2003-11-12 CC Packet - Laserfiche WebLink

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ervir{e 'E.sta6{isfiet{ 1857 1880 Main Street . CentervUfe,9If!J.L 55038 (651) 429-3232 -1"a7C (651) 429-8629 STATE OF MINNESOTA CITY OF CENTERVILLE COUNTY OF ANOKA Appncation No. RENEWAL APPLICATION FOR LICENSE TO SELL TOBACCO PRODUCTS AT RETAIL The undersigned, residing at .51/9.5 J .<;1 ~ S 1'"J Ai in the city of fltI~o in the County of IPIJ.S IJI,1)bt'tX State of Minnesota, Residence Telephone: <b!/)}/o1:- 7./1J1 HEREBY MAKES APPLICATION FOR LICENSE to be issued to TERRY SAGER, SAHAWK INC. DBA SAGER'S LIQUOR, to sell tobacco products at retail at 7093 20TH AVENUE SOUTH, Business Telephone: f6S1 )~- _. UJ.i in the City olCenterville, Anolra County, Mirmesota for the term of one (1) year beginning with the 1st day of January, 2004 , subject to the laws of the State of Minnesota and the ordinances and regulations of said ~ of Centerville pertaining thereto, and herewith deposit $75.00 in payment of the fee therefore. By signing this renewal application, applicant certifies that there has been no change in ownership, corporate officers, or partners. If changes have occurred during the post 12 months, complete in its entirety the attached Tax Clearance Information, then sign below. Date: I/J-} 03 . ~JI 1!~PA"'{f ;i. 5AUR N e (Print) FOR OFFICE USE ONLY (Do not write below this line) Report by ponce Department ~ ~ ~ This is to certi1Y that the applicant ~, named herein~not been convicted within the past five years of any violation of federal, state or local law, ordinance provision, or other regulation relating to tobacco or tobacco products, ortobacco re1aIl:d devicesr fGIolt, -'Iil~ill the last ten _ /' Signature :-,..)- #~ !iIIe ~ -;( ;;;:t:e;, IJ 1/