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HomeMy WebLinkAboutS & S Tree Specialists RECpi YED CITY OF OAK PARK HEIGHTS • DEC 21 ?o 14168 OAK PARK BOULEVARD - BOX 2007 OAK PARK HEIGHTS, MINNESOTA 55082 (651) 439 -4439 CITY OF OAK PARK HEIGHTS 2012 • I TREE WORKER'S LICENSE APPLICATION Date: 1 Firm or Business Name: < � `J I S(C)2 pC( ICt \SSS Type of tree work to be performed: ? X 'I C.Q) 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: • ?CLK.1_1 Has your company ever had a license revoked in any other city? (YES) vii i If yes, where? LICENSE FEE: $30.00 v V vQZl ye cjka I - Name of Business or Company COMPLETION OF THE WORKERS 1 405 \* rcJ {'} ctrl % ► V �J COMPENSATION INSURANCE AND Business Street Address TAX I.D. FORMS IS REQUIRED BEFORE A LICENSE CAN BE ISSUED. S -U \ O( THE FORMS ARE ATTACHED. City State Zip Code LICENSE EXPIRES THE END OF ((2 3 ) (J — °69 THE CALENDAR YEAR WITHIN Phone Nu er WHICH APPLIED FOR OR UPON \ fl Ss-rye ./ • c owl EXPIRATION OF LIABILITY Email Ad ress INSURANCE OR WORKERS' COMP. COMPENSATION INSURANCE, WHICHEVER OCCURS FIRST. License No.TW: Date: 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 1st 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 ((t Business Address: Vt('kYc'( (Man l eji (t( _Cc-/ st. Pcit. t.1 m City State Zip Code Minnesota Tax Identification No.: 71 )o 'f c lg ) Federal Tax Identification No.: -1 - i g Z� If a Minnesota Tax Identification number is not required, please explain: Signature Title Date 4 � `: 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 i 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. i Provide•the 111formation skkified in the spaces provided, or certify the precise reason your business- excluded frbm,coinpliance with the insurance coverage requirement for ..... workei :S''compenL,ation.!°' . r, Insurance Company (nqt the Insurance Agent) � V.I I r (:)u1 I 1 _1Q/a ./ Policy Number or Self- Insurance Permit Number: PV wC 07 !V2 578 32 I Dates of Coverage: C 7/3 - 0/ I I — 9/3o/1 2- rt OR I am not required to have Workers' Compensation Insurance because: (check one) I have no employees covered by law ,Other ci r) ,_ ,, _., ,,,i m I-ha rea ar►d‘up d illy rights any. bligations with regards to business licenses, permits and Workers Corn • - sation coverage .,d hereby certify by my signature below that to the best of my knowl:dge, e informati v pi Tided is true and correct. / A _ . _ i ` 1�(.6b *CI a 1 i St Sign Business Name 435 `1C1 rd AP ftiV Date: \ 1 Ill 11 ?::1 - - - A j + I')'I iN 4 5'501S Business Address Telephone Number: 4360 4 7 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 it obligation under this Contract /Permit, including but not limi -d to i orney fees and c.. i incurred relative to such claims and losses. \ l M 2011 B / Date Corporate • ';Por Iw P . ie , ner F• :•`,¢ K ^" rI EMENTS - re ,, ': lnasota #2.4 31, 2013 Subscri orn to before ' me v this 11 day of NaVZPrro - 0) . 04161N1014140411* I'IOL Oil Mai + , Notary Public. :O County. KARLA J. CLEMENTS My commission expires: I/31/ do) 3 a Notary Public- Minnesota My COMMS111011 Expires .Ion 31, 2013 S:Shared /Forms /Arborist/Tree Worker's License Application • ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYY11 `.------ 10/04/2011 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 ( A/ t .EX}: 651- 4 -1758 (A/C, No): 651- 455 -3923 120 BRIDGEPOINT WAY, SUITE C EMAIL ADDRESS: Dee @shermanins.com SOUTH ST PAUL, MN 55075 -2498 INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Travelers INSURED 651- 451 -8907 INSURER B: Amer Inters. Ins. Co. S & S Tree & Horticultural Specialist Inc. INSURERC: 405 Hardman Ave. S. INSURER D: South St. Paul, MN 55075 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 TYPE OF INSURANCE ADDL wvo POLICY NUMBER (N W IY YY) (MMIDDIYYYY) UMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY CK08102876 09/30/2011 09/30/2012 PREMI DAMAGE Toccurrence) RENTED 100, 000 PREMISES (Ea occurrence) $ CLAIMS -MADE X OCCUR MED EXP (Any one person) $ 5,000 X Professional Liab. $1,000,000 PERSONAL &ADVINJURY $ 1,000,000 X Blkt Contractual Liability GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $ 2,000,000 X PRO LOC Professional Liab $ 1,000,000 POLICY IECT COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY (Ea accident) _s 1,000,000 A X ANY AUTO BA0112P622 09/30/2011 09/30/2012 BODILYINJURY(Perperson) $ ALL OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS AUTOS NON -0WNED PROPERTY DAMAGE $ X HIRED AUTOS X AUTOS (Per accident) $ Ownea Private Pa... 0vned Autos 0/T P... X UMBRELLA UAB X OCCUR EACH OCCURRENCE $ 2,000,000 A EXCESSUAB CLAIMS -MADE QK06503709 09/30/2011 09/30/2012 AGGREGATE $ 2,000,000 DED RETENTION $ $ WORKERS COMPENSATION x WC STATU- OTH- AND EMPLOYERS' UABIUTY OFFICER/MEM EREEXCLUDED ECUTIVE I E.L. EACH ACCIDENT $ 1,000,000 Y Y N TORY LIMITS ER B NIA AVWCMN2057832011 09/30/2011 09/30/2012 (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required) I CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Oak Park Heights ACCORDANCE WITH THE POLICY PROVISIONS. 14168 Oak Park Blvd N PO Box 2007 AUTHORIZED REPRESENTATIVE Oak Park Heights, MN 56357 A" 0.4.1T, CO 1988 -2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD Aco ® CERTIFICATE OF LIABILITY INSURANCE DATE(MM /DD/YYYY) 09/26/2012 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 , 651-451-1758 FAX (A/C, 651 - 455 -3923 120 BRIDGEPOINT WAY, SUITE C E - MAIL Laural @shermanins.com SOUTH ST PAUL, MN 55075 -2498 ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURERA: Travelers INSURED 651- 451 -8907 INSURERB: Amer Inters. Ins. Co. S & S Tree & Horticultural Specialist Inc. INSURERC: 405 Hardman Ave. S. INSURER D South Saint Paul, MN 55075 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP W LIMITS LTR INSR VD POLICY NUMBER (MM /DD/YYYY) (MM /DD/YYYY) GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY ZPP11 56 _ ` - 00/30/3012 09/30/2013 DAMAGE PREMISES (RENTED occurrence) $ 100,000 CLAIMS -MADE X OCCUR L ._. C E IV E D MED EXP (Any one person) $ 5,000 X Professional Liab. $1,000,000 PERSONAL &ADVINJURY $ 1,000,000 X Blkt Contractual Liability GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000 POLICY X jF% LOC Professional Liab $ 1,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1, 000, 000 (Ea accident) $ A X ANY AUTO BA011 P6Ry of Oak Park Heigbp$o/ 012 09/30/2013 BODILYINJURY(Perperson) $ ALL OWNED SCHEDULED AM PM AUTOS AUTOS BODILY INJURY (Per accident) $ NON -OWNED HIRED AUTOS X AUTO- NED PROPERTY DAMAGE S (Per accident) a+ea ei�aae Pa... a.ed Aims o/T P... $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 2,000,000 A EXCESSLIAB CLAIMS -MADE ZUP13T45177 09/30/2012 09/30/2013 AGGREGATE $ 2,000,000 DED RETENTION $ $ WORKERS COMPENSATION X WC STATU- OTH- AND EMPLOYERS' LIABILITY TORY LIMITS ER Y/N B ANY PROPRIETOR/PARTNER /EXECUTIVE E.L. EACH ACCIDENT $ 1,000,000 OFFICER /MEMBER EXCLUDED? Y N/A AVWCMN214872012 09/30/2012 09/30/2013 (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ 1,000,000 If yes, describe under - - .DESCPLPTtnN r)F OPERATIONS beloly 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 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Oak Park Heights ACCORDANCE WITH THE POLICY PROVISIONS. 14168 Oak Park Blvd N PO Box 2007 AUTHORIZED REPRESENTATIVE Oak Park Heights, MN 56357 I © 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD