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<br />CITY OF CENTERVILLE <br />RENEWAL APPLICATION FOR LICENSE TO SELL <br />TOBACCO PRODUCTS AT RETAIL <br /> <br />The undersigned, residing at 1('1'9 1- era ~A ,+"., in the City of <br /> <br />0&1. ld'1 / ~ <br /> <br />in the County of w/rSH>~ 17),1\1 . State of Minnesota, Residence Telephone: ( <br /> <br />>6fL-)1'if kf/Z- HEREBY MAKES APPLICATION FOR LICENSE to be issued to MICHAEL. <br /> <br />WAL.MAR, GNAW INC. DBA CENTERVILLE LIQUOR BARRE~ to sell tobacco products at retail at <br />7093 ~ 20TH AVENUE SOUTHt Business Telephone: (VI ) Ifll ."1"1 in the City ofCenterville, Ano/az <br /> <br />County, Minnesota for the term of one (1) year beginning with the 1st tlJzy of JlllUlory, 2H8 , subject to the <br />laws of the State of Minnesota and the ordinances and regulations of said CJIy of~ pertaining tberetot <br /> <br />and herewith deposit S85. ()() in payment of the fee therefore. <br /> <br />Report below details of tobacco law violations that have occurred within the last five years. (Dates, <br /> <br />offenses, fines or other penalties): <br /> <br />Report below details involving any license rejections or revocations: <br /> <br />By signillg this relleWOl flJIplktlJiOIl, opplicant certifies tlult there Iuu beell lID cluutge ill tMllenldp, <br />corp01Yl1e oJJicers, ",. panrans. If cluuaga '-'e occurMl ""rillg die pIl5I11 ""'IItIts, complete ill its entirety <br />the atItIclaed TtIX Oetl1'tUlCe Illfo17lUltio1l, sigll below. <br /> <br />Date: <br /> <br />/6'3,., <br /> <br />~" w.J?-- <br />Si re <br />)//ec~f r Vv-e;(~ <br />Name (Print) <br /> <br />FOR OmCE USE ONLY (Do not write below this 1iDe) <br /> <br />Report by Police DtpartmeDt <br />This is to certify that the applicant and the associates, named herein have not been convicted within the past five years of <br />8Ily vioIaIiaa of li:denlI, - at ~JE. pIOYisioo, at - Iq!UIatioa rcIaIins to -- at__ <br /> <br />:::~1& y," :.lasttoacridl oP f!rJ,t<L <br />