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<br />--,- <br /> <br />..zo <br /> <br />CEKrfii'1CATE OF COMPLIANCE <br />MINNESOTA WORKERS' COMPENSATION LAW <br /> <br />Minnesota statute,' Section 176.182 requires eVery state and local licensmg agency to withhold <br />the.~ or renewal of a license. or permit to QpC1'8te a business or engage in an activity in <br />~esota. . until the applicant presents acceptable evidence of compliance with the workers' <br />compenSation ~ covemge rCquiremen:ts ofMSSChapt.ei 176. The information required <br />is: the DalIie of the irisurance company, the policy number, ana dates of covemge, or the permit <br />to self-insure. This information.will be collected by the City and retained in the files. <br /> <br />This information is required by law, and licenses and permits to opemte a business may not be <br />iSsued or renewed if it is not provided and/or is :6dsely reported. Fu:rthermore,if this <br />information is not provided or :fidsely stated, it may result in a $1,000 penalty assessed agaiDSt <br />the applicant by the CommiRSioner of the DeparIment of Labor and InduStry. <br /> <br />Insurance Company Name: <br />(NOT the inslU'ance agent) <br /> <br />~~44Iwt. <br /> <br />Policy Number: we ~~-I)l/...ls.G8S5-(JJt:) <br /> <br />Dates of Coverage: ~~ l/fP'/()5' TO 12h/~.r <br />b....... 1.::1 a*7/3,h~- ,'I~J6 <br />I"""" (OR) <br /> <br />I am not required to have workers' compensation liability coverage because: <br /> <br />o <br /> <br />I have no employees <br /> <br />D <br />D <br /> <br />I am self-insured (incI1.Ide permit to self-insure) <br /> <br />I have no employees who are covered by the WO!kers' compensation law <br />(these include: spouse, pareiJ.ts, children and certain fium employees) <br /> <br />. <br /> <br />I certify that the itiformation provided 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 of Business: <br /> <br />/)/EAJ J.J is <br />[Middle] <br />CE prE f{ ftlj}R./ <br />J&'o I In~ st. <br /> <br />eu..l&cHL.E~ <br />[Last] <br /> <br />Name: C/fl. L <br />[First] <br /> <br />Business Address: <br /> <br />~ l:G;.A:JJ!..t- . hIh,- S>o:3 E <br />[City] / [State] [Zip] <br />.., ..' 'B1iSiiieSsPhone:' . IP51- 1;6,... LfB'~ " <br /> <br />J//) ItJit COA~~~ <br />Date Signature <br />