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<br />CITY OF CENTERVILLE <br />RENEWAL APPLICATION FOR LICENSE TO SELL <br />TOBACCO PRODUCTS AT RETAIL <br /> <br />The undersigned, residing at WfZ C~ - in the City of a.J/J.a11!f, <br />WhS~NGT'1" <br />in the County of ~ . State of Minnesota, Residence Telephone: (6~ )1X-- Kt11 HEREBY <br /> <br />MAKES APPUCATION FOR UCENSE to be issued to MICHAEL WALtvtARt GNAW INC. DBA <br /> <br />. CENTERVILLE LIQUOR, to sell tobacco products at retail at 7093 20TH AVENUE SOUTH, Business <br /> <br />Telephone: ." )"I1t -"1f( in the City ofCenterville, Anoka County, Minnesota for the term of ODe (1) year <br /> <br />beginning with the 1st day of JalUlary, 2006 , subject to the laws of the State of Minnesota and the ordinances and <br /> <br />regulations of said City of CeIl~Qe pertaining thereto, and herewith deposit $85.00 in payment of the fee <br /> <br />therefore. <br /> <br />Report below details of tobacco law violations that have occurred within the last five years. (Dates, offenses, <br /> <br />fines or other penalties): <br /> <br />Report below details involving any license rejections or revocations: <br /> <br />By signin, this renewal application, applicant certifies tlud there 1uIs been 110 change ill ownership, <br />corporate officers, or partners. If changes have occu"ed during the past 12 months, complete ill its entirety the <br />attached Tax Clearance Information, sigll below. <br /> <br />Date: <br /> <br />10 - r I--(!) ~ <br /> <br />IA/k-D071 fN~ <br />~ <br />jA..VCi~ r T W,Ic(... n~ ~ <br />Name (Print) <br /> <br />FOR OrnCE 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 loca11aw, 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 />-if <br />