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HomeMy WebLinkAboutSt. Croix Tree Service - O F " 1 VOaa79 } ' y j y CONTRACTOR'S LICENSE APPLICATION City of Oak Park Heights 9 14168 Oak Park Blvd. N. P.O. Box 2007 CItY of Oa:; Par; • � ;g<zis I Oak Park Heights, MN 55082 TELEPHONE: DIRECT: (651) 351.1661 GENERAL: (651) 439 -4439 - FAX: (651) 439 -0574 Email: jhultman @cityofoakparkheights.com Business Name: 5 ((O 1 /` o& ` c (v 1 to Address: (9 V ' tkiri & S 1 Telephone: ((p 4) `11 u 3 - y -I Fax: (1 f 5 1 - T. 34-f r0� E -mail S3611( l fl C 5f D I r V t z,c , CA'y 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 X Other: $30 TY W - b f 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: 1 - 1 - ' I&f Worker's Comp. Insurance Expiration: 1 - ) > jL Mechanical Surety Bond ID : G.3 A Mechanical Surety Bond Expiration: - tJP\ Date License Issued: 124 17 No. 2u1 ?, - 0000 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: C \U I X Tree- Se vv I i✓e C 1 Business Address: Ull & St C6be,(45 to 540 City ` + � State Zip Code Minnesota Tax Identification No.: n 1 �'`r� 1011 11 11 Federal Tax Identification No.: 2)61 - If a Minnesota Tax Identification number is not required, please explain: k -1 I t - - lam c )v r etA ) (Th a y'Vc.„(9,..., • 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): ( 5� S / M 1 (X-( Ill �f 61 V1(� C Policy Number WG NJ 0(9 c ) - 1 1 (o (P 1 Dates of Coverage: 2 (` (- - OR - 1 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 knowledge, the i • r•- : provided is true and correct. '\_/\ A\ 1 Date: U7- Signature Sir ��� ( \ Printed ame 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. 1 /1 2 -41P-- By: Date Corporate Officer or Individual Proprietorship Owner Subscribed and sworn to before me this 2I day of !V (ff.mbV , e LDO- . ( f J ,L ,&_41.4,&_41.44. , Notary Public. 4 t County. May A. Metzger My commission expires: r'�'1' (s! 13 Sta o Wisconsin S:Shared /Forms & Publications/Contractors License Application Updated: 01 -29 -2008 a ACORD CERTIFICATES INSURANCE' 430916 ' -': ;. DATE i2ol PRODUCER THIS CERTIFICATE IS ,ISSUED AS A MATTER OF INFORMATION 8'LORISTS' MUTUI L INSURANCE COMPANY ONLY AND CONFER NO RIGHTS UPON THE CERTIFICATE Mortice. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 41 Horticultural Lane ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P 0 Box 428 - ' Edwardsville, IL 62025 INSURERS AFFORDING COVERAGE _ NAIC # INSURED .INSURER A: PUN:I9TS' E90TQAL INSURANCE COMPANY 349-13978 St Croix Tree Service Ina INSURER B• 675 Grupe Street • Roberts, WI 54023 INSURERC: ( NSURER D: /' ' INSURER E: CQVER GES . ; : ; ; : :` : ; : : s : : 1 , c : ; : : . . ! . .'• - : : ' , I k l : °_:'•.:• -.::• 1 ' s •.•:.::_:::::c•::::•;....'• '. -.:.::' .: • .... :: .. - THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR Ti{E 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. 1NSR ADD'L • LINIR I POLICY EFFECTIVE PDUCY EXPIRATION LTR INSRD TYPE CIF INSURANCE 1 POLICYNUMBER - - - - DATe (flAMiBpIYY�LY} DATEINIUDDNYYY). S GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 x COMMERCIAL GENERAL LIAB1uTY BP 13127 01/01/2012 01/01/2013 I"M IEe 1 $ 1,000,000 A 1 CLAIMS MADE k x OCCUR 219 661 MED CXP (Any one person) $ 5,000 1i PERS0ML&ADVINJURY $ 1,000,000 • GENERAL AGGREGATE $ 2,000,000 OEN'L AGGREGATE UMIT APPLIES PER; PRODUCTS COMP/OP AGG $ 2,000,000 n PRo- LPOUCY I JECT I ILOC AUTOMOBILE LIABILITY COMBINED SINGLE UNIT (Eaecdden0 $ 1,000,000 X ANY AUTO ALL OWNED AUTOS BODILY INJURY $ A SCHEDULED AUTOS FMA 009091 01/01/2012 01/01/2013 (Perpeisan) X HIREDAUTOB 27.9661 BODILY INJURY $ X NON - OWNED AUTOS (Peraaddeng PROPERTY DAMAGE $ (Per sodden() s GARAGE LUIBII.ITY f a $ . I ANY AUTO ' " $ AUTO • C $ EXCESSI UMBRELLA LIABILITY EACH OCCURRENCE $ 5,000,000 OCCUR tCLAIMSMADE EZ 10336 02/01/2012 01/01/2013 AGGREGATE .$ 5,000,000 A 219661 —$ DEDUCTIBLE $ 1 RETENTION $ 10,000 A $ WORKERS COMPENSATION AND ! - � I TORY Limn ER We BTATU• OTH- R EMPLOYERS' UIILITY A. ANY PROPIETOR IPARTNERIEXECUTIVE WON 32669 01107.1201E 01/01/2013 E.LEACH ACtID£NT $ 500,000 OICERIMEMBE EXCLUDED? 219 6 61 E.LDISE.ASE- EAEMPLOYEE $ 500,000 ( Mandatory In NH� Ryes, describe under E.L DISEASE - POLICY LIMIT $ 500,000 OTHER A Peet:icide /Rerbiaide HP 13127 01/01/2012 01/01/2013 $1,000,000 Per Occurrence Applicator Coverage $2,000,000 Aggregate . ���I , TIDtt l�1 i /� OPER T ONS 1 OOOA 1 G TIONS1 VEHICLES 1 EXCLUSIONS ADDED BY ENDORSEMENT t SPE•3AL PROVISIONS ATTACHMENT • • CERTIFICATE HOLDER. RCTI . - .. 221884: CANCELLATION:.. •. ..:; . . . • ' • . • 61- �� \\ _ 3 SHOULD ANY 0P THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION i r k 1 - DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL. 30 DAYS WRITTEN HE NOTICE TO T CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL \' \A -e a \ s \-/-Ye .e-'4, l ` IMPOSE NO OBLIGATION OR LIABIUTY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. e W AUTHORIZED REPRESENTATIVE ' . . 6 e . H - I A . . EPRESENTATIVE • 6N-VN . a , • ACORD 25 2009101 ;;,' T24 - a 1988;2009 AGORD CORPORATIONt All A . his misread. • The ACORD name and logo are registered marks of ACORD \c l „ DATE (MM!DDIYYYY) A CoRO ® CERTIFICATE OF LIABILITY INSURANCE 4 02/26/2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS POLICIES CERTIFICATE DOES BELOW. THIS CERTIFICATE FOF�NS NEGATIVELY X T COVERAGE AFFORDED URANCE DOES NOTCO ST TUTEA CONTRACT BETW EN HE SSUING NSURER(S) 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). CONTACT PRODUCER 1 -800- 851 -7740 co NAME: Lisa Flournoy (Account 4219661) Florists' Mutual Insurance Company PHONE ExD; 800 - 851 -7740 ext 1955 1 ( p , Noy; 866-819-9256 Hor tic a E-MAIL 1 Horticultural Lane ADDRESS: 1 f lournoy®hortica insurance.com INSURERS) AFFORDING COVERAGE NAIC 9 Maguire Agency , IL 62025 INSURER FLORISTS NUT INS CO 13978 - ... ... -.— INSURED INSURER B : - -- St Croix Tree Service INSURER C: - — 675 Grupe Street INSURER D: _ - -- INSURER E : Roberts , WI 54023 INSURER F: COVERAGES CERTIFICATE NUMBER: 32162329 REVISION NUMBER: THIS IS TO THAT THE ND CATED.0 POLICIES NOTWITHSTAN ING ANYREQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER ABOVE HER DOC MENT WI H POLICY RESPECT TOW ICH 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. . .. _ ADDL SUER POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD LIMITS INSR POUCY NUMBER (MMIDDIYYYY) (MMIDOIYYYY) � A GENERAL LIABILITY BP13127 01 /01 /1- 01/01/14 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RANTED 1, 000, CLAIMS•MAOE rX N ERAL LIABILITY 000 X COMMERCIAL GENERAL , PREMISES Ea oc urrence , $ MED EXP (Any one person) $ 5, 000 OCCUR - -- PERSONAL & ADV INJURY $ 1,000,000 - GENERALAGGREOATE $ 2,000,000 ` PRODUCTS•COMP/OP $ 2.000,000 GEM. AGGREGATE LIMIT APPLIES PER: - $ POLICY J ECT LOC • 1 FMA009091 0 r1 ■ • COMBINED SINGLE LIMIT 1,000,000 A AUTOMOBILE LIABILITY Ea accident - $ .. .- ...— BODILY INJURY (Per person) $ X ANY AUTO ALL OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS AUTOS PROPERTY DAMAGE $ _Ter accident),_ HIRED AUTOS AUTOS $ A X UMBRELLALIAB X OCCUR 8X10336 01/01/1`. 01/01/14 EACH OCCURRENCE $ 5,000,000 EXCESS UAB 1 i CLAIMS -MADE AGGREGATE - $ 5,000,000 ii ` 10,000 $ OEO I X {RETENTION $ i WC S TATU - OTN A WORKERS COMPENSATION WCN3266 O1 /O1 /1_ 01/01/14 X]iORY I!MIT5 .. ER -. -- AND EMPLOYERS LIABILITY Y 1 N EACH ACCIDENT $ 500,000 ANY PROPRIETORIPARTNER/EXECUTIVE t 1 N 1 A E.L. EA A. OFFICER/MEMBER EXCWDED? E.L DISEASE - EA EMPLOYEE $ 500,000 _ (Mandatory In NH) 500,000 II es, de un der E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS below A Pesticide /Herbicide BP13127 01 /01 /1 01/01/14 Per Occurrence 1,000,000 Applicator Coverage Aggregate 2,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS (VEHICLES (Attach ACORD 101, Additional Remarks Schedule, H more space is required) Evidence of Insurance 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 ACCORDANCE WITH THE POLICY PROVISIONS. 14168 Oak Park Boulevard Box 2007 AUTHORIZED REPRESENTATIVE Stillwater, MN 55082 !rl +w+ m 14,110419 1 USA © 1988 -2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD . 1flournoy 32162329