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HomeMy WebLinkAboutVineland Tree Service - 26-23CITY OF OAK PARK HEIGHTS 14168OAK PARK BOULEVARD N. - OAK PARK HEIGHTS, MINNESOTA 55082 (651) 439-4439 TREE WORKER'S LICENSE APPLICATION 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. /I(� I Business Name aso� �1sN Business Mailing Address Cold- $ -7a - 0j 0S Phone Number Vo --,rees (Do, n el U nd, co cy) Email Address Type of tree work to be performed: (Lain i oo �vl (, 1 �1 0 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 C_it: ---' "f -- License Number Date Issued _f — General Liability Expiration JAN — 2 2026 Worker's Compensation Expiration 2A 151 City of Oak Park Heights PM API ��-- 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: 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; 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 1st through December 315Y) Personal Information: (Complete only if applicable) Applicant's Name: Applicant's Address: City Social Security No.: State Business Information: (Complete only if applicable) i Business Name: r'W\ — ' e ca— Business Address: 5o a� W n �1eQ Pol k S City Minnesota Tax Identification No.: (P g (9 rA"t L( State Federal Tax Identification No.: C90 - D If a Minnesota Tax Identification number is not required, please explain: Zip Code Zip Code a�- Page 2 CITY OF OAK PARK HEIGHTS 14168 OAK PARK BOULEVARD N. OAK PARK HEIGHTS, MINNESOTA 55082 (651) 439-4439 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 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):_ Policy Number or Self -Insurance Permit Number: V) UP a SG1 �� \ Dates of Coverage: 04151 - i -D-0 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, tir information provided is true and correct. /4nature Business Name 07 I .0 Lrn�a � Date: l� �D� !�I Iji�L` 0 Business Add ess _ Telephone Number: YZX 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. y Date Corporate Officer or Individual Proprietorship Owner Subscribed and sworn to before me this d-q day of V(t6MLr,(o��a5 (Notary Seal/Stamp) Notary Public. County. My commission expires: /� �3a NAOMI R. RODRIGUEZ Notary Public -Minnesota `r My Commission Expires Jan. 31, 2.030 Updated 11.07.23 Page 4 ALLIANCE BANK 18471 55 EAST FIFTH ST, SUITE 115 VINELAND TREE CARE ST. PAUL, MN 55101 2504 25th AVE. S. MINNEAPOLIS, MN 55406 75-121/919 612-872-0205 12/29/2025 s ORDER OF E City of Oak Park Heights _ $ —50.00 � Fifty and 00/100**"* DOLLARS - i City of Oak Park Heights 14168 Oak Park Blvd N Oak Park Heights, MN 55082°. MEMO lie 0W47LIi' 1:09190L2LSi: 229L781 4Mir VINELAND TREE CARE 18471 12/29/2025 City of Oak Park Heights Date Type Reference Original Amount Balance Due Payment 12/01/2025 Bill 50.00 50.00 50.00 Check Amount 50.00 Alliance Bank (1478) 50.00 ao cn Ln 2 u7 LO Fa- O w Z Z_ J D CL F 0 z F W LLI F cn w W m w U') co a w c0 •Q m a .0 zi S, Q ro a LLJ ro o � O � C .2 •� m C m N m � C3 Ck CD_ m y a o W _U — C L m C>gC 0 o��r M D LLJ E r u �_ 1 o U W o (o m W > m z u 2 c Qz J F a o Ll zZQ F�- N a Z N CD co c os co N ca 'a C co 'D N C N N '� (M 'Q C3 'Q W F U ❑ cc Co ❑ .2 i O Z wN> ? W o 1 I- W LL LU p Q �J D � Q 0�a. o W 0 V� u) 69 O Z M cn D Z W N Q a F OWW a-' o Z O W ZF— < O Z a W D O= o � D 0 2� o �gzCj C ZzZ�Q m 0 LLIW Z O � 5; WZZ�Z o Z p Ln z F>QN N Ix F>QN5i N LL' z 2 .J _0 Irlw d LL 0 F- z W d C ��y� LU ■ d O LU c) r z r- LLL m D ^.J J _Uy Lr V LL O f- Z LLJ 2 F- LL a IL 0 U3 us z Z a 0 z z 0 x �- J M U d Lr Z Z _cZ O IL C LU Z w U J Li Ll! N J i~ Wm -CC U Z tD n. 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Attach a printout from the Minnesota Department of Agriculture Website showing your company's Tree Care Registry (link provided below), or other proof of r3 f your ornpany''s registry. j .L http•/lwww2.mda.state.mn.us/webapp/iis/default.isp VFertilizer 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, pleilse indica http://www2.mda.state.mn.us/webapg/lis/cpestapp default.isp G �sL •Uvf �-..fie-�-; 7� ��- 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. .+tue-I C_. LJ--III-, "-� .� >J —Ll`f q 3 -13, -f- (6) http:/Iwww.isa-arbor.com/findanarbc)rist/veriN.asiox C-,"4 Zcertificate 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, ihultman ci ofoak arkhei hts.com. NOTES/COMMENTS: Updated 11.12.25 THEVINE-01 G AC'aR0° DATE(MMIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 8/13/2026 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 endorsements . , PRODUCER HONBackstory Insurance Group, LLC P 1C. r o, Ext): (612) 500-9916 FAX 801 Nicollet Mall Suite 1500 ( Minneapolis, MN 55402 AIL . chris-sirek_@backstoryinsurance.com INSURED Vineland Group Inc 2504 25th Ave S Minneapolis, MN 55406-1235 INSURER F : Insurance 4303 u OVERAGES 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. TYPE OF INSURANCE A I X I COMMERCIAL GENERAL LIABILITY CLAIMS -MADE ❑X OCCUR L AGGREGATE LIMIT APPLIES PER: POLICY ❑ jE& F ] LOC A AUTOMOBILE LIABILITY X ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOSSy� AUTOS ONLY AlU�T65 ONLv A 1 X I UMBRELLA LIAB M OCCUR Il�li EXCESS LIAB CLAIMS -MADE X DED I I RETENTION $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y I N ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ N / A ?pFICEREMBER EXCLUDED? (ManMIdatory In NH) If es, describe under nRORIPTION OF OPERATIONS below POLICY NUMBER 2115/2025 12/15/2026 LIMITS EACH OCCURRENCE S 1,000,000 DAMAGE To RENTED rencel $ 300,000 PR EMIMED EXP (AnX oneperson) S 10,000 PERSONAL & ADV INJURY S 1,000,000 GFNFRAI_ AGGREGATE S 2,000,000 2896278 12/15/2025 2/15/2026 BODILY INJURY BODILY INJURY UP2896280 2/15/2025 2/15/2026 2/15/2025 1 2/15/2026 E 5,000,000 5,000,000 1,000 1,000 1,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORO 101, Additional Remarks Schedule, may be attached If more space Is required) City of Oak Park Height is included as additional Insured on the general liability, where required by written contract or agreement, subject to policy terms and conditions. City of Oak Park Heights 14168 Oak Park Boulevard N Oak Park Heights, MN 55082 ACORD 25 (2016/03) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 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