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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 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 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: cfJtrf?co <br />~OT the insurance agent) <br /> <br />Policy Number: <br /> <br />tJl- Sf - 2317 f~'" ZO <br /> <br />-'p':~71 fJ/ /tJ> TO bt/~/~' <br />_ . i:7;~;:;: ., ' <br />(OR) . ~,.~ <br /> <br />Dates of Coverage: <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: Mlc~1 -r1klN1A:r W~~ <br />[First] [Middle] [Last] <br /> <br />Name of Business: 6)1 Aw JAlC D~A ~/N(/'lI ((" it", ~ <br /> <br />Business Address: 7 fJf"{ 3 tJ..o t1t ~ S <br /> <br />( I!At-~U i <br />[City] <br /> <br />Business Phone: 'f1 - 4~ - ~6 7 cl <br /> <br />~A~r2 <br />Signature <br /> <br />,.A/J <br />[State] <br /> <br />s- ro ; <il <br />[Zip] <br /> <br />/81 ,-Ir -,,~ <br />Date <br /> <br />5.L <br />