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Home My WebLink AboutM & S Tree Removal } 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: o -14 _It/ Firm or Business Name: m / , /f xe, 2f,J2.2 JIQ Type of tree work to be performed: ,Qc r6 9- 7 ?,i-i,rat_i 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: _ S4 I f/Ewzaems` /y�I,J Has your company ever had a license revoked in any other city? (YES) (" If yes,where? LICENSE FEE: $30.00 /219-'S' ! /P f /2PJ0,14PaC,G( Name of Business or Company COMPLETION OF THE WORKERS /067 /Lic34.4vu 4(1.e. 4, COMPENSATION INSURANCE AND Business Street Address TAX I.D. FORMS IS REQUIRED _ BEFORE A LICENSE CAN BE ISSUED. S t icoente /'K►J-J 6-b 7D 2 THE FORMS ARE ATTACHED. City ,, State Zip Code LICENSE EXPIRES THE END OF (C3I ) 5- 3—/76/ THE CALENDAR YEAR WITHIN Phone Number WHICH APPLIED FOR OR UPON EXPIRATION OF LIABILITY Email Address INSURANCE OR WORKERS'COMP. Ud�� COMPENSATION INSURANCE, CO)q.� WHICHEVER OCCURS FIRST. License No.TW: Date: (p//(a 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 1st through December 31St) Personal Information: (Complete only if applicable) Applicant's Name: /_- 5C,1-0'lii Applicant's Address: JO67 Alo taiu A-o /v S-11'11 tAski-e -- M S'SA ez„ City State Zip Code Social Security No.: 1/7 1- 17 S/>9- Business Information: (Complete only if applicable) Business Name: /4 rr6e, lKi•1 Ua.L Business Address: /dC 7 NCCaN 4u ,ti S4 l/ e.' f/4") City State Zip Code Minnesota Tax Identification No.: ' 9L ( BOO Federal Tax Identification No.: 90 --Q 9`f 1 { (.3 If a Minnesota Tax Identification number is not required, please explain: pcv .heA- G -/4 Signature Title Date 1 I. A" 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$1,000 penalty assessed against the applicant by the Commissioner of the Department of Labor and Industry to the Special Compensation Fund. Provide the information specified above, in the spaces provided, or certify the precise reason your business is excluded from compliance with the insurance coverage requirement for workers'compensation. Insurance Company(not the Insurance Agent): Policy Number or Self-Insurance Permit Number: Dates of Coverage: OR I am no required to have Workers'Compensation Insurance because: (check one) I have no employees covered by law Other(specify) I have read and understand my rights and obligations with regards to business licenses, permits and Workers'Compensation coverage and hereby certify by my signature below that to the best of my knowledge,the information provided is true and correct. ,.. 7 /752's Tree .eta vcA/C Signature Business Name Date: 6 '/G —"V Business Address _ Telephone Number: (�$'1/ —50 3-/7G( { 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. •/ `/y By: /I-41mo/ 7�' Date Corporate Officer or Individual Proprietorship Owner Subscribed and sworn to before me this__l0 day of Wit` 4Itk I 4Ir1 L_^ _��Et•• k Notary Public. `Y l 1` County. JULIE A HULTMAN � ¢�i+ MINNESOTA My commission ex t '3 f - 1 S = NOTARY PU6LIC y expires:p � �� ires Jan.31,2015 My CommisJsioln�✓xprr-rl�-�-�.r�.U� 11 Jflll�ffr./ll-/ j S:Shared/Forms/Arborist/Tree Worker's License Application JUN-16-2014 08:23 FROM: TO:6514390574 P. 1/1 A 9d DATE anueo/VYYY) CERTIFICATE OF LIABILITY INSURANCE 08/16/2014 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(8), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the pollcy(les)must be endorsed. If SUBROGATION IS WAIVED.subject to the terms and condttlons of the policy,certain policies may require an sndoreement A statement on this certificate does not confer rights to the cortlftcate holder In nom of such endorssment(s). PRODUCu* B'� Bruce Wegner Clair Wagner end Sons Insurance Agency,Ltd. KPH ds_no, (851)738-1217 66e„ (651)738-1554 6082 12th Street North wbmcna®grnall.cvm �v Oakdale,Mn 55128 INSURERS)AFFORDING COVERAGE NAIL INDVRRR A: West Bend Mutual Ins.Cu. INSURED INSURER s• _ Mathew P.Schmidt dbs INSURER C M 8 S Tree Removal INSURER D: 1067 Nolen Ave N MEURER a: Stillwater,Mn 56082 U,(puRINIU. COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE POR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REOUIREMENT,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 POLICES.LIMITS SHOWN MAY WAVE BEEN REDUCED BY PAID CLAIMS. liras 1100C IOW ' Peaces ' xP urns r TYPE OP INBURANCR , PoU UMBER i..,. ••.�Y• ..,,!•.� er X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 6 1,00_0,000.00 'DAMAGE TO RIO4 TED CLAIU8.MADE I.. OCCUR I4 ISES IEe ocounertpy)_.,, S 100,000,00 M @O EXP(My on..p±,(sa:9 7 6,000.00 A NSN 1876271 01 05/14/2014 05/14/2015 PERSONAL a AM INJURY : 1.000,000.00 GEML AGGREGATE Limit APPLES PER GENERAL AGGREGATE $ 2,000,000.00 POLICY JEI U LOC .fftODUCTO•COMP!OP AGO $ 2,000,000.00 OTHER: S AUTOMODILE LIASILnY ,(E0 SINGLE LIMIT S ANY AUTO BODILY INJURY(Per Ponor) 3 M^ALL OWNED � SCHEDULED BODILY INJURY(Pr ersIdent) S AUTOS NON-OOWNED PROPERLY DAMAGE HIRED AUTOS AUTOS Me ecdilem S UMBRELLA UAS H EACH OCCURRENCE 11 EXCESS LIAR CL 1AIMS.MADE AGGREGATE S - DE071 RETENTIONS pp WORKERSOOMPBNSATION I STATUTE I IQ ,._ AND EMPLOY1Re'LJAOILrrY ANY PAOPRIETORIPARTNL:WBXECUTIVE Y N/A E.L. . .EACH ACCIDENT OFFICdwMrMecM CSCLUDED7 Wandebry In NH) EL.DISEASE-FA cuoL OYFO $ ,4M It YYe�s,de-a Dn unaer DEDCRIPTIOH OF OPESATIPNS below E.I..DIRF.ARF-POLICY LIMIT d DESCRIPTION OP OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Addleenel Remsrb&shadule,m y be PawMO II more woo Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL 88 DELIVERED IN City ORk Park Hots ACCORDANCE WITH THE POLICY PROVISIONS. 14168 Oak Park Blvd-Box 2007 ALITHDRO2D REPRSSSNTATIVE Oak Park Huts,'fat 56082 Attention H n Julia Hultman (�(� 1 (01988.2014 ACORO CORPORATION. All rights reserved. ACORO 25(2014/01) The ACORO name and logo are registered marks of ACORD