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Jul.26. 2006 1:03PM No,4543 P. 2 Business licenses, Page 2 . In ord~r to procen the ri"w "cense, the submittal of thl. appllclltlon and appropriate fee $hould be made .s lroM as possible. Please fill Qut thIs 'ann and ",'um It to 111e City Qf N~w Srlghton, 803 Old Hwy 8 NW, New Brtghton, MN 5511~. AttentIon: Oilvid fj" Fr1dgen, City Sanitarian. . Under Minnesota law (M.S. 270.12). Ihe lIIgen~y issuing you Ihis license Is required to provide tQ the MIM.sota Commls$ioner af Revenue your Minnesota tax Identification number i1nd the Social Security number at each llcen.e applicant. Undor the Minnesota GoVOrl'lmClllt Data Pr.etlcM Act and the Federal Privacy Act of 1974, we must advIse you that: · This IntonnllUon may be used to deny the Issuance, renewal ar transfer af your Ilcen.e If you oWe Ihe M lnn..ola Department of Revanl,le delinquent taxes, penalties, Qr Intarest; . . The licensing agency wlllluPPIy It only ta the Mlnnelota Depa"ment af Reven\.le. However, under the federal t:::x'change af InformaUon Ad, th" Department of Revenue il allowed to supply this Information tQ the Inlemal Revenue Serv'ice; . FallinlllO $upplythls InformaUon may jeapardiR ar delay the 'Auance 01 your IICtlnse or processing your reneWal application. P..... fill In thelnform'tlon on the back pill'. and return this form alang with your application to tho agency 11;&"ln9 the license. Do not return this fonn to the DlIp~r1mf;lf1l 01 Reven"'e. (Please prInt or type.) PROOF OF WORKI:RS' COMPENSATION INSURANCE COVERAGE . .. Minnesota Statllte 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. Thelnfot'mation l'equired is: The nClime 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 fumlshed, upon request, to the Department of Labat' and Industry to check for compliance with Minnesota Statute Sec. 176.181, Subd. 2. This Information 18 reqUired by law, and licenses and permits to operate a buslnes8 may not be issued or renewed if it Is not provided andlor 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 In'annatlon specified above In the spaces prDvided, or certify the precise reason your business is excluded from compUance with the Insurance coverage requirement for workers' . compensation. Insurance Company Name: (NOT the Insurance agent). (" Policy Number or Self-Insurance pennlt Numbet': O\\\O~ 0 '1-<6.-'L<&\ Dates of Coverage: -e.. lo "b - \ ---G '-.D <:t:, - \ -0, . Soeial Security Number: ~9::.:.-Sl.o .5f~ 1) \0 Minnesota Tax 10 Number; 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. ~c0; r-\.\~~v~ (Signature)