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Business Licenses,Page 2 In order to process the new license,the submittal of this application and appropriate fee should be made as soon as possible. Please fill out this form and return it to: City of New Brighton 803 Old Hwy 8NW New Brighton,MN 55112, Attention: Joe Hatch,Code Enforcement Officer. Please fill in the information on the back page and return this form along with your application to the agency issuing the license. Do not return this form to the Department of Revenue. (Please print or type.) Certificate of Compliance Minnesota Worker's Compensation Law Minnesota Statures,Section 176.182 requires every state and local licensing agency to withhold the issuance or renewal of a license or permit to operate a business or engage in any activity in Minnesota until the applicant presents acceptable evidence of compliance with the workers'compensation insurance coverage requirement of Minnesota Statutes,Chapter 176. The required workers' compensation insurance information is the name of the insurance company,the policy number,and the dates of coverage,or the permit to self-insure. If the required information is not provided or is falsely stated,it shall result in a$2,000 penalty assessed against the application by the commissioner of the Department of Labor and Industry. A valid workers'compensation policy must be kept in effect at all times by employers as required by law Business Name(Individual name only if no company name is used) License or Permit No(if applicable) MMi 1 OIL CO PAAJ Doing Business as Name(if applicable) Business Address(PO Box must include street address) City Stit ';-M - -• .Zip rode V-)Liq S. Gn 7 S-r P,0.44x Ls 67,Lcc.,44 -ii- M/) s5a8-4- Your license or certificate will not be issued without the following information. You must complete number 1,2,or 3 below. Number 1: Complete thisportion if you are insured: Insurance Company Name(not the insurance agent) (rn P t-W'1 i 4L OA L iu-A (-- Worker's Compensation Insurance Policy No. Effective Date Expiration Date 'S F-1 r) --. -C 3 �--1)- 3 11-1 k( 73 I 1`/ 11-J Number 2: Complete this portion if Self-Insured: ❑ I have attached a copy of the permit to self-insure. Number 3: Complete this portion if exempt: I am not required to have worker'compensation insurance coverage because: ❑ I have no employees. ❑ I have employees buy they are not covered by the worker's compensation law. (See Minn.Stat.§ 176.041 for a list of excluded employees.)Explain why your employees are not covered: O Other: All Applicants complete this portion: I certify that the information provided on this form Is accurate and complete. If I am signing on behalf of a business,I certify that I am authorized to sign on behalf of the business. A licant Signature(mandatory) 1'itI Date your Worker's Com sa ion policyis cancelled within the license orpermit period,you must otify the agency who issued the license or ii ote:if P� � g Y permit by resubmitting this form. FAILURE TO FILL THIS APPLICATION COMPLETELY WILL DELAY YOUR LICENSE