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HomeMy WebLinkAboutSt. Croix Tree Services, Inc. aka SavaTree/Save-A-Lawn • 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 TREE WORKER'S LICENSE APPLICATION Date: Firm or Business Name: +, C (J -1-f 5e_V'/i Le- X6'1 e Type of tree work to be performed: pokvI■ p,A,1 t kre.r 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: I3dN 1)(1-) C DttA je C aA.Ie/ V O D d Has your company ever had a license revoked in any other city? (YES) (NOj If yes,where? St. 0_1(6 Tee- 5c,(v ► 6e Name of Business or Company COMPLETION OF THE WORKERS 615 k4Z- �t COMPENSATION INSURANCE AND Business Street Address TAX I.D. FORMS IS REQUIRED - f `n '6,23 BEFORE A LICENSE CAN BE ISSUED. � THE FORMS ARE ATTACHED. City State Zip Code LICENSE EXPIRES THE END OF ( 05� ) 'V O J1 LIL THE CALENDAR YEAR WITHIN Phone.Number . WHICH APPLIED FOR OR UPON All) 6 (i b IYC"tyGe_e"J CG-- D 1 EXPIRATION OF LIABILITY Email Address INSURANCE OR WORKERS'COMP. COMPENSATION INSURANCE, WHICHEVER OCCURS FIRST. License No.TW: Date: ao►y - 60000 / 12-(-1,3 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 1n through December 31st) 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) ,/ / / Bdait,e3rNaliie. `f1 (� � � SeA ) c..�e_ Business Address: � � o` UO 623 City State Zip Code G� Minnesota Tax Identification No.: 1 I L 1,1)I Federal Tax Identification No.: L`1 If a Minnesota Tax Identification number is not required, please explain: Signature Title �, �11 S� 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 Qrthepermit 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. .1-,. Insurance Company(not the Insurance Agent): 4 ��rI 51 6' 'A�'+ t& ( S, C emy Policy Number or Self-Insurance Permit Number: \NC- 321p,9 2.19 W.. 1 Dates of Coverage: l�( —( 3 1` (-14 -- — -- Ofl — -- —- - - s'Compensation Insurance because: (check one) WOAH3c. MItitadatoo emplo -es covered by law Nictug YtllxM nienovAk Otfte !(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. Signature Business)Vam Date: ( V2t t (4.6 VII 9(623 Business Address Telephone Number: to5-)1 910 -"Or 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 fully perform its obligation under this Contract/Permit, including but not limited to attorne fees and costs incurred relative to such claims and losses. <01Z21 W By: Date Corporate Officer or Individual Proprietorship Owner Subscribed and sworn to before me this �a dhy of�QVt v�, ✓, o1O B . 1L4041W410 , Notary Public. SABRINA JERLOw .C 10c•u County. Nohry Public State of Wisconsin My commission expires: LA-1- 1-1 S:Shared/Forms/Arborist/Tree Worker's License Application AC OR ® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) �,----. 12/27/2012 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 1-800-851-7740 CONTACT NAME Lisa Flournoy (Account #219661) Florists' Mutual Insurance Company Hortica ((A//cC.No.Ext): 800-851-7740 ext 1955 FAX 866-819-9256 1 Horticultural Lane E-MAIL lflourno ADDRESS: yOhortica-insurance.com Edwardsville, IL 62025 INSURER(S)AFFORDING COVERAGE NAIC# Maguire Agency INSURER A: FLORISTS MUT INS CO 13978 INSURED INSURER B: St Croix Tree Service INSURER C: 675 Grupe Street INSURERD: Roberts , WI 54023 INSURER E. INSURER F: COVERAGES CERTIFICATE NUMBER: 30972768 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 ADDL SUBR LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER POLICY EFF POLICY EXP A GENERAL LIABILITY BP13127 (MMIDDIYYYY) (MMIODIYYYY) LIMITS 01/01/13 01/01/14 EACH OCCURRENCE _ $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED 1,PREMISES(Ea occurrence) $ , CLAIMS-MADE X OCCUR • MED EXP(Any one person) $ 5,000 PERSONAL&ADVINJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GENII AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 —1 POLICY n j� LOC $ A AUTOMOBILE LIABILITY FMA009091 . 01/01/13 01/01/14 COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED -SCHEDULED - AUTOS AUTOS BODILY INJURY(Per accident) $ X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE AUTOS $ (Per accident) $ A X UMBRELLALIAB X OCCUR EX10336 01/01/13 01/01/14 EACH OCCURRENCE $ 5,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $ 5,000,000 DED X—RETENTIONS 10,000 $ A WORKERS COMPENSATION WC STATU- TORY EMPLOYERS'LIABILITY Y/N WCN32669 01/01/13 01/01/14 X TORY LIMITS_ ER ANY PROPRIETOR/PARTNERJEXECUTIVE E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? 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 Pesticide/Herbicide BP13127 01/01/12 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,if more space is required) Evidence of Insurance CERTIFICATE HOLDER ,` ` ( (n C CANCELLATION 2- D I LI Cal l wi 1 ►✓� i J 5(A-ed SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN \ //s.}- j c-e In. Oc! br / ACCORDANCE WITH THE POLICY PROVISIONS. \\Ie,e- K— I n J k -1, 1 ht4-� 44-f-c„•/ AUTHORIZED REPRESENTATIVE • ek(L� (e-f\\vJs and- --,1.5agMy6c-A1/ YV`,Gt( 15` c.r� , M. y • .©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD erinwatson 30972768 IP52600280I2 ® AW O DATE(MMIDD 13 ) CERTIFICATE OF LIABILITY INSURANCE 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 csi REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. p 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 1-800-851-7740 CONTACT Lisa Flournoy (Account #219661) NAME: kn Florists' Mutual Insurance Company/Hortica, Florists• Insurance Services Inc We No,Ezt); 800-851-7740 ext 1955 FAX Ho), 866-819-9256 P 0 Box 428 ADDRESS: lflournoy@hortica.com Z 1 Horticultural Lane Edwardsville, IL 62025 INSURER(S)AFFORDING COVERAGE NAIC 0 Maguire Agency INSURER A: FLORISTS MUT INS CO 13978 INSURED INSURER B: St Croix Tree Service INSURER C: 675 Grupe Street INSURER 0: Roberts , WI 54023 INSURERS: INSURER F: COVERAGES CERTIFICATE NUMBER: 37194798 REVISION NUMBER: THIS iS TQ 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 AWL SUBS. POLICY EFF POLICY EXP LIMITS LTH TYPE OF INSURANCE IHSR WVD POLICY NUMBER (MMIDDIYYYYI IMMIDDIYYYYI A GENERAL LIABILITY BP13127 01/01/14 01/01/15 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES(Ea Eoccu ante ) $1• 000,000 I CLAIMS-MADE X OCCUR MED EXP(Any one person) $5,000 ,.. PERSONAL 8 ADV INJURY $. 1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: ' :PRODUCTS-COMP/OP AGG $2,000,000 X POLICY! JECOT LOC $ A AUTOMOBILE LIABILITY 1 FMA009091 01/01/14 01/01/15 COMBINED SINGLE LIMIT 1,000,000 (Ea accident) $ X ANY AUTO BODILY INJURY(Per person) $ •ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE 'X HIRED AUTOS X AUTOS (Per accident) $ $ A 'X UMBRELLALIAB X OCCUR EX10336 01/01/14 01/01/15 EACH OCCURRENCE $5,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $5,000,000 DED X RETENTION$10,000 $ A WORKERS COMPENSATION WCN32669 01/01/14 01/01/15 X TORY LIMITS ER AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YIN E.L.EACH ACCIDENT $ 500,000 OFFICERIMEMBER EXCLUDED? I N I A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE$ 500,000 II yes describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 A 'Pesticide/Herbicide •HP13127 01/01/14 01/01/15 Per Occurrence 1,000,000 Applicator Coverage Aggregate 2,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If 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 4J.,„ C M- aolem USA ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD erinwatson 37194798 A`,°R°® CERTIFICATE OF LIABILITY INSURANCE 6/26/2014) 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 Andrew Frano NAME: First Niagara Risk Management, Inc WPHCNrEe Fxtt. (716)819-5500 Wit Nol;(716)819-5140 726 Exchange Street Suite 900 E4AAILs:andrew.frano @fnrm.com ADDRES INSURER(S)AFFORDING COVERAGE NAIC# Buffalo NY 14210 JUL - 1 v i i 1 ! INSURER A Natl Union Fire Ins Co of Pitt 19445 INSURED INSURER B:New Hampshire Insurance Company 28341 Nature's Trees, Inc. dba SavaTree/Save-A-Lawn INSURER C:Great American Insurance 22136 St. Croix Tree Service INSURERD: 550 Bedford Road INSURER E: Bedford Hills NY 10507 INSURER F: COVERAGES CERTIFICATE NUMBER:14-15 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 ADDLISUBR POLICY EFF POLICY EXP LTR JEISR i W POLICY NUMBER (MM/DD/YYYY),(MMIDD/YYYY) GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 GE TO X COMMERCIAL GENERAL LIABILITY PREMISES(EaEoccurrence) $ 1,000,000 A I CLAIMS-MADE I^1 OCCUR X X 7267137 7/1/2014 7/1/2015 MEDEXP(Anyoneperson) $ 10,000 X XCU INCLUDED -PERSONAL&ADVINJURY $ 1,000,000 X BLRT. CONTRACTUAL GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 -.POLICY IT!I jrT T1 LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT _ (Ea accident) $ 2,000,000 X ANY AUTO BODILY INJURY(Per person) $ A X ALL OWNED ' SCHEDULED X - X 01 UEN 0E1915 7/1/2014 7/1/2015 BODILY INJURY(Per accident) $ AUTOS AUTOS X HIRED AUTOS X AT-0WNED DAMAGE Perraccident $ — X $250 COMP X $250 COLL PHYSICAL DAMAGE $ A.C.V. X UMBRELLA UAB X OCCUR EACH OCCURRENCE $ 20,000,000 A EXCESS LIAR CLAIMS-MADE AGGREGATE $ 20,000,000 DED I X I RETENTION$ 10,000 X X BE 044156600 7/1/2014 7/1/2015 $ B WORKERS COMPENSATION X X I TORY L MRS I lox AND EMPLOYERS'LIABILITY OF ECUTIVE NN _ N/A. E.L.EACH ACCIDENT $ 1,000,000 (Mandatory In NH) O11EOH2O92 7/1/2014 7/1/2015 E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below -- E.L.DISEASE-POLICY LIMIT $./ 1,000,000 C CONTRACTOR'S EQUIPMENT MACO247225 7/1/2014 /1/2015 LEASED/RENTED -$250,000 ($10,000 Deductible) SCHEDULED $3,503,931 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space Is required) City of Oak Park Heights is an Additional Insured on a primary and non-contributory basis in regard to the above Liability policies when required by executed written contract. A Waiver of Subrogation is included when required by executed written contract. 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. PO Box 2007 ' Oak Park Heights, MN 55082 AUTHORIZED REPRESENTATIVE _---- ..-� .--4.-:.0 Jf°.yl'F - -. M Bonetto/AFRANO ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025l,oi am)nt Tha Ar`fRfl name.anti Innn are renictararl martrc of A(APfl