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TAX CLEARANCE AND CERTIFICATION OF COMPLIANCE WITH THE MN <br /> WORKERS' COMPENSATION LAW <br /> LICENSING AUTHORITY: CITY OF MOUNDS VIEW <br /> TAX CLEARANCE <br /> Type of License Being Applied For Date of License Renewal <br /> On-Sale Liquor and Restaurant MM/DD/YYYY 12/31/2026 <br /> Format:MM/DD/YYYY <br /> Pursuant to Minnesota Statute 270.72 Tax Clearance: Issuance of Licenses, the licensing authoring is required to provide to the Minnesota <br /> Commissioners of Revenue your Minnesota Business Tax Identification Number and the social security 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 of the following <br /> regarding the use of this information: <br /> This information may be used to deny the issuance, renewal or transfer of your license in the event you owe the Minnesota Department of <br /> Revenue delinquent taxes,penalties or interest; <br /> Upon receiving this information,the licensing authority will supply the information only to the Minnesota Department of Revenue.However, <br /> under the Federal Exchange of Information Agreement, the Department of Revenue may supply this information to the Internal Revenue <br /> Service; <br /> 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 RETURN TO THE <br /> DEPARTMENT OF REVENUE. <br /> PERSONAL INFORMATION <br /> Applicant First Name MI *Applicant Last Name Social Security# <br /> 1_QDu Cov'Ov�� � ���1 V 331/Lt <br /> Applicant Address city State Zip *Email <br /> BUSINESS INFORMATION <br /> " Business Name <br /> Business Address city State Zip <br /> MN Tax ID# If MN Tax ID is not required,please explain: Federal Tax ID# <br /> l� I - �3 ►31�-� <br /> CERTIFICATE OF COMPLIANCE WITH THE MINNESOTA WORKERS' <br /> COMPENSATION LAND/ <br /> Minnesota Statute,Section 176.182 requires every state and local licensing agency to withhold the issuance or renewal of a license or permit <br /> to operate a business or engage in any activity in Minnesota until the applicant presents acceptable evidence of compliance with the <br /> Workers' Compensation Insurance Coverage Requirement of Chapter 176. The information required includes: the name of the insurance <br /> company, the policy number, and dates of coverage or the permit to self-insure. This information will be collected by the licensing agent <br /> and retained in their files. <br /> 1/2 <br />