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<br />CITY OF CENTERVILLE <br />RENEWAL APPLICATION FOR LICENSE TO SELL <br />TOBACCO PRODUCTS AT RETAIL <br />./ <br /> <br />Theundersigned,residingat ;.j~(1L (.:JYOf\~ Ave intheCityof~ OaJdevlL <br />Wo. )~[ft~ /1;1'\ <br />in the County of /Jft~,()\l...D... r:- ' State of Minnesota, Residence Telephone: (iI>l ).2Ql- Y'ii' &, 3 HEREBY <br /> <br />MAKES APPLICATION FOR LICENSE to be issued to LISA THEIS, DBA MAINSTREET LiQUOR <br /> <br />BARRE4 to sell tobacco products at retail at 1875 MAIN STREET, Business Telephone: ( <br /> <br />) - in the <br />-- <br /> <br />City ofCenterville, Anoka County, Minnesota for the term of one (1) year beginning with the 1st day of January, <br /> <br />2009, subject to the laws of the State of Minnesota and the ordinances and regulations of said City ofCenterville <br /> <br />pertaining thereto, and herewith dep~S~ p~ym.e~~~L~~f=e~~e~~.~~:~___.~,?J~ 1iP- ~J)7 <br />Report below details oftobacco law violations that have occurred within the last five years. (Dates, offenses, <br /> <br />fines or other penalties): N JP\ <br /> <br />Report below details involving any license rejections or revocations: /\i) It <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 occurred during the past 12 months, complete in its entirety the <br />attached Tax Clearance information, sign below. <br /> <br />Date: Lj- Cj-Dl <br /> <br /> <br />~~c. ;1;1. <br />ame (Print) <br /> <br />---- . <br />I hel S' <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 <br />tobacco re ars. <br /> <br />~.., . ~~. <br />-- <br />- ~ <br />,- -~ <br />- - <br /> <br />itle <br /> <br />a;~ #' !Jj{-(/-/ <br />#fh? <br /> <br />QtL/ <br /> <br />Signature <br />