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HomeMy WebLinkAboutNorthern Arborists .. CITY OF OAK PARK HEIGHTS 14168 OAK PARK BOULEVARD-BOX 2007 OAK PARK HEIGHTS,MINNESOTA 55082 (651)439-4439 CITY OF OAK PARK HEIGHTS 2015 62.c. TREE WORKERS LICENSE APPLICATION Date: q Firm or Business Name: lA5wikle.seet, 1100"-S Type of tree work to be performed: 14144112144444e, ' i04414- 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: ��V-, Gw I •Sfi i 'a✓ atik6c44, Has your company ever had a license revoked in any other city? {YES) 64 If yes,where? LICENSE FEE: $30.00 '•.•( \t1 Y -f1e AN b 0406 0 Name of Business or Company t�/ COMPLETION OF THE WORKERS 0 h 4� 1%��`' W`' t'T 121 I c I)C. COMPENSATION INSURANCE AND Business Street Address (2� l‹ TAX I.D. FORMS IS BEFORE A LICENSE C UBE ISSUED. k Ci V `// rro E N + `1 THE FORMS ARE ATTACHED. City State Zip Code LICENSE EXPIRES THE END OF (t;t ) 43 6- QC'? THE CALENDAR YEAR WITHIN Phone Number WHICH APPLIED FOR OR UPON /160044000a.42&,./5 a p' 1•12.7:1- EXPIRATION OF LIABILITY Email Address INSURANCE OR WORKERS'COMP. !� Nag Q )21 I COMPENSATION INSURANCE, Q0�5-• ag 311.14- 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. 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 311 Personal Information: (Complete only if applicable) Applicant's Name: �a L 'p.sie'411"" Applicant's Address: h(9(A (O ' L 6k City State Zip Code Social Security No.: 9"13-'6 P'CIO 6 Business Information: (Complete only if applicable)J )j Business Name: ` 0/, rN ' Ypwtolld Business Address: cS� City State Zip Code Minnesota Tax Identification No.: Federal Tax Identification No.: 41—r I S DMZ If a Minnesota Tax Identification number is not required, please explain: ;,//•"‘"1149 - ,.-w�— �e�..X-1>0 lit' Signat re Title Date 1 ti 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 requirementof 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): e . Policy Number or Self-Insurance Permit Number: fig AO cro 7Z12 I a Dates of Coverage: ti' d �' - 4' (S' OR I am not required to have Workers' Compensation Insurance because: (check one) -. ,w+I4a0 Iployees covered by law 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. ,a..� il/(Pwr,ad Signa ure Business Name •0664 101'1' Si. OP. l Date: OeG• Business Address Telephone Number: (!r( ) 126-1)67 „ 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. ae._. a -?E9t4t- By: Date Corp..c. e Officer or Individual Proprietorship Owner Subscribed and sworn to before me this - day of c P V►1beC, O 19 . kweitlfoi a , (Y�C,I•Y 5 ry CC , Notary Public. l►�C�Sk1n q 7 o h County. - ;_ MARYSEIGER l NOTARY Pt LAC-MINNESOTA My commission expires: 30.A. 3 I 001S. MYCMefon Expires Jet 31,2018 ,1 S:Shared/Forms/Arborist/Tree Worker's License Application �® CERTIFICATE OF LIABILITY INSURANCE OP ID JH DATE(MM/DD/YYYY) 11/20/14 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). Vt1N I Al.l PRODUCER NAME: PHONE GARRY INSURANCENTER A/MAIL C,No,Ext): (NC,No): - 2555 East 7th Avenue ADDRESS: North St. Paul MN 55109 CUSTOMER ID#: NORTAR1 Phone:651-7 7 7-8 3 61 INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURERA: Westfield Companies 24112 Northern Arborists INSURER B: Gary Wemeier dba 106b4 - 10th St. Court N. INSURERC: Lake Elmo MN 55042 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 AUUL SUMH PULIL.Y'EH- POLICY❑XP TYPE OF INSURANCE LTR INSR WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 UAMACit I U HtN I tU A X COMMERCIAL GENERAL LIABILITY CAG3615975 12/15/14 12/15/15 PREMISES(Ea occurrence) $ 100,000 CLAIMS-MADE X OCCUR MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,0 0 0,0 0 0 GENERAL AGGREGATE $2,000,000 GEN'LAGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $2,000,000 7 POLICY JEI LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $500 000 (Ea accident) r A ANY AUTO CAG3615975 12/15/14 12/15/15 BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ X SCHEDULED AUTOS PROPERTY DAMAGE X HIRED AUTOS (Per accident) $ X NON-OWNED AUTOS $ $ UMBRELLA LIAB , OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIV1 r N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? I l (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/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 OAKP001 THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE City of Oak Park Heights 14168 North 57th Street Oak Park Heights MN 55082 ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD I 'I r .b. o D CERTIFICATE.OF LIABILITY INSURANCE 03/17/ 01 ,'HIS 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: 'Ir the certificate holder is an ADDITIONAL INSURED,the policy(les)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 Jeanne Hartman Garry Insurancenter ': PHONE FAX Nor. 651-777-1264 2555 East 7th Avenue 1 E-rilAtE ADDRESS. North St.Paul,MN 55109 INSURER(S)AFFORDING COVERAGE NAIL 0 (j 4 .y�Ep�1{µ{ 1 INSURER A: MWCARP do RTW,Inc. INSURED Gary Wemeier t ft"E r �`"° ° ` INSURER B DBA:Northern Arborists i INSURER C: ■ 10664 10th Street Court N INSURER D: Lake Elmo,MN 55042 i - 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 POUCY EFF POLICY EXP UNITS LTR TYPE OF INSURANCE INSp WVD POLICY NUMBER (MM/DDIYYYY) IMMIDD/YYYY, I COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ ' MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GE 'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY JET 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 — NON GOWNED PROPEERT DAMAGE $ HIRED AUTOS _ AUTOS (Per accident) $ UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED RETENTIONS $ WORKERS COMPENSATION Y I PER OTH- AND EMPLOYERS'UABIUTY I STAT'U'TE. ER A ANY ECUTIVE YN N/A N MNAR-0000007232-10 04/02/201404/02/2015 E.L.EACH ACCIDENT $ 100,000.00 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 100,000.00 If yes, TOunder DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500.000,00 D DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached H more space is required) Sole Proprietor is excluded from coverage. CERTIFICATE HOLDER CANCELLATION City of Oak Park Heights THE EXPIRATION DATE THEREOF, NOTICE POLICIES WILLL CBE CDELIVERED IN 14168 57th St N 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 DATE(MM/DO/YYYY) ACORD® CERTIFICATE OF LIABILITY INSURANCE `../"' 03/11/2015 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(les)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 Jeanne Hartman NAME: Garry Insurancenter jo.Ext):6517778361 (Am.No): 651777 1264 2555 East 7th Avenue RECEIVED IL North St.Paul,MN 55109 ESS: INSURERS)AFFORDING COVERAGE NAIL N MAR 1 6 2015 RER A: MWCARP co RTW,Inc. INSURED Gary Wemeier DBA:Northern Arborists RER C:10664 10th Street Court Ciy of OPark RER D: Lake Elmo,MN 55042 Hi--__ RER E: RER 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 AWL SUBR POLICY EFF POLICY EXP W M/ LIMITS LTR INSR VD POLICY NUMBER (MDD/YYYY) (MM/OD/YYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR PREMISES Ea occurrence) $ MED EXP(Any one person) $ PERSONAL 8 ADV INJURY $ GE 'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ _ POLICY PRO LOC PRODUCTS-COMP/OP AGG $ PRO- JECT _ 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 UAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION _ v PER I OTH- ----- ---ANDEMPLOYbKS'LIABILIrY -- ---- --- -- - __..- -A STATUTE CR ANY PROPRIETOR/PARTNER/EXECUTIVE �Y/" MNAR-0000007232-11 04/02/2015 04/02/2016 E.L.EACH ACCIDENT $ 100,000.00 A OFFICER/MEMBER EXCLUDED? I' I NIA N (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1 00,000.00 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000,00 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) Sole Proprietor is excluded from coverage. CERTIFICATE HOLDER CANCELLATION CCity of Oak Park Heights SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE ity of O 57th Park THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Oak Park Heights,MN 55082 AUTHORIZED REPRESENTATTIVV�EE'7 I ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD