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HomeMy WebLinkAboutWright Tree ServiceCITY OF O AK PARK HEI 14168 Oak Park Boulevard No. • P.O. Box 2007 • Oak Park Heights, MN 55082 -2007 • Phone: 651/439 -4439 • Fax: 651/439 -0574 Licensee WRIGHT TREE SERVICE INC 139 6TH ST. P.O. BOX 1718 W. DES MOINES, IA 50306 - License Expires 12/31/2011 No.: 2011 -00005 Date: 01 /05/2011 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 Total Fee Paid 30.00 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{'ie Hultman, Planning & Code Enforcement Tree City U.S.A. w 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 WORKERS LICENSE APPLICATION Date: I;l X I o Firm or Business Name: 'Lo '(la'` 06E- ery IY1C Type of tree work to be performed: A -d iN L41�° L Ao rct-- 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: CLU1 L,CI�-rX l 0 Has your company ever had a license revoked in any other city? (YES) O If yes, where? LICENSE FEE: $30.00 COMPLETION OF THE WORKERS COMPENSATION INSURANCE AND TAX I.D. FORMS IS REQUIRED BEFORE A LICENSE CAN BE ISSUED. THE FORMS ARE ATTACHED. LICENSE EXPIRES THE END OF THE CALENDAR YEAR WITHIN WHICH APPLIED FOR OR UPON EXPIRATION OF LIABILITY INSURANCE OR WORKERS' COMP. COMPENSATION INSURANCE, WHICHEVER OCCURS FIRST. Wrfdo' - - ize? C .a? P1 Id , 1 y1G Name oY Business or Company l— (I) w'1 ' r ;y Business Street Address (.), DQS rft(yQS, (A 50�Y� City State Zip Code Phone Np,mber Email s License NoAMJLQW� Date: <QEE?j9ZW 000 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 1 through December 31 Personal Information: (Complete only if applicable) Applicant's Name: Applicant's Address: Social Security No.: City State Zip Code Business Information: (Complete only if applicable) Business Name: Wr - Business Address: tie vvs City Federal Tax Identification No.: If a Minnesota Tax Identification number is not required, please explain: Signature Title (moo j�L) 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. Insurance Company (not the Insurance Agent): - �j��k— Policy Number or Self- Insurance Permit Number: 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 oblI %716;. bns vAtKel Sto, usl6` ss licenses, permits p g ensation coverage and he �� and Workers' Com . } �* rti h` ure below that to the best t�_Y y of my knowledge, the information provided is Signature Date: Bu Me e , 5 A �\11C's ( � Business Address Telephone Number: 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. I )--- L 0 B Date Subscribed and sworn to before me this day of I O . r or e Offic or Individual Proprietorship Owner No t a ry My commission expires: Qo mission Number 1649x116 * * My Commlegim Eris yaw► MARCH 20 2013 (Notary seaftamp) S:Shared /Forms /Arborist /Tree Worker's License Application ACO R N CERTIFICATE OF LIABILITY INSURANCE YYI� 09 /22 /201 09/22/2010 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 1- 612 - 333 -3323 CONTACT NAME: PHONE FAX A No Ext : AIC No): Hays Companies E -MAIL ADDRESS: 80 South Sth Street PRODUCER Suite 700 Minneapolis, MN 55402 CUSTOMER ID #: INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A: CONTINENTAL CAS CO 20443 INSURERB: AMERICAN CAS CO OF READING PA 20427 Wright Tree Service, Inc. INSURER C: TRANSPORTATION INS CO 20494 PO Box 1718 INSURER D: Des Moines, IA 50306 $ 15,000 PERSONAL & ADV INJURY $ 1,000,000 INSURER E : X BI /PD Ded. $350,000 INSURER F: COVERAGES CERTIFICATE NUMBER! 17472500 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 LTR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP POLICY NUMBER MM /DD MMIDD/YYYY LIMITS • GENERAL LIABILITY Oak Park Heights, MN 55082 GL4025754354 10 /01 /1 10 /01 /11 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurrence $ 100,000 CLAIMS -MADE a OCCUR MED EXP (Any one person) $ 15,000 PERSONAL & ADV INJURY $ 1,000,000 X BI /PD Ded. $350,000 GENERAL AGGREGATE $ 2,000,000 GEML AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 1,000,000 $ POLICY X PRO- LOC • AUTOMOBILE LIABILITY ANY AUTO BUA4025754368 10 /01 /1 10 /01 /11 COMBINED SINGLE LIMIT (Ea accident) $ 2,000,000 X BODILY INJURY (Per person) $ ALL OWNED AUTOS BODILY INJURY (Per accident) $ X SCHEDULED AUTOS HIRED AUTOS PROPERTY DAMAGE (Per accident) ( $ $ X NON -OWNED AUTOS X $ BI /PD Ded. $350,000 A UMBRELLALIAB X OCCUR L4017615770 10 /01 /1 10 /01 /11 EACH OCCURRENCE $ 20,000,000 AGGREGATE $ 20, 000, 000 EXCESS LIAB CLAIMS -MADE $ $ Xd DEDUCTIBLE RETENTION $ 10,000 B B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YIN WC425754337 WC425754306 (CA) 10 /01 /1 10 /01 /1 10/01/11 10 /01 /11 X WC LIMIT 0TH E.L. EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? F (Mandatory in NH) NIA E.L. DISEASE - EA EMPLOYEO $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000 C Wor ers Compensation WC425754323 10 01 1 10 01 it EL Each Accident 1,000,000 EL Disease -Ea EE 1,000,000 E Disease Pol Lmt 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) City of Oak Park Heights is an Additional Insured under the General Liability policy as required by contract. CERTIFICATE HOLDER CANCELLATION nhedberg ©1988 -2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD 17472500 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 Box 2007 AUTHORIZED REPRESENTATIVE Oak Park Heights, MN 55082 USA nhedberg ©1988 -2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD 17472500