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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 of MSS 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 />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 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 />~j}xisDn C"6(('~)G{ P <br /> <br />LvC P /O~/Po9L( () (/ <br />101 t:-/rf}{) TO IO/~?/{J/ <br />J f i ~ <br /> <br />Policy Number: <br /> <br />Dates of Coverage: <br /> <br />(OR) <br /> <br />[ am not required to have workers' compensation liability coverage because: <br /> <br />o <br /> <br />I have no employees <br /> <br />D <br /> <br />I am self-insured (include permit to self-insure) <br /> <br />D <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 />A-) Ic(\ <br />[Middle] <br />Name of Business: lAJ4tC[ L\-)OI!<(S L~A-Ch CLLAI) <br />7dg/ /114in ,~6 , <br />~0Vj'/ Ie <br />[City] [State] [Zip] <br />Business Phone: iP:{/ - 1/:)q - 30Z~ _) I 0. C <br />JD/3:0/CJ() _~uLY ~ -- <br /> <br />I , <br />Date Signature <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: OK icJv+rd <br />[First] <br /> <br />ODC FZJ~. <br />[Last] <br /> <br />Business Address: <br /> <br />V11' ./\ <br />// I I <br /> <br />,~505 g <br />