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HomeMy WebLinkAboutBalsam Tree & Shrub Care Inc. - Expired CITY OF OAK PARK HEIGHTS t C t� 1 5 4168 OAK PARK BOULEVARD-BOX 2007 JUL f v %E1/ OAK PARK HEIGHTS,MINNESOTA 55082 (651)4394439 =of Oak Park Height PIN CITY OF OAK PARK HEIGHTS 2015 S TREE WORKER'S LICENSE APPLICATION ( Date: b '/! ' ' J Firm or Business Name: I3 1 sam 1 rtrG SLrL O Ca e Type of tree work to be performed: e J dedil / Jrt.r inM c.d,9 _4- Fe r^d✓a'S LICENSE REQUIREMENTS ♦ Certificate of Insurance, minimum coverage,$1,000,000 combined single limit coverage, covering all operations of the applicant.THE CITY OF OAK PARK HEIGHTS MUST BE NAMED AS AN ADDITIONAL INSURED on this policy. • Agreement to hold THE CITY OF OAK PARK HEIGHTS harmless for ALL claims of damage liability that may come against the license/permit holder. ♦ Proof of WORKERS COMPENSATION INSURANCE. • State and Federal Tax Identification numbers pursuant to MN STATE STATUTE 270.72. ♦ The CONTRACTOR further agrees to adhere to all OSHA STANDARDS, UNIFORM TRAFFIC CODES and any CITY CODES AND STANDARDS that may apply to this license. Licenses held in nearby cities: 51 (4U '' Sig%/w ,er) L/�L 1 k✓k;?s !T-' 7v✓nf/t ' Has your company ever had a license revoked in any other city? (YES) NO If yes,where? I 8 .- I LICENSE FEE: $ t)0 IL`3."_ a Name of Business or Company J IC,, lo)N '15 COMPLETION OF THE WORKERS 4,1? / /Vary/l /Vt. flj COMPENSATION INSURANCE AND Business Street Address TAX I.D. FORMS IS REQUIRED �/� BEFORE A LICENSE CAN BE ISSUED. !" ►4rM e an st Cre4 M/I S S 007 THE FORMS ARE ATTACHED. City State Zip Code LICENSE EXPIRES THE END OF (( Sl ) y 3 3 - 3L / 3 THE CALENDAR YEAR WITHIN Phony/ Number J WHICH APPLIED FOR OR UPON SG.I S'�iy-I- �4 Ctrl �f Mai / .Cr/i-% EXPIRATION OF LIABILITY Email Address INSURANCE OR WORKERS'COMP. COMPENSATION INSURANCE, WHICHEVER OCCURS FIRST. License No.TW: Date: 0 i5 -- / 01 7 -2i-15 LICENSE APPLICANT: Pursuant to Minnesota Statute 270.072 Tax Clearance; Issuance of Licenses,the licensing authority is required to provide the Minnesota Commissioner of Revenue your Minnesota business tax identification number and the social security number of each license applicant. Under the Minnesota Government Data Practices Act and the Federal Privacy Act of 1974, we are required to advise you of the following regarding the use of this information: 1. This information may be used to deny the issuance, renewal or transfer of your license in the event you owe the Minnesota Department of Revenue delinquent taxes, penalties or interest; 2. Upon receiving this information,the licensing authority will supply it only to the Minnesota Department of Revenue. However, under the Federal Exchange of Information Agreement the Department of Revenue may supply this information to the Internal Revenue Service. 3. Failure to supply this information may jeopardize or delay the processing of your licensing issuance or renewal application. Please provide the following information and return along with your application to the agency issuing the license. Do not return to the Department of Revenue. Licensing Authority: The City of Oak Park Heights License Renewal Date: Annually(January 1n through December 31st) Personal Information: (Compl ete only if applicable) Applicant's Name: Cl/lades. S / r;k Applicant's Address: C b ( I /V Or e(( five. N p1 areele on St Crty X MA/ SS of 7 City IState Zip Code Social Security No.: Business Information: (Complete only if applicable) r Business Name: i?a /54.M 1<-e e d S�trkj C-(r i T'G— —j Business Address: ( G / 31 Ne'/ f/I Atm. m Mart.11 e on 51; Cra1k l MA/ SSag7 City 2 / State Zip Code 3 Minnesota Tax Identification No.: 1 2 S 72 � Federal Tax Identification No.: `-+ j` — l b 9 3 01 If a Minnesota Tax Identification number is not required, please explain: Si nature Ti ' itl g Date CITY OF OAK PARK HEIGHTS 14168 OAK PARK BOULEVARD-BOX 2007 OAK PARK HEIGHTS,MINNESOTA 55082 (651)439-4439 PROOF OF WORKERS'COMPENSATION INSURANCE COVERAGE Minnesota Statue,Section 176.182, requires every state and local licensing agency to withhold the issuance or renewal of a license or 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,subdivision 2. The information required is: the name of the insurance company,the policy number, and dates of coverage or the permit to self-insure. This information will be collected by the licensing agency and placed within their company file. It shall be furnished, upon request,to the Department of Labor and Industry to check for compliance with Minnesota Statue,Section 176.182,subdivision 2. Law requires this information; licenses and permits to operate a business may not be issue or renewed if it is not provided and/or is falsely reported. Furthermore,failure to provide or falsely reporting this information may result in a $1,000 penalty assessed against the applicant by the Commissioner of the Department of Labor and Industry to the Special Compensation Fund. Provide the information specified above, in the spaces provided,or certify the precise reason your business is excluded from compliance with the insurance coverage requirement for workers'compensation. , Insurance Company(not the Insurance Agent): /11 Li C� V G/6 R T w/ 1T c c. Policy Number or Self-Insurance Permit Number: Pi NA R 00000 3 (0 7`/ Dates of Coverage: 1 0/1 VV.)i(-( — f U/j t'/ 2-C)i S OR I am not required to have Workers'Compensation Insurance because: (check one) I have no employees covered by law Other(specify) I have read and understand my rights and obligations with regards to business licenses, permits and Workers'Comp- • ation co -r ge and hereby certify by my signature below that to the best oito•yie wledg: ,• /1 io provided is true and correct. err or4 Iy!�'rril i"Li Corr L N C, Signature Business Name ✓�(o !3 J /ore Ave . N Date: l / I a nC 0„ 5fi Cry,X 1 /Iv SS©Y7 Business Address Telephone Number: ((,51) f 33 3 ( 13 r '1 CITY OF OAK PARK HEIGHTS 14168 OAK PARK BOULEVARD-BOX 2007 OAK PARK HEIGHTS,MINNESOTA 55082 (651)439-4439 INDEMNIFICATION AGREEMENT To: The City of Oak Park Heights 14168 Oak Park Boulevard P.O. Box 2007 Oak Park Heights, MN 55082 NOTE: The following must be signed by an-Officer of the-tbrporatttm'•orbyrthe Owner and notarized. In consideration for the granting of this license,the license applicant agrees to hold the City harmless from all damages and claims of damage which may arise by reason of any negligence on the part of the Contractor or the Contractor's agents or employees engaged in the performance of this Contract/Permit,and will indemnify the City for the amount of all claims, liens,expenses and claims for liens of work,tool, machinery, materials or insurance premiums and for the amount of all loss by reason of the failure of the Contractor to fully perform its obligation under this Contract/Permit, including but not I' ite to atto •e f-e a d st incurred relative to such claims and losses. eiiiro ' By: 1,4- Date Corporate Officer or In-' dua • •prie orship Owner Subscribed and sworn to before me this day of , Notary Public. County. My commission expires: S:Shared/Forms/Arborist/Tree Worker's License Application '4 CERTIFICATE OF LIABILITY INSURANCE 6/TE(MWD 5 Y) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Joanna K. Williams NAME: Advance Insurance Agency ?pH/CN Nix Exn. (952)831-1928 in Nob(952)831-0572 5241 Viking Drive Ste 200 AD 'D ss;jkvilliams @advanceins.com INSURER(S)AFFORDING COVERAGE NAIC# Edina MN 55435 INSURER Neat Bend Mutual Ins Co 15350 INSURED INSURER B: BALSAM TREE & SHRUB CARE, INC INSURER C: 16131 NORELL AVE N INSURER D: INSURER E: MARINE ST CRX MN 55047 INSURER F: COVERAGES CERTIFICATE NUMBERWest Bend 14/15 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADOL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER (MM/DDIYYYY) (MMIDDIYYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY PRaENTED 100,000 PREMI EMISE$( RENTED occurrence) $ r A )CLAIMS-MADE X OCCUR N801324151 8/27/2014 8/27/2015 µED EXP(Arty are person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE _ $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG_ $ 2,000,000 X7 POLICY n,!7 n LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 ANY AUTO BODILY INJURY(Per person) $ A ALL OWNED X SCHEDULED N801324151 8/27/2014 8/27/2015 BODILY INJURY(Per accident) $ AUTOS _ AUTOS . X HIRED AUTOS X NNED PROPERTY DAMAGE $ _ AUTON OS-OW (Per accident) Underinsured motorist $ 500,000 X UMBRELLA UAB X OCCUR EACH OCCURRENCE _ $ 1,000,000_ A EXCESS UAB CLAIMS-MADE AGGREGATE $ 1,000,000 DED I X I RETENTION$ 0 NU01884923 8/27/2014 8/27/2015 $ WORKERS COMPENSATION I WC CY LIMITS STATU- I( 10TH- AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS!LOCATIONS!VEHICLES(Attach ACORD 101,Additional Remarks Schedule,it more space is required) City of Oak Park Heights is additional insured. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Oak Park Heights ACCORDANCE WITH THE POLICY PROVISIONS. 14168 Oak Park Boulevard PO Box 2007 AUTHORIZED REPRESENTATIVE Oak Park Heights, MN 55082 Jay Larson/2147 ■ ACORD 25(2010105) ©1988-2010 ACORD CORPORATION. All rights reserved. 11145025 r91-11(Y0S\01 Th.Af`.(1Rrl n.me and Innn aro rnnic+nrad mftrfa elf Annan ACa U� DATE(MMIDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 06/29/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Joanna Williams NAME: Advance Insurance Agency,Inc. N,, 952-831-1928 (ArAXC,N,): 952-831-0572 5241 Viking Dr EAess: Edina,MN 55435-5313 INSURERS)AFFORDING COVERAGE NAIC Y INSURERA, MWCARP do RTW,Inc. INSURED Balsam Tree Shrub Care Inc INSURER B: 16131 Norell Ave N INSURER C: Marine St Croix,MN 55047 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POUCY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUER POUCY EFF POUCY EXP LTR TYPE OF INSURANCE INS° WVD POLICY NUMBER 81MIDDiYYYY1 (MMIDWYYYYI UNITS COMMERCIAL GENERAL LIABIUTY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ PERSONALS ADV INJURY $ _ GEN'L AGGREGATE LIMIT APPUES PER: GENERAL AGGREGATE _ $ POLICY JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE UABIUTY COMBINED SINGLE UNIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS _ AUTOS NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per accident) $ UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED RETENTIONS $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'UABILRY X STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE YIN MNAR-0000036749-1 10/14/201410/14/2015 EL EACH ACCIDENT $ 100,000.00 A OFFICER/MEMBER EXCLUDED? IY I N/A N --(Mandatory in NH) E.L DISEASE-EA EMPLOYEE $ 100,000.00 If yes,describe under DESCRIPTION OF OPERATIONS below EL DISEASE-POUCY UMIT $500.000.00 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks SeMdule,may be attached if mac space is moulted) Officers are excluded from coverage. CERTIFICATE HOLDER CANCELLATION City of Oak Park Heights SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 14168 Oak Park Blvd THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 14 14 Box ak P ACCORDANCE WITH THE POLICY PROVISIONS. Oak Park Heights,MN 55082 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD PDF created with pdfFactory trial version www.pdffactorv.com CUSTOMER NO. 0110315251 WEST INSURANCE BEND W R NSE West Bend Mutual Insurance Company 1900 S.18th Avenue I West Bend,WI 53095 POLICY NUMBER: NSO 1324151 04 ENDORSEMENT EFFECTIVE JULY 13, 2015 DELETING ADDITIONAL INSUREDS, ADDING BLANKET ADDITIONAL INSURED/FORM WB1890 COMMERCIAL GENERAL LIABILITY ADDITIONAL INTEREST CITY OF OAK PARK HEIGHTS PO BOX 2007 OAK PARK HEIGHTS, MN 55082 VARIOUS LOCATIONS FORM CG2026 APPLIES DESIGNATED PERSON OR ORGANIZTN ADDITIONAL INSURED HAS BEEN DELETED RECEIVED 4 City of Oak Park Heights AM PM INSURED: BALSAM TREE & SHRUB CARE, INC 16131 NORELL AVE N MARINE ST CRX, MN 55047 AGENCY: ADVANCE INSURANCE AGENCY INC 22-018 POLICY PERIOD FROM: AUG. 27, 2014 TO: AUG. 27, 2015 ISSUED 08/19/15 ADDL INTEREST COPY ACOR ® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) klift.../- 9/17/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Joanna Williams Advance Insurance Agency PHONE (952)831-1928 ' FAX (A/C,No E)(tl: 1(A/C,No):(952)831-0572 5241 Viking Drive Ste 20 RECEIVED EMAIL -- ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# Edina MN 55435 INSURER A:West Bend Mutual Ins Co 15350 INSURED SEP 2 1 INSURER B: Balsam Tree & Shrub Care, Inc INSURERC: 16131 Norell Ave N INSURER D: City of Oak Park Heights _INSURER E: Marine On Saint Cro MN 5544-7- '748 AM PM INSURER F: COVERAGES CERTIFICATE NUMBER:15-16 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR 'ADDL SUBR POLICY EFF I POLICY EXP I - - LTR TYPE OF INSURANCE I INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY)I LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE X J OCCUR DAMAGE TO RENTED PREMISES S(Ea occurrence) $ 100,000 1324151 8/27/2015 8/27/2016 MED EXP(Any one person) $ 5,000 PERSONAL 8 ADV INJURY $ 1,000,000 GE 'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY l JECOT [ J LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: Additional Insured $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT _(_Ea accident) $ 1,000,000 _ l ANY AUTO BODILY INJURY(Per person) $ A 1 ALL OWNED I X SCHEDULED - - AUTOS AUTOS 1324151 8/27/2015 8/27/2016 BODILY INJURY(Per accident) $ X X NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per accident) $ Underinsured motorist $ 500,000 X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS LIAB CLAIMS-MADE I AGGREGATE $ 1,000,000 DED X 1 RETENTION$ o NUO1884923 8/27/2014 8/27/2015 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y I N j i STATUTE - ER ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N/A E.L.EACH ACCIDENT $ (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under — — DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) City of Oak Park Heights is additional insured. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Oak Park Heights THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 14168 Oak Park Boulevard ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 2007 Oak Park Heights, MN 55082 AUTHORIZED REPRESENTATIVE Jay Larson/S140 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(201401)