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<br />STATE OF MINNESOTA <br /> <br />CITY OF CENTERVlLLE <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 :~ 7/q l5u[XUl!JV DR in the City of W4!l/ <br />in the County of .PlltDTlf , State of Minnesota, Residence Telephone: (6/2. )~3 - SbJ1 <br /> <br />HEREBY <br /> <br />MAKES APPLICATION FOR LICENSE to be issued to JEDEDIAH G. MAREK, DBA Jed's Liquor to sell <br /> <br />tobacco products at retail at 7093 - 20TH AVENUE SOUTH, Business Telephone: (612)483-5634 in the City of <br /> <br />Centerville, Ano/ca County, Minnesota for the term of six (6) months beginning on the 1st day of July, 2009, <br /> <br />subject to the laws of the State of Minnesota and the ordinances and regulations of said City of Centerville <br /> <br />pertaining thereto, and herewith deposit $85.00 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 offteers, or partners. If changes hlll'e occurred during the past 12 months, complete in its entirety the <br />attached Tax ~rance Information, then sign below. <br /> <br />Date: ~ vi . <br /> <br />~. <br /> <br />~ture / . . <br />JE/)[/JI!l)/ I- If/ftil( <br />Name (Print) <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 related dev' or an I . . . ten years. _& \ ^ of t /. _ <br /> <br />Signature.. Title " tf .C~ <br /> <br /> <br />~'-/ <br />