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Business Licenses,Page 2 <br /> 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 <br /> this form and return it to: <br /> City of New Brighton <br /> 803 Old Hwy 8NW <br /> New Brighton,MN 55112, <br /> Attention: Joe Hatch,Code Enforcement Officer. <br /> 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 <br /> return this form to the Department of Revenue. (Please print or type.) <br /> Certificate of Compliance Minnesota Worker's Compensation Law <br /> Minnesota Statures, Section 176.182 requires every state and local licensing agency to withhold the issuance or renewal of a license or <br /> permit to operate a business or engage in any activity in Minnesota until the applicant presents acceptable evidence of compliance with the <br /> workers' compensation insurance coverage requirement of Minnesota Statutes,Chapter 176. The required workers' compensation <br /> insurance information is the name of the insurance company,the policy number,and the dates of coverage,or the permit to self-insure. If <br /> the required information is not provided or is falsely stated,it shall result in a$2,000 penalty assessed against the application by the <br /> commissioner of the Department of Labor and Industry. <br /> A valid workers'compensation policy must be kept in effect at all times by employers as required by law <br /> Business Name(Individual name only if no company name is used) License or Permit No(if applicable) <br /> 6aS , i V � <br /> Doing Business as Name(if applicable) <br /> )&Press S1-0do <br /> Business Add ess(PO EkLmust include street address) City State Zip Code <br /> c P-/ old H y �� Are�brit h �e`.� .�,nO ✓1 CM 4U 5 )12 <br /> /I/ <br /> Your license or certificate will not be issued without the following information. <br /> You must complete number 1,2,or 3 below. <br /> Number 1: Complete this portion if you are insured: <br /> Insurance Compa y Name(not the insurance agent) <br /> n'" •rvvN <br /> Worker's Compensation Insurance Policy No. Effective Date Expiration Date <br /> (13_ lcrt— oilsc- cae nay 2oi3 jMcty zoI� <br /> Number 2: Complete this portion if Self-Insured: <br /> ❑ I have attached a copy of the permit to self-insure. <br /> Number 3: Complete this portion if exempt: <br /> I am not required to have worker' compensation insurance coverage because: <br /> ❑ I have no employees. <br /> ❑ I have employees buy they are not covered by the worker's compensation law. (See Minn. Stat. § 176.041 for a list <br /> of excluded employees.)Explain why your employees are not covered: <br /> ❑ Other: <br /> All Applicants complete this portion: <br /> 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 <br /> authorized to sign on behalf of the business. <br /> A 'cant Signature(mandatory) Title Date <br /> �w J 'rrSecie 4 5/2-3>/3 <br /> Note:if your Worker's Compens olicy is cancelled within the license or permit period,you must notify the agency who issued the license or <br /> permit by resubmitting this form. <br /> FAILURE TO FILL THIS APPLICATION COMPLETELY WILL DELAY YOUR LICENSE <br />