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Home My WebLink AboutM & S Tree Removal ( 1-139- or CITY OF OAK PARK HEIGHTS 14168 OAK PARK BOULEVARD - BOX 2007 OAK PARK HEIGHTS, MINNESOTA 55082 (651) 439 -4439 CITY OF OAK PARK HEIGHTS 2010 TREE WORKER'S LICENSE APPLICATION Date: � /� Firm or Business Name: n ") i c fde Type of tree work to be performed: ! / Ce. ,Lt� ` 1/� fj1 fro \ 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) (NO) If yes, where? LICENSE FEE: $30.00 fl�Q aVO -ni Name of Business or Company � 1 COMPLETION OF THE WORKERS COMPENSATION INSURANCE AND Business Street Address TAX I.D. FORMS IS REQUIRED BEFORE A LICENSE CAN BE ISSUED. THE FORMS ARE ATTACHED. City State Zip Code LICENSE EXPIRES THE END OF ( ) THE CALENDAR YEAR WITHIN Phone Number WHICH APPLIED FOR OR UPON -/ 4 f EXPIRATION OF LIABILITY Email Address _ p , 1 INSURANCE OR WORKERS' COMP. COMPENSATION INSURANCE, . W� C 6 - C 1 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 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: City State Zip Code Minnesota Tax Identification No.: �) / 86 �® t Federal Tax Identification No.: 440 Q of i b s If a Minnesota Tax Identification number is not required, please explain: 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): Self_ 1 Policy Number or Self- Insurance Permit Number: Dates of Coverage: OR I am not required 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. 3" / C / jJ Signature Business Name 4 /4( J Date: ' Business Address Telephone Number: ( )1,0 i , / �6 i f 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 its obligation under this Contract /Permit, including but not limited to attorney fees and costs incurred relative to such claims and losses. 3 By: Date Corporate Officer or Individual Proprietorship Owner Subscribed and sworn to before me this day of (Notary Seal/Stamp) , Notary Public. County. My commission expires: S:Shared /Forms /Arborist/Tree Worker's License Application JUN -25 -2013 09:22 FROM: TO:6514390574 P.1/1 A R a CERTIFICATE OF LIABILITY INSURANCE I DATE 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 poilcy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms end 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), estrum' PRODUCER _NAMu; Bruce Wagner — Clair Wagner and Sons Insurance Agency, Ltd PHONE JAIC,.NaOW (651)738 - F. M9I` (651)738 - 1554 6082 12th Seem North _ o uRE e e ; wbmcna(�pmaq.com — Oakdale, Mn 55128 INSURERLS) AFFORDING COVSRAG_ _ NAIL 0 INSURER A , West Bend Mutual Ins. Co. INSURED rNSURERII : ,_ . Matthew P Schmidt dm INSURER C : ... M & S Tree Removal INSURER 0 : _ _ - -. 1087 Nolan Ave N INSURER II : Stillwater, Mn 55082 INSURERP; 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 REOUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY RE 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. iNU1' AUDI Sues YOIICY aP P uCV e� UNITS TYPE OP INSU 1N3R JNYIL POLICY NUMBER IMMIDDIYYYYt (MM/QQQ'f MINERAL L muuTY EACH OCCURRENCE a 1,000,000.00 "orYO E 6 100,000.00 X COMMERCIAL GENERAL LIABILITY PREMISES IIp,SEONI IEDEL, 3 CLAIMS-MADE C OCCUR MEO EXP (Any one Demon) _ 6 5,000.00 A NSN 1878271 00 05114!2013 05/14/2014 PERSONAL A ADV INJURY = 1,000,000.00 GENERAL AGGREGATE $ 2,000,000.00 GEN'L AGOREGATE LIMIT APPLIESPER: PRODUCTS - COMP/OP AGO $ 2,000,000.00 PRO- _ LOC 6 POLICY IFGT COMBINED Ell3GLE LIMIT AUTOMOBILE unelLrTY .t6A.Afdldsno _ ANY AUTO BODILY INJURY (Pm person) 3 __ All OWNED _ SCHEDULED BODILY INJURY (Pa na:idatl) S _, AUTOS - ' NON-OWNED Mar * 7171471 _ HIRED AUTOS _ AUTOS S UMBRELLA ALA!! OCCUR EACH OCCURRENCE 1 SXC$SE LAB � .. CLAIMS -MADg AGGREGATE 3 .. 3 DE R asAno ON WORKERS COMPO a s T HSM1ON 1'S_.., .,. ^ AND EMPLOYERS' LIABILITY Y / N E.L. EAC�r ACGDENT S , ANY PROPRIETOR/ PARTNER!!SECUTiVE` 1. /A OOP I CE RIM EMBER EXCLUDED9 E.L. DISEA6E • EA EMPLOYEE 3 (Mandatory In NH) It yes, desrna under E.L. DISEASE •POLICY LIMIT $ DESCRIPTIQf14F OPERATIONS belEyr DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES Attach ACORD 101, AddIIWnd Ram•rla SIMGUM, N more spoon Is ,nlusnd) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROV1S1OH8. City of Oak Park Hgts 14168 Park Blvd AUTHORIZED RePRasaITA'rne Box 2007 t c�� Oak Pork Hgts, Mn 55082 A-1-4..4,4a C7r: I 019884010 ACORD CORPORATION. All rights reserved. ACORD 26 (2010/03) The ACORD name and logo are registered marks of ACORD JUN -25 -2013 09:37 FROM: TO: 6514390574 P.1/1 n CERTIFICATE OF LIABILITY INSURANCE l DA r THIS CERTIFICATE IS ISSUES AS A MATTER OF INFORMATION ONLY AND CONFFRS 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 pollcy(les) must be endorsed. If SUBROGATION IS WAIVED, sub)ect 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 or such endorsement(s). Hire Berkley Assigned Risk Services Wagner Clair 8 Sons Ins Agency LTD - _�. (8881 548-7431 I � AG.N•J1 (866) 215 -8118 6082 12th St N ADDRFse: PolicyServioeenrberkleyrlsk.com Oakdale, MN 65128 INSURERrei AFFOIODINQ commie ) NAIC INLURCR MN Workers' Compensation Assigned Risk Plan 99961 INSURED INSURER S. MATTHEW P SCHMIDT INSURER C: dba: M 8 S TREE REMOVAL INSURER D: 1067 NOLAN AVE N INSURER c: 1 STU l WATFR. MN 5RfR2 INSURER P. COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: I I O CE I -11 A 'O 1 •_ U I' -. e 0 Y `AT BE I A D O TH INSUR D NAMED A8•VE FOR THE POLL 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 SUOJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS INSR TYPO OP INSURANCE ADM BURR W POLICY NUMDER • pOLILT EP POLILT EXP LIMITS LTR INBR VO (MM M/ /DD /YYTY) (MDD/YYYYI OSNBRAL LIABILITY EACH OCCURRENCE --- $ DAMAGE TO RENTED i • COMMERCIAL GENERAL LIABILITY PRIIMIBCS (C.. oecerronee) $ II ❑ CLAIMS - MADE ❑ OCCUR ❑ ❑ , - PXP far r pal e•npnl $ • P ER6GNAL a ADV INJURY $ NPRAL AOORPO TP $ SENT AOORCOATE LIMIT APPLIOS PER' PRODUCTS - COMPIOP A00 S . POLICY ❑�IF,GT ❑ LOC - .. 'EOUWNED SINGLE LIMIT $ $ AUTOMOBILE LIABILITY U ❑ (Ea ■dNdenll ■ ANY AUTO BODILY INJURY (Per person) $ - AUTOS eo ❑ 6CHODULED AUTOS Rkb6ERNUDALIAG�pgela�l $ NI HIRED AUTOS ❑ AUTOS NED (Per e5cIQ•nll S IN UMBRELLA LIAB OCCUR U EACH OCGURRGNCD, $ • EXCESS LIAR 0 CLAIMS-MADE AOOREOATs -• DEC 11 RETENTION $ $ WORKERS COMPENSATION y, WC 8TATU- ICI ASM- AND EMPLOYERS' LIABILITY YIN " TORY LIMITS u ER ANY PROPRIGTOR/PARTNERIfiXECUTIVB 13 8 LEACH ACCIDENT 8100,000 A OFPICE/MSUBER EXCLUDCOT NIA ❑ WC- 22 -04- 221326 -00 08/132013 06/09/2014 - (M.ndelery In NH) E.L. DISEASE -EA EMPLOYEE $100,000 If y.•, d••dn.. under 500,000 DESCRIPTION OP OPERATIONS anise S.I, -POLICY LIMIT ❑ • ❑ •: :f , ••; • •0 • 1 , r. eA• 'sMer.`. ••u0,' reefs apse. Irade Election Category Election Status Name All EMNle5/1nsuretioL Sole Propreter Exclude MATTHEW P SCHMIDT MATTHEW P SCHMIDT CERTIFICATE HOLDER CANCELLATION City Of Oak Park Heights SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN 14168 Oak Park Blvd Box 2007 ACCORDANCE WITH T46 POLICY PROVISIONS. Oak Park Heights, MN 65082 AUth4RIY b espken2NTAYIvE — _X .. _ a __-eze -.._ ACORD 25 (2010/05) BRAC 3139