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HomeMy WebLinkAboutWoodchuck Tree Care - 26-24CITY OF OAK PARK HEIGHTS 14168OAK PARK BOULEVARD N. - OAK PARK HEIGHTS, MINNESOTA 55082 (651) 439-4439 ,f* �46 TREE WORKER'S LICENSE APPLICATION ,o�` % 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 pursuantto 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. woodchadt- Business Name -731 D �UGt Business Mailing Address Phone Number Email Address Type of tree work to be performed: X&;'1.411 WZ f� fJ'E CJ Fully Completed Applications Are Required, Including Worker's Compensation Insurance & Tax ID forms. J 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 F $50.00 Write Check Payable to: ity of ark Heights Licenses Will Be Mailed Upon Issuance To Be Completed By City: License Number (0 — � Date Issued I � `►' '�f� General Liability Expiration ?) Worker's Compensation Expiration L�Y� Page 1 LICENSE APPLICANT: Pursuant to Minnesota Statute 270.072 Tax Clearance; Issuance of Licenses, the licensing authority is required to provide the Minnesota Commissioner of Revenue your Minnesota business tax identification number and the social security number of each license applicant. Under the Minnesota Government Data Practices Act and the Federal Privacy Act of 1974, we are required to advise you of the following regarding the use of this information: This information may be used to deny the issuance, renewal or transfer of your license in the event you owe the Minnesota Department of Revenue delinquent taxes, penalties or interest; 2. Upon receiving this information, the licensing authority will supply it only to the Minnesota Department of Revenue. However, under the Federal Exchange of Information Agreement the Department of Revenue may supply this information to the Internal Revenue Service. 3. Failure to supply this information may jeopardize or delay the processing of your licensing issuance or renewal application. Please provide the following information and return along with your application to the agency issuing the license. Do not return to the Department of Revenue. Licensing Authority: The City of Oak Park Heights License Renewal Date: Annually (January VY through December 315t) Personal Information: (Complete only if applicable) Applicant's Name: Applicant's Address: -2✓10 J� /R l l /L1 r1IOB"Z. City State Zip Code Social Security No.: �'/ Z - /-7' d 7& r Business Information: (Complete only if applicable) Business Name: WoodLhita(, -rye..o— et m Business Address: !�;&k City State Minnesota Tax Identification No.: 95,51 If S Federal Tax Identification No.: 'Yk— S'Z?o$:5`f If a Minnesota Tax Identification number is not required, please explain: re Title Zip Code zl; ?,) op, Date Page 2 t-- CITY OF OAK PARK HEIGHTS 14168 OAK PARK BOULEVARD N. OAK PARK HEIGHTS, MINNESOTA 55082 (651)439-4439 PROOF OF WORKERS' COMPENSATION I I)RANCE 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. � H'i � Insurance Company (not the Insurance Agent): t?�wl a h i ors b.0- Policy Number or Self -Insurance Permit Number: g �►�1GM�/33 �l Dates of Coverage: 0117,1,IM'S f O-7 �?-O 21-Sy 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. 5i ature Business Na Date: Business Address Telephone Number:) Page 3 CITY OF OAK PARK HEIGHTS 14168 OAK PARK BOULEVARD N. OAK PARK HEIGHTS, MINNESOTA 55082 (651)439-4439 INDEMNIFICATION AG EEMENT 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. By: Date Corpo to Officer or Indiy d I Proprietorship Owner Subscribed and sworn to before me this J1day of UtG1; -2 OZr� Notary Public. �f V(wk i v4--j m County. My commission expires: (Notary Seal/Stamp) PINSK' NUT�,RN- PUBLIC MINNE50101 �y Commisstia-"• ExDKes 1a1 ,2027 Updated 11.0Z23 Page 4 _DOCW__,_-_MEN _,_� « 00 7 K to @ 0 q d $ f - 2 m k 3 � ■ k § � q 0 0 2 Z I ca kf % cn �L MC'& O" O % ±2CL Ok�O � � � ru � � � A m ru -a O Ir m L%- O no M1DEPARTMENT OF(hUR7,71/www.ni(la.Statc.lnn.iL4I AGRICULTURE New Search ( fa ItjsP) License Number:20106295 License Type: TREE CARE REGISTRY (ht Hiring a Tree Care Company_(httl)://www.mdi.st;tle.mn.usiliirii gatreecarecompany.aspx) NAfAi E i III➢DR OCe AD➢RMS9 CW ATO ZIP COUNTY PHOIiE RELAii0ri8HIP VYQDnCHI]Ct( TREE ARE LLC �370 JDCEIYH RD N STILLWATER N 55082 WASWNW ONI REGfSTRANT License Period INITIAL DATE STARM ENDS 021437Yfl08 [O1fO1r&z6t12F3i12 Categories E The data within this site is public information as defined in Minnesota Statutes, er l� (httn7//www.revisorleg.state.mn.us/stats/13/) (http://www.revisor.leg.state.mn.us/stats/13/) (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. (http://wwwi (/home) (http://www.i sa- tcc-isa.com/) ((/home) ESr.uih-.- '- SEARCH TREES ter- ; , Ir. . ;. AREGOD� `r R.. About (https://www.treesaregood.org/about) Tree Owner Resources (https://www.treesaregood.org/treeowner) Education (https://www.treesaregood.org/home/education) Find an Arborist(https://www.treesaregood.org/findanarborist) Get Involved(https://www.treesaregood.org/getinvolved) Newsroom (https://www.treesaregood.org/newsroom) Shop (https://www.treesaregood.org/shop) About Home s� s: ak. a p cslTmcsflrcGnndnrg/11757263498750 (htt{}sl7vnvw.tressarega�g{ 'https://www.treesaregood.org/abo 11) ) Fled anAibOriS[_{fps://www.Ueesaregood.orglftndanatorist) Find an Arborist Canopy Partners(httpsJlvnnv.[reesare000d.oralfind8oerbarBVf ndansrtsodst) ;https://www.treesaregood.org/abo Tree Owner Resources ttps://www.treesaregood.org/tree ,Benefits of Trees Find an Arborist Sack to Search Results New Search Arborist Information Name: Planting a Tree Tyler Jacobson ps://www.treesaregood.org/tree ler/plantingatree) Company: Choosing the Right Tree Woodchuck Tree Care ps://www.treesaregood.org/tree ler/choosi ngtherigertttree) Address: Why Hire an Arborist? 7310 Jocelyn Road rs://www.treesaregood.org/ho Stillwater, MN 55082 tree-owner-resources/why- - UNITED STATES arborist) Phone: "Pruning Your Trees 651-429-7267 s //w"' .treesaregood.org/ho tree- w17er-i'@Sallrees/pruning- Email: r-trees) 1y ch C tr rn aiit ' er[a7wnndchuektree.com), Managing Tree Hazards and Risk ps://www.treesaregood.org/tree Plant Health Care Tree Owner's Manual s://www.treesaregood.org/triee Translated Brochures s://www.treesaregood.org/tree Education ips://www.treesaregood.org/ho Youth in Arboriculture s://www.treesaregood.oTg/ho ;duration/vouth-in- Tree Benefits s://www.treesaregood.org/ho Credentials ISA Certified Arborist® ISA Tree Risk Assessment Qualification Direct ]ink to this nrr201c ( o ' nx?TD=205261} Find an Arborist APPLICATION REVIEWED & ALL ITEMS H V EN RECEIVED M7 2026 City of Oak Park Heights Tree Worker's License Application Checklist Company: Date Received: 2 0 2—C Date Reviewed: ' + �,,2-G / 7 Lbd 2026 Calendar -Year License Fee: $50.00 (Check payable to City of Oak Park Heights) Require . 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 c mpany's registry. http://www2.mda.state.mn.us/webapp/lis/default.isp 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 of have r a Fertilizer License or Licensed Commercial Pesticide Applicators, please indicate,� - �1,cZ �V `'� r htt :./tvww2.mda.state.mn.us weba its c esta default.os ry M 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 rborrfist(s) who will be directly supervising all work performed in the City. http:l/www.isa-arbor.com/findanarborist(veri as x b 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. NOTES/COMMENTS: Updated 11.12.25 l 0 DATE (MM/DDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 12118/2025 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 Jenna Anderson Eagle Point Insurance Group, Inc. PHONE FAX 8665 Eagle Point Blvd. EMAIL t651 209.9330 [AfC,.No}; (651)209�9332 Lake Elmo, MN 55042 ARDRESS, jennaWi glepointins.aom License #: 40290913 INSURER(5) AFFORDING COVERAGE NAIC# INSURER A: West Bend Mutual 115350 INSURED Woodchuck Tree Care, LLC 7310 Jocelyn Rd N Stillwater, MN 55082-8324 INSURER C : INSURER E : nce 11-.— roDTrrlrAre A11111a92CD• nnnn99ii9_n RFVIRIAN NIIMRFR- d5 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 I ADDL SUBR POLICY EFF POLICY EXP I LIMITS LTR TYPE OF INSURANCE POLICY NUMBER MM/DD MMI A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE FxJ OCCUR B775450 08/27/2025 08/27/2026 I EACH OCCURRENCE $ 1,000,000 NTED PREMISES Ea occurrence $ 100,000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY JpCGTT LOC OTHER GENERAL AGGREGATE $ 2,000,000 PRODUCTS -COMP/OP AGG $ 2,000,000 $ A AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY X_ AUTOS HIRED I NON -OWNED X AUTOS ONLY X_' AUTOS ONLY B775450 08/27/2025 08/27/2026 (EaCI accdeOnsSING E LIMIT $ 1 000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAM GE (Per accidari $ A X UMBRELLA LIAB OCCUR EXCESS LIAB CLAIMS -MADE B775450 08/27/2025 08/27/2026 EACH OCCURRENCE $ 2,000,000 AGGREGATE $ 2,000,000 DED X RETENTION $ 10,000 $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y� OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A AVWCMN3394512025 07/26/2025 07/26/2026 PER OTH_ X STATUTE ER E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE - EA EMPLOYEE $ 500,000 E.L. DISEASE - POLI 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) rF:PTIFIf_ATF wni r1FR CANCELLATION City of Oak Park Heights PO BOX 2007 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. AUTF�g ED�I El�PRESE�N�TNE © 1988-2015 ACORD CORPORA I IUN. All rignts reservea. ACORD 25 (2016/03) The ACORD name and loao are reaistered marks of ACORD Printed by JLA on 12/18/2025 at 12:21 PM