The URL can be used to link to this page

Home My WebLink AboutM & S Tree Removal b ? PY CITY OF OAK PARK HEIGHTS 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 -00109 Licensee : M & S Tree Removal Date: 06/17/2011 1067 Nolan Ave. N. STILLWATER, MN 55082 - 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 ltman, Planning & Code Enforcement Tree City U.S.A. 3 t � , 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: 6 - [ 7 - / Firm or Business Name: / Tree I/ c ta.. Type of tree work to be performed: g', fa /0f/ii/A-40 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: Has your company ever had a license revoked in any other city? (YES) <� �'" If yes, where? LICENSE FEE: $30.00 / - {e Ze Name of Business or Company COMPLETION OF THE WORKERS /[fig 7 , (,t- AUK?, COMPENSATION INSURANCE AND Business Street Address TAX I.D. FORMS IS REQUIRED BEFORE A LICENSE CAN BE ISSUED. /ie/CJ THE FORMS ARE ATTACHED. City State Zip Code LICENSE EXPIRES THE END OF (eS I ) 3 THE CALENDAR YEAR WITHIN Phone Number WHICH APPLIED FOR OR UPON EXPIRATION OF LIABILITY Email Address INSURANCE OR WORKERS' COMP. COMPENSATION INSURANCE, WHICHEVER OCCURS FIRST. License No.TW: Date: A011 _1() f' - -II 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: /49‘7 /2 /4!/G ti 57 // wser &*2- City g State Zip Code Social Security No.: Z/7/-/ 7 - 30// Business Information: (Complete only if applicable) Business Name: /f' 5 7?ee i21ue -L Business Address: `i,47 /L t A) /De /C> 56 City �, . If a Minnesota Tax Identification number is not required, please explain: Ott/AA/6c 6 —/7—! f 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. Insurance Company (not the Insurance Agent): Policy Number or Self- Insurance Permit Number: Dates of Coverage: OR I am no quired 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. Siure Business Name Date:‘ / 7 Business Address C57 Telephone Number: ( ) 7-/X? 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. By: ."' Date Corporate Officer or Individual Proprietorship Owner Subscribed and sworn to before me this Ir day of a V 1 k! Notary Public. County. ti , JULIE A. HULTMAN �) �; _ NOTA PUBLIC - MINN My commission expires: 1 — 7j J — ( �1r1' MY mluronExpir.sJ�n. 3 015 S:Shared /Forms /Arborist/Tree Worker's License Application JUN -17 -2011 12:05 FROM: WAGNERINSURANCE 6517381554 TO:6514390574 P.1/1 A D " CERTIFICATE OF LIABILITY INSURANCE °"T" 08/172011 THIS CERTIFICATE 18 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEOATNELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(8), AUTHORIZED REPRESENTATIVE OR PRODUCER. AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the pollcy(les) must be endorsed. N SUBROGATION IS WAIVED, subject to the terms and conditions of fire 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 T. r Bruce Wegner Clair Wagner & Sons Insurance Agency, Ltd. PHONE (851)738 -1217 r�Att ales (851)738-1554 851)738 -1554 , aI,s.est.- uuc ...... . North . 608217th Street NorAOOtusst...__ _ . -. -. Oakdale, Mn 55128 INsUREn(et At1"ORDwe COVERAGE _._ _ RAC* RwVRRRA, West Bend Mutual Ins. Co. INSURID N10�1N RR P : M and S Tree Service IwsunuR c : __...... 1087 Nolan Ave. NO. iasuaaa D: Stillwater, Mn 55082 erwRaR a : _, , . INSURER P : , COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POUCIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REOUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR NAY PERTAIN, THE IN$URANCE AFFORDED BY THE POUCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. • ADat. SUER POLICY POLICY aXP MN TYPE OP INSURANCE ?Am wvn twYYO • POLICY NUWSEA luwn IMMENNYYM UNITE GENERAL UA&JTY EACH OCCURRENCE . _ _ $ 1,000,000.00 X COMMERCIAL GENERAL LIAItiuTY PREMI M' enast s 100.000.00 _ ] CWMS•MAD1 U el sew) MED EXP (Any Or) S 5,000.00 A NSN 1090792 02 0412212011 04/22/2012 pERSONAL 6 AoV INJURY $ 'I ,000 .000.00 GENERAL AGGREGATE $ 2,000,000.00 GENI. AGGREGATE LIMIT APPLIES PER. PRODUCTS - COMP /OP AGG t 2.000,000.00 7 POLICY n F n LOC AUTOMOSILE UAaLJTY COMBINED SINGLE .lEs.ts ntl.. 3 MY AUTO BODILY INJURY (Pa moon) S . _ AUTOS UYINEU SCHE ED UOOILY INJURY (Par accident) 1 NON-OWNED - FROFEN1Srlil itME -- - ........ HIRED AUTOS _ AUTOS /Par a R119nll _.. $ UMEREIU► UM OCCUR EACH OCCURRENCE S - — MESS %ME CAIMS•MADE AGGREGATE S DEO 1 RETENTIONS S wont ekS COirrsasSitON " ITA 1 I cal.'. _ ...... AND IBPLOYERa' LIABILITY ANY PROPRIETDR,PARTNERIEXECUT1VE Y E1. EACH ACCIDENT 3 _ ...`.. 0 OPPICERAIEYBER EXCI.I IDED II I A mandate" in Nil) E.L. DISEASE • EA EMPLOYEE 8 D Map OF „r DESCRIPTION O OPERATIONS helm EL DISEASE • POLICY LIMIT 1 DESCRIPTION Or OP$RAY10N0 / LOCAYION$1 VVNIGi ee (Aeaan AGGRO 101. AOI10snsI NamwM. earlaaaN, NNW* aPeaa N AARARD) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE City of Oak Perk Heights THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 14188 Oak Park 81vd ACCORDANCE NTH T E POLICY PRO1nSWNS. P.O. Box 2007 AUTMORIMI RaPRae erATIve Oak Park Helghb, Mn 55082 4 0 1.4.4..-CA-07 d 60 06 , -- vi... 4 -1 ACORD 25 (2010/05) m 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo ars registered marks of ACORD