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Home My WebLink AboutFireside Hearth & Home 26-07CONTRACTOR 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) 439-0574 Email: jhultman@cityofoakparkheights.com Business Name: Hearth & Home Technologies LLC dba Fireside Hearth & Home Address: 7571 215th Street W., Lakeville, MN 55044 Permit/inspect: 651-638-3321 Telephone: Admin; 612-900-9771 Fax: ( 952 ) 513-2113 E-mail Install/Inspect - roseville builder-ops@hnicorp.com Admin - LKV Staff Accounting@hearthnhome.com 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 p r 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 - $50 X Heating, Ventilation & A/C - $50 Building Moving -$50 *'` Attach copy of MN Mechanical Bond Concrete and Masonry - $50 Outside Sewer & Water -$50 Excavating/Grading - $50 Siding - $50 Pool Installation - $50 Signs & Billboards - $50 Irrigation System Installation - $50 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 APPLICATION. Office Use Only: Liability Insurance Expiration: _2_ Worker's Comp. Insurance Expiration: Mechanical Surety Bond ID: 01 Mechanical Surety Bond Expiration: LEAD ID & Expiration: ff Date License Issued; 1 Z 214� /Z No. 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: City of Oak Park Heights License Period: Annual: January 1 through December 31 Personal Information: (Complete only if applicable) Applicant's Name: Applicant's City Social Security No.: State Zip Code Business Information: (Complete only if applicable) Business Name: Hearth & Home Technologies LLC dba Fireside Hearth & Home Business Address: 7571 215th Street W. Lakeville MN 55044 City State Zip Code Minnesota Tax Identification No.: 4124682 Federal Tax Identification No.: 42-1161782 If a Minnesota Tax Identification number is not required, please explain: Date: 12/10/2025 Signature: { ' Title: Staff Accou nta n William J. Johnson 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. ZI((311,S-- Date By. 11 Car rate Officer or Individual Proprietorship Owner Subscribed and sworn to before me this } OM day of DeCfMV2a 2 026 46P j, . Notary Public. DQ� VCounty. My commission expires: JM VG.t�_ 3) . 2-D2- to Updated: 01-01-2018 ° �:F•,r KATY N GOMEZ NOTARY PUBLIC MINNESOTA My Commission Expires Jan 31 2026 Construction Codes and Licensing Division Licensing and Certification Services 443 Lafayette Road North St. Paul, MN 55155 E-mail: d1i. lizenseCcDstate.mn.us Website: www.dii.mn.gov Phone: (651) 284-5034 Print in ink or type DEPARTMENT OF Ll LABOR AND INDUSTRY Certificate of Compliance Minnesota Workers' Compensation Law This form must be completed by the business license applicant. Minnesota Statutes § 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 Minn. Stat. chapter 176. If the required information is not provided er is falsely stated, it shall result in a $2,000 penalty assessed against the applicant by the commissioner of the Department of Labor and Industry. A valid workers' compensation policy must be kept in effect at all times by employers as required by law. License or certificate number (if applicable) Business telephone number Alternate telephone number 1612-900-9771 Business name (Provide the legal name of the business entity. If the business is a sale proprietor or partnership, provide the owner's name($), for example John Doe, or John Doe and Jane Doe.) Hearth & Home Technologies LLC DBA ("doing business as" or "also known as" an assumed name), if applicable Fireside Hearth & Home Business address (mast be physical street address, no P.C. boxes) City State ZIP code 7571 215th Street W. Lakeville MN 155044 County Email address Dakota LKV—Staff.Accounting@hearthnhome.com You must complete number 1 or 2 below. Note: You must resubmit this form to the authority issuing your license if any of the information you have provided changes. 1.0 1 have a workers' compensation insurance policy. Insurance company name (not the insurance agent) Arch Insurance Company Policy number Effective date Expiration date 41 WCX1010107 107/01/2025 107/01/2026 ❑ I am self -insured for workers' compensation. (Attach a copy of the authorization to self -insure from the Minnesota Department of Commerce.) 2. 1 am not required to have workers' compensation insurance because: ❑ I only use independent contractors and do not have employees. (See Minn. Stat. § 176.043 fortrucking and messenger courier industries; Minn. Stat. § 181.723, subd. 4, for building construction; and Minnesota Rules chapter 5224 for other industries.) ❑ I do not use independent contractors and have no employees. (See Minn. Stat. § 176.011, subd. 9, for the definition of an employee.) ❑ I use independent contractors and I have employees who are not required to be covered by the workers' compensation law. (Explain below.) ❑ I only have employees who are not required to be covered by the workers' compensation law. (Explain below.) (See Minn. Stat. § 176.041 for a list of excluded employees.) Explain why your employees are not required to be covered certify the m ormaton t is arm is accurate and compete. If I am signing on behalt ot a business, I ceffify I am authorized to sign on behalf of the business. Print name William J. Johnson Applic s ture (r rr I,Title Date Staff Accountant 19/10/2025 If you have questions bout completing this form or to request this form in Braille, large print or audio. Certificate of Compliance MN Workers' Compensation Law 8.1.2024 Minnesota Department of Labor and Industry Construction Codes and Licensing Division 443 Lafayette Road N Saint Paul, MN 55155 NOTICES NOT TRANSFERABLE IF YOU CHANGE YOUR BUSINESS STRUCTURE, YOU MUST OBTAIN A LICENSE FOR NEW ENTITY WHEN YOU RENEW OR REPLACE INSURANCE POLICY,, PLEASE SUBMIT NEW CERTIFICATE OF INSURANCE NOTIFY;'US OF THESE CHANGES TO YOUR BUSINESS. Failure to do so may result";in fines. Licensing and Certification Services Phone: 651-284-5034 Email: dii.license@state.mn.us Website: www.dii.mn.gov HEARTH & HOME TECHNOLOGIES LLC MA FIRESIDE HEARTH & HOYE 7571 215TH STREET W LAKEVILLE, MN 55044 15-day notice requirement— Forms availabW6f illi.mn.gov. • Change:in business' physical address, rnailln :address, phone number or email address. • Change In control, owner% officers, directcws ;members or partners. • Change In business' legal name and/or assumed name. • Loss of or change in . Responsible Individual - • Change in general liability Insurance or workers' compensation Insurance coverage: YOUR CERTIFICATE IS BELOW THE PERFORATION. MDEPARTMENT OF LABOR AND INDUSTRY ' Construction Codes and Licensing Division Webslte: www.dll rhn.gov ' vg VS. SHOW CERTIFICATE WHEN OBTAINING PERMITS. 3 wnW 2@ MECHANICAL CONTRACTOR BONS Ucensing and Certification Services 443 Lafayette Road N St. Paul, MN 55155 Email: dliaicenseoista[e:mn.LL. Phone: 651-284-5034 Td'is is to certify that the certificate holder is registered as a MECHANICAL CON TRACTOR, BOND in the state of Minnesota and is in compliance with Minnesota Statutes 32613.197, and has filed a $25,000 mechanical bond to perform gas, heating, ventilation, cooling, air conditioning, fuel burning, or refrigeration work-in all areas ot the state, during the registration period; provided the work perfonmd_eomplies with the State Mechanical Code and tKe'eei•tificate hoidu rriaintains-caiiipliance with the required bond and workers' aanl isa ion Ij1W s-z.=" 1 4 Registration MECHANICAL CONTRACTOR BOND L� RegNumber: MB662572 HEARTH & HOME TECHNOLOGIES LLC-. I B Effective date: 06/26/2024 DBA FIRESIDE HEARTH & HOME L Expiration date: 07/01/2026 7571 215TH STREET W o T LAKEVILLE, MN 55044 1 ��• � Corr C�R 1 0 CERTIFICATE OF LIABILITY INSURANCE 7/1/2026 1 DATE (MMIDD/YYYY) 6/26/2025 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. 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 Lockton Companies, LLC 444 W. 47th St., Ste. 900 Kansas City MO 64112-1906 (816) 960-9000 kcasu@lockton.com NTACT CONAAME PHONE FAX C No : E-MAIL D s: INSURER(S) AFFORDING COVERAGE NAIC# 7L INSURER A: Ch InsUrance CompaU 11150 INSURED HEARTH & HOME TECHNOLOGIES LLC, 1062840 DB/A FIRESIDE HEARTH & HOME, INSURER B : Arch Indemnity Insurance Com aLi 30830 INSURER C : ACE Property and Casualty Insurance Company 20699 INSURER D : HNI CORPORATION, PARENT INSURER E 600 E. 2ND STREET MUSCATINE IA 52761 INSURER F COVERAGES CERTIFICATE NUMBER: 13279192 REVISION NUMBER: xXXXxxx 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 LTH TYPE OF INSURANCE POLICY NUMBER POLTCY EFF MMIDD/YYYY POLICY EXP MM/DD/YYYY LIMITS A A COMMERCIAL GENERAL LIABILITY CLAIMS -MADE U OCCUR $250,000 DED N N 41GPP1010207(PREMISES) 41GPPI010307 (PRODUCTS) 7/1/2025 7/1/2025 7/1/2026 7/1/2026 EACH OCCURRENCE S 1,000,000 DAMAGE TO RENTED PRawsm rEao_Crurrance S 1,000,000 X MED EXP (Any one person) S 1 Q 0.00 X PROD/COMPOPS $2M SIR PERSONAL & ADV INJURY S 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: RPOLICY ❑X PpROT- �X LOC X OTHER, CONTRACTUAL LIAR. GENERAL AGGREGATE S 2.0000.00 PRODUCTS -COMP/OP AGG I S 4.000 OOO I s A A AUTOMOBILE LIABILITY x ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY x 'Ssoo,00a D1;>� N N 41CABI010607 41CAB1010607 7/1/2025 7/1/2025 7/1/2026 7/1/2026 • MBINED IN GIE L1M Eae dent s 2,000,000 BODILY INJURY (Per person) S XXXXXXX BODILY INJURY (Per accident) S YX=XYX PROPERTY DAMAGE Per S XXXXXXX s x=xxX ANUMBRELLA CEXCESS LIAB LIAR �' OCCUR CLAIMS -MADE N N 41UFP1055007 (S5M) XEU G49348873 001 (S1OM) 7/1/2025 7/1/2025 7/1/2026 7/1/2026 EACH OCCURRENCE S 15,000,000 AGGREGATE S 15,000,000 DED I I RETENTION S SxxxXxxx A $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY v/N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED? ❑N (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A N 41WCX1010107 (GA + IA) 44WCI1010007 AOS ( ) 7/1/2025 7/1/2025 7/1/2026 7/1/2026 PER OTH- x sTnTuT E.L. EACH ACCIDENT S 1.000.000 EL, DISEASE - EA EMPLOYEE S 1.000 000 E.L. DISEASE -POLICY LIMIT S j QQQ,000 T, DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Ut:K 1 IFII:A I t PIULUtK I IV IV 13279192 CITY OF OAK PARK HEIGHTS 14168 OAK PARK BLVD N OAK PARK HEIGHTS MN 55082 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 REPRESENTA m n 1�,�nl5 ACORD CORPORATION_ All rights reserved ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD