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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 $1,000 penalty assessed against <br />the applicant by the Commissioner of the Department of Labor and Industry. <br /> <br />Insurance Company Name: <br />(NOT the insurance agent) <br /> <br />Policy Number: <br /> <br />Dates of Coverage: <br /> <br />TO <br /> <br />(OR) <br /> <br />I am not required to have workers' compensation liability coverage because: <br /> <br />r& <br /> <br />I have no employees <br /> <br />o <br /> <br />I am self-insured (include permit to selfinsure) <br /> <br />o <br /> <br />I have no employees who are covered by the workers' compensation law <br />(these include: spouse, parents, children and certain farm employees) <br /> <br />I certifY that the information provided above is accurate and complete and that a valid <br />workers' compensation policy will be kept in effect at all times as required by law. <br /> <br />Name: .YJJmmH <br />(First] (Middle] <br /> <br />Name of Business: JS)'S LiQUOr <br /> <br />Business Address: 7D~5 20111 /J1/E ).. <br /> <br />C[IV!lR(J/tt{ /YJN <br />(City] [State] <br />6~ 426 6 :;. <br /> <br />blOP.LC <br /> <br />!f7/lffl <br />[Last] <br /> <br />$'Z)SB <br />[Zip] <br /> <br /> <br /> <br />jL <br />