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<br />CI1Y OF CENTERVILLE <br />RENEWAL APPLICATION FOR LICENSE TO SELL <br />TOBACCO PRODUcrs AT RETAIL <br />The undersigned, residing at 57 is J S' 7 1) .S t. ;4/. in the City of If J /;0 <br /> <br />in the County of W/i) H . State of Minnesota, Residence Telephone: CifiJ}-Yd17 jo/ <br /> <br />HEREBY <br /> <br />MAKES APPLICATION FOR LICENSE to be issued to TERRY SAGER, SAHAWKOF MINNESOTA, INC. DBA <br /> <br />SAGER'S BAR-N-GRILL, to sell tobacco products at retail at 7098 CENTERVILLE ROAD, Business Telephone: ( <br /> <br />bS J )Jlll..-.J11L in the City ofCenterville. AnoIra County. Minnesota for the term of oae (1) year beginning with the <br /> <br /> <br />1st 4ay of JIIIIIUIIY, 21101, subject to the laws of the State of Minnesota and the ordinances and regulations of said <br /> <br /> <br />City ofCentevi1le pertaining thereto~ and herewith deposit SBS.OO 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 /> <br />fines or other penalties): <br /> <br />Report below details involving any license rejections or revocations: <br /> <br />By signiag t1ds reJIeWfJI tlJlPIiadio1l, "Pplicat cmiJies t1uIt tIrNe .. been lID c1uuage ja OWIIDSltip, <br />corpl1I'IIIt! ojficers, or ptlrlnerS. 1/ cIumges Iuwe tJCCIIfWtlduri,., tlte pat 11111011th, colllpkte;" its ndirdy tile <br />tlttileW TDX Cletznmce InJontUItioll, sig,. below. <br /> <br />Date: If} .. .s "(}h <br /> <br />I <br />I <br /> <br />: ,f;l I . <br /> <br />~R,21.JlL J. SI/b$/( <br />Name (Print) <br /> <br />FOR. OrnCE USE ONLY (Do DOt write below dais tiDe) <br />Report by Police Department <br />This is to certify that the applicant and the assocUBs. named baein have DOt been COIIYic:ted within the past five years of any <br />violation of fcdcra1, state or local law, ontiDance provision, or other regulation relating to tobacco or tobacco products, ortobao:o <br />related . (]I' within the last ten <br />Sipature <br /> <br /> <br />t:,.a r: <br /> <br />3~ <br />