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<br /> <br />CERTIFICATE OF COMPLIANCE <br />. ~ , <br />MINNESOTA WO~RS' COMPENSATION LAW <br /> <br />lVlinnesota 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: ~QrtlM AUIY';,\i,1r.. t;,,'l <br />(NOT the insurance agent) / <br /> <br />Dates of Coverage: <br /> <br />we J~o '-//0 '65'3 I <br />1Jt"( J.-. 01 TO D,e d. 0) <br /> <br />Policy Number: <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 />o <br /> <br />I am self-insured (include permit to seJlinsure) <br /> <br />o <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 />[ certify that the information provided above is accurate and complete and that a valid <br />workers' cOlnvensation policy will be kept in effect at all times as required by law. <br /> <br />Name: 'l? \ eked 1\ )=V.E'- <br />[First] [Middle] [Last] <br />(;v~W 0,,)., ISd'l{" ctJ <br /> <br />Name of Business; <br /> <br />Business Address: <br /> <br />7;' 's I <br /> <br />(h~'\{t <br /> <br />{2J\ t"'r 1.1' \ I{ <br />[City] <br /> <br />5Sos9, <br />[Zip] <br /> <br />'1? n fJJl <br /> <br />, <br /> <br />Business Phone; ((",5 l) (I)cl- ')0" '> <br />I <br />(').. /~. /c'1 <br />Date <br /> <br />Signature <br />