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2002-12-09 CC Packet
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2002-12-09 CC Packet
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<br />I- <br />I <br />, <br />, <br />I <br />I <br />I <br /> <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 infonnation 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 ofthe Dfpartment of Labor and Indu.stry. <br /> <br />Insurance Company Name: <br />(tlOT the insurance agent) <br /> <br />'?>~ r\<. ( 'y <br /> <br />, <br />4d""N.slrtl-lor~ <br /> <br />Policy Number: <br /> <br />iN c:. Z z. O'i 1:;,:5 "3311- 00 <br />t l /0 J TO ~ Z /3 i /6 'I. <br />I I ' ; <br /> <br />Dates of Coverage: <br /> <br />(OR) <br /> <br />1 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 self-insure) <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 />1 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: I;..), { I , ~_ <br />[First] <br /> <br />::rt /' O"M t:- <br />[Middle] <br /> <br />73IHK <br />[Last] <br /> <br />Name of Business: ~~ {{ 'r I S I/D,....J ./' . J:J1JG. <br /> <br />Business Address: _.10'1 'if - Cf.,w fir II Ii (( I2d <br /> <br />C'Ady,),!!~ /YI,J <br />[City] [State] <br /> <br />~~--..' <br /> <br />55tJJg <br />[Zip] <br /> <br />Business Phone: <br /> <br />t,..5/-&S3- ~1ft~ <br /> <br />p~ <br />Signatur <br /> <br />or;)/. I', () ?_ <br />Date <br />
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