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<br /> <br />ervi{{e <br /> <br />1880 !Main Street _ Centeroilfe, 'M'J{ 55038 <br />(651) 429.3232 _ :Fa7( (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 / ~ 8'7 /l1~ z;:.L in the City of ~,~ <br />. '" <br />lit /d2sC. <br />in the County of ~ , State of Minnesota, Residence Telephone: f.51 )_- HEREBY <br />MAKES APPLICATION FOR LICENSE to be issued to ~ -C 1?A' /, ~ ~ <br />DBA ~ /J?a.d t..tc.. . to sell tobacco products at retail at / l? 0 I /J1~ 4:t. . <br />Business Telephone:4-[1 )3f') - 358~ the City ofCenterville, Anoka County, Minnesota for the term of seven <br /> <br />(7) months beginning with the 1st day of June, 2004 , subject to the laws of the State of Minnesota and the <br /> <br />ordinances and regulations of said City of Centerville pertaining thereto, and herewith deposit $84.00 in payment of <br /> <br />the fee therefore. <br /> <br />By signing this renewal application, applicant certifies that there has been no change in ownership, <br />cotporate officers, or partners. If changes have occurred during the past 12 nwnths, complete in its entirety the <br />attached Tax Qeorance Information, then sign below. <br /> <br />Shllol-/ <br /> <br />Date: <br /> <br />~~ ~~ "- <br />Signature <br />O/ML D 8aeo//.L~K <br />Name (Print) <br /> <br />Report by Police Department <br />This is to certi1Y that the applicant and the associates, named herein have not been convicted within the past five years of any <br />violation of federal, state or local law, ordinance provision, or other regqIation relating to tobacco or toba% P.:$IIcts, or tob~. <br />relateddCV1ce~. _, ~~ ~f74t A-J;,k'11-u ~~~ ~(I#A. A e~ fa.... tffl . '/:_' <br />. . . ~ ,hj/' ~""",,,", <br />Signature . 4{ff;t...-;7'./ Title ~..; /1, d'uce ~ <br />