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HomeMy WebLinkAboutSt. Croix Tree Service CITY OF OAK PARK HEIGHTS w 3i.tv 14168 Oak Park Boulevard No. • P.O. Box 2007 • Oak Park Heights, MN 55082 -2007 • Phone: 651/439 -4439 • Fax: 651/439 -0574 No.: 2011 -00003 Licensee : ST. CROIX TREE SERVICE, INC. Date: 01/05/2011 675 GRUPE ST. ROBERTS, WI 54023 - License Expires : 12/31/2011 In accordance with provisions of the City of Oak Park Heights Ordinance(s), the above -named licensee is granted the following license(s): License Type : TREE WORKER TREE WORKER 30.00 Total Fee Paid 30.00 - NOT TRANSFERRABLE - This Certificate of License is hereby issued conditioned that said licensee shall comply with all the requirements set forth in the City Ordinances, pertinent Building Codes, and the laws of the State of Minnesota. A License issued under this Certificate may be suspended or revoked for violations thereof. Ju Q. Hultman, Planning & Code Enforcement Tree City U.S.A. 4 r nrr CITY OF OAK PARK HEIGHTS 14168 OAK PARK BOULEVARD - BOX 2007 OAK PARK HEIGHTS, MINNESOTA 55082 (651) 439 -4439 CITY OF OAK PARK HEIGHTS 2011 TREE WORKER'S LICENSE APPLICATION Date: i Firm or Business Name: S • CS b , \ 1-- , 1 f 5-e v C -e Type of tree work to be performed: \, , — `C `YY11M ■ In cj , ce o VcL1 S u t S LICENSE REQUIREMENTS ji • 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. Licenses held in nearby cities: Cv� • - Q 1v ` Q\ - 5 \■e,oC,4 Has your company ever had a license revoked in any other city? (YES) 0C1O If yes, where? LICENSE FEE: $30.00 5 � « -e Name of Business or Company COMPLETION OF THE WORKERS ( Q S+ COMPENSATION INSURANCE AND Business Street Address TAX I.D. FORMS IS REQUIRED BEFORE A LICENSE CAN BE ISSUED. 0 (A UTN 6\--A02.3 THE FORMS ARE ATTACHED. City State Zip Code LICENSE EXPIRES THE END OF_) k THE CALENDAR YEAR WITHIN Phone Number e WHICH APPLIED FOR OR UPON � j \ � C rcuo S}Cr b \* - -e se cQ `C EXPIRATION OF LIABILITY Email Address Lc) nt) INSURANCE OR WORKERS' COMP. COMPENSATION INSURANCE, WHICHEVER OCCURS FIRST. License No.: Date: 2,0 — 06 1 -5 -11 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 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: (C,'C 6 1`� 1 ��e e of C -P Y1� Business Address: C7 M S 0 d , - City State Zip Code Minnesota Tax Identification No.: ( If a Minnesota Tax Identification number is not required, please explain: 'Sr 1 Signature Title Date A CITY OF OAK PARK HEIGHTS 14168 OAK PARK BOULEVARD - BOX 2007 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): �(Y\ eAC `\ C Policy Number or Self- Insurance Permit Number: Dates of Coverage: \ \ -1 OR 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. • C \C b l SeJ vc Signature Business Nam Date: \� �� \ Business Address Telephone Number: ) - no-- 3� CITY OFOAK PARK HEIGHTS 14168 OAK PARK BOULEVARD- BOX 2007 OAK PARK HEIGHTS, MINNESOTA 55082 (651) 439 -4439 INDEMNIFICATION AGREEMENT To: The City of Oak Park Heights 14168 Oak Park Boulevard 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. /1-4IC110 By: Date Corporate Officer or Individual Proprietorship Owner Subscribed and sworn to before me this )C, day of of (140 . Y0 � C " t o ARy • * , Notary Public. 7. * • 7C • C 3 t County. l4 % A l/ BO ' y: My commission expires: C - 2 t ' a Z ' ���9 T F OF WIS,�" l hNHI %% ' • S:Shared /Forms /Arborist /Tree Worker's License Application Client #: 9406 STCROIXI ACORDTM CERTIFICATE OF LIABILITY INSURANCE DATE(MM /DD/YYYY) 12/03/2010 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Security Insurance Svcs., Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 3701 East Evergreen Dr, Ste 100 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR g ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Appleton, WI 54913 920 - 739 -3035 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A: General Casualty Company of WI St. Croix Tree Service, Inc. INSURER B: Amerisafe, Inc. 675 Grupe Street INSURER C: Roberts, WI 54023 INSURER D: INSURER E: COVERAGES 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD'L TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR INSRC DATE (MM /DDY) DATE (MM /DD/YY) A GENERAL LIABILITY CCI0417582 01/01/11 01/01/12 EACH OCCURRENCE $1, 000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISFS (RENTED Ea $100,000 I CLAIMS MADE © OCCUR MED EXP (Any one person) $5, PERSONAL & ADV INJURY $1,000, GENERAL AGGREGATE $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $1,000,000 n POLICY I� JECT F I LOC A AUTOMOBILE LIABILITY CBA0417582 01/01/11 01/01/12 COMBINED SINGLE LIMIT X ANY AUTO (Ea accident) $1,000,000 ALL OWNED AUTOS — BODILY INJURY SCHEDULED AUTOS (Per person) $ X HIRED AUTOS BODILY INJURY X NON -OWNED AUTOS (Per accident) $ X Comp Ded $250 PROPERTY DAMAGE CoII Ded $500 (Per accident) $ GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ A EXCESS /UMBRELLA LIABILITY CCU0417582 01/01/11 01/01/12 EACH OCCURRENCE $5,000,000 OCCUR n CLAIMS MADE AGGREGATE $5, 000,000 $ DEDUCTIBLE $ X RETENTION $ 10,000 $ B WORKERS COMPENSATION AND AVWCW11977512011 01/01/11 01/01/12 X I WC STATUS I IOFR TORY I IMITS EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $100,000 OFFICER/MEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE $100,000 If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $500,000 A OTHER Contr Equip CCI0417582 01/01/11 01/01/12 $347,715 w/$250 ded DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS Certificate holder is named as additional insured for general liability only, for work performed by the named insured. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION City of Oak Park Heights DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL Rrt DAYS WRITTEN 14168 Oak Park Blvd Box 2007 NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL Stillwater, MN 55082 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE cita,ad4.4 d .. ACORD 25 (2001/08) 1 of 2 #S207175/M207140 LRT 0 ACORD CORPORATION 1988 I. IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 254 (2001/08) 2 of 2 #S207175/M207140 MINNESOTA DEPARTMENT OF AGRICULTURE COMPLIANCE AGREEMENT 1. Name or Address of Person or Firm: 2. Location: Dennis UIIom St. Croix Tree Service, Inc. 675 Grupe St. Roberts, WI 54023 3. Regulated Article(s): Approved Establishment Inside Quarantined Area Handling Ash Lops. Lumber, Stumps. Roots, Limbs. Branches. Chips, Mulch and All Hardwood Firewood 4. Applicable Laws/Regulations: Emerald Ash Borer (Agrilus planipennis), MN Statutes 18G, 18J, 239 and the State of Minnesota EAB Interior Quarantine Section I. Agreement I/We agree to the following: St. Croix Tree Service, Inc. hereby enters into a Compliance Agreement with the Minnesota Department of Agriculture (MDA) under the provisions of the Emerald Ash Borer quarantine and agrees to handle regulated articles intrastate only as provided for on this Compliance Agreement. Section II. Conditions ❑ This establishment will not move regulated articles out of the quarantined area. If these practices change this establishment will contact Teresa McDill with MDA at 651- 201 -6448, before the change occurs to give notification and ensure adherence to the State Quarantine. r This stahlichmant wilLmnw Y treated (see subsection A.) regulated (circle all that appl ash logs umber, s roots, limbs, branches, chips, mul ood packing material (WPM), or hardwood firewood intrastate from a quarantined area. ❑ This establishment is located outside of a quarantine area and will accept untreated regulated (circle all that apply) ash logs, lumber, stumps, roots, limbs, branches, chips, mulch and /or hardwood firewood moved intrastate from a quarantined area only during the period of September 1 — April 30. This facility will ensure that ALL regulated material will be treated (see subsection A.) by April 30. Any untreated material remaining after April 30 will be considered a violation of this agreement. A. Treatment: This establishment will ensure that all regulated articles will be treated properly at the establishment's expense under the treatment option(s) below (circle all that apply): 1. Remove the bark and an additional'/ inch of wood. The bark and wood removed will be regulated separately. 2. Kiln Sterilization Treatment. The maximum thickness of allowable wood is three inches. See Attachment A -1. 3. Fumigate according to a treatment schedule. See Attachment A -2. 4. Heat Treatment. See Attachment A -3. 5. Produce mulch chips that comply with the Mulch and Chip Sampling Protocol provided in Attachment A-4. 6. Composting process as provided in Attachment A -5. o f s ieat Treatment in accordance with Regulated WPM treatment T404 -e-2. See Attachment A -6. (WPM only) hip untreated regulated articles to an approved receiving facility destination without stopping (except for refueling and traffic conditions) during the period of September 1 to April 30. (No shipments of untreated regulated articles are allowed during the period of May 1 to August 31.) If regulated items are present in violation of this agreement they will be immediately treated/disposed of under the MDA supervision using appropriate safeguards at the establishment's expense. B. Standard Operating Procedure: A standard operating procedure (SOP) must be prepared outlining the procedures to be used to meet state quarantine regulation requirements. The SOP will be attached as a part of this Compliance Agreement. See Attachment A -7. C. Out of State Product: If this establishment receives regulated ash material sourced from another state, or transports regulated articles to another state, additional stipulations will apply. Please contact local USDA APHIS PPQ office. D. Records: This establishment will maintain records of all shipments of regulated materials. Shipment and treatment records must be maintained for at least 36 months by this establishment and broker /supplier. All document requests will be filled within 96 hours of the initial request. 5. (contd) Section III. Inspection Authority The MDA retains the right to conduct unannounced inspections of regulated articles, monitor inspection procedures and examine shipment and treatment records at any time. Section IV. Failure to Comply If St. Croix Tree Service, Inc. fails to comply with the provisions of this Compliance Agreement and/or the Emerald Ash Borer Quarantine regulations, this Compliance Agreement may be canceled. Violations of Minnesota state regulations are subject to civil penalties of up to $7,500 per day of violation, the criminal penalties of misdemeanor, or both. (Minnesota Statutes Section 18J.10 and 18J.11 (2008).) Section V. Notification of Change The establishment must notify the local MDA offices in the event that: 1) the designated signatory individual in block 6 changes; 2) the applicant/company physically relocates; 3) the company name or ownership changes; or 4) any other event which may affect the handling of the regulated article occurs. Section VI. Agreement Validation This Compliance Agreement replaces and supersedes any other Compliance Agreements issued to St. Croix Tree Service, Inc. by the MDA for the handling of regulated articles described in box 3 above. Compliance Agreements are non - transferable to another location or another person. Signing below will validate this agreement, which shall remain in effect one year, but may be revised as necessary or revoked for noncompliance. 6. Signature 7. Name and Title (Please Print) 8. Date Signed cij 2) m"vS 4 Akil 1.4 /0/2-0 9. Agreement Number. 10. Date of Agreement RF -1419 M/2410 11. State Agency Official (Name, Title, Agency) 12. Address `( Geir Friisoe Minnesota Department of Agriculture Director, Plant Protection Division Plant Protection Division 4. Minnesota Department of Agricul - 625 Robert Street North, Saint Paul, MN 55155 13. Signature 14. Date In accordance with t eri . s h Disabilities Act, an alternative form of communication is available upon request. TTY:1- 800 -627 -3529.