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HomeMy WebLinkAboutCoolsys Light Commercial Solutions 26-10City of Oak Park Heights 14168 Oak Park Blvd. N. Oak Park Heights, MN 55082 TELEPHONE: DIRECT: (651) 351.1661 GENERAL: (651) 439-4439 — FAX: (651) 439-0574 Email: ihultman@cityofoakparkheights.com Business Name: Address: .?!, 14 Telephone: (%)) 3 71- 4 ] -2j2- Fax: E-mail ���� �►r� 5. LaYYN 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 - $50 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: / d - 1 -? 0 Worker's Comp. Insurance Expiration: ICJ ­/ Mechanical Surety Bond ID: o, Mechanical Surety Bond Expiration: - LEAD ID & Expiration: Date License Issued: �Z r No. 2-kO— 10 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 Address: City State Zip Code Social Security No.: Business Information: (Complete only if applicable) Business Name: Business Address: 11� LAYState Zip Code Minnesota Tax Identification No.: % 4 11 l0% Federal Tax Identification No.: '% ';.— 01% 0 261 If a Minnesota Tax Identification number is not required, please explain. Date: _� Signature:4j;49��{ Title: RJ 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. n Insurance Company (not the Insurance Policy Number Rai I V*4-C- D Q� Dates of Coverage: job - OR - I am not required to have Workers' Compensation Insurance because: (check one) have no employees covered by law; am self -insured (include permit to self -insure); or Other (specify) have read and understand my rights and obligations with regards to business licenses, permits a d War ers' Compensation coverage and hereby certify by my signature below that to best my kn edge, the information provided is true and correct. Date: " 0 ��0 Si nature Printed Name of Signature b c-e Yuk Title/Position of Per on Signing 01 Docusign Envelope ID: 93D6C533-2E43- 868-8991-732EA04039AC INDEMNIFICATION AGREEMENT To: City of Oak Park Heights 14168 Oak Park Boulevard, N. 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 Contractors 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 bruited to attomey fees and costs incurred relative to such claims and losses. 11/30/2025 Date Subscribed and sworn this day of A My commission expires: Updated 01-01-2018 before DocuSigned by: By. ��iw (,dursc,ln, C7irpe7rati Wirer or Individual Proprietorship Owner ,22.?,5,— _ Notary Public. County. 13-20__4 PATRtCiA fC FtRIEf,J. iVOTARY PUBLIC MINNESDTA R�yCammission Expires Jan, 31, 202p Minnesota Department of Labor and Industry Construction Codes and Licensing Division 443 Lafayette Road N Saint Paul, MN 55155 Coolsys Light Commercial Solutions LLC 21486 Humboldt Court Suite 100 Lakeville, MN 55044 NOTIFY US OF THESE CHANGES TO YOUR BUSINESS. Failure to do so may result in fines. 15-day notice requirement — Forms available at dll.mn.gov. • Change in business' physical address, mailing address, phone number or email address. • Change in control, owners, officers, directors, members or partners. • Change in business' legal name and/or assumed name. • Loss of or change in Responsible person, if applicable. • Change in general liability insurance or workers' compensation insurance coverage. YOUR CERTIFICATE 15 BELOW THE PERFORATION. MDEPARTMENT OF LABOR AND INDUSTRY Construction Codes and Licensing Division Website: www.dli.mn.gov Licensing and Certification Services Phone: 651-284-5034 Email: dli.license@state.mn.us Website: www.dii.mn.gov 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 SHOW CERTIFICATE WHEN OBTAINING PERMITS. MECHANICAL CONTRACTOR BOND Licensing and Certification Services 443 Lafayette Road N St. Paul, MN 55155 Email: dli license@staLe.mn,us Phone: 651.284-503a This is to certify that the certificate holder is registered as a MECHANICAL CONTRACTOR BOND in the state of Minnesota and is in compliance with Minnesota Statutes 326B.197, and has riled a S25,000 mechanical bond to perform gas, heating, ventilation, cooling, air conditioning, fuel burning, or refrigeration work in all areas of the state during the registration period; provided the work performed complies with the State Mechanical Code and the certificate holder maintains compliance with the required bond and workers' compensation laws. License: MECHANICAL CONTRACTOR BOND Number: MB782222 Coolsys Light Commercial Solutions LLC Effective date: 4/24/2025 21486 Humboldt Court Expiration date: 6/3/2027 Suite 100 Lakeville, MN 55044 � d DATE (MM/DDIYYYY) A CC CERTIFICATE OF LIABILITY INSURANCE 9/26/2025 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 CONTACT Howden US Specialty, LLC PHONE FAX 1350 Avenue of the Americas 646-s65 4930 Nn . 33rd Floor 9-MAIL _ New York NY 10019-4705 INRt1RFR1S1 AFFORnING COVERAGE NAIC tt INSURER A: Everest National Insurance Company 10120 INSURED GOOLINC-01 jNsuRERB: Everest Premier Insurance Company 16045 CoolSys Light Commercial Solutions, LLC 645 E Missouri Ave Suite 205 INsuRERc: Starr Indemnity 8 Liability Co 38318 Phoenix, AZ 85012-1334 INSURER o: Axis Surplus Insurance Company 26620 INSURER E: AXIS Surplus Insurance Company _ _ 26620 I1n11COAnrQ CERTIFICATE NIIMRFR• IIIrAGOQOQI RFVIRlnN 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 TYPE OF INSURANCE ADDL SUBR POLICY NUMBER lPSA0AILICI]pIrYEYY] 1NOM/LDi D CY EXP �T LIMITS 7INSD D X COMMERCIAL GENERAL LIABILITY P-00 1 -00 1757263 — 01 10/1/2025 10/1/2026 EACH OCCURRENCE s2,000,000 CLAIMS -MADE u OCCUR DAMAGE TO RENTED 6 $ 300.000 MED EXP An one erson $ 10,000 PERSONAL 8 ADV INJURY $ 2,000.000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $4,000,000 PRODUCTS - COMP/OP AGG s4,000,000 1 - - I [71 LOC POLICY JE� $ OTHER: A A AUTOMOBiLELwBILITY X ANY AUTO RMlCA00065-251 (AOS) RMlCA00066-251 (MA) 10/1/2025 10/1/2025 10/1/2026 10/1/2026 � D SINGLE LIMIT $5,000,000 BODILY INJURY (Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ X HIRED X NON -OWNED AUTOS ONLY AUTOS ONLY pROPERTYDAMAGE $ C X UM13RELLALIAB X OCCUR 1000586021251 10/1/2025 10/1/2026 EACH OCCURRENCE $10,000.000 AGGREGATE $ EXCESS LIAB CLAIMS -MADE $ DED RETENTIONS B B B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANYPROPRIETOR/PARTNER/EXECUTIVE RM1WC00075-251 AOS ( ) RM1WC00077-251 (FL,ME,NJ) RMlWC00076-251 (MA, WI) 10/1/2025 101112025 10/1/2025 10/1/2026 10/1/2026 10/1/2026 STATUTE ERH E.L. EACH ACCIDENT $1,000,000 OFFICER/MEMBEREXCLUDED? ❑ (Mandatory In NH) N/A E.L. DISEASE- EA EMPLOYEE $ 1,000.000 E.L. DISEASE - POLICY LIMIT $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E Contractors Professional and Pollution Liability CM005171-03-2024 i 10/1/2024 11/1l2025 Each Claim Retention $10,000,000 $75,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) City of Oak Park Heights is/are included as Additional Insured (except Workers' Compensation) where required by written contract. t1rK I11-IC-A I t r"LLi tK LHIW r_LLM I lVIY City of Oak Park Heights Attn: J Hultman 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 REPRESENTATIVE bl&4 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD