Loading...
HomeMy WebLinkAboutRainbow Treecare 1 CONTRACTOR'S LICENSE APPLICATION • City of Oak Park Heights 14168 Oak Park Blvd. N. • P.O. Box 2007 - 007 Oak Park Heights, MN 55082 �� S TELEPHONE: DIRECT: (651) 351.1661 GENERAL: (651) 439 -4439 - FAX: (651) 439 -0574 Email: jhultman ©cityofoakparkheights.com Business Name: Pc t..1 (.,) Address: as v. T �JN I 14 Telephone: eIS:2) c 12-2-32. VD Fax: (%2.). 2-5 2- ( 4^1 - 2_0 E -mail GU`r sou` '429 e41e',P ell LICENSE REQUIREMENTS • Fee based on trade. State license is required for residential general contracting, roofing, plumbing and fire protection. Mechanical Contractors require MN State Surety Bond. • Certificate of Insurance, minimum coverage, $100,000 per person, Public Liability; $250,000 per accident, Bodily Injury; and $100,000 Property Damage. CITY OF OAK PARK HEIGHTS MUST BE NAMED AS AN ADDITIONAL INSURED on this policy. • Agreement to hold 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 if required, by law, to be carried. • 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. • License period: January 1 to December 31 of each year. Cancellation will occur upon failure to provided continued proof of insurance coverage. LICENSE CLASSIFICATIONS: Commercial General Contractor - $50 Blacktopping - $30 Heating, Ventilation & NC - $30 Building Moving -$30 **Attach copy of MN Mechanical Bond Concrete and Masonry - $30 Outside Sewer & Water -$30 Excavating /Grading - $30 Siding - $30 Pool Installation - $30 Signs & Billboards - $30 Irrigation System Installation - $30 J Other: $30 ' (�r. COMPLETION OF THE WORKERS COMPENSATION INSURANCE ANDTAX I.D. FORMS IS REQUIRED BEFORE A LICENSE CAN BE ISSUED. THESE FORMS ARE ATTACHED AND MADE PART OF THIS APPLICATION. Office Use Only: Liability Insurance Expiration: Co - I - / Worker's Comp, Insurance Expiration: (n- I - l / Y Mechanical Surety Bond ID : OP Mechanical Surety Bond Expiration: rJ A Date License Issued: I /j 1 IA No. 013 - O0OO7 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 Govemment 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: City of Oak Park Heights License Period: Annual: 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: l S l City ' State Zip Code t Minnesota Tax Identification No.: -t ?L132\ D Federal Tax Identification No.: ` ILA L 32�R, If a Minnesota Tax Identification number is not required, please,explain: Date: Signature: Title: �g, _1 . 1 ■. _ / • 0 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 Chapter 176. 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 retained within their files. This information is required by law. Licenses and permits to operate a business may not be issued 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 $2,000 penalty assessed against the applicant by the Commissioner of the Department of Labor and Industry. 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): iS Ita!, 1.-A111111 r. iv Gt_ 1A Policy Number U3 C,\..) VD O tc -1c Dates of Coverage: (p (1 ( 12 — (p 1 1 I 13 - OR- I am not required to have Workers' Compensation Insurance because: (check one) ( ) I have no employees covered by law; ( ) I am self- insured (include permit to self - insure); or ( ) 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 knowedge, he information pr aided is true and correct. Date: 1 ( I') l t2 - Signature 1 C k W4, �Ar Skant5/1A Printed Name of Signature Title /Position of Person Signing • INDEMNIFICATION AGREEMENT To: City of Oak Park Heights 14168 Oak Park Boulevard, N. 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 attomey fees and costs incurred relative to such claims and losses. Dat " ` I 1 By � Co to fficer or Individual Proprietorship Owner Subscribed and sworn to before me - 1 d of this � " y _thixtia., , Notary Public. County. My commission expires: d ,+ng+r t TODD ST ry SCHW Pubii A C RZROCK r ar State of Minnesot y1'* _* - M Comm Exp ires JCItWar 3 2015 S:Shared /F s & Pu ications/Contractor's License Application Updated: 01 -29 -2008 • RAINTRE OP ID: .i AC■RGE DATE (MM /DD/YYYY) .,.- CERTIFICATE OF LIABILITY INSURANCE 11/07/12 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 763 - 746 -8000 CONTACT • RJF Minneapolis PHONE FAX 7225 Northland Dr N #300 (A /C, No. Est): (A /C, No): Minneapolis, MN 55428 E -MAIL Greg Sandvig ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURER A : Western National Insurance 15337 INSURED Rainbow Treecare Scientific INSURER B : Advancements, Inc.; Rainbow Tree Company dba Rainbow INSURER C : Treecare; Rainbow Pest Experts INSURER D : 11571 K Tel Drive Minnetonka, MN 55343 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 LIMITS LTR INSR WVD POLICY NUMBER (MM/DD/YYYY) (MMIDD/YYYY) GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY CPP105916800 06/01/12 06/01/13 DAMAGE TO RENTED 200,000 PREMISES (Ea ocarrence) $ CLAIMS -MADE X OCCUR MED EXP (Any one person) $ 10,000 X BI /PD Ded $1,000 PERSONAL & PDV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $ 2,000,000 — 1 POLICY X PRO- ,IFS;T LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 (Ea accident) $ A X ANY AUTO CPP105916700 06/01 /12 06/01 /13 BODILY INJURY (Per person) $ ALL OWNED SCHEDULED BODILY INJURY (Per accident) $ AUOS AUTOS X H R AUTOS X NON -0WNED PROPERTY DAMAGE AUTOS (Per acadent) X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS LIAB CLAIMS -MADE UMB100963800 06/01/12 06/01/13 AGGREGATE $ 1,000,000 DED X RETENTION$ 10,000 $ WORKERS COMPENSATION X we STATU TH - O - AND EMPLOYERS' LIABILITY TORY LIMITS ER A ANY PROPRIETOR /PARTNER/EXECUTIVE / WCV100719400 06/01/12 06/01 /13 E.L. EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? N I N/A (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ 500,000 If yes, describe under _ DESCRIPTION OF OPERATIONS below - E.L. DISEASE - POLICY LIMIT , $ 500,000 A Leased /Rented CPP105916900 06/01/12 06/01/13 Limit 25,000 Equipment Deduct 500 DESCRIPTION OF OPERATIONS/LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) The City of Oak Pak Heights is General L Additional Insured on a primary and non - contributory basis when required by written contract or agreement. A Waiver of Subrogation applies in favor of the Additional Insured as respects General Liability when required by written contract or agreement. CERTIFICATE HOLDER CANCELLATION CITYOAK SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE ( of Oak Park Heights THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City g ACCORDANCE WITH THE POLICY PROVISIONS. 14168 Oak Park Boulevard Box 2007 AUTHORIZED REPRESENTATIVE Oak Park Heights, MN 55082 © 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD Xy - Client#: 15516 RAITR ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 6/03/2013 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: Jeanette Kraemer J. A. Price Agency, Inc. (NCN o, Ext): 952 944-8790 FAX 952 944-0097 6640 Shady Oak Road E - MAIL ADDRESS: Jmk@japrice.com (NC, No): Suite 500 INSURER(S) AFFORDING COVERAGE NAIC # Eden Prairie, MN 553444176 INSURER A: Western National Insurance Grp INSURED INSURER B : The Builders Group Rainbow Tree Company INSURER C : 11571 K - Tel Drive INSURER D : Minnetonka, MN 55343 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 INSR WVD POLICY NUMBER POLICY EFF POLICY EXP LIMITS (MM/DD/YYYI') (MM /DD/YYYI) A GENERAL LIABILITY CPP1059168 06/01/2013 06/01/2014 EACH OCCURRENCE $1,000,000 PR X COMMERCIAL GENERAL LIABILITY EMISES (Ea occu ence) $300,000 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 $2,000,000 7 POLICY n PRO- LOC $ I ^IJECT A AUTOMOBILE LIABILITY CPP1059167 06/01/2013 06/01/2014 (E° acddeDn SINGLE LIMIT $1,000,000 - X ANY AUTO BODILY INJURY (Per person) $ ALL OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS AUTOS X HIRED AUTOS X NON -OWNED PROPERTY DAMAGE AUTOS (Per accident) A x UMBRELLALIAB X OCCUR UMB1009638 06/01/2013 06/01/2014 EACH OCCURRENCE $1,000,000 EXCESS LIAB CLAIMS -MADE AGGREGATE $1,000,000 DED X RETENTION $10,000 $ B LIABILITY WORKERS COMPENSATION 010001740 06/01/2013 06/01/2014 X WC STAU- 0TH - AND EMPLOYERS' ABILITY TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N E.L. EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? N N / A (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 / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) Certificate holder included as additional insured on the general liability, including primary and non - contributory, if required by written c r CERTIFICATE HOLDER CANCELLATION City of Oak Park Heights THE SHOULD EXEXPIR DATE V THEREOF, E NOTICE IE WILL C BE DELIVERED N 14168 Oak Park Boulevard ACCORDANCE WITH THE POLICY PROVISIONS. Box 2007 Oak Park Heights, MN 55082 AUTHORIZED REPRESENTATIVE 4Z2 ©1988 -2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #S115387/M115314 JMK