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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 oU. form and return it to the City of New Brighton, 803 Old Hwy 8 NW, New Brighton, MN 55112, Attention: David A. Fridgen, City Sanitarian. Under Minnesota law (M.S. 270.72), the agency Issuing you this license Is required to provide to the Minnesota Commissioner of Revenue your Minnesota tax identification number and the Social Security number of each license applicant Under the Minnesota Government Data Practices Act and the Federal Privacy Act of 1974, we must advise you that: . This Information may be used to deny the Issuance, renewal or transfer of your license if you owe the Minnesota Department of Revenue delinquent taxes, penalties, or Interest; . The licensing agency will supply It only to the Minnesota Department of Revenue. However, under the Federal Exchange of Information Act. the Department of Revenue Is allowed to supply this Information to the Internal Revenue Service; . Failing to supply this Information may jeopardize or delay the issuance of your license or processing your renewal application. 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.) PROOF OF WORKERS' COMPENSATION INSURANCE COVERAGE Minnesota Statute 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 in Minnesota until the applicant presents acceptable evidence of compliance with the workers' compensation insurance coverage requirement of Section 176.181. Subd. 2. The information required is: The name of the insurance company, the policy number, and dates of coverage or the permit to self-insure. This Information will be collected by the licensing agency and put In their company file. It will be furnished, upon request, to the Department of Labor and Industry to check for compliance with Minnesota Statute Sec. 176.181, Subd. 2. This information is required by law, and licenses and permits to operate a business may not be Issued or renewed if it is not provided and/or is falsely reported. Furthermore, if this information Is not provided and/or falsely reported, it may result In a $1,000 penalty assessed against the applicant by the Commissioner of the Department of Labor and Industry payable to the Special Compensation Fund. Provide the information specified above in the spaces provided, or certify the precise reason your business is excluded from compliance with the Insurance coverage requirement for workers' compensation. .'~ Insurance Company Name: (NOT the insurance agent) s Policy Number or Self-Insurance Permit Number: Dates of Coverage: Or coverage because: Social Security Number:~ Minnesota Tax 10 Number: (~f ~'-Cf..I2> L I HAVE READ AND UNDERSTAND MY RIGHTS AND OBLIGATIONS WITH REGARD TO BUSINESS LICENSES, PERMITS AND WORKERS' COMPENSATION COVERAGE, AND I CERTIFY THAT THE . INFORMATION PROVIDED IS TRUE AND CORRECT. f:r-tJ~ V1'1 tl-?~ Q7 f> s: ~ - () J (Signature)