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Home My WebLink AboutNorthern Arborists - 26-11CITY OF OAK PARK HEIGHTS 1416E OAK PARK BOULEVARD N. -OAK PARK HEIGHTS, MINNESOTA (651) 439-4439 TREE WORKER'S LICENSE APPLICATI LICENSE REQUIREMENTS: RFc �r�yof ♦ 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 this12olicy. ♦ 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. ArAMP_N 'l bnr��S Business Name Business Mailing Address (05 1 — S a_ y — a� i% 0r Ckf, l7 r 5 bw-�-o. `� , r1 e Phone Number Email Address Type of tree work to be performed: bt' 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. LICENSE FEE: $50.00 Write Check Payable to: City of Oak Park Heights licenses wni oe maneu UPvn rssuan16c To Be Completed By City: License Number 2.0-- 11 Date Issued General Liability Expiration 2 Worker's Compensation Expiration 12- tJ 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 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 1rt 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: Nor—ic ayr\ Business Address: )DLA(oLi 10-VA S-�C+ N rr, o M N SSv I> City State Zip Code Minnesota Tax Identification No.: CII a lU a — Federal Tax Identification No.: ' C1 If a Minnesota Tax Identification number is not required, please explain: —V11VtWWVW'�,T-- ouy-A� I I - Zb - 7-IS-1 Signature Title Date Page 2 CITY OF OAK PARK HEIGHTS 14168 OAK PARK BOULEVARD N. OAK PARK HEIGHTS, MINNESOTA 55082 (651) 439-4439 PROOF OF WORKERS' CO PE T O INSURANCE COVERAGE 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 Industryto 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): U I C1 Policy Number or Self -Insurance Permit Number: G (Z. ISW G'I OOD y-1 / 1 Dates of Coverage: OR I 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. AUQr-:ffi ego Ar bon Sts U C Signature Business Name Date: I I ~ 2-Z Inia(0 j J!ikM Shy' Business Address Telephone Number: ((051) '391)— aj)[� Page 3 CITY OF OAK PARK HEIGHTS 14168 OAK PARK BOULEVARD N. OAK PARK HEIGHTS, MINNESOTA 55082 (651) 439-4439 INDEMNIFICATION AGREEMENT To: City of Oak Park Heights 14168 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/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. l(-'.� ( - aS By: i Date Corporate Officer or Individual Proprietorship Owner Subscribed and sworn to before me this day of lP / / (Notary Seal/Stamp) Notary Public. County. My commission expires: �54n �1 1 262.6 CARMEN CECILIAJIh4ENEZ NOTARY PUBLIC - P1II NESOTA My Commission Expires Jan. 31. 2026 Updated 11.07.23 Page 4 k I � � | � | � , � I} � � , � CL- m ccl ca � � 0 _ Va ru ru O O O ,a Er S & C13 ru � � 0 MIDEPARTMENT O F-(hitns:�r�� ww.t 1L�i a.statc 1nn.us) AGRICULTURE Licensing Information Search New Search-(default.isp). License Number:20256889 License Type: TREE CARE REGISTRY_ hitn; /Avwwnida.state-inn.us/1 icenses"lid= 116) Hiring a Tree Care CompaUlhltn://%vw� y.nida.state.mli.cis/hiringgireecarecompany.a. ). NAME 1ADDRESS1 ADDRESS2ICITY ISTATEZIP_ COUNTY PHONE:_RE_LATI_ONSWI: NORTHERN ARBORISTS LLCI10664 10TH STREET COURT NORTH ILAKE ELMONN J55042JWASHINGTON - REGISTRANT i License Period iNfTIAL DATE TARTS ENDS 01/01024 10110112026 1213112026 Categories CATEGORY ANOKA CHISAGO DAKOTA I_HENNEPiN RAMSEY V1IASHINGTON The data within this site is public information as defined in Minnesota %tatutes. Chanter 13 gyp://www.revisor.1 9.statc.Mri.us/stats/13J1(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. lip The International Society of Arboriculture �Hye-reby Announces That VGlil Welffeier Has Earned the Credential ISA Certified Arborist By successfully meeting ISA Certified Arborist certification requirements through demonstrated attainment of relevant competencies as supported by the ISA Credentialing Council � CrLI}a 14,ISikm CEO & Executive Dinctur 4 April 202-1 30 June 2628 %JN4945A Issue Date Expiraliun Date C aAifi auun Nlunber min 0 aw aunwv- Att.,d�uxon enura A C C R E D I T E D P S�eNEL CEFfeFICATgH 90T! kuXJ7 LM CndflA A,b-W ;a APPLICATION REVIEWED & ALL ITEM HAV EEN �.ECEIVED 2026 City of Oak Park Heights Tree Worker's License Application Checklist Company: V' y�►� �; Date Received: 1I ;-GL Date Reviewed: b-a ;Z CDC• -1545 t&c_ LA2025 Calendar -Year License Fee: $50.00 (Check payable to City of Oak Park Heights) Required 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 your company's registry. &c.e se_ ZU 2S�6 b''1 http-,//www2.mda.state.mn.us/webapo/lis/defau)t.isp Fertilizer and Commercial Pesticide Applicators Licenses. Attach a printout from the Minnesota Department of 7 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 oes not have a Fertilizer License or Licensed Commercial Pesticide Applicators, please indicate. "-f� http://www2.mda.state.mn.us/webapp/lis/cpestapp default.'s Ll, 1SA 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. 'be.,._ LJe-ii e , �,--- /U(A1 — q I cf :S-4 http://www.isa-arbor.com/findanarbor'ist/verify-aspx 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 ci ofoak arkhei hts.corri. NOTES/COMMENTS: Updated 11.12.25 _ 7 ® DATE (MM/DDlYYYY) A�a�o CERTIFICATE OF LIABILITY INSURANCEF 11/121202 5 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 NAME: Cheryl Busker Garry Insurancenter PHONE 651)777-8361 acC (651)777-1264 2555 7th Ave E ARr�. cbusker1ga insurance.com North Saint Paul, MN 55109 INSURERS AFFORDING COVERAGE NAIC# INSURER A: In-clipe Casually Company INSURED Iucnaca R • Inclina Insllrnnca Cmmnanv Northern Arborists LLC Lake Elmo Mn Lake Elmo, MN 55042 INSURER C : INSURER E : INSURER F : nnVFRAnPq CFRTIFICATF NIIMRFR• OnfillSfAR-0 REVISION NUMBER: 41 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. )NSR TYPE OF INSURANCE A D U R POLICY NUMBER POLICYEFF POLICY MWDD EXP LIMITS LTR A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE lFvlOCCUR GRBCP7001485-1 12/15/2025 12/15/2026 EACH OCCURRENCE $ 1,000,000 PREWSES EaE rre $ 300,000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 11000,000 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY ❑ PRO- JECT LOC OTHER: GENERAL AGGREGATE $ 2.000.000 PRODUCTS - COMP/OP AGG $ 2,000,000 $ B AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY X AUTOS HIRED NON -OWNED x AUTOS ONLY I x AUTOS ONLY CA7000595-1 12/1512025 12/15/2026 (EaCOMeB��ISINGLE LIMIT $ 1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY IN ANY PROPRIETOR/PARTNER/EXECUTIVE Y❑ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A GRBWC70004711 12115/2025 12/15/2026 X PETAR TLITE ER EL. EACH ACCIDENT $ 1002,000 E.L. DISEASE - EA EMPLOYEE $ 100,000 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) e'r-PTtCIf'ATF unt r1;=P f_ANr FI I ATIf)N SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Oak Park Heights THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 14168 Oak Park Blvd. N. AUTHORIZED REPRESENTATIVE Oak Park Heights, MN 55082 (CLB) U 19BB-ZU15 AGURD GURPURA] IUN. All rlgnts reserves. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD Printed by CLB on 11/12/2025 at 08:17AM