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Form SP:CI <br />LICENSE APPLICANT: <br /> <br />Pursuant to Mimmsota Statute 270.72 Tax Clearance; Issuance of Licenses, the licensing authority is required to provide to <br />the Minnesota Commissioner of Revenue your Minnesota business tax identification number and the Social Security Number <br />of each license applicaot. <br /> <br />Under the Minnesota Government Data Practices Act and the Federal Privacy Act of 1974, we are required to advise you of <br />the tbllowing regarding the use of this infotxnation: <br /> <br />I. This intbrmation 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 attthority will supply it only to the Minnesota Department of Revemte. <br /> However, under the Federal Exchange of Information Agreement the Department of Revenue may supply this <br /> in~brmation to the Internal Revenue Service. <br />3. Failure to supply this infbrmation may jeopardize or delay the processing of your licensing issuance or renewal <br /> application. <br /> <br />Please supply the following information and remm along with your application to the agency issuing the license. DO NOT <br />RETURN TO THE DEPARTMENT OF REVENUE. <br /> <br />License Being applied tbr or renewed: <br /> <br />Temporary Special Events Permit <br /> <br />Licensing Authority: City of Ramsey <br />(Name of City, County, or State Agency issuing License) <br /> <br />PERSONAL INFORMATION (il' applicable): <br /> <br /> Name: <br />Applicant's <br /> <br />Applicant's Address: <br /> <br /> City <br /> <br />State <br /> <br />I,',.)& ,/ <br /> ! <br /> <br />ZIP <br /> <br />Social Security Number: <br /> <br />BUSINESS INFORMATION (il' applicable): <br /> <br />Business Address: <br /> <br />Miunesota 'fax Identification No.: <br /> <br />),:fro <br /> <br />State <br /> <br />-/,S'¢? 3 o 3 <br /> <br />Federal Tax Identification No.: <br />Ifa. limlesota~~/.~,t ,_.~'" Za('~anon number)z- ~_/~t.~...,.~ is not required, please~,~l,6~(_Lyt4explain on the reverse side. <br />Signature Position (Officer, Partner, etc.) <br /> <br />ZIP <br /> <br />Date <br /> <br /> CERTIFICATION OF COMPLIANCE <br />MINNESOTA WORKERS' COMPENSATION LAW <br /> <br />Minnesota Statute, Section [76. 182 requires every state and local licensing agency to withhold the issuance or <br />renewal ol"a license or permit to operate a business or engage in an activity in Minnesota until the applicant <br />presents acceptable evidence of compliance with the workers' compensation insurance coverage requirement of <br />MSS ¢:hapter 176. The information required is: The name of the insurance company, the policy number, and <br /> <br /> <br />