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<br />CERTIFICATE OF COMPLIANCE <br />MINNESOTA WORKERS' COMPENSATION LAW <br /> <br />Minnesota Statute, Section 176.182 requires every state and local licensing agency to withhold <br />the issuance or renewal of a license or permit to operate a business or engage in an activity in <br />Minnesota until the applicant presents acceptable evidence of compliance with the workers' <br />compensation insurance coverage requirements ofMSS Chapter 176. The information 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 />1bis infonnation is required by law, and licenses and pennits to operate a business may not be <br />issued or renewed if it is not provided and/or is falsely reported. Furthermore, if this <br />information is not provided or falsely stated, it may result in a $1,000 penalty assessed against <br />the applicant by the. Commissioner of the Department of Labor and Industry. <br /> <br />Insurance Company Name: <br />(NOT the insurance agent) <br /> <br />Gas;- fJ f1 k () rn J.n Or! /YJ n 'r1.1 e.. 0 . <br /> <br />Policy Number: <br /> <br />/JJ Cg. 0 .. 0003 3 :Y-7 - 0 0 <br />67"'07" ;)000 TO 67 -09- Zoo 7 <br />(OR) <br /> <br />Dates o/Coverage: <br /> <br />I am not required to have workers' compensation liability coverage because: <br /> <br />o <br /> <br />I have no employees <br /> <br />o <br />o <br /> <br />I am self-insured (include permit to self-insure) <br /> <br />I have no employees who are covered by the workers' compensation law <br />(these include: spouse, parents, children and certain farm employees) <br /> <br />I certify that the information provided above is accurate and complete and that a valid <br />workers' compensation policy will be kept in effect at all times as required by law. <br /> <br />Name: ~17()enJ ftZlhJt!.,.5 i/t1rJt)t;)eBee/~' <br />[First] [Middle] [Last] <br /> <br />Name of Business: (J//5e 6(..) y~ f12-'ZA <br /> <br />Business Address: 7CJ9$ ~CfTH" /9VC <br /> <br />(;/)7t'rt/J {,-Lr::: m /'i <br /> <br />[City] [State] <br /> <br />6,-';1- (-,53-/077 <br /> <br />//V~ <br />5 <br /> <br />55038 <br />[Zip] <br /> <br />Business Phone: <br /> <br />/'0" Z-$'--O ~ <br />Date <br /> <br /> <br />;};/ <br />