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3 Certificate of Workers Compensation Insurance FormSI-12 Certificate of Workers Compensation Self-Insurance GSI 105. SECTION A Facility Information Facility Name Facility Address Telephone Number Fax Number and Municipality Self explanatory Capacity A. SECTION C Complete only for temporary food service establishments regulated under Subpart 14-2 NYSSC Check the appropriate type of unit. Children s camp enter the maximum number of campers the camp is approved for at one time. Temporary...

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