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CITY OF MOUNDS VIEW - TAX CLEARANCE <br />Pursuant to Minnesota Statute 270.72 Tax Clearance: Issuance of Licenses, the licensing authoring is required to provide <br />to the Minnesota Commissioners of Revenue your Minnesota Business Tax Identification Number and the social security <br />number of each license applicant. <br />Under the Minnesota Government Data Practices Act and the Federal Privacy Act of 1974, we are required to advise you <br />of the following regarding the use of this information: <br />1. This information may be used to deny the issuance, renewal or transfer of your license in the event you owe the <br />Minnesota Department of Revenue delinquent taxes, penalties or interest; <br />2. Upon receiving this information, the licensing authority will supply the information only to the Minnesota Department <br />of Revenue. However, under the Federal Exchange of Information Agreement, the Department of Revenue may <br />supply this information to the Internal Revenue Service; <br />3. Failure to supply this information may jeopardize or delay the processing of your licensing application. <br />Please supply the following information and return along with your application to the agency issuing the license. DO NOT <br />RETURN TO THE DEPARTMENT OF REVENUE, <br />License Applied for/Renewed: <br />1To,r , L. y' Qe- L—'e tM� <br />Licensing Authority: <br />CITY OF MOUNDS VIEW U e <br />License Renewal Date: <br />Personal Information <br />Applicant Name: <br />Applicant Address: <br />A. • licant SS #: <br />Business Information <br />Business Name: <br />U-' SC"A'A ` S -ii3 , S -Te v‘ `j'c& 1e V <br />Business Address: <br />L-r) G'41, 1,U'C.L1-) lk: <br />PiVtU-1 <br />k--kA\S , v%v\N! <br />551 i.'. <br />MN Tax ID #: <br />CI k71L--\ OS <br />Federal Tax ID#: <br />yI • GS O5-P-4 <br />If Minnesota Tax ID is not <br />required, please explain: <br />CERTIFICATION OF COMPLIANCE WITH THE - MINNESOTA WORKERS' COMPENSATION LAW <br />Minnesota Statute, Section 176.182 requires every state and local licensing agency to withhold the issuance or renewal of <br />a license or permit to operate a business or engage in any activity in Minnesota until the applicant presents acceptable <br />evidence of compliance with the Workers' Compensation Insurance Coverage Requirement of Chapter 176. The <br />information required includes: the name of the insurance company, the policy number, and dates of coverage or the permit <br />to self -insure. This information will be collected by the licensing agent and retained in their files. <br />This information is required by law and a license or permit to operate a business may not be issued or renewed if information <br />is not provided and/or is falsely reported. Further, if this information is not provided or is falsely stated, it may result in a <br />$2,000 penalty assessed against the applicant by the Commissioner of the Department of Labor and Industry. <br />Insurance Company (Not Agent): <br />i. A_,)( • <br />.,?(, ., r ( <br />Policy Number: <br />( P.S 4n <br />7-7 9 ) <br />Dates of Coverage: <br />I / i /3Q1 c! <br />` r/ I /2 D,cj <br />(OR) <br />am not required to have workers' compensation liability coverage because: <br />() <br />() <br />() <br />I have no employees <br />I am self -insured (include permit to self -insure) <br />I have no employees who are covered by the workers' compensation law (these include: Spouses, Parents, <br />Children and certain farm employees) <br />certify that the information provided above is accurate and complete and a valid workers' compensation policy will be <br />kept in effect at all times as required by law. <br />X ignature of Applicant: ( <br />,� i•Y;., r,1, ,SA_ <br />£..;1 <br />ompany Name: ! illY <br />r% v, j sr,, ;.,:,„,•. <br />( -. i L i, 14_ Date: ft. , , <br />