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HomeMy WebLinkAboutWoodchuck Tree Care • CONTRACTOR'S LICENSE APPLICATION City of Oak Park Heights 14168 Oak Park Blvd. N. P.O. Box 2007 Oak Park Heights, MN 55082 TELEPHONE: DIRECT:(651)351.1661 GENERAL:(651)439-4439-FAX:(651)439-0574 Email:jhultman @cityofoakparkheights.com Business Name: I v OOd ci2 a- "Thee„ e e- Address: / ThA /11/1 still cfha t.-e r- / /HHAI 5S-Dg 2-- Telephone: ({S() C./2g— 72-4, 7 Fax: ( ) E-mail i JoO Get Alin°• arnA LICENSE REQUIREMENTS • Fee based on trade. State license is required for residential general contracting,roofing,plumbing and fire protection.Mechanical Contractors require MN State Surety Bond. • Certificate of Insurance,minimum coverage,$100,000 per person,Public Liability;$250,000 per accident,Bodily Injury;and$100,000 Property Damage.CITY OF OAK PARK HEIGHTS MUST BE NAMED AS AN ADDITIONAL INSURED on this policy. • Agreement to hold 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 if required,by law,to be carried. • 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. • License period:January 1 to December 31 of each year. Cancellation will occur upon failure to provided continued proof of insurance coverage. LICENSE CLASSIFICATIONS: Commercial General Contractor-$50 Blacktopping-$30 Heating,Ventilation&NC -$30 Building Moving-$30 "Attach copy of MN Mechanical Bond Concrete and Masonry-$30 Outside Sewer&Water-$30 Excavating/Grading-$30 Siding-$30 Pool Installation-$30 igns&Billboards-$30 Irrigation System Installation-$30 Other:$30 77v 5,-vv(GE� COMPLETION OF THE WORKERS COMPENSATION INSURANCE ANDTAX I.D.FORMS IS REQUIRED BEFORE A LICENSE CAN BE ISSUED.THESE FORMS ARE ATTACHED AND MADE PART OF THIS APPLICATION. Office Use Only: Liability Insurance Expiration: Worker's Comp. Insurance Expiration: -a(4. — Mechanical Surety Bond ID: JJ Pr Mechanical Surety Bond Expir tion: tit Date License Issued: No. 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: City of Oak Park Heights License Period: Annual: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: WoodChuc-fe--> "T .2e, &re, Business Address: 73 a 119 cat/1 AI. City State Zip Code Minnesota Tax Identification No.: Federal Tax Identification No.: 46 —S z 70 ZS- If a Minnesota Tax Identification number is not required, please explain: Jill cax ( IA Date: e'/51/ Signature: ��[�� ).■dt� _.( Title: le t �' 'it:, 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 Chapter 176. 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 retained within their files. This information is required by law. Licenses and permits to operate a business may not be issued 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$2,000 penalty assessed against the applicant by the Commissioner of the Department of Labor and Industry. 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'com.- sation. Insurance Company(not the Insurance Agent): ''• :....4, ------;•.-----=—:,7--!-- 4 S)_ Policy Number 1:74g70le-B©,j - - Dates of Coverage: 7/ Z co/2.0/? 7i2—lo/Z4/ / - OR- I am not required to have Workers'Compensation Insurance because: (check one) ( ) I have no employees covered by law; ( ) I am self-insured(include permit to self-insure);or ( ) 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 k owledge,the information provided is true and correct. '• O Sr /11 411CL. Date: nature . :v , '« . Prioited Name of Signature O L T sition of P on Sig • INDEMNIFICATION AGREEMENT To: City of Oak Park Heights 14168 Oak Park Boulevard, N. 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. /5/Z- l Date Co t rate Officer or Ina' • al Proprietorship Owner Subscribed and sworn to before me l I this 5 day of v v�e- 0 '1 a , Notary Public. _ • 1 n County. My commission expires: t/a 0 I . ■ MARY SEKIER NOTARY PUBLIC-1111111111110TA r tk Commission EtpYa An.81.201E S:Shared/Forms&Publications/Contractor's License Application Updated:01-29-2008 �.�..•"'ilN WOODC-7 OP ID: KT AA�,,,.---- CERTIFICATE OF LIABILITY INSURANCE °"'� `5/14 �'' osro5r,a 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 pollcy(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 Iteu of such endorsement(s). PRODUCER Phone:952-996-8818 tmg: Terry orthern Capital Insurance Op Fax:952-829-0482 wC No.EA; I(�,No): P.O.Box 9396 E-16611. Minneapolis,MN 55440-9396 ADDRESS. Torras Reinhardt INSURER(S)AFFORDING COVERAGE NAIL II INSURER A:Western National 15377 INSURED Woodchuck Tree Care LLC INSURER B:SFM 11347 Tyler Jacobson INSURER C 7310 Jocelyn Road Stillwater,MN 55082 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. itiV ADC*. -• �= POLICY EFF POLICY EXP TYPE OF INSURANCE yµ yyVp POLICY NUMBER (MMIDDIYYYY) (MMIDDIYYW) LNRS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY CPP1029461 03 08/27/13 08/27/14 DAMAGES O RENTED 100000 PREMISES(Ea occurrence) $ + _ CLAIMS-MADE X OCCUR MED EXP(Any one person) $ 5,000 e PERSONAL&ADV INJURY $ 1,000,006 — GENERAL AGGREGATE $ 2,000,000 GEML AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 2,000,000 7 POLICY n PEef LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 (Ea accident) $ A ANY AUTO CPP1029270 03 08/27/13 08/27/14 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS X HIRED AUTOS X NON OWNED PROPERTY DAMAGE $ AUTOS (Per accident) $ UMBRELLA LAB — OCCUR EACH OCCURRENCE $ EXCESS LAB ,CLAIMS-MADE AGGREGATE _ $ DED RETENTIONS $ WORKERS COMPENSATION WC STATU- OTH- AM)EMPLOYERS'LABILITY TORY LIMITS ER B ANY PROPRIETORIPARTNERIE)(ECUTIVE YIN Ni A 048706.803 07/26/13 07/26/14 E.L.EACH ACCIDENT $ 100,000 OFFICERIMEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 100,E If DESCRIPTION IPTION under E.L.DISEASE-POLICY LIMIT S 500,000 DESCRIPTION OF OPERATIONS belovr DESCRIPTION OF OPERATIONS I LOCATIONS I VEHCLES(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. AUTHORIZED REPRESENTATIVE I ®1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD ��1 WOODC-7 OP ID: KT AC 2• RO° DATE(MM/DD/YYYY) -4,........--- CERTIFICATE OF LIABILITY INSURANCE 08/18/14 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 ACT Phone:952-996-8818 NAME Terry Reinhardt PHONE FAX Northern Capital Insurance Gp Fax:952-829-0482 (NC,No,Ext): (A/C,No): P.O.Box 9396 E-MAIL Minneapolis,MN 55440-9396 ADDRESS: Terras Reinhardt INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Western National 15377 INSURED Woodchuck Tree Care LLC INSURER B: 7310 Jocelyn Road ,`i ';-, , Stillwater,MN 55082 INSURER C: 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 W POLICY NUMBER (MM/DD/YYYY) (MM/DDM/YY) LIMITS LTR INSR VD GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY CPP1029461 08/27/14 08/27/15 PREM SES Ea NTuEnDence)te) $ 100,000 CLAIMS-MADE X OCCUR MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 7 POLICY PEA LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 (Ea accident) $ A ANY AUTO CPP1029270 08/27/14 08/27/15 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS X AUTOS X HIRED AUTOS X AON-0WNED Peer accident) DAMAGE $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N 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 I LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space Is required) City of Oak Park Heights is named as Additional Insured 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 Terras Reinhardt i ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD DATE(MM/DD/YYYY) AC stn CERTIFICATE OF LIABILITY INSURANCE 08/18/2014 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 SFM Risk Solutions Northern Capital Insurance Group NAME: PO Box 9396 (nHCO,No,Extl: 9524384430 FAX No): 952-838-2000 Minneapolis,MN 55440-9396 E-MAIL ADDRESS: arp_phs @sfmic.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: MWCARP c/o SFM Risk Solutions INSURED Woodchuck Tree Care LLC INSURER B: 7310 Jocelyn Rd N INSURER C: Stillwater,MN 55082-8324 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 ADDL SUBR POLICY EFF I POLICY EXP LTR TYPE OF INSURANCE INSD WV POLICY NUMBER (MM/DDIYYYY)I(MMIDD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE O RENTED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) --$-_ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ �- POLICY I PERT LOC PRODUCTS_COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident)_ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED I 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$ rr f' WORKERS COMPENSATION n STATUTE IJ OTH- ER A AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ $100,000 OFFICER/MEMBER EXCLUDED? N/A 48706.804 07/26/2014.07/26/2015 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ $100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ $500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Special provision:WC 00 03 08.Partners,Officers,and Others Exclusion Endorsement is attached to the policy. An owner/officer/other has rejected coverage. CERTIFICATE HOLDER CANCELLATION City of Oak Park Heights SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 14168 Oak Park Blvd THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Oak Park Heights,MN 55082-6476 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE `-W2 {T�\ tom/�J I ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD WARNING NOTICE: REGARDING WORKERS' COMPENSATION BENEFITS PAYABLE OUTSIDE OF MINNESOTA Workers' compensation insurance policies issued by the Minnesota Workers' Compensation Assigned Risk Plan DO NOT provide coverage for workers' compensation benefits to injured employees which you are obligated to provide under the workers' compensation laws of any other state. This policy only covers lawful claims for workers' compensation benefits allowed under Minnesota law. This policy DOES NOT provide coverage for your workers' compensation liability to injured employees that work outside of Minnesota, and who are not entitled to receive benefits under Minnesota's workers' compensation law. This policy also DOES NOT cover your workers' compensation liability under another state's workers' compensation law if your injured employee elects to receive benefits under that other state's workers' compensation law in lieu of receiving workers' compensation benefits payable under Minnesota law. This policy DOES provide coverage under Minnesota's workers' compensation law for benefits to your injured employees who regularly perform their primary duties of employment within Minnesota but who are injured outside of this state, as required by Minn. Stat. §176.041, subd. 2-4 (2009). Coverage for out of state employees can be complicated. If you do business outside Minnesota, employ persons that perform work outside Minnesota or have any question regarding what benefits are provided to your employees by Minnesota's workers' compensation law, you should consult your insurance agent or other knowledgeable professionals regarding your obligations in this area.