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<br />CERTIFICA TlON OF COMPLIANCE <br />MINNESOTA WORKERS' COMPENSATION LAW <br /> <br />Minnesota Statute, Section 176.182 req~lires every state and local licensing agency to withhold the issuance or <br />renewal of a license or permit to operate a business or engnac in an activity in Minnesota until the applicant <br />presents acceptable evidence of compliance with the workers' compensation inllurance coverage requirt;:tnent of <br />MSS Chapter 176. The information .required is: The name of the insurance company, the policy number, and <br />dates of ooverage or the permit to self~insure. This informfltion will b~ colleSl1~cJ by the ligel1sing !!gency and <br />r~tflined in their tiles. <br /> <br />This information is required by law, and licenses, and permits to operate a business may not be issued or renewed <br />if it is not provided and/or is falsely reported. Furthermore, if this information is not provided or falsely stated, it <br />may result in a $1,000 penalty assessed against the applicant by the Commissioner of the Department of Labor <br />and Industry. <br /> <br />Insurance Company Name: <br />(NOT the insurance agent) <br /> <br />Policy Number: <br /> <br />Dates of Coverage: <br /> <br />(or) <br /> <br />I am not required to have workers' compensation liability coverage because: <br /> <br />( )< ) <br />( <br /> <br />I have no employees covered by the law. <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 (these include: Spouse, <br />Parents, Children, and certain farm employees). <br /> <br />Name: PerC~SON. If'd.oy flfvi,,'l <br />(Last, First, Middle) , <br /> <br />Doing Business As: <br /> <br />H / 6/f Sc hoo L ,f E t.Jl1ion ."Un' ~ J) L-, L. L j A <br />(Business Name if different than your name) <br /> <br />Business Address: <br /> <br />7c,o() Pa,fTi.:;4NI,J Av S, <br /> <br /> <br />SS'Y J 3 Phone: ((P I J,) !J'~ <e ~I ~J ~ <br />D ~.'.'. 2S -- 2...CJC)O <br />ate:' q <br />