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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 . - 78 g:L . - in the City of . ~ <br />1 . W /~ -c::, <br />in the County of ~'^. State of Minnesota, Residence Telephone: ( )~- t) ~, HEREBY <br /> <br />MAKES APPUCATION FOR LICENSE to be issued to ~-=-Vb r 1\ J~-L-Jrl, MOUNTAIN ENTERPRISES, <br /> <br />INC. DBA TRIO INN, to sell tobacco products at retail at 7082CENTERVILLE ROAD, Business Telephone: ( <br />bS~ Jfo ( ').J "1 the 'City of Centerville, Anolra' County, Minnesota for the term of one (1) year beginning with the <br /> <br />1st day of Ja""lUY, 2006, subject to the laws of the State of Minnesota and the ordinances and regulations of said <br /> <br />City of Centerville pertaining thereto, and herewith deposit $85.00 in payment of the fee therefore. <br /> <br />Report below details of tobacco law violations that have occurred within the last five years. (Dates, offenses, <br />fines or other penalties): M~ <br />'1~)'r$xJlf'-~h .(aP-'1Jibkctt71JII1;ntJy.y[II11~~-H~~ .c ~ ~ <br /> <br />Report below details involving any license rejections or revocations: ~ <br /> <br />By siglling this renewal application, applicant certifies that there has been 110 cha1lge in ownership, <br />corporate officers, or partners. If changes have occun-ed during the past 12 months, complete in its entirety the <br />attached TtIX Clearance Information, sign below. <br /> <br />II-J'&~ <br /> <br />~~A~ <br />Signature t1 i!t /1 ) <br />. . C/~ . (}jV1iJ/IV <br />Name (print) <br /> <br />Date: <br /> <br />FOR OFFICE USE ONL Y (Do not write below this tine) <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 tobacco <br />related devices, or any felony within the last ten years. <br /> <br />Signature <br /> <br />Title <br /> <br />~/ <br />