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 Govemment 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 Infomhaiion 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: Off Sale Lam„ iauor, LICENSING AUTHORITY: _ - City of Orono. Hennepin County, Minnesota. LICENSE RENEWAL. DATE:._ January,1.2016 PERSONAL. INFORMATION (If applicable): Applicant's Name Richard J Wood (Flat) (Middle) (Last) Applicant's Address L660 LakaAmod Lane Mound MN 55364 (sheet) (C110 (State) (gyp) Social Security Number: BUSINESS INFORMATION (if applicable): Business Name: Navarre Li uors Business Address: 3421 Shoreline Drive. PO Box 50 Navarre MN 66392 (5) (t* (state) (Zip) MINNESOTA TAX IDENTIFICATION NO: 1564505-7 FEDERAL TAX IDENTIFICATION NO: 41-1711643 If a Minnesota Tax Ideptifi n numo6r is not required, please explain on the reverse side. r GWK- r uta ' PosMon (Officer, Partner, etc.) f Date Page 5