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_ Environmental Health RAMSEY COUNTY 2785 White Bear Ave.North Suite 350 Saint Paul—Ramsey County Public Health Maplewood,MN 55109 651-266-1199 ramseycounty.us Certificate of Compliance M nnesota Department of Revenue Information Minnesota law(MS y270C.72 s 4 Licensing Authority:duties)states All licensing authorities must require the applicant to provide the applicant's Social Security number or individual taxpayer identification number and Minnesota business identification number,as applicable,on all license applications.Upon request of the commissioner,the licensing authority must provide the commissioner with a list of all applicants, including the name,address,business name and address,and Social Security number or individual taxpayer identif cation number and business Identification number,as applicable,of each applicant.The commissioner may request from a licensing authority a list of the applicants no more than once each calendar year." Enter Minnesota Business ID Number also called Minnesota Tax ID Number)OR enter tax-exempt number: 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 or renewal of your license if you owe the Minnesota Department of Revenue delinquent taxes,penalties,or interest. • The licensing agency(Ramsey County)will supply this information only to the Minnesota Department of Revenue(Commissioner). However,under the Federal Exchange of Information Act,the Department of Revenue is allowed to supply this information to the Internal Revenue Service, Federal Employer Identification Number Afederal employer ID number is required for the Ramsey County Finance Department's records.Alternatively,you can provide the business owner's social security number.Call 651-266-1199 to provide SSN securely by phone. Enterfederal employer ID number Workers' Compensation Insurance Coverage Law Minnesota Statute 176.182 requires every state and local licensing agency to withhold the issuance or renewal of licenseor 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 s 2.The information required is:name of insurance company,policy number,and dates of coverage;OR the permit to self-insure.This information will be furnished upon request to the Department of Labor and Industry to checkfor compliance with MS 176.1815 2.If this information is not provided and/or falsely reported,It may result In a$2,000 penalty assessed against the applicant by the Commissioner of the Department of Labor and Industry payable to he Special Compensation Fund. Workers'C mpensatlon Insure cg Co�r Ipanr Coverage Dates (it Irf1S From:OLll`1I'1lo To:04i5/24 OR,I certify thatliam not required to carry workers'cotwoensaTTO i7soulffig"cause(check one): 0 lam the sole proprietor and have no employees. ❑ lam self-insured(you must include a copy of the permit to self-insure). ❑ 1 have no employees who are covered by workers'compensation law. (Exempt employees include:spouse,parents,and children—all other employees must be covered). I i Certification I certify under penalty of the low 1 have personally examined and am fomillor with the information submitted In this and all attached documents.Based on my inquiry of those Individuals immediately responsible for obtaining the information,I believe the submitted Information Is true,accurate and complete.I am aware there are significant penalties for submitting false information,including the possibility of fine and imprisonment.I hereby apply for a Ramsey County License subject to all relevant conditions and provislons of the Ramsey County Administrative Ordinance and the Ramsey County Food Protection,Lodging,Manufactured Home Parks&Recreational Camping Areas,Public Swimminy Pool,Youth Camp,Hazardous Waste Mona ement or Solid Wosre Ordinance as appilcable. Name: �z bCl Cc Icon CI Title: coop Signature: /• Date: 10.10.23