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<br /> <br />1880 Main Street .;> Centervi{{e, M'J{ 55038 <br />(651) 429-3232 () 'Ffh{ (651) 429-8629 <br /> <br />STATE OF MINNESOTA <br /> <br />aTY OF CENTERVILLE <br /> <br />COUNTY OF ANOKA <br /> <br />Application No. <br /> <br />RENEWAL APPLICATION FOR LICENSE TO SELL <br />TOBACCO PRODUCTS AT RETAIL <br /> <br />The undersigned, residing at (.All., ~'lLl~ 01L. <br /> <br />intheCityof c.~'i("-.)\':\...~ <br /> <br />in the County of At-:>'O\l-f>.. , State of Minnesota, Residence Telephone: ("S\ ~l -1..-'S~2- <br /> <br />HEREBY <br /> <br />MAKES APPLICATION FOR LICENSE to be issued to TODD STEFF.;N, ,..pBA CORNER EXPRESS, to <br /> <br />sell tobacco products at retail at 1990 MAIN STREET, Business Telephone: (/I;)\)~.Lk08 in the City of <br /> <br />Centerville, 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 ofCenterviOeperW.ining <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 months, complete in its entirety the <br />attached Tax Gearance Information, then sign belml'. <br /> <br />\b \ \Io\tl~ <br /> <br />Date: <br /> <br />Si~: .16 <br />\"""D <;~~ <br />Name (print) <br /> <br />FPRQFFICE USE ONLY (Do not ;vite below this line) <br /> <br />~d'5~~~~ <br /> <br />This is to certiry that appIican the associates, named herein have not been convicted within the past five years of any <br />violation of federal, state or ocallaw, ordinance provision, or other regulation relating to tobacco or tobacco products, or tobacco <br />related devices~ the las en years. <br /> <br />S. a;f:,,<. ~. 7/ <br />19nature ~ - <br /> <br />--.",--",,,,,. <br /> <br /> <br /> <br />Title <br /> <br />d#~ <br /># <br />