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2005-11-09 CC Packet
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2005-11-09 CC Packet
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5/9/2006 2:38:08 PM
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11/4/2005 2:35:26 PM
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<br />CERTIFICATE OF COl\1PLIANCE <br />MINNESOTA WORKERS' COl\1PENSATIONLAW <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 infonnation requirea <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 infonnation 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 $1,000 penalty assessed against <br />the applicant by the Commissioner of the Department of Labor and Industry. <br /> <br />Insurance Company Name: <br />(HOT the insurance agent) <br /> <br />Policy Number: ()) - Br - 2'3'1710- 20 <br /> <br />Dates of Coverage: --p'_7/ () 1/ () .~ TO /Jfl ~! ~ t <br />~"~~'~_~___'_~ ~. ~__________~~________..___. ____ _ _ _ _ _ _ _ _..., _,_ _--:L; _ _ _,_ ________ _ _______ ____--J.,~7.~~:2-.~ _~_~..___ _:____ <br />. . (OR) ,. .:-~r . <br /> <br />J.It r f?[O <br /> <br />I am not required to have workers' compensation liability coverage because: <br /> <br />D <br /> <br />I have no employees <br /> <br />D <br />D <br /> <br />I am self-insured (include permit to self-insure) <br /> <br />I have no employees who are covered by the workers' compensation law <br />(these include: spouse, parents, children and certain farm employees) <br /> <br />I certify that the information provided above is accurate and complete and that a valid <br />workers' compensation policy will be kept in effect at all times as required by law. <br /> <br />Name: ;VI, c 4~i <br />[First] <br /> <br />-r1k;A/l,4:f <br />[Middle] <br /> <br />Wh~ <br />[Last] <br /> <br />Name of Business: 6 AlItw JIlIC DZ$A ('~41~c/il {L it", ~ <br /> <br />Business Address: <br /> <br />7&Cf3 ~-h1 ~ S' <br />(~+wvJi{e <br />[City] <br /> <br />0-tJ <br />[State] <br /> <br />j- SV ; <6 <br />[Zip] <br /> <br />18' --II' -o~ <br />Date <br /> <br />C)I - i..j,;l.-' -t67 c( <br /> <br />~A~ <br />Signature <br /> <br />Business Phone: <br /> <br />.59 <br />
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