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<br />. <br /> <br /> <br />i"'f.,,:""" <br />!U{;f <br /> <br />:;' 11{1{~."; <br />"d ::....,j.J'f;.. <br /> <br />1880 fjI;[ain Sireet J Centervi[[e, M:t{ 55038 <br />(651) 429-3232 ":!(JJC (651) 429-8629 <br /> <br />STATE OF MINNESOTA <br /> <br />CITY OF CENTERVILLE <br /> <br />COUNTY OF ANOKA <br /> <br />Application No. <br /> <br />RENEWAL APPLICA nON FOR LICENSE TO SELL <br />TOBACCO PRODUCTS AT RETAIL <br /> <br />TheunderSigned,residingarr;;~VV'b;:tJ:J.q5 in the City of Ctnkv\li )\0 <br />in the County of &Ol:A1J , State of Minnesota, Residence Telephone: MI>13.1- qD 9. '3 HEREBY <br />MAKES APPLICATION FOR LICENSE to be issued to DBA TOM THUMB FOOD MARKETS, to sell <br />tobacco products at retail at 801 MAIN STREET, Business Telephone: <I/J{ )ft6;. 1~q${n the City of <br /> <br />'~enterville, Anoka County, Minnesota for the term of one (1) year beginning with the 1st day of January, 2003 , <br /> <br />subject to the laws of the State of Minnesota and the ordinances and regulations of said City of Centen>ille pertaining <br /> <br />thereto, and herewith deposit $75.00 in payment of the fee therefore. <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 nwnths, complete in its entirety the <br />attached Tax Oearance lnformation, then sign below. <br /> <br />Date:[b.MOCr rB, ,:),{;Od-.. <br /> <br />Ltr7uku ,It ~- <br /> <br />Signature <br /> <br />&(/(J;ijle~ K r;,'t.;.,L-c <br />ame (print) <br /> <br />FOR OFFICE USE ONLY (Do not write below this line) <br /> <br />Report by Police Department <br />Tbis is to certify that the applicant and the associates, named herein have not been convicted within the past five years of any <br />.tion of federal, state or local law, ordinance provision, or other regulation relating to tobacco or tobacco products, or tobacco <br />ed devices, or any felony within the last ten years. <br /> <br />Signature Title <br />lo/;oltn- ~5Az.6 ~F 1fJ64ccu ;r dJ/,yrt~ ~ <br />I!~~~ O! -:~~f)~?~~Q_~~/11~--:'~~/<:r!d~ <br /> <br />I <br /> <br />;iP tJlmlflGttdwJ, <br />/Jon- rent <br />