97-968Council File # �
Ordinance �
Green Sheet # J ����
Presented By
Referred To
���i�f�,i� �
RESOLUTION
CITY OF SAINT PAUI,, MiNNESOTA
�
Committee: Date
1
2
3
RESOLVED: That applicarion (ID #23347) for an Auto Repa'u Garage License by Wayne F. Anderson DBA
Hillcrest Certicare (Wayne Anderson, Owner) at 1581 W}ute Beaz Avenue North be and the same is
hereby approved
4
5
6 Yea Nava Absent
7 B a e� �
8 Bostrom �`
9 Harris
i 0 Me ar __��
14 Morton � �
15 "�'
16 Adopted by Council: Date �
17
18 Adoption Certified by Council Secretary
19
20
21 By: � � ��._.,�
22 � I
23 Approved by Mayora Date �{I���
24
25
26 By: �, 1!
27
Requested by Department of:
• - • - -- - - • - -
_i . n-e. • - .,
By: l/'{'V�"^i" �" /�
Form Approved by City Attorney
�_.- l
By: � f � a�-,..��
Approved by Mayoz for Submission to
Council
By:
�� �q�
DEMq7MENTNFFlGER:OUNCIL DATE INITIATED GREEN SHEE �����
LIEP/Licensin
CONTACT PERSON & PHONE INITIAVDATE INITIAVDATE
�OEPARTMENTOIRECTOR OCITYC�UNd�
Christine Rozek 266-9108 A��G ❑arrm OCYTYCLERK
NUM9ERFON
MUST BE ON COUNCILAGENDA BV (DA7E) p011TING � BUDGET DIREGTOR � FIN. & MGT. SERVICES DIR.
For hearin : ( �� ORDER �MAYOR(ORASSI5TANT) ❑
TOTAL # OF SIGNATURE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE)
ACTION RE�UESTED.
Wayne Anderson DBA Hillcrest Certicare requests Council approval of its application for an
Auto Repair Garage located at 1581 White Bear Avenue North (ID 23347).
RECOMMENDA7iON5. Apprwe (A) er liejaet (q) pER50NAL SERVICE CONTRACTS MUST ANSWER THE FOLLOWING QUESTIONS:
_ PIANNING COMMISSIQN _ qV1�SERVICE COb1MISS10N �� Has tnis personttirm ever worked under a contract !or this tlepartment?
_ CIB COMMITTEE _ YES NO
_�� 2. Has this person/firm ever been a ciry amplayae?
— YES NO
_ ois7qiCTCOURi _ 3. Does this personRirm possess a skill not normally possessed By any curceot ciry employee?
SUPPORTS WHICN GOUNCII.OBJECTfVE? YES NO
Ezplain atl yas answers on separate sheat antl attaeh to green sheet
INITIATING PROBLEM, ISSUE. OPP�RNNIN (Who, What, When. Where. Why): p � i �
����'.��
APFc 2�s ����
C1�� ����� EY
ADVANTAGESIFAPPROVED:
DISAOVANTFGES IF APPROVED.
DISADVANTAGES IF NOTAPPROVED:
.� ��i C�t��
JUL 2 3 ;; ��
TOTAL AMOUNT OF TRANSAC710N S COST/REVENUE BUDGETED (CIRCLE ONE) YES NO
FUNDIfdG SOURCE ACTIVITY NUMBER
FINAyCIAL INFORF4ATION: (EXPLAIN)
Greensneet# 37946 L.I.E.P. REVIEW CHECKUST Date: 4115/97 ��1 `
In Tracker .23 aPP�n aece�ved J App'n Processed
License ID # 23347 License Type: Auto Repair Garage
CompBny Name: Wayne F. Anderson DBA: Hillcrest Certicare
Business Addresss: 1551 White Bear Avenue North Bus)ness Phone: 771-D302
Contact Name j.
Date to Councii
Pubiic Hearing I
Not+ce Sent to �
3
MN 55123
Home Phone: 454-8715
Labels Ordered:
District Council #: n
� ��/`( � �� �
Notice Sent to Public: // {I / ` / /'� Ward #: �
Departmentf Date Inspections Comments
C1ty Attorney
�' �'' t �• I'� `
Environmental
Heaith
�J •
Fire
�' �' `� ��� •
License Site Plan Received:
. � � Lease Received:
�- � � -�l �,�„F,� .��. �� ��
Police
� 2l -��- �. � .
Zoning
� ,�' '��"' Q .
\ �;
�
CLASS III
LICENSE APPLICATION
THIS APPLICATION IS SUBJECT TO REVIEW SY I'F� PU13LiC
PLEASE TYPE OR PRINI' IN INK
Company Nazne:
Corporalion / PaAnaship / Sole fropr
If b ess 's in� gi��e date of incorporalioi
�o�� s As`�
�
IIusiness Address: GC
sa� naa�
Betueen H�hat cross strcets is the business located? �
Are tttie premises now o s cup'ed7 �K./ � at
Mai] To Address:
seren nadrc�,
Applicant Infomadon: �
Name and Tille: Qi
Fust � !.Siddle
Home Address: ��'� 11 �
S
S �3 i f � L�"U
S
S
Lesi
���
�
CITY OF SAINT PAUL
�ce ar L;cense, Inspeccions
and Em�vonmertai Protection
s5luraascS.dm3oa �
Sc�nPeul,hfumesota 55103 �
(FIi1166-W9p Gx(61])2669I7y���
y
Title
' Sircet Addrem V V Cif� �Siete � Zip /� /
Date of B' `' ' Plaee of Birth: ���cJ �� Home Phone; " S� `, ' I t�
Ha��e you ever been comicted of any felony, crime a violation of any city ordinance other than traffic? YES I�TO X
.�
Date of azrest: Where�
Charge:
Comiction: Sentence:
List the names and residences of thrce persons of good mora] character, living w�ithin the Twin Cilies Metro Area, not related to the applicant
or financially interested in the premises or business, who may be refetred to as to the applicanYs character:
NAME �. ADDRES� �) i PHONE
hold, tormer3y held, or may ha��e an interest in:
�)
/�
Ha�•e any of lhe abo��e named licenses ever been revoked? YES �_ NO ff yes, list the dates and reasons for revocation:
2f18797
Are yuu going to operate this business personally? �YES NO If not, who wi11 operate it? Q/) „Q� \ �
_ � �
F'vatName MiddleLtitial (�faidrn) i.a+t Deteo£Birth "�
Strat \cmc
Aeeyou going to ha��e a manager orassistant in this business7
please complete the following infonnation:
NGddle Initinl
HomeAddresT: Sircet;:ame
Cin'
YES
(`kidrn)
Citq
S�ate � Zip Phone Numbcr
NO If the manager is not the same as the operator,
Last
S�ete Zip
Detc of Bvth
Phane Number
Please list your employment hisfory for the pre�rious five (5) }'zaz period:
If business is a partnership, please include the folloa�ing information for each partner (use additional pages if necessaey):
Fint Name Middle Ltitial (:Naidrn) LaR Da4 of Birth
Home Addma: Svat Name
FinlName
A�iddle I�utial
Hame Addrees: Street t�.ame
City
tete Zip Phone Numher
Last DateoFB'uth
S�ate Zip Phane Number
MII�INESOTA TAX IDENTTFICATION NUMBER - Pursuant to the Laws of Mnu�esota, 1984, Chapter 502, Article 8, SecUon 2(270.72)
(fax Clearance; Issuance of Licenses), licensing authorities ara required to provide to the State of Minnesota Commissioner of Revenue, the
Minnesota business ta�t identification number and the social security number of each license applicant.
Under the Minnesota Government Data Practices Act and the Federal Privacy Aci of 1974, we are required to adi�ise you of the following
regazding the use of the Minnesota Tax Identification Number:
- This infmmation may be used to deny the issuance or renewal oFyour license in ihe eveni you owe Mim�esota sales, employer s
withholding or motor vehic3e excise ta�tes;
- Upon receiving tlris information, the licensing authority uill supply it only to the Minnesota Department of Revenue. However,
under the Federal Exchange of 3nformation Agreement, the Departrnent of Revenue may supp]y tivs iuformation to the Intemal
Revenue Service.
Minnesota Ta�c Identification Ntunbers (Sales & Use Tae Number) may be obtained from the State of Minnesota, Business Recorcis Departrnent,
10 I2iver Park Plaza (612-296-618] ).
Social Security Number: '�1 (� ��SS � M'vmesota Tax Idrntification Number: ' ` '��
_ If a Minnesota Tax Idrntification I�um6er is not requ'ued for the business being oper' ated, �3cate so tiy pla��ng �"X" &t the'5
2.'18-57
List all other officers of the corporation: ' U
OFFICER TITLE HOME HOME BUSINESS DATE OF
NAME (OfficeHeld) ADDRESS PHONE PHONE BIRTH
Council File # �
Ordinance �
Green Sheet # J ����
Presented By
Referred To
���i�f�,i� �
RESOLUTION
CITY OF SAINT PAUI,, MiNNESOTA
�
Committee: Date
1
2
3
RESOLVED: That applicarion (ID #23347) for an Auto Repa'u Garage License by Wayne F. Anderson DBA
Hillcrest Certicare (Wayne Anderson, Owner) at 1581 W}ute Beaz Avenue North be and the same is
hereby approved
4
5
6 Yea Nava Absent
7 B a e� �
8 Bostrom �`
9 Harris
i 0 Me ar __��
14 Morton � �
15 "�'
16 Adopted by Council: Date �
17
18 Adoption Certified by Council Secretary
19
20
21 By: � � ��._.,�
22 � I
23 Approved by Mayora Date �{I���
24
25
26 By: �, 1!
27
Requested by Department of:
• - • - -- - - • - -
_i . n-e. • - .,
By: l/'{'V�"^i" �" /�
Form Approved by City Attorney
�_.- l
By: � f � a�-,..��
Approved by Mayoz for Submission to
Council
By:
�� �q�
DEMq7MENTNFFlGER:OUNCIL DATE INITIATED GREEN SHEE �����
LIEP/Licensin
CONTACT PERSON & PHONE INITIAVDATE INITIAVDATE
�OEPARTMENTOIRECTOR OCITYC�UNd�
Christine Rozek 266-9108 A��G ❑arrm OCYTYCLERK
NUM9ERFON
MUST BE ON COUNCILAGENDA BV (DA7E) p011TING � BUDGET DIREGTOR � FIN. & MGT. SERVICES DIR.
For hearin : ( �� ORDER �MAYOR(ORASSI5TANT) ❑
TOTAL # OF SIGNATURE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE)
ACTION RE�UESTED.
Wayne Anderson DBA Hillcrest Certicare requests Council approval of its application for an
Auto Repair Garage located at 1581 White Bear Avenue North (ID 23347).
RECOMMENDA7iON5. Apprwe (A) er liejaet (q) pER50NAL SERVICE CONTRACTS MUST ANSWER THE FOLLOWING QUESTIONS:
_ PIANNING COMMISSIQN _ qV1�SERVICE COb1MISS10N �� Has tnis personttirm ever worked under a contract !or this tlepartment?
_ CIB COMMITTEE _ YES NO
_�� 2. Has this person/firm ever been a ciry amplayae?
— YES NO
_ ois7qiCTCOURi _ 3. Does this personRirm possess a skill not normally possessed By any curceot ciry employee?
SUPPORTS WHICN GOUNCII.OBJECTfVE? YES NO
Ezplain atl yas answers on separate sheat antl attaeh to green sheet
INITIATING PROBLEM, ISSUE. OPP�RNNIN (Who, What, When. Where. Why): p � i �
����'.��
APFc 2�s ����
C1�� ����� EY
ADVANTAGESIFAPPROVED:
DISAOVANTFGES IF APPROVED.
DISADVANTAGES IF NOTAPPROVED:
.� ��i C�t��
JUL 2 3 ;; ��
TOTAL AMOUNT OF TRANSAC710N S COST/REVENUE BUDGETED (CIRCLE ONE) YES NO
FUNDIfdG SOURCE ACTIVITY NUMBER
FINAyCIAL INFORF4ATION: (EXPLAIN)
Greensneet# 37946 L.I.E.P. REVIEW CHECKUST Date: 4115/97 ��1 `
In Tracker .23 aPP�n aece�ved J App'n Processed
License ID # 23347 License Type: Auto Repair Garage
CompBny Name: Wayne F. Anderson DBA: Hillcrest Certicare
Business Addresss: 1551 White Bear Avenue North Bus)ness Phone: 771-D302
Contact Name j.
Date to Councii
Pubiic Hearing I
Not+ce Sent to �
3
MN 55123
Home Phone: 454-8715
Labels Ordered:
District Council #: n
� ��/`( � �� �
Notice Sent to Public: // {I / ` / /'� Ward #: �
Departmentf Date Inspections Comments
C1ty Attorney
�' �'' t �• I'� `
Environmental
Heaith
�J •
Fire
�' �' `� ��� •
License Site Plan Received:
. � � Lease Received:
�- � � -�l �,�„F,� .��. �� ��
Police
� 2l -��- �. � .
Zoning
� ,�' '��"' Q .
\ �;
�
CLASS III
LICENSE APPLICATION
THIS APPLICATION IS SUBJECT TO REVIEW SY I'F� PU13LiC
PLEASE TYPE OR PRINI' IN INK
Company Nazne:
Corporalion / PaAnaship / Sole fropr
If b ess 's in� gi��e date of incorporalioi
�o�� s As`�
�
IIusiness Address: GC
sa� naa�
Betueen H�hat cross strcets is the business located? �
Are tttie premises now o s cup'ed7 �K./ � at
Mai] To Address:
seren nadrc�,
Applicant Infomadon: �
Name and Tille: Qi
Fust � !.Siddle
Home Address: ��'� 11 �
S
S �3 i f � L�"U
S
S
Lesi
���
�
CITY OF SAINT PAUL
�ce ar L;cense, Inspeccions
and Em�vonmertai Protection
s5luraascS.dm3oa �
Sc�nPeul,hfumesota 55103 �
(FIi1166-W9p Gx(61])2669I7y���
y
Title
' Sircet Addrem V V Cif� �Siete � Zip /� /
Date of B' `' ' Plaee of Birth: ���cJ �� Home Phone; " S� `, ' I t�
Ha��e you ever been comicted of any felony, crime a violation of any city ordinance other than traffic? YES I�TO X
.�
Date of azrest: Where�
Charge:
Comiction: Sentence:
List the names and residences of thrce persons of good mora] character, living w�ithin the Twin Cilies Metro Area, not related to the applicant
or financially interested in the premises or business, who may be refetred to as to the applicanYs character:
NAME �. ADDRES� �) i PHONE
hold, tormer3y held, or may ha��e an interest in:
�)
/�
Ha�•e any of lhe abo��e named licenses ever been revoked? YES �_ NO ff yes, list the dates and reasons for revocation:
2f18797
Are yuu going to operate this business personally? �YES NO If not, who wi11 operate it? Q/) „Q� \ �
_ � �
F'vatName MiddleLtitial (�faidrn) i.a+t Deteo£Birth "�
Strat \cmc
Aeeyou going to ha��e a manager orassistant in this business7
please complete the following infonnation:
NGddle Initinl
HomeAddresT: Sircet;:ame
Cin'
YES
(`kidrn)
Citq
Please list your employment hisfory for the pre�rious five (5) }'zaz period:
S�ate � Zip Phone Numbcr
NO If the manager is not the same as the operator,
Last
S�ete Zip
Detc of Bvth
Phane Number
If business is a partnership, please include the folloa�ing information for each partner (use additional pages if necessaey):
Fint Name Middle Ltitial (:Naidrn) LaR Da4 of Birth
Home Addma: Svat Name
FinlName
Hame Addrees: Street t�.ame
City
tete Zip Phone Numher
Last DateoFB'uth
S�ate Zip Phane Number
MII�INESOTA TAX IDENTTFICATION NUMBER - Pursuant to the Laws of Mnu�esota, 1984, Chapter 502, Article 8, SecUon 2(270.72)
(fax Clearance; Issuance of Licenses), licensing authorities ara required to provide to the State of Minnesota Commissioner of Revenue, the
Minnesota business ta�t identification number and the social security number of each license applicant.
Under the Minnesota Government Data Practices Act and the Federal Privacy Aci of 1974, we are required to adi�ise you of the following
regazding the use of the Minnesota Tax Identification Number:
- This infmmation may be used to deny the issuance or renewal oFyour license in ihe eveni you owe Mim�esota sales, employer s
withholding or motor vehic3e excise ta�tes;
- Upon receiving tlris information, the licensing authority uill supply it only to the Minnesota Department of Revenue. However,
under the Federal Exchange of 3nformation Agreement, the Departrnent of Revenue may supp]y tivs iuformation to the Intemal
Revenue Service.
Minnesota Ta�c Identification Ntunbers (Sales & Use Tae Number) may be obtained from the State of Minnesota, Business Recorcis Departrnent,
10 I2iver Park Plaza (612-296-618] ).
Social Security Number: '�7 (� ��SS � M'vmesota Tax
_ If a Minnesota Tax Idrntification I�um6er is not requ'ued for the business b
A�iddle I�utial
Idrntification Number: ' ` '�
eing oper' ated, �3cate so tiy pla��ng �"X" &t the'5
2.'18-57
List all other officers of the corporation: ' U
OFFICER TITLE HOME HOME BUSINESS DATE OF
NAME (OfficeHeld) ADDRESS PHONE PHONE BIRTH
Council File # �
Ordinance �
Green Sheet # J ����
Presented By
Referred To
���i�f�,i� �
RESOLUTION
CITY OF SAINT PAUI,, MiNNESOTA
�
Committee: Date
1
2
3
RESOLVED: That applicarion (ID #23347) for an Auto Repa'u Garage License by Wayne F. Anderson DBA
Hillcrest Certicare (Wayne Anderson, Owner) at 1581 W}ute Beaz Avenue North be and the same is
hereby approved
4
5
6 Yea Nava Absent
7 B a e� �
8 Bostrom �`
9 Harris
i 0 Me ar __��
14 Morton � �
15 "�'
16 Adopted by Council: Date �
17
18 Adoption Certified by Council Secretary
19
20
21 By: � � ��._.,�
22 � I
23 Approved by Mayora Date �{I���
24
25
26 By: �, 1!
27
Requested by Department of:
• - • - -- - - • - -
_i . n-e. • - .,
By: l/'{'V�"^i" �" /�
Form Approved by City Attorney
�_.- l
By: � f � a�-,..��
Approved by Mayoz for Submission to
Council
By:
�� �q�
DEMq7MENTNFFlGER:OUNCIL DATE INITIATED GREEN SHEE �����
LIEP/Licensin
CONTACT PERSON & PHONE INITIAVDATE INITIAVDATE
�OEPARTMENTOIRECTOR OCITYC�UNd�
Christine Rozek 266-9108 A��G ❑arrm OCYTYCLERK
NUM9ERFON
MUST BE ON COUNCILAGENDA BV (DA7E) p011TING � BUDGET DIREGTOR � FIN. & MGT. SERVICES DIR.
For hearin : ( �� ORDER �MAYOR(ORASSI5TANT) ❑
TOTAL # OF SIGNATURE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE)
ACTION RE�UESTED.
Wayne Anderson DBA Hillcrest Certicare requests Council approval of its application for an
Auto Repair Garage located at 1581 White Bear Avenue North (ID 23347).
RECOMMENDA7iON5. Apprwe (A) er liejaet (q) pER50NAL SERVICE CONTRACTS MUST ANSWER THE FOLLOWING QUESTIONS:
_ PIANNING COMMISSIQN _ qV1�SERVICE COb1MISS10N �� Has tnis personttirm ever worked under a contract !or this tlepartment?
_ CIB COMMITTEE _ YES NO
_�� 2. Has this person/firm ever been a ciry amplayae?
— YES NO
_ ois7qiCTCOURi _ 3. Does this personRirm possess a skill not normally possessed By any curceot ciry employee?
SUPPORTS WHICN GOUNCII.OBJECTfVE? YES NO
Ezplain atl yas answers on separate sheat antl attaeh to green sheet
INITIATING PROBLEM, ISSUE. OPP�RNNIN (Who, What, When. Where. Why): p � i �
����'.��
APFc 2�s ����
C1�� ����� EY
ADVANTAGESIFAPPROVED:
DISAOVANTFGES IF APPROVED.
DISADVANTAGES IF NOTAPPROVED:
.� ��i C�t��
JUL 2 3 ;; ��
TOTAL AMOUNT OF TRANSAC710N S COST/REVENUE BUDGETED (CIRCLE ONE) YES NO
FUNDIfdG SOURCE ACTIVITY NUMBER
FINAyCIAL INFORF4ATION: (EXPLAIN)
Greensneet# 37946 L.I.E.P. REVIEW CHECKUST Date: 4115/97 ��1 `
In Tracker .23 aPP�n aece�ved J App'n Processed
License ID # 23347 License Type: Auto Repair Garage
CompBny Name: Wayne F. Anderson DBA: Hillcrest Certicare
Business Addresss: 1551 White Bear Avenue North Bus)ness Phone: 771-D302
Contact Name j.
Date to Councii
Pubiic Hearing I
Not+ce Sent to �
3
MN 55123
Home Phone: 454-8715
Labels Ordered:
District Council #: n
� ��/`( � �� �
Notice Sent to Public: // {I / ` / /'� Ward #: �
Departmentf Date Inspections Comments
C1ty Attorney
�' �'' t �• I'� `
Environmental
Heaith
�J •
Fire
�' �' `� ��� •
License Site Plan Received:
. � � Lease Received:
�- � � -�l �,�„F,� .��. �� ��
Police
� 2l -��- �. � .
Zoning
� ,�' '��"' Q .
\ �;
�
CLASS III
LICENSE APPLICATION
THIS APPLICATION IS SUBJECT TO REVIEW SY I'F� PU13LiC
PLEASE TYPE OR PRINI' IN INK
Company Nazne:
Corporalion / PaAnaship / Sole fropr
If b ess 's in� gi��e date of incorporalioi
�o�� s As`�
�
IIusiness Address: GC
sa� naa�
Betueen H�hat cross strcets is the business located? �
Are tttie premises now o s cup'ed7 �K./ � at
Mai] To Address:
seren nadrc�,
Applicant Infomadon: �
Name and Tille: Qi
Fust � !.Siddle
Home Address: ��'� 11 �
S
S �3 i f � L�"U
S
S
Lesi
���
�
CITY OF SAINT PAUL
�ce ar L;cense, Inspeccions
and Em�vonmertai Protection
s5luraascS.dm3oa �
Sc�nPeul,hfumesota 55103 �
(FIi1166-W9p Gx(61])2669I7y���
y
Title
' Sircet Addrem V V Cif� �Siete � Zip /� /
Date of B' `' ' Plaee of Birth: ���cJ �� Home Phone; " S� `, ' I t�
Ha��e you ever been comicted of any felony, crime a violation of any city ordinance other than traffic? YES I�TO X
.�
Date of azrest: Where�
Charge:
Comiction: Sentence:
List the names and residences of thrce persons of good mora] character, living w�ithin the Twin Cilies Metro Area, not related to the applicant
or financially interested in the premises or business, who may be refetred to as to the applicanYs character:
NAME �. ADDRES� �) i PHONE
hold, tormer3y held, or may ha��e an interest in:
�)
/�
Ha�•e any of lhe abo��e named licenses ever been revoked? YES �_ NO ff yes, list the dates and reasons for revocation:
2f18797
Are yuu going to operate this business personally? �YES NO If not, who wi11 operate it? Q/) „Q� \ �
_ � �
F'vatName MiddleLtitial (�faidrn) i.a+t Deteo£Birth "�
Strat \cmc
Aeeyou going to ha��e a manager orassistant in this business7
please complete the following infonnation:
NGddle Initinl
HomeAddresT: Sircet;:ame
Cin'
YES
(`kidrn)
Citq
Please list your employment hisfory for the pre�rious five (5) }'zaz period:
S�ate � Zip Phone Numbcr
NO If the manager is not the same as the operator,
Last
S�ete Zip
Detc of Bvth
Phane Number
If business is a partnership, please include the folloa�ing information for each partner (use additional pages if necessaey):
Fint Name Middle Ltitial (:Naidrn) LaR Da4 of Birth
Home Addma: Svat Name
FinlName
Hame Addrees: Street t�.ame
City
tete Zip Phone Numher
Last DateoFB'uth
S�ate Zip Phane Number
MII�INESOTA TAX IDENTTFICATION NUMBER - Pursuant to the Laws of Mnu�esota, 1984, Chapter 502, Article 8, SecUon 2(270.72)
(fax Clearance; Issuance of Licenses), licensing authorities ara required to provide to the State of Minnesota Commissioner of Revenue, the
Minnesota business ta�t identification number and the social security number of each license applicant.
Under the Minnesota Government Data Practices Act and the Federal Privacy Aci of 1974, we are required to adi�ise you of the following
regazding the use of the Minnesota Tax Identification Number:
- This infmmation may be used to deny the issuance or renewal oFyour license in ihe eveni you owe Mim�esota sales, employer s
withholding or motor vehic3e excise ta�tes;
- Upon receiving tlris information, the licensing authority uill supply it only to the Minnesota Department of Revenue. However,
under the Federal Exchange of 3nformation Agreement, the Departrnent of Revenue may supp]y tivs iuformation to the Intemal
Revenue Service.
Minnesota Ta�c Identification Ntunbers (Sales & Use Tae Number) may be obtained from the State of Minnesota, Business Recorcis Departrnent,
10 I2iver Park Plaza (612-296-618] ).
Social Security Number: '�7 (� ��SS � M'vmesota Tax
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2.'18-57
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OFFICER TITLE HOME HOME BUSINESS DATE OF
NAME (OfficeHeld) ADDRESS PHONE PHONE BIRTH