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HomeMy WebLinkAboutS & S Tree & Horticultural Specialists 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: 2: 114 I1-I Firm or Business Name: J S Q \* *ia,k.*wi-ctA S ) ( ' J'\ Type of tree work to be performed: 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: \' CA kX I `• \ 11 reapQ\1 Has your company ever had a license revoked in any other city? (YES) (NO) If yes,where? LICENSE FEE; $30.00 V1 Q AA ktrat 5° cAciA�•S� Name of Business or Company COMPLETION OF THE WORKERS 4( ,0{6.rnuir\ Ni4a jcLb COMPENSATION INSURANCE AND Business Street Address 9 _ �) TAX I.D. FORMS IS REQUIRED % Mt3 ���� t BEFORE A LICENSE CAN BE ISSUED. VV l C 'MK THE FORMS ARE ATTACHED. City State (,� Zip Code J LICENSE EXPIRES THE END OF (� )L Ji c" O1 THE CALENDAR YEAR WITHIN Phorw N ber _ WHICH APPLIED FOR OR UPON 11/t % Q (>0^ ^ EXPIRATION OF LIABILITY Email Address INSURANCE OR WORKERS'COMP. COMPENSATION INSURANCE, f WHICHEVER OCCURS FIRST. License No."F Date: .3 /3/1* o;4 - 34 LICENSE APPLICANT: w 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 1st 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) Business Name: 5E -NC Q F `\l CU \A &,∎,\SceCA GA1 SM Business Address: 0� \-101,(CA1'1Ct.(1 c iQ Ssp ' AL) SSc 1 City State Zip Code Minnesota Tax Identification No.: 35Ule-1 8 Federal Tax Identification No.: q I ).j v'v1 Z N If a Minnesota Tax Identification number is not required, please explain: Sr------ itle Date l f 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 • •• ,f' • Individual Proprietorship Owner Subscribed and sworn to before me this day of Obitito , Notary Public. County. My commission expires: . S:Shared/Forms/Arborist/Tree Worker's License Application 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. yr In ('p Insurance Company(not the Insurance Agent): 1 ` e1Ne Q'4�—I1SI�V- Policy Number or Self-Insurance Permit Number rc— "/ 1�6 H Dates of Coverage: �. , ) )L — ) J 1 1 ) F- 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 knowl dge,the information provided is true and correct. °_ I 1 °. EA lrt I' " I S-'r S B,usiness Name } i1,.. ci n ff1/2)9 Date: 2 l I l L-1 c=j Business Address Telephone Number: ( ) • l 49 DATE(MM/DDNYYY) A� 02/19/2014 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). CONT PRODUCER NAMEACT Sherman Ins. Agcy., Inc. SHERMAN INSURANCE AGENCY, INC PHONE 651-451-1758 F'O'X IA/C.No.ExEst): (A/C.No): 651-455-3923 120 BRIDGEPOINT WAY, SUITE C EMAIL ADDRESS: ron @shermanins.com SOUTH ST PAUL, MN 55075-2498 INSURER(S)AFFORDING COVERAGE NAIC 6 INSURER A: AmTruSt Group - Wesco Ins. Company 018533 INSURED 651-451-8907 INSURER B: American interstate Insurance Company S & S Tree & Horticultural Specialist Inc. INSURER C: St. Paul Fire and Marine 405 Hardman Ave. S. INSURER D: AmTruSt Group - Security National South Saint Paul, MN 55075 INSURER E: AmTrust North America INSURERF: St. Paul Fire & Marine Insurance Company 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 ADDL SUER POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER (MMIDDIYYYY) JMM/DD/YYYYI GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 E X COMMERCIAL GENERAL LIABILITY WPP1117941 09/30/2013 09/30/2014 DAMAGE PREEMIMI ESES(Ea occurrence) $ 100,000 CLAIMS-MADE X OCCUR MED EXP(Any one person) $ 5,000 X Professional Liab. $1,000,000 PERSONAL a ADV INJURY $ 1,000,000 X Blkt Contractual Liability GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 x l POLICY Fl, 1-7 LOC Professional Liab $ 1,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 (Ea accident) $ E X ANY AUTO SPP1105139 05/16/2013 05/16/2014 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ OT (Per accident) $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 2,000,000 F EXCESSLIAB CLAIMS-MADE ZUP13T45117 09/30/2013 09/30/2014 AGGREGATE $ 2,000,000 DED I RETENTION$ $ WORKERS COMPENSATION X I WC STATU- 10TH- AND EMPLOYERS'LIABILITY TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE YYN NIA E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBEREXCLUDED? AVWCMN2259572014 01/01/2014 01/01/2015 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required) II 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 N PO Box 2007 AUTHORIZED REPRESENTATIVE Oak Park Heights, MN 56357 I ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD AC d CERTIFICATE OF LIABILITY INSURANCE DATE/2014(MM/DD/YYYY) • `../ 08/26/2014 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 MARSH USA INC. PHON: 200 PUBLIC SQUARE,SUITE 1000 (A/C. ONE Ext): C.Not: CLEVELAND,OH 44114-1824 E-MAIL A031:cleveland.certrequest@marsh.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# 08670-ALL-GAWU-14-15 100131 RESICA COLE SEP 2 .-, (INSURER A:Old Republic Insurance Co 24147 INSURED "' +�INSURER B:National Union Fire Ins Co Pittsburgh PA 19445 THE DAVEY TREE EXPERT COMPANY 1500 N.MANTUA ST. INSURER C:STANDING ROCK INSURANCE COMPANY KENT,OH 44240 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: CLE-003978110-02 REVISION NUMBER:1 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 SUBR POLICY EFF POLICY EXP LIMITS LTR INSR VD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) A GENERAL LIABILITY MWZY 302374 09/01/2014 09/01/2015 EACH OCCURRENCE $ 2,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED 2 000 000 PREMISES(Ea occurrence) $ CLAIMS-MADE X OCCUR MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 2,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY Ti jE 0 Ti LOC $ A AUTOMOBILE LIABIUTY IAMB 302373- 09/01/2014 09/01/2015 COMBINED SINGLE LIMIT 2,000,000 rEa accident) $ X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS NON-OWNED PROPERTY DAMAGE $ X HIRED AUTOS X AUTOS (Per accident) $ B X UMBRELLA LIAB X OCCUR BE 12322281 09/01/2014 09/01/2015 EACH OCCURRENCE $ 5,000,0_ EXCESS LIAB CLAIMS-MADE LIMITS ARE EXCESS OF AGGREGATE $ 5,000,000 DED RETENTION$ SR 2014-1 $ A WORKERS COMPENSATION MWC 302372-00(AOS) 09/01/2014 09/01/2015 X I WC STATU- IoTH- AND EMPLOYERS'LIABILITY TORY I IMITS ER A ANY PROPRIETOR/PARTNER/EXECUTIVE YIN MWXS 302375(CA,OH,NC,PA,WA) 09/01/2014 09/01/2015 E.L.EACH ACCIDENT $ SEE ATTACHED OFFICER/MEMBER EXCLUDED? N N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ SEE ATTACHED If yes,describe under SEE ATTACHED DESCRIPTION OF OPERATIONS below , E.L.DISEASE-POLICY LIMIT $ C ADD'L GENERAL LIABILITY SR 2014-1 09/01/2014 09/01/2015 GENERAL LIABILITY LIMIT 10,500,000 C ADD'L AUTO LIABILITY SR 2014-1 09/01/2014 09/01/2015 AUTO LIABILITY LIMIT 3,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required) STANDING ROCK IS A WHOLLY OWNED CAPTIVE INSURANCE COMPANY OF DAVEY TREE. IT PROVIDES COVERAGE EXCESS OW REPUBLIC. r 1 141— ,p,i OA cca \A - c,9) , 60 &_s ou AA • CERTIFICATE HOLDER CANCELLATION CITY OF OAK PARK HEIGHTS SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 14168 OAK PARK BLVD N THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN PO BOX 2007 ACCORDANCE WITH THE POLICY PROVISIONS. OAK PARK HEIGHTS,MN 56357 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Luann M.Glavac or 1444.u,, M • ew ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: 08670 LOC#: Cleveland ACCORD ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY NAMED INSURED MARSH USA INC. THE DAVEY TREE EXPERT COMPANY 1500 N.MANTUA ST. POLICY NUMBER KENT,OH 44240 CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance Workers Compensation does not apply in MN.Coverage is obtained from Workers Compensation Reinsurance Association(W.C.R.A.)as required by the state.Minnesota Employers Liability is covered by policy number MWC 302372-00.All above referenced Workers Compensation policies are Statutory. All Employers Liability limits are Each Accident;Disease-each employee;Disease-policy limit and are:$5MM,policy MWC 302372 -00;$1MM,policy MWXS 302375(excess$5MM SIR). ACORD 101(2008101) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD