10-001246 Department Of Financial Services, Division Of Workers&Apos; Compensation vs. Beles And Company Custom Decorating/Draperies, Inc. Status: Closed Settled and/or Dismissed prior to entry of RO/FO on Monday, September 27, 2010.

FILED

DEC 282010 004953

Chief Financial Officer REPRESE1'o'TING

Docketed __ ALEX SINK

CHIEF STATE FINANCIAL OFFLORIDA OFFICER

IN THE MATTER OF:

Case Number: 1 0-005-D3- WC

BELES & COMPANY CUSTOM

DECORATING/DRAPERIES, INC.

--------------_-.:/

FINAL ORDER

THIS PROCEEDING came onforfinal agency action and Alex Sink, Chief Financial

Officer of the State of Florida, orher designee, having considered the record inthiscase,

including the Stop-Work Order and Order of Penalty Assessment, the Amended Order of Penalty

Assessment, the2nd Amended Order of Penalty Assessment, andthe3rd Amended Order of

Penalty Assessment, served in Division of Workers' Compensation CaseNo. 10-005-D3, and

being otherwise fully advised inthe premises, hereby findsthat:

1.On January 11,2010, the Department of Financial Services, Division of Workers'

Compensation (hereinafter "Department") issued a Stop- Work Order and Order of Penalty

Assessment in Division of Workers' Compensation Case No.1O-005-D3to BELES &

COMPANY CUSTOM DECORATINGIDRAPERIES, INC. (BELES). The Stop-Work Order

and Order of Penalty Assessment included a Notice of Rights wherein BELES was advised that

any request foran administrative proceeding to challenge or contest the Stop-Work Order and

Order of Penalty Assessment must befiled within twenty-one (21)days of receipt of theStop-

Work Order and Order of Penalty Assessment in accordance with Sections 120.569 and120.57,

Florida Statutes.

2.OnJanuary 11,2010, theStop-WorkOrderandOrder of Penalty Assessment was

servedviapersonalserviceonBELES.Acopy of the Stop-Work OrderandOrder of Penalty

Assessment isattachedheretoas "Exhibit A"andincorporatedhereinbyreference.

3.OnJanuary27,2010,the Department issuedanAmendedOrder of Penalty

Assessment toBELESinCaseNo.10-005-D3.The Amended Order of Penalty Assessment

assessedatotalpenalty of $66,004.52againstBELES.TheAmendedOrder of Penalty

Assessment includedaNotice of Rights wherein BELESwasadvisedthatanyrequestforan

administrative proceeding tochallengeorcontesttheAmendedOrder of PenaltyAssessment

mustbefiledwithintwenty-one(21)days of receipt of theAmendedOrder of Penalty

Assessment inaccordancewithSections120.569and120.57,FloridaStatutes.

4.TheAmendedOrder of Penalty Assessment wasservedonBELESbycertified

mailon February 2,2010. Acopy of the Amended Order of Penalty Assessment isattached

heretoas "Exhibit B"andincorporatedhereinbyreference.

5.OnFebruary 22,2010, BELESfiledatimelyPetitionforaformaladministrative

hearingin accordance withSections120.569and120.57,FloridaStatutes.The Petition was

forwardedtotheDivision of Administrative HearingsandassignedCaseNo.10-1246.

6.OnMarch 19,2010, the Department issueda2ndAmendedOrder of Penalty

Assessment toBELESinCaseNo. 1O-005-D3. The2ndAmendedOrder of PenaltyAssessment

assessedatotalpenalty of $64,690.23againstBELES.The2ndAmendedOrder of Penalty

Assessment wasservedonBELES through the Division of Administrative Hearings.Acopy of

the2nd Amended Order of Penalty Assessment isattachedheretoas "Exhibit C"andis

incorporated hereinbyreference.

7.OnSeptember 24,2010, theDepartmentissueda3rdAmendedOrder of Penalty

Assessment toBELESinCaseNo. 1O-005-D3. The3rdAmendedOrder of PenaltyAssessment

assessedatotalpenalty of$35,341.21 againstBELES.The3rdAmendedOrder of Penalty

Assessment wasservedonBELESthroughtheDivision of AdministrativeHearings.Acopyof

the3rd Amended Order of Penalty Assessment isattachedheretoas "Exhibit D"andis

incorporated hereinbyreference.

8.OnSeptember 27,2010, the Department filedaNotice of SettlementinDOAH

CaseNo.10-1246.Acopy of theNotice of Settlement filedbytheDepartmentisattached

heretoas "Exhibit E."

9.OnSeptember 27,2010, Administrative LawJudgeWilliamF.Quattlebaum

enteredanOrderClosingFile,relinquishing jurisdiction totheDepartment.Acopy of the

September 27,2010OrderClosingFileisattachedheretoas "Exhibit F."

FINDINGSOFFACT

10.Thefactualallegationsinthe Stop-Work OrderandOrder of PenaltyAssessment

issuedonJanuary 11,2010, theAmendedOrder of PenaltyAssessmentissuedonJanuary27,

2010,the2ndAmendedOrder of Penalty Assessment issuedonMarch 19,2010 andthe3rd

Amended Order of Penalty Assessment issuedon September 24,2010,whicharefully

incorporated hereinbyreference,areherebyadoptedasthe Department's Findings of Factinthis

case.

CONCLUSIONSOFLAW

11.BasedontheFindings of Factadoptedherein,theDepartmentconcludesthat

BELESviolatedthespecificstatuesandrulesallegedintheStop-WorkOrderandOrder of

Penalty Assessment, theAmendedOrder of Penalty Assessment,the2nd Amended Order of

Penalty Assessment, andtheThirdAmendedOrder of PenaltyAssessment,andherebyadopts

theviolationschargedintheStop-WorkOrderandOrder of Penalty Assessment, theAmended

Order of Penalty Assessment, the2nd Amended Order of Penalty Assessment, andtheThird

AmendedOrder of Penalty Assessmentasthe Conclusions of Lawinthiscase.

PENALTY IMPOSED

12.The Notice of SettlementandresultingOrderClosingFile, wherein BELESno

longercontestedtheThirdAmendedOrder of Penalty Assessment pursuant toSections120.569

and120.57,FloridaStatutes,takentogetherwiththeFindings of Factand Conclusions of Law

adoptedherein, constitute groundsforthe Chief FinancialOfficertoimposethe penalty and

orderthecessation of business operationsassetforthherein.

ITIS THEREFORE ORDEREDthat:

a)BELESshall immediately paythetotalpenalty of $35,341.21infulltothe

Department fordepositintothe Workers' Compensation Administration TrustFund,or

shallenterintoa Payment AgreementScheduleforPeriodicPayment of Penaltyand

demonstrate compliance withthe coverage requirements of Chapter440,FloridaStatutes,

pursuant to Section 440.107(7)(a), Florida Statutes,andRule69L-6.025, Florida

Administrative Code,baseduponits violation of the workers' compensation coverage

requirements contained inChapter440, Florida Statutes.

b)BELESshall immediately ceaseallbusiness operations intheState of

Floridauntilsuchtimeasthe Department issuesanOrderReleasingtheStop-WorkOrder

andOrder of Penalty Assessment.The Department shallnotissuean Order Releasingthe

Stop-Work Order andOrder of Penalty Assessment untilBELEShascomeinto

compliance withthecoverage requirements of Chapter 440, Florida Statutes,andhaspaid

thetotal penalty of$35,341.21 tothe Department.

DONEAND ORDERED this day of ,2010.

TANNER HOLLOMAN, DIRECTOR,

DIVISION OF WORKERS' COMPENSATION

... 1. NOTICE OFRIGHTS

Any party tothese proceedings adversely affected bythis Order is entitled toseek review

ofthis Order pursuant to Section 120.68, Florida Statutes,and Florida Rule of Appellate

Procedure 9.110. Review proceedings must be instituted byfilinga Notice of Appeal with the

Agency Clerk at Room 612Larson Building, 200EastGainesStreet, Tallahassee, Florida,

32399-0333 andacopy of theNotice of Appeal,acopy of thisOrderandfilingfee with the

appropriate District Court of Appeal within thirty (30)days of rendition of thisOrder.Copies

furnished to:

Beles & Company Custom Decorating/

Draperies, Inc.

c/o Morgan R. Bentley, Esq.

200S. Orange Avenue

Sarasota, Florida 34236

Timothy L. Newhall

Assistant General Counsel

Department of Financial Services

200E. Gaines Street

Tallahassee, FL 32399-4229

STATE OF FLORIDA, DEPARTMENT OF FINANCIAL SERVICES

DIVISION OF WORKERS' COMPENSATION

EMPLOYERNAME: BELES & COMPANY CUSTOM DECORATING/DRAPERIES, INC. I STOP-WORK ORDERNo.:

10-005-03

FEIN: 651119566 ISSUANCE DATE: 03119/2010

EMPLOYER ADDRESS: 2901 HERMITAGE BLVD

CITY: VENICE STATE:FL ZIP: 34292

2nd AMENDED ORDER OF PENAL TV ASSESSMENT

The Division ofWorkers' Compensation issueda Stop-Work Orderagainstthe above-referenced Employer on

01/1112010. The Stop-Work Order included anOrderof Penalty Assessment that identified the penalties assessable

under sections 440.10 and 440.107, F.S.

Based upon additional information, the Division hereby amendsthe Amended Orderof Penalty Assessment issued on

01127/2010 and assesses the penalty(s) as specified inthePenalty Worksheet, which is attached heretoand made apart

hereof.

It is ORDERED that the Employer is hereby assessed a TOTAL PENAL TV of $64,690.23.

The penalty(s) assessed herein supersedes any penalty(s) previously assessed inthis case. The Employer shall pay the

TOTAL PENALTY bymoneyorderorcashier's check, made payable tothe DFS-Workers' Compensation Administration

Trust Fund, orenterintoa Payment Agreement Schedule forPeriodic Payment of Penalty withthe Division of Workers'

Compensation.

Ifthetotal penalty assessed inthis Amended Orderof Penalty Assessment isless than thetotal penalty assessed in the

Amended Orderof Penalty Assessmentissuedon 01/27/2010, the Division willmaila refund intheamountofthe

difference tothe Employer.

Pursuant toRule 69l-6.028, Florida Administrative Code, ifthe Division imputes the employer's payroll, the employer shall

have twenty business daysafterserviceoftheorder assessing the penalty to provide business records sufficient forthe

Division to determine the employer's payroll forthe period requested inthe business records requestforthe calculation of

the penalty. Ifsufficient business recordsarenot provided withintwenty business days afterserviceoftheorder

assessing the penalty, the calculation ofthe penalty imputing the employer's payroll will remain ineffect.

LIEN NOTICE

Pursuant to Section 440.107(11), F .5., theDepartmentmay initiate lien proceedings to collect any penalty duethat has not

beenpaid.In addition, the Department may refer anyunpaid penalty that isduetoa collection agency for the initiation of

proceedings to collect the unpaid penalty.

Pleaseseethe Notice of Rights onthereserve side that pertains toyour rights regarding this action.

CERTIFICATE OFSERVICE

Pursuant to section 440.107(4), F .s.,COLLEEN WHARTON

servedatrue copy of this 2nd Amended ---------------------------1 Order of Penalty Assessment:

DBy hand delivery: DATE: TIME: _ SERVER: _

D By certified mail: DATE: TIME: _ ARTICLE: _

Odober2009

EXHIBIT

I

NOTICEOFRIGHTS

Youhavearightto administrative review ofthis action bythe Department under sections 120,569 and 120.57, Florida

Statutes.

To obtain review, youmustfilea written petition requesting review. Ifyou dispute a material fact contained inthis action,

youare entitled toa hearing under Sections 120.569 and 120.57(1), Florida Statutes, atwhichyoumaybe represented by

counsel, presentevidenceand argument onthe issue(s), examine witnesses, submita proposed recommended order, and

file exceptions tothe recommended orderofthe Administrative law JUdge. Ifyoudonotdisputea material fact contained

inthis action, youare entitled toa hearing under section 120.57(2), Florida Statutes, at which you may be represented by

counsel, present documentary evidence, and presenta written statement in opposition tothis action.

A petition forahearingunder sections 120.569 and 120.57, Florida Statutes, mustconformtoRule 28-106.2015, Florida

Administrative Code.The petition shall contain a)the name, address, and telephone number, and facsimile number (if

any)ofthe petitioner; b)thename, address, and telephone number, and facsimile numberofthe attorney or qualified

representative ofthe petitioner (ifany) upon whomserviceof pleadings andotherpapersshallbe made; c)a statement

requesting an administrative hearing identifying those material factsthatarein dispute. Ifthereare none, the petition must

so indicate; d)astatementofwhenthe petitioner received noticeofthe agency action; ande)a statement including the file

numbertotheagency action.

You'mustfilethe petition for hearing sothatitis received bythe Department within twenty-one (21) days ofyour receipt

ofthis agency action.The petition mustbefiledwithJulie Jones, DFS Agency Clerk, Department of Financial Services,

612 larson BUilding, 200 EastGaines Street. Tallahassee, Florida 32399·0390.

FAILURE TOFILEA PETITION WITHINTHE TWENTY-ONE (21) DAYS CONSTITUTES A WAIVER OF YOUR RIGHT

TO ADMINISTRATIVE REVIEWOFTHE AGENCY ACTION.

Mediation undersection 120.573, Florida Statutes, isnot available.

ISSUING AGENCYNAMEAND ADDRESS

Division ofWorkers' Compensation, Bureau of Compliance: --:.. _

Attn: C. 0 \\ <><... y---.,="" w="" h="" ci..="" y--="" to="" 0="" ,telephone:="" cf="" y\\="" -="" '3="" l="" 4-="" i="" 1'2=""><>

October 2009

Noticeof Rights Updated 11/2312009

State of Florida, Department of Financial Services

Division of Workers' Compensation, Bureau of Compliance

Penalty Worksheet

BUSINESSNAME:BELES&COMPANYCUSTOMDECORATING/DRAPERIESINC DWCCaseNo. 10-005·03

Employee Name

BARBARA BELES-eORP OFF J{. 1 8810 IIIIIIIIIIIII

BELES-eORP OFF 8810

BELES-CORP OFF gr 881

IBRYANBELES-CORPOFF gr 1 j 5474 °_ _

IBRYANBELES-CORPOFF J?I f 5474 ,liliiii

tBRYAN BELES-CORPOFF gr I 5474 __ .. __ _ ,_., •. ,., .

IRONSECKFORD P 1 5474 ,_

IRONSECKFORD P 1. 5474 liliiii

IRICHDRAKE P 1 5474 _

!RICH DRAKE P 1 5414 _

riCH DRAKE p 1 5474 'liliiii

rAUL MCCLARIN P I 5MB liliiii

INICKDOW P 1 5437 liliiii

INICKDOW P 5437

PUSTIN MCNESKY P t. j 5474 .'- liliiii

.. P 1 5474 .. -

PIM HUDDLESTON P J 5474 _

PEFFSWENSON P 1 5474 liliiii

PEFF SWENSON P I 5474 .liliiii

PEFF SWENSON P 1 5474 liliiii

HERNANDEZ P 5474

jDAVE DRYAN P 1 J 5474 .- liliiii

* Ifthe employer has failedto provide business records sufficient to enable the Department to determine the employer's payroll, payroll shall be

imputed tobethe statewide average weekly wageas defined in 5.440.12(2) F.S.multiplied by1.5,(440.1 07(7)(e».

** Premium multiplied by statutory factor of 1.5

*** Greater ofpenalty under column (9)or $1000. s440.107(d)(1)

State of Florida, Department of Financial Services

Division of Workers' Compensation, Bureau of Compliance

Penalty Worksheet

BUSINESSNAME: BELES & COMPANYCUSTOM DECORATING/DRAPERIES INC OWCCaseNo. 10-oGS-D3

. "RIS . 1;;:11· .. 100=009 I I 7S00

!CHRIS MARCHAND PI 5474 '06122/2009 I 0612212009 I 50.00_

!CARLOS ALBINO PI 5474 107/09/2009110/02/20091 1,215.00 _

!CARLOS ALBINO P I 5474. 106/19/2009106127/2009 I 349.00' _

BELES PI 5474 I 0412212009 I 04122/2009 , 80.00 ._

IBRADBELES P J 5474 03/06/20,091 200.00_

FNDY MIROTZNIK PI 5474 107/0312009 J 12/24/2009 I 16,985.0?:

FNDY MIROTZNIK P J 5474 , 04/0112009 I 06127/2009 J 8,975.00 _

FNDY MIROTZNIK PI 5474101/07/2009103/2912009 19,4!5.00 _

IBARBARABELES-CORPOFF gr I S810 10110112008 1 12/31/200S_

BElES-CORP OFF gr I 5474101/01/2008 1 1 2/31 12 008 _. ",_

fTODD MINGO P I. 547 4 . 1°5/09/2,008 I L

triM MONTGOMERY PI 5474 I 071251200s1 07125/200S I 110.00; . . .

IRICHDRAKE PI 5474 J 01103I200S 11212412008 I. 33.826.00 _

IRAYGARDNER P I 5474101/0312008 109/17120081 5,895.00' _

IpAULMCCLARIN P J 5348 101131/200810810812008 6.090.00 . _

BELES PI 5414101/11/2008) 01111/2008 L _

!MARK HOFF PI 5474.1 06/19/2008 I 09/23/2008 I 572.00 ._

POE RICHARDS PI 5474110/1012008 110/1012008 I

PIM HUDDLESTON P I. 5474,103/2212008110/0212008 _

PEFF SWENSON PI 5474 J 01102/2008112/31/2008 J _

PANIELBURDA PI 547410810112008111/01120081 _

* If IheemployerhasfailedtoprovidebusinessrecordssufficienttoenabletheDepartment 10 determinetheemployer'spayroll,payrollshall be

imputedto be thestatewideaverageweekly wage asdefinedin s.44O.12(2) F.S.multiplied by 1.5.(440.107(7){e».

•• Premiummultiplied by statutoI)' factorof 1.5

* .. Greaterofpenallyundercolumn (g) or$1000.s440.107(d)(1)

StateofFlorida, Department of Financial Services

DivisionofWorkers' Compensation, Bureauof Compliance

Penalty Worksheet

BUSINESSNAME:BELES& COMPANY CUSTOM DECORATING/DRAPERIES INC owe CaseNo. 10-005·03

Employee Name

f-NUY M.,ROTZNIK

!BRADBELES

FARLOS ALBINO

FARLOS ALBINO

FHRIS MARCHAND

IBRYAN BELES- CORP OFF

'BARBARA BELES-eORP OFF

IDAVID REYNOLDS

'FRED STEWART

PEFF SWENSON

PIM HUDDLESTON

IMARK ELLIOT

IMARKHOFF

FICKDOW

IRICHARD DRAKE

'BRYAN BELES- CORP OFF

lBARBARA BELES-CORP OFF

* Ifthe employer hasfailedto provide business records sufficient to enable the Department to determine the employer's payroll, payroll shallbe

imputed tobethe statewide average weekly wage asdefinedin 5.440.12(2) F.S.multlplied by 1.5, (440.107(7)(e».

** Premium multiplied by statutory factor of1.5

*** Greater ofpenalty under column (9)or$1000. s440.107(d)(1)

Page3 of3

STATEOF FLORIDA, DEPARTMENT OF FINANCIAL SERVICES

DIVISION OF WORKERS' COMPENSATION

EMPLOYERNAME:BELES & COMPANYCUSTOM DECORATING/DRAPERIES, INC. I STOP.WORKORDERNo.: 10-005-03

FEIN:651119566 ISSUANCEDATE: 09124/2010

EMPLOYERADDRESS:2901HERMITAGEBLVD

CITY:VENICE STATE:FL ZIP:34292

3rd AMENDED ORDER OF PENAL TV ASSESSMENT

The Division ofWorkers' Compensation issueda Stop-Work Orderagainstthe above-referenced Employer on

01/11/2010. The Stop-Work Order included anOrderof Penalty Assessment that identified the penalties assessable

undersections440.10and 440.107, F.S.

Based upon additional information, the Division herebyamendsthe Amended Orderof Penalty Assessment issued on

01/27/2010 andassessesthe penalty(s) as specified inthe Penalty Worksheet. whichis attached hereto and made apart

hereof.

Itis ORDERED that the Employer is hereby assessed a TOTAL PENALTV of $35,341.21.

The penalty(s) assessed herein supersedes any penalty(s) previously assessed inthiscase.The Employer shall pay the

TOTALPENALTYbymoneyorderor cashier's check, made payable tothe DFS-Workers' Compensation Administration

Trust Fund, orenterintoa Payment Agreement Schedule for Periodic Payment of Penalty withthe Division of Workers'

Compensation.

Ifthetotalpenalty assessed inthe3rd Amended Orderof Penalty Assessment islessthanthetotal penalty assessed in

theAmendedOrderof Penalty Assessment issued on 01/27/2010, the Division willmaila refund inthe amount ofthe

difference tothe Employer.

PursuanttoRule 69L-6.028, Florida Administrative Code, if the Division imputes the employer's payroll, the employer shall

havetwentybusinessdaysafterserviceoftheorder assessing ttle penalty to provide business records sufficient forthe

Division todeterminethe employer'S payroll forthe period requested inthe business records requestforthe calculation of

the pe"lalty. Ifsufficient business records arenot provided within twenty business days after service of theorder

assessing the penalty, the calculation ofthe penalty imputing the employer's payroll will remain ineffect

LIEN NOTICE

Pursuant to Section 440.107(11),F.S., the Department may initiate lien proceedings to collect any penalty due that has not

been paid. In addition, the Department may refer any unpaid penalty that isduetoa collection agency for the initiation of

proceedings to collect the unpaid penalty.

Please seethe Notice of Rights onthe reserve side that pertains to your rights regarding this action.

CERTIFICATE OF SERVICE

Pursuanttosection440.107(4),F.S., COLLEEN WHARTON

served a truecopyofthis3rdAmendedOrderofPenaltyAssessment: ---------------------------1

DBy hand delivery: DATE: TIME: _ SERVER: _

D By certifiedmail: DATE: TIME: _ ARTICLE: _

October 2009

EXHIBIT

I D

NOTICEOF RIGHTS

Youhavea right to administrative reviewofthisactionbytheDepartment under sections 120.569 and 120.57, Florida

statutes.

Toobtain review, you mustfileawrittenpetition requesting review. Ifyou dispute a material fact contained inthis action,

youareentitledtoa hearing undersections120.569and 120.57(1), Florida Statutes, at which youmay be represented by

counsel,present evidence andargumentonthe issue(s), examine witnesses, submita proposed recommended order, and

fileexceptionstothe recommended orderofthe Administrative Law Judge. Ifyoudonotdisputea material fact contained

inthisaction,youare entitled toa hearing undersection 120.57{2}, Florida Statutes, atwhichyoumaybe represented by

counsel,present documentary evidence, andpresentawrittenstatementin opposition tothis action.

Apetitionfora hearing under sections 120.569and 120.57, Florida Statutes, mustconformtoRule 28-106.2015, Florida

Administrative Code. Topetitionforahearing,youmustsendineithera completed Election of Proceedings form

(attached)withany required attachments ora petition requesting a hearing, which containsa)thename, address, and

telephone number, andfacsimilenumber(ifany)ofthe petitioner; b)the name, address, and telephone number, and

facsimilenumberoftheattorneyor qualified representative ofthe petitioner (ifany)uponwhomserviceof pleadings and

otherpapersshallbe made; c}astatement requesting an administrative hearing identifying thosematerialfactsthatarein

dispute.Ifthereare none, the petition mustso indicate; d)astatementof when thepetitioner received notice ofthe agency

action;ande)a statement including thefilenumbertotheagency action. Iftherearenofactsin dispute, the petition must

so indicate.

Youmustfilethe petition for hearing sothatitis received by the Department within twenty-one (21)daysofyour receipt

ofthisagency action. The petition mustbefiledwithJulie Jones, DFS Agency Clerk, Department of Financial Services,

612 Larson-Building, 200EastGaines Street, Tallahassee, Florida 32399-0390.

FAILURETOFILEA PETITION WITHINTHE TWENTY-ONE (21)DAYS CONSTITUTES AWAIVEROF YOUR RIGHT

TO ADMINISTRATIVE REVIEWOFTHEAGENCYACTION.

Mediation under section 120.573, Florida Statutes, isnot available.

ISSUINGAGENCYNAMEAND ADDRESS

Division ofWorkers' Compensation, Bureau of Compliance: _

Attn: ----, , Telephone: _

October2009

NoticeofRightsUpdated 613012010

.. State of Florida, Department of Financial Services

Division of Workers' Compensation, Bureau of Compliance

Penalty Worksheet

BUSIN'ESS NAME: BELES & COMPANY CUSTOM DECORATING/DRAPERIES, INC. DWC Case No. 10-005·03

(bf .

Employee Name pertOdOf··.······

lBARBARA BELES-CORP OFF 8810 107/01/2009 112131/2009

(BARBARA BELES·CORP OFF gr ,8810 104/01/2009106/30/2009_

'BARBARA BELES-CORP OFF gr I 8810 f 01/01/2009 I 03/3112009_

JBRYAN BElES·CORP OFF gr J 5474 107/01/2009 112131/2009 1

IBRYAN BElES-CORP OFF gJ I 5474 I 04101/2009 I 06/30/2009_ l '. ; 1)/, W!"f,f"'; I W11·r,UWI!' 1,1

IBRYAN BELES·CORP OFF gr I 5474101/0112009 10313112009 _ II ... ':, L I...., '/, I' p. ,1,;4 IHI i .,'t 1 ,\\ .f,"K\\ : ... ;/ t;" 'ul'l! )llll",l',i:,t!

IRONSECKFORD P I 5474108/24/2009 "11212312009 1,555.00 'iif'il;j' ,:<"'i" ':="">

IRON SECKFORD P I 5474 103/10/200910311012009 400.00 _

'ROBERTHARRIS P I 5474 103/1812009103/1912009 3750.00 , .• ,:'I'W,ljlj!lltill!P'''I:;t

IRICHDRAKE P I 5474 I 07/03/2009 11212412009 17,670.00 I;:! !;II,jll:jif!:T1iii:l.,;;Y' :' <:>

IRICHDRAKE P I 5474 I 04/0212009 I 06/27/2009 8,085.00 __

IRICHDRAKE P I 5474 101/09/200910312312009 8,390.00 riJIm ,?', ..-

IPAULMCCLARIN P I 5348111/0112009111101/2009 700.00 :'

. 1'{II( '11' \\' IIW N""t ... ·,'j t' .Iil ' {'ff" !"'pl'll' IIlII81IlIIIIlI

INICKDOW P II 543707/0112009 I 1213012009 7,525.00 :::;,:" ii"'" ';;, 'I':i;i',;" l

rNICKDOW P J ----+---.;-.--....;..-1----- 5437 105/01/2009105/0712009 620.00 :1/!lil'1r" , "::,:';" ,tTl,ll "I'N/II;IIIIIltI;',::', I. .::<' 'r="" ",_i="" "="" c/l"",="" ii="" ••="">

jMAnSHAW p I 5474 108/06/200911213112009 10,110.00 I fl i m:: ,Iil:,;":; I!I!!I! ll\\il!,,;!d; .. ,:

PUSTIN MCNESKY P I 5474 111/06/2009 111/2512009 I . 415.00 Ili'I'.'i,: k .• _ \\-< jl="" ,ft.="" i,'j"="" :ij1fllil"="" 1="" ii="" l="" j="" 1="" i,it",="" f{,="" "="" 'j"="" .,.'.="" ,"",:',="" ,l':'i!'!i'tii'u,.'h;'="" .j="" j="" t.,ii1if:::"'if;i]·.="" i'="" 't,="" illllllllllllllbukillillr="">

plM HUDDLESTON P I 5474 I 0 7/01/20091 0811512009 I 37500 • j ..

}jIM HUDDLESTON P I 5474 104/1412009104/14/2009 ' ..... ....;. ... 2 ... 00 . .... -0-0 lPi,!:'r,"\\!in;:lIl;l' j inm'!i!I'!i1itqw, ," 1;!:J:llii'IJ'iWi"i:' ,,::;:, -

PEFF SWENSON P I 5474 108/28/2009 112131/2009 1r--"1-1,-35--5-.0-0·

PEFF SWENSON P I 5474 I 04102/2009 I 06/30/20091 8,530.00 _

PEFF SWENSON P I 5474 10110912009 103/29/2009 I 8375.00 , IrE'! • H 'PI' 1 i I.,. ,1\\ •• <, i="" h="" '"="" 11="">1 ,I )I.i./t., r: rt JHIitiUIHIBttrIftlfIfitm

* If theemployerhasfailedtoprovidebusinessrecordssufficienttoenablethe Department todeterminetheemployer'spayroll,payrOllshallbe

imputedtobethestatewideaverageweeklywageasdefinedins,440.12(2)F.S.multipliedby1,5,(440.107(7)(e».

** Premiummultipliedbystatutoryfactorof1.5

*** Greaterofpenaltyundercolumn(g)or$1000.s440.107(d}(1}

State of Florida, Department of Financial Services

Division of Workers' Compensation, Bureau of Compliance

Penalty Worksheet

BUSINESS NAME: BELES & COMPANY CUSTOM DECORATING/DRAPERIES, INC. DWC Case No. 10-005-03

. .. ,,:: ..... ".... .... , ... t· .. ,·w

Employee Name I Imputed I

IEMPIMENIO HERNANDEZ I 08113/2009 I 08113/2009 I

'DAVEDRYAN PI 5474107/09120091 07/09/2009 ·i'I'I,'II"H ),Ii:;!' r:'"i"'" 1/;,,'/ "I"tWit' :1,' ,l:l I '-° f !'f1 I' 'j""11I Ullflr;'IUIi;";:'''i'1j''';, J./\\;- • ,,1'T t11';1 'I"'; :' WI"'''' ;'tJ:.tr;t/i' '·'C'JIR.

[CHRIS MARCHAND P1 5474 I 08/2612009 I 08126/2009

!CHRIS MARCHAND PI 5474 1061221200910612212009 I.

ICARLOSALBINO p 1 5474107/0912009110/02/2009" 1,215.00

lCARLOS ALBINO P I 5474 106/1912009 I 06/2712009 I 349.00 1;:':' ':':

IBRADBELES P I 5474 I 0412212009 I 04/22/2009 I 80.00 ':;';1;' t: ,:tf:' i }!, li)lf"; _

IBRADBELES P I 5474 I 0310612009 I 0.3/06/2009 I 200.00 '" , ,,, en "'" "., ,," .. •• "I

IBRADALDEN P i ____ 5474 ..... ) 07/0312009 112109/2009 ( , 720.00 11j!l-:"iW\\lUi 11. > ,,11\
1J !i:,:"; •• 1 i;1 ,. 'I I:" ( I r. ", t\\ _ . ••

MIROTZNIK PI 5474107/0312009112/2412009 I 16,985.00 P:o "'., 1·:::(1:

MIROTZNIK PI 5474 I 04/0112009 I 06/27/2009 I 8,975.00 : ,.1;: ?:J!!::: ';!',I!lj!!!lWi";!I!i j ': .I t·

FNDYMIROTZNIK PI 5474101/0712009103/29120091 9,475.00 __

I BARBARABELES-CORPOFF p f7T f 8810 101/01/2008112/31/2008 _ I';!i"!':::';":":!"" \\'1. 0':'\
'\
,',,1 }'FI:!)';!; ,

I BRYANBELES-CORPOFF I7r P f 5474 II 01/01/2008 12/31/2008 _ 'M' :::;: ,,::I',,!,;:':'r' "':':'>':; ':;',";:, l,g.,r.:.

MINGO P f 5474 105/09/2008 I 05/09/2008 I 400.00 ";': ::':',",; ',:, ,;, ,:

MONTGOMERY PI 5474 107125/2008107/25/2008 110.00 :,;1':,:: '; :IW'::

IRICHDRAKE PI 5474 '01/03/200a\Q2412008 J 33.826.00 _

'RAYGARDNER PI 5474 101/0312008 I 09/171200a I 5,895.00 f;' ,; c •• J .'; :!fjm11:hl;;:'Jk'd!'

I PAULMCCLARtN PI 5348101131/2008 108/0812008 I r--4-oo-.0-0- .' 6 090.00 i ). \\ 1,1 1 ,1,,;1. i,'h,:f".:lil·::"II:'.:/'\\,:·': ,t. 'I\\!l d'"f. I .. I:!.r l 1-_ (, 11 _Ui!llmilllllll!ll

1tl /"" 1 KE BELES PI 5474 I 01/1112008!-0-1-11-1-/2-0-0-a-l .'lll\\\\ ,: ""1: 1,;:1 ,',"".,I\\:< '11"1"="" :;="">1,:, .. ,111,/' IllIlliimliilil JIlIJmlllllfll1Jllf -'

f#'RK HOFF PI 5474106/19/2008109/2312008 1 5_72_._0_0 ii:;, , ft1!ltiIH'nh:,;:;;'..;:'F' __

1l0ERICHARDS r p I 5474 '110/10/2008110/10120081 .. . 'In: DƒN I ... , 'fj,'" II,"';: >† fD i: < i=""> P I Dfff†D r 1,1'111 †ƒ ,., j1J a ,tlHUIlBDJIIlI •.

* Iftheemployer has failedtoprovidebusinessrecordssufficienttoenablethe Department todeterminetheemployer's payroll, payrollshallbe

imputedtobethestatewideaverageweeklywageasdefinedin5.440.12(2) F.S.multiplied by1.5,(440.107(7)(e».

** Premiummultiplied by statutory factor of1.5

••• Greaterofpenaltyundercolumn(9)or$1000.s440.107(d)(1)

State of Florida, Department of Financial Services

Division of Workers' Compensation, Bureau of Compliance

Penalty Worksheet

BUSINESS NAME: BELES & COMPANY CUSTOM DECORATING/DRAPERIES, INC. OWC Case No. 10-005-03

Employee Name I Imputed I

1M HUDOLESTON rr 5474 I 03/22/2008 110/02/2008 I 175.00

PEFF SWENSON P l 5474 I 01/0212008 112/31/2008 I 25,966.00

IDANIELBURDA PI 5474 I 08/0112006 111/01/2006 I 4,438.00

FNDYMIROTZNIK PI 5474 1 21,260.00 'I"j' " r 'f!' ,;ill'" .l.l I m U, '1" t '," ) -j II\)-424(I, J I,'! ... II 'I' r I j 'I' I',!I ! 'I' I>'1.1,1 "" fit I" llTiJT:" J li",l".,,,' fl 1 j ']T:fT::[<-'i'i'p •="" :11,"="" to="">

!BRAD BELES PI 5474101/0212008 110/10/2006 I 4,600,00 ,1jY f..l. \)-1085(,",,' • J '( tt;.lf'Nl!rlITtlj'1lljHlfl'll \
\\' f'i l' 1/'; r I, ) r l'i .', 1l1'llw:r"U!'t11 :'1." W:'t t:ll J I

BELES PI 5474 11110112007112/2812007 I 3,315.00 ; I \\ ';) ;;'V' ."j' Ir· '.; ',' 'It! ("II;!lll; . r: ',. 4U{#m! '''B' ': I :,1; 111 - 1

\\BRIAN ALDEN PI r-- 5474 -r- I 05/15/2008 I i 09/0512008 I r-- 804.00 " nmliifflll·l; i'll j <,; r·="">, , ::':11::: II \\J I Ii, \\t 9 I ,i;;,:;':: t··, 1"(;' _ ,

FARLOSALBINO PI 5474 108124/2007112/2212007 I 2,053.00 , _

fCARLOSALBINO PI 5474 '1 01/04/2008110112120081 fffX ‰‰‰>NN N> Dƒ

!CHRIS MARCHAND PI 5474 110/11/2006\A2012008 I 325,00

I BRYANBELES-CORPOFF m p r 5474 I 01./12/200711213112007 _ lrl, l: I g!j" tl i'.: ,1,1 ',1.,; «:;1....

lBA RBARA BELES-CORP OFF gr I 8810 101/01/2007 11213112007 D‰ >W >W ::::.:-X I !W1::1lft{;' :: liliiii

I OAVIDREYNOLDS PI 5437 10813112007112120120071 7,950.00 ' ,l(./ 1\\." :ill"', •• ',,;,.1'1' ,'.j ,;'il',;, 'T'llrl:,

'FRED STEWART P , 5474 101/12/2007 1 0 31 21/2007 I 1,005.00 __

PEFF SWENSON P I 5474 112129/2007112129/2007 I 260.00 IIIIIIII

PIM HUDDLESTON P I 5474 I 06122/2007 111/09/2007 I 3,434.00 ::,"1',: ::t:' TI i

rlMRK JU: ELLIOT p i j 5474 III 04106/2007 04106/2007 . 550.00 j:' H' i,;:;I';jll:':,:" , '"''1'''''U''' .:Ii Ii·ji:: "·f.''P''''!IIl;l Ill' :;<': ,.,.="" ulp="" 1':="" 'cul"fp'·\\i('·-'r="">

f'AARK HOFF P J 5474 101/19/2007 104119/2007 I 4,580.00 !11;,1: 1!:fiiiil:iW:, ;r';:,,;,

I RICHDRAKE P I 5474 111130/2007112128/2007 I _ 2,015,00 'rrrrJil!lllt:i:::";j·!:.t: t.tlh-, .. li"< "::,.'="">

. _ ...... .'

* Iftheemployerhasfailedtoprovidebusinessrecordssufficienttoenablethe Department todeterminethe employer's payroll, payrollshall be

imputedto be thestatewideaverage weekly wage as definedins,440,12(2) F.S.multiplied by 1,5, (440.107(7)(e».

** Premium multiplied by statutoryfactorof 1.5

*** Greaterofpenaltyundercolumn(g)or$1000.5440.107(d)(1}

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