11-28-2016 Council Packet - Laserfiche WebLink

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Form SP -CI LICENSE APPLICANT: Pursuant to Minnesota statute 270.72 Tax Clearance: Issuance of Licenses, the licensing authority is required to provide to the Minnesota Commissioner of Revenue your Minnesota business tax identification number and the social security number of each license applicant. Under the Minnesota Government Data Practices Act and the Federal Privacy Act of 1974, we are required to advise you of the following regarding the use of this information: 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 this information, the 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 information to the Internal Revenue Service; 3. Failure to supply this information may jeopardize or delay the processing of your licensing issuance 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 OF REVENUE. LICENSE BEING APPLIED FOR OR RENEWED: 3.2 Off Sale LICENSING AUTHORITY: _ City of Orono. Hennepin County, Minnesota LICENSE RENEWAL DATE:_ January 1. 2017 PERSONAL INFORMATION (If applicable): Applicants Name John Michael O'Sullivan (First) (Middle) (Lazo Applicant's Address_ _ 8047 Ranchview Lane _ Maple Grove MN 55311 (Swat) (City) (stare) (ZIP) Social Security Number: BUSINESS INFORMATION (if applicable): Business Name: O'Sullivans Holida Business Address: 2420 Shadvwood Road Navarre MN 55M (Street) (City) (State) (Zip) MINNESOTA TAX 10ENTIFICATION NO: 751820 FEDERAL TAX IDENTIFICATION NO: 41-0951420 If a Mirtesota Tax Identification number is not required, please explain on the reverse side. 1 A! ` A A � 0 I 11b12.0 //6 Page 5