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HomeMy WebLinkAboutHoffman & McNamara Co. CITY OF OAK PAARK K RECEIVED AUG HEIGHTS 17.2015 14168 OAK PARK BOULEVARD-BOX 2007 OAK PARK HEIGHTS,MINNESOTA 55082 (651)439-4439 CITY OF OAK PARK HEIGHTS 2015 J TREE WORKER'S LICENSE APPLICATION Date: 8/ 3))� Firm or Business Name: I-1 ocky)tun N.Itovtct,l(G4 Co, Type of tree work to be performed: Tot pI&nf1YhL{ 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: 1Z-O01 e_S h/X"1 M NI Has your company ever had a license revoked in any other city? (YES) NO If yes,where? ii ff f LICENSE FEE: $30.00 t'IU( \(Ua/1 'I Mc.NIa aint CO, Name of Business or Company COMPLETION OF THE WORKERS iO4 L 0 S+ COMPENSATION INSURANCE AND Business Street Address TAX I.D. FORMS IS REQUIRED A' 2 BEFORE A LICENSE CAN BE ISSUED. 140.0'1 nGIS M '`� S O3 J THE FORMS ARE ATTACHED. City State Zip Code LICENSE EXPIRES THE END OF ( cos I ) 'f 3 7—qL14.03 THE CALENDAR YEAR WITHIN Phow Nu b ((��� WHICH APPLIED FOR OR UPON I nit o i'IVI(/,1°And m,m.P1 iti-c,.toM EXPIRATION OF LIABILITY Email Address (.1\ INSURANCE OR WORKERS'COMP. COMPENSATION INSURANCE, J\ ' WHICHEVER OCCURS FIRST. License No.TW: Date: 8119 I S N\t 2,o16 .- I1c\ a 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 1st through December 31st) Personal Information: (Complete only if applicable) Applicant's Name: Applicant's Address: City State Zip Code Social Security No.: Business Information: 11(Comp�(Complete only if applicable) Business Name: t4 o.(1Vt.(i, `11) C N LonnuArz Co . Business Address: c City State Zip Code Minnesota Tax Identification No.: SS 2.02_i S Federal Tax Identification No.: 4 I '" ) 34 S(40 I If a Minnesota Tax Identification number is not required, please explain: Signature Title Date }°sF 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): '� vCIS Q IJ2'YIA Policy Number or Self-Insurance Permit Number: ‘tAC1•1\1-1.32.c-59 Dates of Coverage: I 3 h — 1l 13o I s OR I tam not`required to have Workers'Compensation Insurance because: (check one) i flave 12Aroployees covered by law Other(specify) I have read and understand my rights and obligations with regards to business licenses, permits and Workers'Compensation coverage and hereby certify by my signature below that to the best of my knowledge,the information provided is true and correct. `IAA ■ acnU al ► M AA,vvla rm Co Signature Business Name (4045 1Q S Date: 0/13116- 14C LS ')S IM Sll 3 Business Address Telephone Number: Val) 1R-3-q4le 5 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 Corporation or by the 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 limited to attorney fees and costs incurred relative to such claims and losses. 8/13/I'S By: -/-\7\ Date Corporate Officer or Individual Proprietorship Owner Subscribed and sworn to before me this I 2.7tVI day ofkA-b)(49--/t- . ? ?tc5 ((4irftvs �M LISA MCDQWfII 414 Notary Pubbc State of Minnesota ���-•k- Notary Public. ,�v;t "';a uo ry 31n201t7eS County. My commission expires: l/j 1/2-0 I:1 S:Shared/Forms/Arborist/Tree Worker's License Application A`°R°® CERTIFICATE OF LIABILITY INSURANCE DATE 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 Alice Celt NAME: C.O. Brown IA/C.NN Extr (651)388-6716 I IA/C.No):(651)388-8443 620 Main Street E-MAIL ADDRESS:acelt @cobrown.com INSURER(S)AFFORDING COVERAGE NAIC# Red Wing MN 55066 INSURER A:West Bend Mutual 15350 INSURED INSURERB:The Hanover Insurance Group 22292 HOFFMAN & MCNAMARA COMPANY INSURER C: 9045 180TH ST E INSURERD: INSURER E: HASTINGS MN 55033 INSURERF: COVERAGES CERTIFICATE NUMBER:11/30/14-15 Master 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 A S LTR .TYPE OF INSURANCE INSR WVD POLICY NUMBER JMM DDIYYYYUMM/DD //YYYYL LIMITS GENERAL UABIUTY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED X COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) $ 200,000 A CLAIMS-MADE X OCCUR CPN1223256 11/30/2014 11/30/2015 MED EXP(Any one person) $ 10,000 - PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GENII_AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG_ $ 2,000,000 TI POLICY n!r n LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 X ANY AUTO BODILY INJURY(Per person) $ A ALL OWNED SCHEDULED CPN1223256 11/30/2014 11/30/2015 BODILY INJURY(Per accident) $ AUTOS _ AUTOS HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS (Per accident) Underinsured motorist $ 1,000,000 X UMBRELLA LIAR — OCCUR '- EACH OCCURRENCE ._ $ 3,000,000 A EXCESS LIAB CLAIMS-MADE AGGREGATE $ 3,000,000 DED X(RETENTION$ 0 CUN1223258 11/30/2014 11/30/2015 $ A WORKERS COMPENSATION WC STATU- 1 10TH- AND EMPLOYERS'UABILITY Y/N TORY I IMITS I I ER ANY PROPRIETOR/PARTNER/EXECUTIVE N E.L.EACH ACCIDENT $ 500,000, OFFICER/MEMBER EXCLUDED? WCN1223257 11/30/2014 11/30/2015 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below _ E.L.DISEASE-POLICY LIMIT $ 500,000 B Employment Practices LHx9377435 11/30/201411/30/2015 Limit 500,000 Liability Deductible 10,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space is required) 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 Blvd. N PO Box 2007 AUTHORIZED REPRESENTATIVE Oak Park Heights, MN 55082 Jay Bohmbach, CIC/BJ1 ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025 omnnsi ni The.A(:(1RIl nme.and Inn^arta re.niate.rmrl marks^f Ar:r1Rr1