RETAIL <br /> <br />The undersigned, residing at <br /> <br />''1<\'0 VV\-A:..... <:':''1', <br /> <br />in the City of <br /> <br />~...1i.1i I L.~G <br /> <br />in the County of _~clj...A , State ofMmnesota, Residence Telephone: (r.",> \ )1101- - 1.- <;'S 7... HEREBY <br /> <br />MAKES APPLICATION FOR LICENSE to be issued to TODD STEFFEN. DBA CORNER ExPRESS, to <br /> <br />sell tobacco products at retail at 1990 MAIN STREET, Business Telephone: (Vll )1YL- u,.cg in the City of <br /> <br />Centervil/e. Ano/ca County, Minnesota for the term of one (I) year beginning with the 1st day of January, 2002 , <br /> <br />subject to the laws of the State of Minnesota and the ordinances and regulations of said City ofCenten>i/leperlaining <br /> <br />thereto, and herewith deposit $75.00 in payment of the fee therefore. <br /> <br />By signing this renewal application, applicunt 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 Clearance lnfomudion, then sign below. <br /> <br />1/1"\ \0'- <br /> <br />Date: <br /> <br />." ~ <br />Signature(!J::> . <br /> <br />.~o>o ~H'I'-':> <br />Name (Print) <br /> <br />FOR OFFICE USE ONLY (Do not write below this tine) <br />j . <br />Report by Police Depa~ . ~t q ,....,jIV" <br />This is .!O certify that th !lPPlican ae6-~ llIIseeiate9, named herein have not been convicted within the past five years of any <br />violation of federal, state or I 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 />~ume T~ ~~~ <br /> <br />~ 4~ ' <br />;V~; r~ik, ckJ.-. ~- ~/N~ tPSrPJ }/D,~..v ~ ~v,i1 <br />(1hz ~ ~~ "'0 $6 ~ ~ Auuw eifel<:> ~ ~/tJL-- <br />