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HomeMy WebLinkAboutYTS Companies LLC CONTRACTOR LICENSE APPLICATION City of Oak Park Heights 14168 Oak Park Blvd. N. P.O. Box 2007 Oak Park Heights, MN 55082 TELEPHONE: DIRECT:(651)351.1661 GENERAL:(651)439-4439—FAX:(651)439E-0574 Email:jhultman@cityofoakparkheights.com Business Name: l_,,1 S C m, ens 1US .1 Address: \l \ `�oeus YrNC1 , SS - Telephone: (1p12)' `3\- 113 Fax: ("\o ) E-mail Y.z:,}1ne LICENSE REQUIREMENTS • Fee based on trade. State license is required for residential general contracting, roofing, plumbing and fire protection. Mechanical Contractors require MN State Surety Bond. •Certificate of Insurance, minimum coverage,$100,000 per person, Public Liability;$250,000 per accident, Bodily Injury;and$100,000 Property Damage.CITY OF OAK PARK HEIGHTS MUST BE NAMED AS AN ADDITIONAL INSURED on this policy. •Agreement to hold 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 if required, by law,to be carried. •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. • License period:January 1 to December 31 of each year. Cancellation will occur upon failure to provided continued proof of insurance coverage. LICENSE CLASSIFICATIONS: Commercial General Contractor-$50 Blacktopping - $30 Heating, Ventilation&A/C -$30 Building Moving-$30 'hi Attach copy of MN Mechanical Bond Concrete and Masonry-$30 Outside Sewer&Water-$30 Excavating/Grading -$30 Siding -$30 Pool Installation -$30 Signs&Billboards-$30 Irrigation System Installation-$30 k Tree Worker:$30 COMPLETION OF THE WORKERS COMPENSATION INSURANCE ANDTAX I.D.FORMS IS REQUIRED BEFORE A LICENSE CAN BE ISSUED.THESE FORMS ARE ATTACHED AND MADE PART OF THIS APPUCATION. Office Use Only: Liability Insurance Expiration: JI►( I(o Worker's Comp. Insurance Expiration: Sig/ t(o Mechanical Surety Bond ID: Mechanical Surety Bond Expiration: LEAD ID& Expiration: — Date License Issued: )4, /l`5 No. C'/5 C C) UCENSE 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: City of Oak Park Heights License Period: Annual:January 1 through December 31 Personal Information: (Complete only if applicable) Applicant's Name: Ke_.°,- , Applicant's Add ss: 1`{3 C) Vl 'L c i rv,v-N SS3`1'F City D State Zip Code Social Security No.: Business information: (Complete only if applicable) Business Name: LA"T" C ,aw,�a,�•�,�� , j`C.. Business Address;, '`k tC) - '�o W. n SS3^1`�- City State Zip Code Minnesota Tax Identification No.: tc)15 `t4S Federal Tax Identification No.: 2:1 -9°t3 Y CAC) If a Minnesota Tax Identification number is not required, please explain: Date: 1.016 I t< SignatuDe: Title: Y', 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 Chapter 176. 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 retained within their files. This information is required by law. Licenses and permits to operate a business may not be issued 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$2,000 penalty assessed against the applicant by the Commissioner of the Department of Labor and Industry. 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 nsurance Agent): t e:�-c-v-n (A cry,0—(2_ iikAtzk52. . , Policy Number L -- 1 D% i s'i C 1 Dates of Coverage: S i t i S — 51111 t o - OR- I am not required to have Workers' Compensation Insurance because: (check one) ( ) I have no employees covered by law; ( ) I am self-insured (include permit to self-insure);or ( ) 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 t best of my knowledge,the information provided is true and correct. 4- • Date: l0(S1 t`f gnature Kiz_,\-\._ .,-k"2_0-r- Printed Name of Signature r?-4\--Q..Ak Cke-v----t Title/Position of Person Signing INDEMNIFICATION AGREEMENT To:City of Oak Park Heights 14168 Oak Park Boulevard, N. 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. 0 (6 By: C)L Dat= Corporate Officer or ividual Proprietorship Owner Subscribed and sworn to before me this / (-(h day of CT__k,h J , LC1 n � "fc JULIE A.HULTMAN L a A �`�c �-�r r,Q,,� , Notary Public. <� �� NOT f PI' t IC MIN ;��OTA l ����,,�,r: }u� County. My Co, 'oft- 31 My commission:eecpires: i - 31 c.2 c `y ` '11;,,te JUUE A.HULTMAN tip NOTARY PUBLIC•MINNESOTA : _} I Canmission Expires den.31.2020<' caf�.�J Updated:08-18-2015 Client#:7130 YETZTREI ACORDr. CERTIFICATE OF LIABILITY INSURANCE DATE(MMlDD1YYYY)70!05/2075 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 ICONTACT NAME: MN-COMMERCIAL LINES I PHONE612 349-2400 [�AXAIC ) 612 349 2490 (A/C,No,Ext): ---_ ___._. _ ... ......... ...... .._........ ,No COBB STRECKER DUNPHY&ZIMMERMANN I E-MAIL :ADDRESS: _ 150 S FIFTH ST STE 2800 INSURER(S)AFFORDING COVERAGE NAIC# MINNEAPOLIS,MN 55402 INSURER A:WESTERN NATIONAL MUTUAL INSURAN INSURED INSURER B: YTS COMPANIES LLC =— INSURER C: DBA YETZERS TREE SERVICE 14310 NORTHDALE BLVD !.INsuRER D ROGERS,MN 55374 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 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 J IADDL SUBRI POLICY EFF POLICY EXP . LIMITS LTR _.,.,_.TYPE OF INSURANCE INSR WVD ....._.____ POLICY NUMBER (MM.ODIYYYY) (MMMDD/YYYYj. A X COMMERCIAL GENERAL LIABILITY 1 CPP109040001 05/01/2015 05/01/2016 EACH OCCURRENCE $1,000,000 CLAIMS-MADE [__ I OCCUR DAMAGE TO RENTED X ,PREMISES(Ea occurrence) $300,000 X Contractual Liab Per MED EXP(Any one person) $10,000 X Policy Form and XCU PERSONAL&ADV INJURY $1,000,000...__....._._..._ GEN'L AGGREGATE LIMIT APPLIES PER - I GENERAL AGGREGATE $2,000,000 �POLICY I XI-JECT I ; ., ______.__ _.____ .__.•._...__. _.._____ _______-_-.- .___.__-_- PRODUCTS COMP/OP AGG $2,000,000 I OTHER._ PRO- LOC --1 COMBINED SINGLE LIMIT $ - -- _ - - A AUTOMOBILE LIABILITY CPP108942801 05/01/2015 05/01/2010,(Ea accident) 81,000,000 X ANY AUTO • BODILY INJURY(Per persona $ ALL OWNED I SCHEDULED I 1 BODILY INJURY(Per accident) $ ..___.....__ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ X HIRED AUTOS X AUTOSi(Per accident) A X UMBRELLA LIAB X OCCUR UMB101503201 05/01/2015 05/01/2016 EACH OCCURRENCE 4,000,000 --- EXCESSILIAB CLAIMS-MADE AGGREGATE $4,000,000 ................._......__DED....1XI RETENTION$10,000_----- —._...-----.__._........................................................_._....__......._...........................__. ...... _...._..1: $..._.._....._..__.._._.-_._..._._......_..__._.. WORKERS COMPENSATION ,—_—�,EATUTE._ FR A WCV101758901 05/01/2015 05/01/2016 X PER OTH- — — AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE!Y!N E.L.EACH ACCIDENT $500,000 OFFICER/MEMBER EXCLUDED? L----YI I N/ A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $500r 000 If yes,describe under ...._ _..._—. ........ _.._._ _...._ ........- DESCRIPTION OF OPERATIONS below I E.L.DISEASE-POLICY LIMIT $500,000 • DESCRIPTION OF OPERATIONS!LOCATIONS!VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) LICENSE/PERMIT REQUIREMENTS CERTIFICATE HOLDER • CANCELLATION Cit of Oak Park Heights SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Y g THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 14168 Oak Park Blvd N ACCORDANCE WITH THE POLICY PROVISIONS. Oak Park Heights,MN 55082 AUTHORIZED REPRESENTATIVE I ©1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014/01) 1 of 1 The ACORD name and logo are registered marks of ACORD #S748780/M707765 AMW