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<br /> <br />Or~O~1Ltg <br /> <br />tervi{{e <br />'Esta6[isfied 1B57 <br /> <br />1880 :Main Street . Centervi((e, 'M2{ 55038 <br />(651) 429-3232 .;Fa>( (651) 429-8629 <br /> <br />STATE OF MINNESOTA <br /> <br />CITY OF CENTERVILLE <br /> <br />COUNTYOFANOKA <br /> <br />Application No. <br /> <br />APPLICA nON FOR LICENSE TO SELL <br />TOBACCOPRODUCTSATRETML <br /> <br />The undersigned, residing at 1-fJ92 C r444.d'., /lvt::. <br /> <br />in the City of () ai-&! ff Ie <br /> <br />in the County of 1v4sIIIJV6ToA!, State of Minnesota, Residence Telephone: (ion) 33D - 4600 HEREBY <br /> <br />MAKES APPLICATION FOR LICENSE to be issued to DNfllII IJJC. <br /> <br />. DBA Cl1PmUVotd LI'lilO/!;D <br />, <br /> <br />sell tobacco products at retail at 70'/; ).0"'" AlI?.s _ Business Telephone: (651 ) 'Iz6 - it 7'1 in the City of <br /> <br />enterviIle, Anoka County, Minnesota for the term of one (1) year beginning with the 1st doy of January, 2004, <br /> <br />subject to the laws of the State of Minnesota and the ordinances and regulations of said City ofCentervi1kpertaining <br /> <br /> <br />thereto, and herewith depo~~'IDn 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 />afiached Tax Oearance Information, then sign below. <br /> <br />Date: <br /> <br />2. -7.--?--~(J4' <br /> <br />~ ",. 4/Q~ <br />Signature <br /> <br />11.c It iiI'- I T Wet I "'" a t" <br />Name (Print) <br /> <br />FOR OFFICE USE ONLY (Do not write below this line) <br /> <br />Report by Police Department c:::;::;;:? <br />This is to certify that the applicant ll"1I1~.d _, named herein ha~ not been convicted within the past five years of any <br />violation of federal, state or IOC.al.. .18. w, ordinance provision, or o~ regulationrelating tg,toP8CC9 or )obacco products, or tobacco <br />lteddevices~elonywith#in the last years. (}'?1 tJ"~. ~.AI.ur ~~. <br /> <br />Signature ",J~ /;l... _. Title ~~A~~~ <br />) /I <br />