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HomeMy WebLinkAboutS & S Tree Specialists Inc. CITY OF , A OAK PARK HEIGHTS 14168 Oak Park Boulevard No. • P.0. Box 2007 • Oak Park Heights, MN 55082 -2007 • Phone: 651/439 -4439 • Fax: 651/439 -0574 No.: 2011 -00031 Licensee : S & S Tree Specialists Date: 01/19/2011 405 Hardman Ave. SOUTH ST PAUL, MN 55075 -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. Julie Hultman, Planning & Code Enforcement Tree City U.S.A. CITY OF OAK PARK HEIGHTS 14168 OAK PARK BOULEVARD - BOX 2007 OAK PARK HEIGHTS, MINNESOTA 55082 ` " `' I (651) 439 - 4439 CITY OF OAK PARK HEIGHTS 2011 nn II TREE WORKER'S LICENSE APPLICATION Date: • 2 k . • Firm or Business Name: y J \ V•P'P,) C (\ -1, t S4 Type of tree work to be performed: 4 S"e V Vt aJ 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: •. TCUAI Has your company ever had a license revoked in any other city? (YES) IUM If yes, where? LICENSE FEE: $30.00 ( 1 Y-e ,, e(t1t Name of Business o r oo mpany COMPLETION OF THE WORKERS "� 4UrrtMCUr\ COMPENSATION INSURANCE AND Business Street Address TAX I.D. FORMS IS REQUIRED r BEFORE A LICENSE CAN BE ISSUED. � V � THE FORMS ARE ATTACHED. City State Zip Code Q' � 0� LICENSE EXPIRES THE END OF (j& t) L • C7 THE CALENDAR YEAR WITHIN P,hon m/ r��/) WHICH APPLIED FOR OR UPON ` l 'I • 1. `--'� ' EXPIRATION OF LIABILITY Ema ddress INSURANCE OR WORKERS' COMP. COMPENSATION INSURANCE, WHICHEVER OCCURS FIRST. License No.TW: Date: awl- 14941 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: Business Address: i4CUrd, i r \ c/ N•Q City State Zip Code If a Minnesota Tax Identification number is not required, please explain: Signature Title Date 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 fa r - . mount of all claims, liens, expenses and claims for liens of work, tool, machinery, m.' -rials o insurance premiums and for the amount of all loss by reason of the failure of t (Ai to fully perform its obligation under this Contract /Permit, including but not i' d to attorney fees and costs incurred relative to such claims and losses. '�� ID By: f .. Date orpo ate Offic- • - - - :: er h p Owner•- Subscribed and sworn to before me this r1 day of j � _, )// (Notary Seal/Stamp) K74 (jy2?&'2/i , Notary Public. / ,1. KARLA .I rL EMENTS l fI k(i , County. *" Note ,c- Minnesota . My commission expires: 1/2// d " d / 3 \:„ s`` My Comm: __,;r Expires Jan 31,2013 S:Shared /Forms /Arborist /Tree Worker's License Application r , 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); - exi cc u \ J q ca l-e .e . Policy Number or Self-Insurance Permit Number: 4 N LM,N, 75 t 1 ` 200 Dates of Coverage: ot • . . OR 1 am not required to have Workers' Compensation Insurance because: (check one) I have no employees covered by law Other (specify): I have read and u erstand my rights Id obligations with regards to business licenses, permits and Worke s' C. pensation w r. : and hereby certify by my signature below that to the best of my kno led:r, the informmro 'rovided is true and correct. . 4 / ST L .1 ' ' i 0. Signature Bus ness N me (S rat-, , r - A1V Date: ' l—+ - I I (_ o- R4A NA\r` CCR Business Address Telephone Number: ( • A ° CG CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 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 CONTACT NAME: SHERMAN INSURANCE AGENCY, INC PHONE 6 51 - 451 -1758 120 BRIDGEPOINT WAY, SUITE C (A/C.No.Ext): (A/C, No): 651- 455 -3923 SOUTH ST PAUL, MN 55075 2498 ADDRESS: Dee @shermanins.com PRODUCER 1005222 CUSTOMER ID #: INSURED INSURER($) AFFORDING COVERAGE NAIC # INSURER A: Travelers 25674 S & S Tree & Horticultural Specialist Inc. INSURER B : American Interstate Insurance Co 31895 405 Hardman Ave. S. South St. Paul, MN 55075 INSURER C: INSURER D : INSURER E : 651- 451 -8907 INSURERF: 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 ADDL SUBR LTR TYPE OF INSURANCE INSR VD POLICY NUMBER ( MM /D D Y /Y YYY ) (M M/DD/ YYY Y W ) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY CK08102876 09/30/2010 09/30/2011 DAMAGE TO RENTED PREMISES (Ea occurrence) $ 100,000 CLAIMS -MADE X OCCUR MED EXP (Any one person) $ 5,000 X Professional Liab $1 mil PERSONAL & ADV INJURY _ $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 —1 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $ 2,000,000 POLICY n PRO - IFS•T LOC Professional Liab $ 1,000,00 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT A X ANY AUTO BA0112P622 09/30/2010 09/30/2011 (Ea accident) $ 1,000,000 ALL OWNED AUTOS BODILY INJURY (Per person) $ SCHEDULED AUTOS BODILY INJURY (Per accident) $ X HIRED AUTOS PROPERTY DAMAGE (Per accident) X NON -OWNED AUTOS $ Owned Private Pass. Autos $ X UMBRELLA LIAB X OCCUR A EXCESS LIAB EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE GL08102378 09/30/2010 09/30/2011 AGGREGATE $ 1,000,000 000 DEDUCTIBLE — — RETENTION $ WORKERS COMPENSATION $ AND EMPLOYERS' LIABILITY X WC STATU OTH- TORY LIMITS ER B ANY PROPRIETOR/PARTNER/EXECUTIVE Y/ N E.L. EACH ACCIDENT $ 1,000,000 OFFICER/MEMBEREXCLUDED? © FA N/A AVWCMN1856912009 09/30/2010 09/30/2011 (Mandatory in NH) If es, describe under E.L. DISEASE - EA EMPLOYEE $ 1,000,000 DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Oak Park Heights THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 14168 Oak Park Blvd N ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 2007 Oak Park Heights, MN 56357 AUTHORIZED REPRESENTATIVE ©1988 -2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD