11-28-2016 Council Packet - Laserfiche WebLink

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Form SP -CI LICENSEAPPLICANT: Pursuant to Minnesota statute 270.72 Tax Clearance: Issuance of Licenses, ft 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 IMormation 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: On Sale and Sunday Liquor LICENSING AUTHORITY: Cibf of Orono Henna in County, Minnesota LICENSE RENEWAL DATE: Janus 1 2017 PERSONAL INFORMATION (if applicable): Applicant's Name Paul Robert Gustafson (First) (Middle) (Last) Applicant's Address 1721 Mayappig Pass Chanhassen MN $6317 ( ) (am (stab+) (Zp) Social Security Number: BUSINESS INFORMATION (If applicable): Business Name: Woodhill Country Club Business Address: &QO Woodhill wm=w MN 55391 (869d) (City) (State) (zip) MINNESOTA TAX IDENTIFICATION NO: 8183048 FEDERAL TAX IDENTIFICATION NO: 41-0619490 If a Minnesota Tax Identification number Is not required, please explain on the reverse side. 0