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Certificate of Compliance <br />Minnesota Workers' Compensation Low <br />PRINT IN Mill or TYPE. <br />Minnesota Stmkitesi Section 176.182 regulra rvery state and Ivwl fussing agency to withhold the hwatiance or renewal <br />of a licensa or permit to operate a business in Mbhnesota until the applicant presents acceptable eWdanm of compliance <br />with the workeW compensation Insurance coverage requirl:meflt of Mlnnesatsr 5t h tes, Chapter 276 If the required <br />Information is not provided or is falsely stated, it sawn result In a $2#W0 penalty assessed against the appftnt by the <br />cornmissiarer of the Department of Labor and industry. <br />A valid worimrs' COMPORMthM PoNcy must be kW In effect at all tlrhhels bv ampkron ars <br />LiCENSEorCERTIFICATE NO (if applicable) BUSNESS TELEPHONE NQ <br />MM -473 -ISM <br />BUSINESS NAME (Use the persorh($) rune If business structure is sole pmprietcrr or partnership <br />Jane Doe), of wvwlse It Is the legal name of the business entity.) <br />Wng MR Goff Club <br />DBA {`doina burin= i <br />Spring HNi Golf Club <br />or elso Irnown as an <br />BUSINESS ADDRESS (must <br />725 Coulft Road 6 <br />plhyslcal street <br />FAX TELEPHONE N0. <br />952-473.11 <br />Doe„ or John Doe and <br />d name) (ff applicable) <br />no PO bohaw) £i1Y SYATIE: ZIP CODE <br />MN 55391 <br />cvun"I S MALADRESS - -- <br />Hanrlepire r JWVsprtn0111xcAwn <br />YOUR LICENSE OR CERTIFICATE WILL NOT BE ISSUED WITHOUT THE FOLLOWING <br />INFORMATION. YOU mustCOMplete number l or 2 below. <br />NUMBER i — Workene compensatio <br />INSURANCE COMPANY NAME (not the Insurance <br />_M I I wo-�&1k 0.s <br />POLICY WO. <br />Imurance pollcv information <br />Ce <br />EFFECTIVE DATE <br />I 1, <br />NAIL <br />NUMBER 2— Reason for exemption from workers' compensation insurance <br />If you have questions resarding tie Tread to obtaln workers' compimmUm wveraga. Induding ems+ nk Contact 651.28UD32 or <br />I have no amplaVem (See Mine. Stat f 176.011, subd. 9 for the definition of an employee.) <br />lam es1f4mured for warMW ampenwMan (Include a oopY of audwrbWm to self4nsurebam the Mlnnwaam Deprtnm t of <br />Commerce). <br />I have employees but they are not covered by the worhere comparmtlon law. (See Minn. Stat. i 176.+041 for a itst of wWuded <br />employsm) bgbin whyyour employees am not cawed: <br />Other. <br />I certify that the infwmatlon provided an this form is am rate <br />am authorlaed toM on behalf of the business. <br />APPUCAIr SIGNATURE Omndata ) <br />ff I am signing on behalf of a business, I oartft that I <br />T>ITi,E <br />DATE <br />Z -7c 07 � 6 I Il - fe-- /�, <br />You must noM us IF tfien IS any change to your workers' Compenation Insurance Intornrslon or Ernployoe 9talus Chance by resubffmie <br />this form. This rtalTerial can be made available In different for=, such es !arae Arrest, araEle or on a tope. <br />LEC 04 (9/ja <br />Pepe 3 <br />