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<br />.' <br /> <br />TAX CL.EARANCE INFORMATION <br /> <br />TO LICENSE APPLICANT: <br />Pw:suautto Minnesota Statute 270.72 Tax Oearance: Issuance of Licenses, the JiCP.nRillg authority is <br />required to provide to the Minnesota CommiRonet' of Revenue your Minnesota Business Tax <br />,J~ Nmnberand ~ secmitynmnberofeachJi~ appJicaut. . <br /> <br />~ {- <br />Under the Minnesota Govemment~ P.ractic:es Act and the Federal Privacy Act of 1974, we are lQ{uh~ <br />to advise you of the fo1lowingregardingthe use oftbis infulmahon'. . <br /> <br />1. This .information may be used to deny the issuance, renewal or ttansfer of yom <br />license 1n the event you owe the).finnesota Department of ReVenue de1inquent <br />taxes, penalties or.interest; . <br />2. Upon n=iving tbis int(\r1nmiOJl,. the til"P-mling ....fl.....lty wiJ1 supply it oiJ1y to the <br />Minnesota Department of Revenue. However, under the Federal Exchange of <br />'nm. ,~ Agreement the Department ofRevenne may sopplythis iofurmation <br />to the Tntei-rml Revenue Service. <br />3. Failure to supply tbis information may jeopatdize or. delay the process"lg of <br />yout Ji~~ or renewal. application. <br /> <br />Please supply the fo1lowing 1nfonn3tion and retum along with your appJic:a1ion to the agency issuing the <br />licxmse. DO NOT DTUBN TOTIU DEPARTMENT OF REVENUE. <br /> <br />LICENSE TYPE: <br /> <br />T~ <br /> <br />NEW! ] <br /> <br />RENEWAL J>4:- <br />I~A/~s- <br /> <br />. . <br />LICENSING AUIHORITY: <br />LICBNSBRBNBWALDAm: <br /> <br />. CitY of C'..enterville <br />1/, /(Jff" <br />. . <br /> <br />. '~, <br /> <br />b.g~ <br />[Zip] <br /> <br />Business Telephone Number: <br /> <br />my <br />[S.l <br />"~/- 1{ ~~ - 'IYI'&) <br /> <br />ListofOJJroers or Partners (full name, tit:k; and social security number): <br />FoIl Name: t:Jlfll L- .BUlPtJlli..E~ <br />- <br /> <br />Title: ~ Social ~Number: <br />FoIl Name: t.u T 11 tl'l RulE & Hi..$"A... <br /> <br />TItle: ~ <br />FoIl Name: r.~. <br />Title: V.. P .. <br />FoIlName: ~ ~ <br />Title: ~. <br />D A CORPORATION: <br />Corpo1ationName: ('D~ nUll. T LLi!. dba 1'14..,.~ /J1~. <br />Business Address: J~P I /J1~ S::/. ~ <br /> <br />Social ~Number: <br /> <br />~~ <br />Social Secority NumbeI <br /> <br />~ <br />Social Secority Number: <br />