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HomeMy WebLinkAboutSavATree LLC - 26-01CITY OF OAK PARK HEIGHTS 14168OAK PARK BOULEVARD N. -OAK PARK HEIGHTS, MINNESO' (651)439-4439 TREE WORKER'S LICENSE APPLICATI LICENSE REQUIREMENTS: ♦ Please _make sure that ALL ITEMS on Page 5 are submitted with application. ♦ 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. LL Business Name Business Mailing Address Phone Number Email Address Type of tree work to be performed: Ov u rt Ivc. ►,C1I , hP- (Vt Gv Fully Completed Applications Are Required, Including Worker's Compensation Insurance & Tax ID forms. Licenses expire at the end of the calendar year or upon expiration of liability or worker's compensation insurance, if update updated certificate is not received in a timely manner — whichever occurs first. LICENSE FEE: $50.00 Write Check Payable to: City of Oak Park Heights Licenses Will Be Mailed Upon Issuance To Be Completed By City: License Number _ Date Issued Z� —L General Liability Expiration () —1 72 Worker's Compensation Expiration Page 1 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 orinterest; 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 I' through December 31") Personal Information: (Complete only if applicable) Applicant's Name: Applicant's Address: city State Zip Code Social Security No.: Business Information: (Complete only if applicable) Business Name: � L--�`— Business Address: q S-T) 4tj-� 7c�0 City -7 State Zip Code Minnesota Tax Identification No.: 0 -� C 3 l _--I Federal Tax Identification No.: 1 3 " 11-5 � � If a Minnesota Tax Identification number is not required, please explain. 1 _ Signature Title Date Page 2 CITY OF OAK PARK HEIGHTS 14168 OAK PARK QouLE m N. OAK PARK HEIGHTS, MINNESOTA 55082 (651) 439-4439 RitQ01` Df U+�OR�CERS' eomPl NSA71C3N INS�INCECOVERAG Minnesota Statue, Section 176.182, requires every state and local licensing agencyto 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): 1 : � Y . i , , y Z� Policy Number or Self -Insurance Permit Number.. lA/G I� [ - Q Dates of Coverage: _7s OR 1 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' Compensation coverage and hereby certify by my signature below that to the best of my knowledge, the information provided is true and correct. Signature Date: 4 I\) r Fry Business Name s �4 1--i.; sG4 i i d S Business Address Telephone Number: papa A CITY OF OAK PARK HEIGHTS 14169 OAK PARK BOULEVARD N. OAK PARK HEIGHTS, MINNESOTA 55082 (651) 439-4439 INDEMNIF"MT-1014 AGREEMENT To: City of Oak Park Heights 14268 Oak Park Boulevard 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/Permlt, 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 ' Igat on er this Contract/Permit, including but not limited to attorney fees and costs Vdurred relative to sucV claims and losses. Hate ien Y a`} Proprietorship Owner Qye0(A W (l'I'1nc�Cr1 Subscribed and sworn to before me this : � i day of-/uoVCW_bfz�.eloas . (Notary Seal/Stamp) Notary Public. :County. My commission expires: QC'a7} eil�, oZi3 CELESTE SMITH NOTARY PUBLIC -STATE OF NEW YORK No. 01SM4081995 Qualified In Westchester County My Commission Expires October 21, 20M Updated 11.0Z23 Page 4 GTY OF OAK PARK HEIGHTS 14168 OAK PARK BOULEVARD N. OAK PARK HEIGHTS, MINNESOTA SS082 (651) 439-4439 Tree Worker's License - Commercial License Addendum Calendar -Year License Fee: $50.00 Please make your check payable to City of Oak Park Heights. Required Documentation: 1. Tree Care Registry. Attach a printout from the Minnesota Department of Agriculture Website showing your company's Tree Care Registry (link provided below), or other proof of your company's registry. htt www2.mda.state.mn.us webs lis default.*[s;1 2. Fertilizer and Commercial Pesticide Applicators Licenses. Attach a printout from the Minnesota Department of Agriculture website (Fertilizer Companies with Commercial Pesticide Applicators Search- link provided below) showing your company's Fertilizer License No. and Licensed Commercial Pesticide Applicators, or other proof of your company's Fertilizer License and Licensed Commercial Pesticide Applicators. If your company does not have a Fertilizer License or Licensed Commercial Pesticide Applicators, please indicate. http,U!A w2.mda.state.mn.us/webappllis/cpestapp default.isp 3. ISA Certifications. Attach printouts from the International Society of Arboriculture website (link provided below) or copies showing each individual certified by the ISA and name the Certified Arborist(s) who will be directly supervising all work performed in the City. http //www,isa-arbor.com/findanarborist,/ye�.as rp 4. Certificate of Liability Insurance. Provide a certificate of insurance covering all operations for the sum of at least one million dollars ($1,000,000) liability for bodily injuries or death to more than one person from one accident and for at least one million dollars ($1,000,000) against liability for damage or destruction of property. Policy shall provide that it may not be canceled by the insurer except after ten (10) days written notice to the City. Certificate holder should be listed as City of Oak Park Heights,14168 Oak Park Blvd N, Oak Park Heights, MN 55082, jhultman@cityofoakparkheights.com. Updated 11.13.20I9 Page 5 y. CITY OF OAK PARK HEIGHTS 14168 OAK PARK BOULEVARD N. OAK PARK HEIGHTS, MINNESOTA 55082 (651)439-"39 Diseased Tree Care Treatment Notification Please provide this form to the City Arborist for treatment of any trees in the City of Oak Park Heights for the purpose of preventing or otherwise controlling the spread of disease. Make additional copies as necessary. Return form in person at City Hall or via email Ida nielson;H7cityofoakaarkheii,hts_com Business Name (including contact information): Property Address: Tree Information: Type of Tree Location on Property For City Arborist Use Date Reviewed: Signature: Comments: Size Treatment Method Chemicals Date of Used Proposed Treatments_ Page 6 v) a N 2 1 a ru 0 0 0 0 V rLj �u o" -. W m J Q x J Ln ni 0 i 3 —.J r MD E PA R T M E M T a F s,; I��.ti�+,msia_ tatc.tttn) I AGRICULTURE New Search ( a lt.j�jp) License Number.2O162272 License Type:TRFi_ CAR£ RWISTRY firms rr+�z4�c rn .xr mn +1' ?li =E l6) Hiring a Tree Care Company_(httpalwww.nlda.state.ntn.uc/hiringatreecarecompany.aspx) NAME IADDRESS1 +4jADDRESS2'CITY ISTATE]ZIP COUNTY PHONE RELATIONSHIP •SAVATREE LLC 8000 POWELL RD #160 HOPKINS ]MN 55343 HENNEPIN REGISTRANT •SAVATREE LLC 12450 HUDSON RD 1AFTON 1MN 155001 WASHINGTON— MAILING ADDRESS SAVATREE LLC 12450 HUDSON RD AFTON ]MN 55001 WASHINGTON — PHYSICAL LOCATION SAVATREE LLC 8430 SUNSET RD NE SPRING LAKE PARK MN 55432 ANOKA PHYSICAL LOCATION License Period INITIAL DATE'STARTS .ENDS ]01/16/2015 ;01101M26112f3112026 Categories CATEGORY ANOKA CARVER CHISAGO DAKOTA GOODHUE (HENNEPIN 1RAMSEY 1RICE SCOTT WASHINGTON WRIGHT The data within this site is public information as defined in \linncscta Statutes. Chapter 13 (http:-%*.%v%v.re� isrer.]rg.+taic.rimpos,Nums ] ). (Minnesota Government Data Practices Act). Information provided lists all individuals or companies who hold licenses, certificates, and/or permits required by state law and regulated by the Department. Additionally, LIS lists all companies who must register products with the Department before being used or sold in commercial channels within the state. Note: The data on this site is real time and therefore constantly changing. W W m � � ' o� J c z o R JW .Q E V N l�l a o N a LEb /yam YW1 ci -i x U� G li U7 Z ❑ W Q ❑ m a jyi7y C1 f -j �Z z ,`7� ? !fin �. _� n W •� LU Lu c J '}�rS LKL F Q:•s. W CL �N d aw Ulu9 o o f � r ix � a <a �� a w °ao LL a m �LO ���z z Z LU�2 z nZ Z Qzoo�j[ N Vfr Q Q NJ OD Q 9. • 0 fnQcoi N { 1 N m © Lei L eo cc o 0 r0 v W 0 0 a a _ F- W N � fad 7 J � ,r W V W U G9 z W Q J N a_ c«� om to LU W o Z W V 71Ljr{ir , SC o •Z Jycw� o W m > MQ J C;I �. 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CO a pp any n z aisp H LU Z � aui n$ W jZ'o"O °° h >zmLL y azaY N < 00Z0 N z c¢na�¢ aia8m W Q�K8o rL `° � > a m e g N z Qcci N R' Va1Q� N n c ,r 0 0 v fa n W 0 Name WI Cert. # WE License # MN License # 77837 90128 279807-CA 20138516 280567-CA 20142337 89115 287357-CA 20144880 105822 473060-CA 20197592 90099 1 91500 287354-CA 20144876 287353-CA 20244877 102709 322725-CA 20223746 50850 255747-CA 20109360 112273 504570-CA 20233906 43130 257558-CA 20126663 101708 321540-CA 20184929 109308 484775-CA 20211592 300028 498152-CA 20227675 71102 194005-CA 20160282 NA 20237443 NA 70238793 NA 20249230 NA 505568-CA 20146979 NA 506752-CA 20233911 NA 500249-CA 20224979 NA 20244466 NA 305958-RA 20163153 NA 508289-CA 20235838 NA 507613-CA 20234904 NA 515364 20238134 jenny *hies NA - 20247210 ISA Certifications Name Cert # Anton Anday WI-1367A Evan Anderson MN-4841A Mike Anderson W I-0946A Guy Carlson WI-1894A Matt Erdman WI-0956A Curtis Frandrup MN-4231A Mark Gondreau WI-0292A Scott Henke MN-0268A Travis Hunter WI-1368A Brandon Kenall WI-1318A Kent Lindahl WI-0619A Ryan Mack MN-4864A Katelyn Nelson WI-1575A Jake Olp WI-1341A Mike Pizzi MN-4892A Mike Sombrio MN-4043A APPLICATION REVIEWED & ALL ITEMS AV EEN RECEIVED �- - 2026 City of Oak Park Heights Tree Worker's license Application Checklist Company:.v, Date Received: ll Date Reviewed: it LL-L 6' 2025 Calendar -Year License Fee: $50.00 (Check payable to City of Oak Park Heights) Requirpd Documentation: Tree Care Registry. Attach a printout from the Minnesota Department of Agriculture Website showing your company's Tree Care Registry (link provided below), or other proof of our company's registry. http://www2.mda.state.mn.us/webapp/lis/default.isp 13 Fertilizer and Commercial Pesticide Applicators Licenses. Attach a printout from the Minnesota Department of Agriculture website (Fertilizer Companies with Commercial Pesticide Applicators Search- link provided below) showing your company's Fertilizer License No. and Licensed Commercial Pesticide Applicators, or other proof of your company's Fertilizer License and Licensed Commercial Pesticide Applicators. If your company does not have a Fertilizer License or Licensed Commercial Pesticide Applicators, please indicate. http-://www2.mda..state.mn.us/webapp/­lis/cpestapp default.os g ISA Certifications. Attach printouts from the International Society of Arboriculture website (link provided below) or copies showing each individual certified by the ISA and name the Certified Arborist(s) who will be directly supervising all work performed in the City. http:l/www.isa-arbor.com/findanarborist/­verify.aspx 19' Certificate of Liability Insurance. Provide a certificate of insurance covering all operations for the sum of at least one million dollars ($1,000,000) liability for bodily injuries or death to more than one person from one accident and for at least one million dollars ($1,000,000) against liability for damage or destruction of property. Policy shall provide that it may not be canceled by the insurer except after ten (10) days written notice to the City. Certificate holder should be listed as City of Oak Park Heights, 14168 Oak Park Blvd N, Oak Park Heights, MN 55082, ihultmanC@citvofoakQa_rkhei.-Lhts.com. NOTES/COMMENTS: Updated 11.12.25 !�to►ea� CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DDrfYYY) 6/27/2025 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. 1 IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or 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 NAME: Arthur J. Gallagher Risk Management Services, LLC Pk"k - FAX 300 Madison Ave 28th Floor IEO! L.w-e' e'I' - -- - - New York NY 10017 GGS.SevATreeC01@ajg.com _ INSURER(S) AFFORDING COVERAGE NAILS IwsuRERA: Everest National Insurance Company 10120 _ INSURED SAVALLC-01 INSURER8. Everest Denali Insurance Company_ 16044 SavATree, LLC IwaURERc: American Guarantee and Liability Ins Go_ 26247 550 Bedford Road Bedford Hills, NY 10507 _INSURERD: Lloyd's 5ynd 2791 ManagingAgnc Partners _ INSURER E : Great American Insurance Company 16891 INsuRERF: Everest Premier Insurance Company 16045 COVERAGES CERTIFICATE NUMBER: 1590908608 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 SUER POLICY EFF POLICY EXP LTR TYPE OF INSURANCE -ihYi v.v POLICYN MMMD YYY MMMblYYYY1 LIMBS A X COMMERCIAL GENERAL LIABILITY 'I, RM5GL00091-251 7/1I2025 7/1/2026 EACH OCCURRENCE 52,ODO,000 _ CLAIMS -MADE X OCCUR - PREMLSES Ea occurcence, $ 1AD0400 MED EXP (AN one person) $ 10.D00 PERSONAL 6 ADV INJURY $ 2,000,f100 GEN'LAGGREGATE LIMIT APPLIES PER: _ GENERAL AGGREGATE $4.00,00D POLICY I PEt° 7 LOC PRODUCTS - 60MP10 AOG $4,00000 - $ OTHER: B AUTOMOBILE LIABILITY RM5CA00082-251 7/112025 71112026 CC I E S LIMIT ' $2,000,000 B RM5CA00083-251 7/112025 711/2026 X ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED BODILY INJURY (Per accident)' $ AUTOS ONLY _ _ _ AUTOS HIRED NON -OWNED PROPERTY DAMAGE $ AUTOS ONLY -----.AUTOS ONLY- $ A X UMBRELLA LIAB X OCCUR XC4C000043-251 7/1/2025 7I1/2026 . EACH OCCURRENCE $5,00D.000 EXCESS LIAB CLAIMS -MADE AGGREGATE j$,{IDO,DOD QED X RETENTION $ + z ; F WORKERS COMPENSATION RM5WC00117.251 7/112025 7/1/2026 OTH- X PERSER7UTE-,_ ER F AND EMPLOYERS' LIABILITY YIN RM5WC00118-251 7/1/2025 7/1/2026 F ANYPROPRIETORiPARTNER!EXECUTIVE RM5WC00119-251 7/112025 71112026 E.i FhCJ! AC iDENT $1.000.DO0 OFFICE RIM E M B E R EXC LU D E D? F—N ] N / A'I (Mandatory In NH) 1 E.L. DISEASE - EA EMPLOYEE $1,0D0,000 II describe under DESCRIPTION OF OPERATIONS beroa E.L. DISEASE - POLICY LIMIT $1.000,000 C Excess Liebdity AEC 0178816-10 7/1)2025 7/1/2026 Each OcclAggregate $10.000,000 D Excess AuWohile Liability CD2500954 711)2025 I 71112027 Each OcclAggregate $31V1$6M E Pollutlon/Professional Liability PCM4884816-16 11/1/2024 { 111112026 I Each OcclAggregate $10.000,000 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) TEHOLDER City of Oak Park Heights 14158 Oak Park Blvd N Oak Park Heights MN 55082 USA 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. AUTttORRED r3EPRESENTATIVE l� ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD