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HomeMy WebLinkAboutBJ Haines Tree Service CITY OF OAK PARK HEIGHTS 14168 OAK PARK BOULEVARD-BOX 2007 OAK PARK HEIGHTS,MINNESOTA 55082 (651)439-4439 CITY OF OAK PARK HEIGHTS 2015 TREE WORKER'S LICENSE APPLICATION Date: 6 --30 _A 65 Firm or Business Name: R.3 4A C v2.44-lJurus. �-- Type of tree work to be performed. : ai& : ..:, 1 aA Cr1J-aX at A_Ji 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: , l r rQ L_' .WA_LI.Q Has your company ever had a license revoked in any other city? (YES) O) If yes,where? LICENSE FEE: $30.00 6- Name of Business or Company n , COMPLETION OF THE WORKERS • ...Li:16- • • !. COMPENSATION INSURANCE AND Business Street Address TAX I.D. FORMS IS REQUIRED 1 yy, 1 BEFORE A LICENSE CAN BE ISSUED. .��= � 5 , � , I l I1) 5�$c - THE FORMS ARE ATTACHED. City State Zip Code L1 LICENSE EXPIRES THE END OF ( 125 I ) -t - l 3 c THE CALENDAR YEAR WITHIN Phone Numbed ii� WHICH APPLIED FOR OR UPON 1' ' U L •C e , C EXPIRATION OF LIABILITY Email Address INSURANCE OR WORKERS'COMP. COMPENSATION INSURANCE, WHICHEVER OCCURS FIRST. License No.TW: Date: 41-2-0r5— iy2— 1C- 9 —) `� 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 31s) Personal Information: (Complete only if applicable) Applicant's Name: Be, el,vc; e_ t tct ,-e_S Applicant's Address: 9-2, to `-k v-1- City State Zip Code Social Security No.: I T7 — I G ( 1 Business Information: ((Complete only if applicable)"'"( Business Name: \� g'1C1 can � ln.t-Sc U�CSL. Business Address: 9 tL2 ;4\42. J\ `(YL ) S sG g;) City State Zip Code Minnesota Tax Identification No.: (0 9 y 0D- Federal Tax Identification No.: ( -' O c)cj y ic 9 CJ If a Minnesota Tax Identification number is not required, please explain: &/1-4,1109 . (0-36 -1 ,5 Signature Title Date vy 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): b— Policy Number or Self-Insurance Permit Number: lcg.g s Dates of Coverage: 4-- 1 -1 1 v `( I - I OR I am not required to have Workers'Compensation Insurance because: (check one) } + * I INiimond employees covered by law • . -- ' Ottier1sgecify) 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 14111i4 A It AQL.k."&e.LCA131 knowledge,the information provided is true and correct. Signature B iness Na e ef," Date: 1.0'3 a - l S 6 • L) 55c Business Address (p5 Telephone Number: ( ) , -39 -7I) 1 RECEIVED OCT 0 2 CITY OF OAK PARK HEIGHTS City of Oak Park Heights 14168 OAK PARK BOULEVARD-BOX 2007 — —.__AM OAK PARK HEIGHTS,MINNESOTA 55082 ____PM (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. 3 0 --1 _ ,fat e� , -s By: �.c�� � v Date Corporate Officer or Individu I Proprietorship Owner Subscribed and sworn to before me 30 this "Bay of agiAlyttailiKAD15. oimartomitommo CXtha Dies) CV dal/IWO , Notary Public. L J.JOHNSON• County. k : Nolen/Public Minnesota My commission expires: l-3/- O . ., _� 3, ma S:Shared/Forms/Arborist/Tree Worker's License Application ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) M 03/19/2015 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 Bibi Gross NAME: Ken Jarcho Agency, LLP ,a"CC No,Ext): 952-641-6941 FA,No); (952)884-6540 9052 Lyndale Avenue South RECEIVED %DOAESS: bibi @kenjarchoagency.com Bloomington, MN 55420 INSURER(S)AFFORDING COVERAGE NAIC# Ken Jarcho Agency INSU ERA: Midwest Family Mutual 23574 INSURED BJHaines Tree Service OLT 7 Ns ER B: Auto Owners 18988 DBA: Bonnie Haines INS RERC: 9264 Otchipwe Avenue N INS RERD: Stillwater, MN 55082 =Oak Park Heights INS RER E: — _PIN RERF: 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-AU-THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR AUUL S POLICY EFF POLICY EXP LTR TYPE OF INSURANCE N W SR VD POLICY NUMBER LIMITS (MM/DD/YYYY) (MM/DD/YYYY) GENERAL LIABILITY ACMN0560050612 04/01/2015 04/01/2016 EACH OCCURRENCE $ 1,000,000 DAMAGE IU HEN ItU X COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) $ 50,000 CLAIMS-MADE X OCCUR MED EXP(Any one person) $ 5,000 A X • PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GE 'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ i ncl uded POLICY PRO- JECT LOC $ AUTOMOBILE LIABILITY 4437063100 03/29/2015 03/29/2016 COMIBINEU (Ea accident)SINGLE LIMI $ 1,000,000 ANY AUTO BODILY INJURY(Per person) $ B ALL OWNED X SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS (Per accident) $ UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS LIAB CLAIMS-MADE CUMN0560050612 04/01/2015 04/01/2016 AGGREGATE $ X DED RETENTION$ 10,000 $ WORKERS COMPENSATION X WC STATU- 0TH- AND EMPLOYERS'LIABILITY TORY LIMITS ER B ANYICEEMEM ER EXCLNER/ XECUTIV- N/A 08026781 04/14/2015 04/14/2016 E.L.EACH ACCIDENT $ 500,000 (Mandatory in NH) I I E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 Equipment ACMN0560050612 04/01/2015 04/01/2016 $1,000 deductible, Special A including theft. 1 DESCRIPTION OF OPERATIONS/LOCATIONS/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 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE City of Oak Park Heights. b i 6-05J ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD