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HomeMy WebLinkAboutNorthern Arborists CITY OF a 0 a ..ro OAK PARK HEIGHTS { _t 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 -00004 Licensee : NORTHERN ARBORISTS Date: 01/05/2011 10664 LOTH ST. CT. N. LAKE ELMO. MN 55042 -0000 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 d Hultman, Planning & Code Enforcement Tree City U.S.A. >4 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 r�n/ TREE WORKER'S LICENSE APPLICATION Date: Jac 2 ) Firm or Business Name: b ` . Ori Li , 440v-10e Type of tree work to be performed: rv • "( 4 w-Q- /I oova /(/'" 60 LICENSE REQUIREMENTS ♦ 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: �: ��G `f'JA.�^% Gisn,L &) / Has your company ever had a license revoked in any other city? (YES) ((N!.)-- If yes, where? �1 LICENSE FEE: $30.00 �O�T�+or... 1/14•0,4 d J Name of Business or Company` /�( COMPLETION OF THE WORKERS 1 464 0 \S� Vti L Q COMPENSATION INSURANCE AND Business Street Address TAX I.D. FORMS IS REQUIRED 611446 n, �� BEFORE A LICENSE CAN BE ISSUED. � �/fr C) y THE FORMS ARE ATTACHED. City State Zip Code LICENSE EXPIRES THE END OF (01 ) tt' Z b " (c3 6� THE CALENDAR YEAR WITHIN Phone Number WHICH APPLIED FOR OR UPON 1 C.4e6Ov`bt'h C- �9^MC� _ �T EXPIRATION OF LIABILITY Email Address INSURANCE OR WORKERS' COMP. COMPENSATION INSURANCE, WHICHEVER OCCURS FIRST. License No.12Y: Date: 2 - 600 I-5 41 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: 7 1 / 4 - 0^e : i e t , - A p p l i c a n t ' s Address: 1 0 6 CO Sri Ci-� Sro City State Zip Code Social Security No.: Business Information: (Complete only if applicable) \ Business Name: 1 - CL.v , �'y " Business Address: [ r�6Lac - 1 S � CL 74 City State Zip Code Minnesota Tax Identification No.: � Federal Tax Identification No.: (- (�- If a Minnesota Tax Identification number is not required, please explain: Signature Title Date 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. ^�-7 ' Insurance Company (not the Insurance Agent): 1 5 Policy Number or Self- Insurance Permit Number: 011A64146660-0n 7 '3 aZ 6 Dates of Coverage: (9470X /?-0/ U — 6314 '`6)2/0 1 6`r 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. Sig -ture Business O661. `O [ f Date: . ?')- X10 � � 6 a 4/ (4 573 ��- Business Address Telephone Number: ((, ��6- 67 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 Toss 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. fl, By: Date CorporaOfficer or Individual Proprietorship Owner Subscribed and sworn to before me this t 3 day of ei 2Z 2 6. (Notary Si/Stamp) P. Notary Public. IAA SL7 f k 1 Y7 County. � / ` No ARNIFE R P I My commission expires: ��l`�1l �.Z �yco rnnn. „ NN � A S t r an 1 (( S:Shared /Forms /Arborist /Tree Worker's License Application q5.p DATE (MM /DD/YYYY) R CERTIFICATE OF LIABILITY INSURANCE OP ID JH 12/08/10 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 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 wry Hit. I NAME: HU GARRY INSURANCENTER PHONE ( No, Ext): (A/C, No): 2555 East 7th Avenue ADDRESS: North St. Paul MN 55109 PRODUCER CUSTOMER ID #: NORTAR1 Phone: 651 - 777 -8361 INSURER(S) AFFORDING COVERAGE NAIC # INSURED INSURERA: Westfield Companies 24112 Northern Arborists INSURER B: Gary Wemeier dba 10604 - 10th St. Court N. INSURERC: Lake Elmo MN 55042 INSURER D : INSURER E : INSURER F : COVERAGES 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. INSR DL TYPE OF INSURANCE AU S W URF POLICY EFF POLICY EXP LIMITS LTR INSR VD POLICY NUMBER (MM /DD/YYYY) (MM /DD/YYYY) GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY CAG3615975 12/15/10 12/15/11 PREMISES (Ea occurrence) $ 100,000 CLAIMS -MADE X OCCUR MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $ 2 , 000 , 0 00 — 1 POLICY PRO- LOC $ JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ 500,000 A ANY AUTO CAG3615975 12/15/10 12/15/11 BODILY INJURY (Per person) $ ALL OWNED AUTOS BODILY INJURY (Per accident) $ X SCHEDULED AUTOS PROPERTY DAMAGE $ X HIRED AUTOS (Per accident) X NON -OWNED AUTOS $ UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE AGGREGATE $ _ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS' LIABILITY Y / N TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVS t N / A E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? I l (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) CERTIFICATE HOLDER CANCELLATION RECEIVED DEC 10 2010 OAKP001 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Oak Park Heights AUTHORIZED REPRESENTATIVE 14168 North 57th Street Jeanne Hartman Pak Park Heights lei 55082 © 1988-2009 ACORO.•CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORO Minnesota Workers' Compensation Assigned Risk Plan Standard Workers' Compensation and Employers' Liability Policy Contract Administrator: . RTW Inc. rev Carrier Number: 39579 P.O. Box 390901 A rD , ' Minneapolis, Minnesota 55439 -0901 1 f -J 1(3 1- 888 - 273 -9709 CERTIFICATE OF INSURANCE 1. — The Insured Policy Number: MNAR- 0000007232 -6 Gary Wemeier Association File Number: 1732951 DBA :Northern Arborists 10664 10th Street Court N Tax ID #: 411579312 Lake Elmo, MN 55042 UIC #: 2781128000 Policy Period: From 04/02/2010 To: 04/02/2011 Date of Mailing: 03/29/2010 The Certificate is issued as a matter of information only and confers no rights upon the Certificate Holder. This Certificate does not amend, extend or alter the coverage afforded by the Policy listed above. This is to certify that the Policy of Insurance described herein has 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 Policy described herein is subject to all the terms, exclusions and conditions of such Policy. TYPE OF INSURANCE LIMITS OF LIABILITY Part One Workers' Compensation Statutory Part Two Bodily Injury by Accident $100,000.00 each accident Employers' Liability Bodily Injury by Disease $500,000.00 policy limit Bodily Injury by Disease $100,000.00 each employee Should the above policy be canceled before the expiration date thereof, the Company will endeavor to mail 30 days written notice to the below named Certificate Holder, but failure to mail such notice shall impose no obligation or liability of any kind upon the Company. Sole Proprietor is excluded from coverage. Authorized Representative: , „! ., -_,,,,,, Agency Name and Address: Certificate Holder's Name and Address: Garry Insurancenter 2555 East 7th Avenue North St. Paul, MN 55109 City of Oak Park Heights 14168 North 57th Street Insured Name and Address: Oak Park Heights, MN 55082 Gary Wemeier 10664 10th Street Court N Lake Elmo, MN 55042 CertificateMNARP (7 -1 -2004)