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HomeMy WebLinkAboutNorthern Arborists CITY OF OAK PARK HEIGHTS 14168 OAK PARK BOULEVARD-Box 2007 OAK PARK HEIGHTS,MINNESOTA 55082 (651)439-4439 CITY OF OAK PARK HEIGHTS 2014 rn TREE WORKER'S LICENSE APPLICATION Date: 1FJ9--c- 1.q. 1.3 Firm or Business Name: No:::.0t14044,1 b vlochAStzi Type of tree work to be performed: I d'itiY► 4 h 5, /2e4.s- w✓I —'v"26.1 rls Z, 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: v �• w l Cc tI w4i -_ , •4„ E/44.74.1 Has your company ever had a license revoked in any other city? (YES) d If yes,where? nn '' /� LICENSE FEE: $30.00 L�Or` ► I']r^LGrl674r N ame of Business or Company / �( COMPLETION OF THE WORKERS {�F 1 4 107-4 c ) c ` COMPENSATION INSURANCE AND Business Street Address TAX I.D. FORMS IS REQUIRED r __ 61(44") �/J�( BEFORE A LICENSE CAN BE ISSUED. Li, t I L J THE FORMS ARE ATTACHED. City State Zip Code LICENSE EXPIRES THE END OF ‘17' Ak. /267 7 THE CALENDAR YEAR WITHIN Phone Number SA(I) WHICH APPLIED FOR OR UPON 000441 Ct otto tr.® c 4.ic ,Q' . `t.ey' EXPIRATION OF LIABILITY Email Address -1 -Z--(y 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 yo r _ 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 31s1) 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: OV i'��y:x.1ILS Business Address: ©G��{ 1Orh Si:_ t4- City State Zip Code Minnesota Tax Identification No.: t_754 7o?G1 Federal Tax Identification No.: 46— 1S' 79,E 6 If a Minnesota Tax Identification number is not required, please explain: A e-. I l)c,/) Signa. re 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): P\TG-Jr G Policy Number or Self-Insurance Permit Number: 11/141414 C9a7DC290 72.3 2, 4, Dates of Coverage:00)"2.663 4 X9/{70)./ `�j 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. Sign..ure B siness Name 066 4 IOfis g2.. 64- L Date: , /�- C' vL3 �-{, E'! a r/I .575-0t2. Business Address 42g*- 167 Telephone Number: 1rO • CITY OF OAK 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. Date Corpora icer or Individual Proprietorship Owner • Subscribed and sworn to before me 21ft this �day of tx i . — 'otary Public. Mak ;frfrlfltll County. My commission expires: I/31 /2..O!7 S:Shared/Forms/Arborist/Tree Worker's License Application w DATE(MM/DD/YYYY) ' i�CO ;I F CERTIFICATE OF LIABILITY INSURANCE OP ID JH 12/11/13 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 WIN I Al.I NAME: GARRY INSURANCENTER (ICO,Nro,Ext): FAX No): E-MAIL 2555 East 7th Avenue ADDRESS: North St. Paul MN 55109 PRODUCER Phone: NORTARl CUSTOMER Phone:651-777-8361 INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: Westfield Companies 24112 Northern Arborists INSURER B: Gary Wemeier dba 106b4 - 10th St. Court N. INSURERC: Lake Elmo MN 55042 INSURER D: 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. 1NSR TYPE OF INSURANCE AUUL SDBh POLICY bFh POLICY tXP LIMITS LTR INSR WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 UAMACit I KEN ED A X COMMERCIAL GENERAL LIABILITY CAG3615975 12/15/13 12/15/14 PREMISES(Ea occurrence) $ 100,000 CLAIMS-MADE X OCCUR MED EXP(Any one person) $ 5,000 PERSONAL&ADVINJURY $ 1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 POLICY PE� LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $500,000 A ANY AUTO CAG3615975 12/15/13 12/15/14 BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ X SCHEDULED AUTOS PROPERTY DAMAGE X HIRED AUTOS (Per accident) $ X NON-OWNED AUTOS $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIV1 ( N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? ` (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 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 OAKPO 01 THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE City of Oak Park Heights 14168 North 57th Street ,,;5 pak Park Heights MN 55082 ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD AW CERTIFICATE OF LIABILITY INSURANCE D04/18 2013YY) -_�r 04/18/2013 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). _ CONTACT RTW,Inc. PRODUCER NAME: --�? PHONE 952-893 0403 FAX Not 952-893-3700 Garry Insurancenter (A/C.uu. 3: 2555 East 7th Avenue E-MAIL ADDRESS: North St.Paul,MN 55109 . „ PRODUCER CUSTOMER ID#: INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: MWCARP C/O RTW,Inc. I Gary Wemeler INSURER B DBA:Northern Arborists INSURER C: 10664 10th Street Court N `_ INSURER D: - Lake Elmo,MN 55042 -- -- 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. ADDL SUBR POLICY EFF POLICY EXP ILTR TYPE OF INSURANCE INSR WVD POLICY NUMBER .JMMIODIYYYYI_,JMMIDDIYYYYL LIMITS GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) $ CLAIMS-MADE I OCCUR MED EXP(Any one person) $ PERSONAL 8 ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ IPRO- POLICY LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE $ HIRED AUTOS (Per accident) NON-OWNED AUTOS $ --- $ -__ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ _ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ WORKERS COMPENSATION WC STATU- 0TH- A i AND EMPLOYERS'LIABIUTY Y/N MNAR-0000007232-9 04/02/2013 04/02/2014 X TORY LIMITS FR ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000.00 OFFICER/MEMBER EXCLUDED? Y N/A N 100 000.00 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ IT yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000.00 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more apace is required) Sole Proprietor is excluded from coverage. CERTIFICATE HOLDER CANCELLATION City Oak Park Heights SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE }' g THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 14168 57th St N ACCORDANCE WITH THE POLICY PROVISIONS. Oak Park Heights,MN 55082 AUTHORIZED REPRESENTATIVE ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD '/.....". 00 DMZ(MM/DD/YYYY) ACORD CERTIFICATE OF LIABILITY INSURANCE 44...--- 03/17/2014 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 Jeanne Hartman NAME: Garry Insurancenter lac"r o,Extc 651-777-8361 FAX No): 651-777-1264 2555 East 7th Avenue E-MAIL ADDRESS: North St.Paul,MN 55109 INSURER(S)AFFORDING COVERAGE NAIC N INSURER A: MWCARP do RTW,Inc. INSURED Gary Wemeier .x:;r. 4. INSURER B DBA:Northem Arborists INSURER C: 10664 10th Street Court N INSURER D: Lake Elmo,MN 55042 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 INSURANCE ADDL SUER POLICY EFF POLICY EXP LTR INSD WVD POLICY NUMBER IMMIDD/YYYY) IMMIDD/YYYY), LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES Ea occurrence) $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 1 POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABIUTY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ _ $ WORKFRS COMPENSATION _ - v- PER 1 OTH- AND EMPLOYERS'LIABILITY _.- —.. _ -.. STATUTE- —-t-ER---- ------ -- A ANYIPROPRIE ER EXCLUDED ECUTIVE IrN N/A N MNAR-0000007232-10 04/02/201404/02/2015 E.L.EACH ACCIDENT $ 100,000.00 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000.00 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $504,000,00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached N more space Is required) Sole Proprietor is excluded from coverage. CERTIFICATE HOLDER CANCELLATION City of Oak Park Heights SHOULD H POLICIES C R EXPIRATIION DATE THEREOF, NOTICE WILLL CBE DELIVERED THE IN 14168 57th St N ACCORDANCE WITH THE POLICY PROVISIONS. Oak Park Heights,MN 55082 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD