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Certificate of Compliance <br />Minnesota Workers' Compensation Law <br />PRINT IN INK or WK <br />Minnesota Statutes, Section 175.182 requires every state and local iioenske agency to withhold the Issuance or renewal <br />of a license or permit to operate a business In Minnesota until the applicant presents acceptable evidence of compliance <br />with the workers' compensation Insurance coverage requirement of Minnesota StatutM Chapter 176. If the required <br />Information Is not provided or Is falsely stated, It shall result In a $2,0W penalty assessed against the applicant by the <br />commissioner of the Department of Labor and industry. <br />A gelid woarkeW compensation policy must be kap! In effect at all timesto ars ss rec�ulred h law. <br />LICENSE or CERTIFICATE NO (if applicable) BUSINESS TELEPHONE NO. FAX TELEPHONE <br />#02-16 AGE dub On Sale Liquor License 952-473.813+ts 958-475-9748 <br />BUSINESS NAME ( Use the persons) name 9 business structure is ole proprietor or partnership (i e., john Do^ ear h <br />lane Doel, otherwise it Is the legal name of the business entity.) <br />Yilm!r CourtttY Club <br />DBA ("doing business as" or also known as an assumed name) (if applicable) <br />Wayzata Country Club <br />BUSINESS ADDRESS (must be <br />200 Ways Blvd. West <br />Hennepin <br />street address, no PO boxes) CITY <br />Wlayrata <br />E-MAIL ADRESS <br />cbprang@wavmaca.coom <br />STATE ZIP cc <br />MN 55391 <br />VDU1R LICEkSE Ci CERTiFICAi E WILL NOT 13E ISSUED WiT OIJT TWE F0Li.04&J1W(; <br />INFORMATION. You must complete number 1 or 2 below. <br />NUMBER 1— Wort W I <br />INSURANCE COMPANY NAME (not the insurance <br />Continental MfesWn Group <br />POLICY NO. - - - <br />Insurance <br />11C Nun <br />10904 <br />EFFECTIVE DATEI EXPIRATION DATE <br />1,0 M f G 11 10/01/201.7 <br />NUMBER 2 — Reason for exefnptlorl from - ricers' compensation Insurance <br />If you have questions regarding rite need to -obtain worker' compensation coverage, including exemptions, contact 651.284 5032 or <br />1-804-342-5354. <br />I have no employees. (See Minn. Stat. § 176.011, subd 9 for the deflnlivan of an employee') <br />I pm self-insured for workers' compensation (include a copy of authorizadon to self -insure from the Minnesota Department of <br />Commerce). <br />Q I have emplayees but they are not covered by the workers' compensation law. (See Minn. Stat. § 176.041 for a Ret of excluded <br />employees.) Explain why your employees are not covered: <br />Other: -. <br />at the inferrnation provided on this farm is accurate a <br />am signing =behalf of a business, i certify that I <br />am author to !.%n on behalf of the business <br />Vprmou7r <br />NATURE atory� - TITLE DATE <br />s if there is any change to yourWormers' Compensation Insurance Information or Employee Status Change by resubmittingcan be made available In different farms, such as large prFM, Braille or on a tape.i inn uppF�rpn�. <br />LIC 134 (9/12) <br />Pogo 5 <br />