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<br />" <br /> <br /> <br />'(\r\ \) Y\; Q.AJ e.- <br /> <br />STATE' <br /> <br />VJ Y I <br />f, \0..; <br /> <br />n.e. <br /> <br />S~\.J J +r () n.... ) <br />I 1)0 d 5treet. Centerviffe, 'JvtJ{ 55038 <br />+--~ 'A l~& IV "2M" .~,<('5')<"'-8629 <br />jlq ~ AUL (l[ tY 1'" <br />(l) I'J f ,r tj J 'I I' I i'i' () OTY OF CENTERVILLE <br />I) fJ!) <. i\pp6cation No. <br />. d- / <br />'!~A'I;-5;6(l . ',l{/:'/./ <br />Iv' i It:' <br />t-' <br /> <br />COUNT <br /> <br />'SELL <br /> <br />" <br />i <br /> <br />~/~ _ n..... <br />, '-= '-- <br />:.s; 1Ii J;;St. '" <br />,State of Minnesota, Residence Telephone: f )_- HEREBY <br /> <br />in the County of ~ <br /> <br />MAKES APPLICATION FOR LICENSE to be issued to ~ "Ii ~.. 7: ~~ <br />DBA ~;nad t.. t.C . to sell tobacco products at retail at J f? CJ / /)fa;;.... -JY. . <br />usiness Teleph()ne:~fLy~~'J~3:8"~1:heCiijoICenteiVille;7l.nokii COwiij;Mtriiresoiafori:heiermorseVen-= <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 Oty ofCenterville 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 />corporate officers, or partners. If changes have occu"ed during the past 12 months, complete in its entirety the <br />attached Tax Oearancelnformation, then sign below. <br /> <br />s/'),Iol--/ <br />, <br /> <br />Date: <br /> <br />~~~L~ <br />Signature <br />O.lfJtL 0 BaetJ//"L,E/Z <br />Name (Print) <br /> <br />Report by Po6ce Department <br />Dis is to certify that the applicant and the associates, named herein have not been convicted within the past five years of any <br />,lation of federal, state or local law , ordinance provision, or other regulation relating to tobacco or tobacco products, ortobacco <br />related devices, or any felony within the last ten years. <br /> <br />Signature <br /> <br />Title <br /> <br />1_ _ _ _ <br />