06-10-1997 Council Agenda - Laserfiche WebLink

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Form SP:C1 State of Minnesota License Applicant Information Under Minnesota law (M.S. 270.72), the agency Issuing you this license 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 must advise you that: • This information may be used to deny the issuance, renewal or transfer of your license 11 you owe the Minnesota Department of Revenue delinquent taxes, penalties, or interest; • The licensing agency will supply it only to the Minnesota Department of Revenue. However, under the Federal Exchange of Information Act, the Department of Revenue is allowed to supply this information to the Internal Revenue Service; • Failing to supply this information may jeopardize or delay the Issuance of your license or processing your renewal application. Please fill in the following information and retum this form along with your application to the agency Issuing the license. Do not return this form to the Department of Revenue. Pleas. print or typo Name of license being applied for and license number Off —Sale Liquor License Licensing Authonty (name of aty, county, or state agency issuing Icense) City of Little Canada License renewal date Personal information: Applicant's last name Lee Applicant's address 2260 Plymouth First name and mlttal Annette Luccia City Road South #206 Minnetonka Social Secunty number 468 -72 -2188 State Zip Code MN 55305 Business information (if applicable): 9usiness name Mintahoe, Inc. Business address City 1021 Bandana Blvd. East St. Paul Minnesota tax identification number 1928784 -7 State Lp Code MN 55108 Federal tax Identification number 41- 1734575 Ifa Minna to tax'dentalcatt n number 7 n required, please explain on the reverse side of this form. Signature //irZt L tOr -rcU President 'die 6/2/97 Date SS# nr MBI# Page 38