2005-12-14 CC Packet - Laserfiche WebLink

Home Browse Search

TAX CLEARANCE INFORMATION TO LICENSE APPLICANT: Pursuant to Minnesota Statute 270.72 Tax Oearance: Issuance of Licenses, the licensing authority is required to provide to the Minnesota Commissioner of Revenue your Minnesota Business Tax Identification Number and social security number of each license applicant. Under the Minnesota Government Data Practices Act and the Federal Privacy Act of 1974, we are required roa~~m~fu&mgre~~~~~~mm~ 1. This information may be used to deny the issuance, renewal or transfer of your license in the event you owe the Minnesota Department of Revenue delinquent taxes, penalties or interest; . 2. Upon receiving ~ information, ~ licensing authority will supply it only to the Minnesota Department of Revenue. However, under the Federal Exchange of Information Agreement the Department of Revenue may supply this ~rmation to the Internal Revenue Service. . 3. Failure to supply this information may jeopardize or delay the processing of your licensing issuan~. or renewal application. Please supply the following information and. return along with your application to the agency issuing the license. DO NOT RETURN TO THE DEPARTMENT 01' REVENUE. UCENSE TYPE: 0 F f 'At6 LICENSING AUTHORITY: City of Centerville LICENSE RENEWAL DATE: 1/1/ fJ' NEW[] RENEWAL [~ BUSINESS INFORMATION: Business Name: C e, fJ ~"i -lie Business Address: 1IJ 1'3 'to -fs. C #?J .fe-r~~ 7 ( ~ [City] LI1 vd-- ~ Business telephone Number: . MIl [State] Ir)~ --Lt.U - ,-.S -? '1 ..r JTJ~J> [Zip] List of Officers or Partners (full name, title, and social security number): Full Name: /1tv~/ r W~M~ Title: Ow.- n.f;;' Social Securi1y Number: . Full Name: Title: Social Security Number: Full Name: Title: , Social Security NmD.ber: . Full Name: Title: Social Security Number: D A CORPORATION: Corporation Name: G N At;v 1:""c . dba Cbi.kvvl/I-t.- ~. ~ Business Address: 31