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<br />. <br />CERTIFICATE OF COMPLIANCE <br />MINNESOTA WORKERS' COMPENSATION LAW <br /> <br />, , <br />Mirm.esota Statute, Section 176.182 requires every state and loca1licensing agency to withhold <br />:the issuance or renewal of a license or permit to opeIate a business or engage in an activity in <br />,Mirm.esota until the appliqurt presents acceptable evic;lence of compliance with 1:he workers' <br />compensation insurance coverage requirements ofMSS Chapter 176. The .infonnation required <br />is: 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 City and retained in the files. <br /> <br />, , <br /> <br />This information is required by law, and licenses and permits to operate a business may not be <br />issued or renewed if it is not provided and/or is fillsely reported. Furthermore, if this <br />information is not provided or :falsely stated, it may result in a $1,000 penalty assessed against <br />the applicant by the CommiASioner of the Department of Labor and Industry. <br /> <br />Insurance Company Name: <br />(NOT the insurance agent) <br /> <br />F,lls.,- DAKorn rlllll1l.JtlAJl1 <br /> <br />W (,20 - (J 00 ();).ILJ.. () 0 <br />-l-I- ~ '1- 0) TO-L1- "Lt/ -0 vi <br />(OR) <br /> <br />Policy Number: <br />Dates of Coverage: <br /> <br />1 am not required to have workers' compensation liability coverage because: <br /> <br />o <br /> <br />I have no employees <br /> <br />o <br />o <br /> <br />I am self-insured (inclutk permit to self-insure) <br /> <br />I have no employees who are covered by the workers' compensation law <br />(these include: spouse, parents, children and Certain farm employees) <br /> <br />1 certify that the irformation provitkd above is accurate and complete and that a valid <br />workers' compensation policy will be kept in effect- at all times as required by law. <br /> <br />Name: 1!-~t1.eTl4 F~C!-lS VItl-fnD (l (?~l~ <br />[First] [Middle] [Last]- <br /> <br />Name of Business: WI> e G lJ '\., ~ R"'l.. 'Z..~ <br />I <br />Business Address: 70 i s ~ qH J91/E' S <br /> <br />Ce1'JTeO dJ ~U- m", 55033' <br />[City] [State] [Zip] <br /> <br />Business Phone.:. .. Cs /-{S7-~ <br /> <br />;0- 25'-0'-/ . __ _ _ <br />Date ' Signature <br />