Loading...
HomeMy WebLinkAboutTerra's Canopies LLC CITY OF OAK PARK HEIGHTS 171f 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: 12 13 Firm or Business Name: I C rra& Caiiibr,'8S 1 L-L-C Type of tree work to be performed: p1^Ll,n I r re,MO val 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: 5f. Paul Miv v 1a..pot15 Has your company ever had a license revoked in any other city? (YES) (® If yes,where? y- LICENSE FEE: $30.00 1 e Yra c Q io i z5; / 1 � Name of Business or Compan r.y COMPLETION OF THE WORKERS 3610 400,2 Ave COMPENSATION INSURANCE AND Business Street Address TAX I.D. FORMS IS REQUIRED p e ( , L BEFORE A LICENSE CAN BE ISSUED. RI?bb1 i' ,4/ Mk 55L1 THE FORMS ARE ATTACHED. City ,I/State j Zip Code LICENSE EXPIRES THE END OF ( �j 51 ) 2T1Q - ,53Q(p THE CALENDAR YEAR WITHIN Phone Number WHICH APPLIED FOR OR UPON (i f -+evrd,&lnopieS.COM EXPIRATION OF LIABILITY Email Address INSURANCE OR WORKERS'COMP. COMPENSATION INSURANCE, - UO60 12- 11-511 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. Failure to i;"upOfy this ntfiorr" .: -, ,., . . .. • _ _ 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 311 Personal Information: (Complete only if applicable) Applicant's Name: ph,i lip Casino) Applicant's Address: ?. 4b 4101/01 Av'C 141)101`0dtil e MW 5S422- City State Zip Code Social Security No.: 1-173 -7b - 1)+10 Business Information: (Complete only if applicable) Businessl�Tame: _ eVa. Business Address: 5 Ai 1 City State Zip Code Minnesota Tax Identification No.: 7 $ q 7 Federal Tax Identification No.: 0 1+51 l b* If a Minnesota Tax Identification number is not required, please explain: winer' lZ-2—I3 Signature Title g Date J h 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. r, Insurance Company(not the Insurance Agent): Jjerkl c y Q A Vo Iti j 517 I YS Policy Number or Self-Insurance Permit Number: W C-27-0L}-/(eos uq 6V Dates of Coverage: I2-/b j h ' r alb 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. 1 - I It,.NL. Te r ra s Cl v n fobs, Signat re / Business Name / iCo '—k f A-- Date: I KF�1O1'JI'elsda le MILL 5172 Business Address Telephone Number: 664 2!-!(o '9386 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. By: Date Corporate Officer or Individual Proprietorship Owner Subscribed and sworn to before me this day of , Notary Public. County. My commission expires: . S:Shared/Forms/Arborist/Tree Worker's License Application 1 1 ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(Mi"'°°""YY) `....!� 12/2/2013 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 NAME:TACT Karen Hawkinson Blakestad/Phenow, Inc. PHONE F>rte (763)574-7447 I PAIC No),(763)574-7504 6875 Highway 65 NE RESs,khawkinson @blakes tad.com ryv INSURER(S)AFFORDING COVERAGE NAIC* Fridley MN 55432 lNsuRERANational Specialty Insurance INSURED INSURER 8: Terra's Canopies LLC INSURER C: 3610 46 1/2 Ave INSURERD: INSURER E: Robbinsdale MN 55422 INSURER F: _ COVERAGES CERTIFICATE NUMBER:CL13102401509 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 LTR TYPE OF INSURANCE INSDR SUBR POLICY NUMBER PMID Y EFF POLICY EXP UNITS 1MMIDD/YYYN)�(MMIDDIYYYY), GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED 100 000 PREMISES(Ea occurrence) $ � A CLAIMS-MADE X OCCUR NSN0693680 11/5/2013 11/5/2014 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEM_AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 X 'POLICY I I [1 LOC $ AUTOMOBILE UABIt, Y COMBINED SINGLE LIMB $ 1,000,000 (Ea accident)A ANY AUTO BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED NSN0693680 11/5/2013 11/5/2014 BODILY INJURY(Per accident) $ AUTOS AUTOS X X NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS ^AUTOS (Per accident) Uninsured motorist combined $ 1,000,000 X UMBRELLA UAB _ OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1,000,000 DED I I RETENTION$ NON1895980 11/5/2013 11/5/2014 $ WORKERS COMPENSATION I TORY A U-I I OT ER AND EMPLOYERS'LIABILITY Y I N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (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 I 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 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Oak Park Heights ACCORDANCE WITH THE POLICY PROVISIONS. 14168 Oak Park Blvd Oak Park Heights, MN 55082 AUTHORIZED REPRESENTATIVE Steve Swanson/KARFI ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INSO2S owl tins)m Thn ArnPn memo an,I Inns am rani.t•arad marls of AI"T FI DATE(MM/DD/YYYY) AFRO CERTIFICATE OF LIABILITY INSURANCE 03/14/2014 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 Karen Hawkinson NAME: Blakestad Phenow,Inc. PHONE No E,d);763 574-7447 FAX No): 763-574-7504 6875 Hwy 65 NE ADDRESS: Fridley,MN 55432 INSURER(S)AFFORDING COVERAGE NAIL# INSURER A: MWCARP C/O RTW,Inc. INSURED Terra's Canopies LLC INSURER B: 3610 46 1/2 Ave N INSURER C: Robbinsdale,MN 55422 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. INSR TYPE OF INSURANCE ADDL SUER POLICY EFF POLICY EXP W LIMITS LTR D VD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) 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 POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS (Per accident) _ UMBRELLA LIAB OCCUR EACH OCCURRENCE _ $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER AND EMPLOYERS'LIABILITY X STATUTE OTH- ER 1-W- ANY PROPRIETOR/PARTNER/EXECUTIVE Y -MN-AR-0000034598-1 -03/04/201403/04/20 T5 E.L.EACH ACCIDENT $ 100,000.00 A OFFICER/MEMBER EXCLUDED? Y NIA N (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/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required) Officers are excluded from coverage. CERTIFICATE HOLDER CANCELLATION City of Oak Park Heights SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 14 14168 Oak Park Blvd N THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 14 Box a P 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 •