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CITY OF MOUNDS VIEW -TAX CLEARANCE Pursuant to Minnesota Statute 270.72 Tax Clearance: Issuance of Licenses, the licensing authoring is required to provide to the Minnesota Commissioners 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 the information 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; 8. Failure to supply this information mayjeopardize or delay the processing of your licensing 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. LicenseA lied for/Renewed: Licensing Authority: CITY OF MOUNDS VIEW License Renewal Personal Information Asolicant Name: 6 C : Applicant AddressBusiness Information Business Name: r,,,.,�} rrr ,^ J, P. t Business Address: !. 10, Ao.hdl)aw In N $SN MN Tax ID #: p Federal Tax ID M / If Minnesota Tax ID is not required, please ex lain: CERTIFICATION OF COMPLIANCE WITH THE - MINNESOTA WORKERS' COMPENSATION LAW Minnesota Statute, Section 176.182 requires every state and local licensing agency to withhold the issuance or renewal of a license or permit to operate a business or engage in any activity in Minnesota until the applicant presents acceptable evidence of compliance with the Workers' Compensation Insurance Coverage Requirement of Chapter 176. The information required includes: the name of the insurance company, the policy number, and dates of coverage or the permit to self -insure. This information will be collected by the licensing agent and retained in their files. This information is required by law and a license or permit to operate a business may not be issued or renewed if information is not provided and/or is falsely reported. Further, if this information is not provided or is falsely stated, it may result in a $2,000 penalty assessed against the applicant by the Commissioner of the Department of Labor and Industry. Insurance Corn an Not Agent): Policy Number: Dates of Covers e: (OR) I am not required to have workers' compensation liability coverage because: I have no employees I am self -insured (include permit to sell -insure) I have no employees who are covered by the workers' compensation law (these include: Spouses, Parents, Children and certain farm employees) I certify that the information provided above is accurate and complete and a valid workers' compensation policy will be kept in effect at all limes as required by law.