Loading...
HomeMy WebLinkAboutWoodchuck Tree Care LLC Y ;. 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 TREE WORKER'S LICENSE APPLICATION Date: Jz/l 1 / Z OL Firm or Business Name: W0 oatC-Ii u c-k 7 k & ( r1�VG L- L 6 Type of tree work to be performed: keh d yu.( 7144-W1/41 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: Has your company ever had a license revoked in any other city? (YES) (NO) If yes,where? � ) w „wL ,0 ,I LICENSE FEE: $30.00 ('V oddjJ �V-e1 L - IL (.. Name of > A Business or Company J o COMPLETION OF THE WORKERS �0 , ce-i i1 /24 /”- COMPENSATION INSURANCE AND Business Street Addres _ - 12-111S— TAX EF I.D. FORMS IS RAN BE ISSUED. �'1 1(W M €4' Hry SSOg . C BEFORE A LICENSE CAN BE ISSUED. b Q THE FORMS ARE ATTACHED. City State Zip Code WC., WI)I i 5 LICENSE EXPIRES THE END OF ( 66/ ) 421 72-/ 7 THE CALENDAR YEAR WITHIN Phone Number ,` 'f WHICH APPLIED FOR OR UPON VOOdc u cicA L Vita i. o 0 • (nil EXPIRATION OF LIABILITY Email Address / INSURANCE OR WORKERS'COMP. 2_UI S ^ 0°())° )1/ 111(/' COMPENSATION INSURANCE, WHICHEVER OCCURS FIRST. License No.TW: Date: LICENSE APPLICANT: z 1 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: Business Address: City State Zip Code Minnesota Tax Identification No.: 3575 61 t t S Federal Tax Identification No.: 14 1v— 52 7O's1 If a Minnesota Tax Identification number is not required, please explain: Signature Title Date 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. G Insurance Company(not the Insurance Agent): 3 F 1�l 218 lc, Se b ms Policy Number or Self-Insurance Permit Number: 171 8 706, $O if Dates of Coverage: ?/Z b l w 14— 7/Z(0 110 l S" OR I am not required to have Workers'Compensation Insurance because: (check one) I have no employees covered by law Other p ify) 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. 41110. tAlPhdlAtta.. Sig hure Business Name ' / 131b 'Doti u . Date: ��- f l- ``�' 64/ W "t,v A-P4 �r��Z // Business Address Telephone Number: (i66 ,Z9— 7ZL9l 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. s/f By: tl Date Corpo ate Officer or Individ al Proprietorship Owner Subscribed and sworn to before me thisJt� day of .t ' ZO I ! SSSS `µ�r / I Notary Public. SS � nd County. NON,�FN" ,FFR_ 41' yes 4 My commission expires: 173 f/gpl 7 ,8074 SSS 2b»SSS S:Shared/Forms/Arborist/Tree Worker's License Application o.■•• WOODTRE OP ID:DE '`��RL CERTIFICATE OF LIABILITY INSURANCE DA y1� Y) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS 1 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 CO TACT Deb Erickson Eagle Point Insurance PHONE 651-209-9330 651-209-9332 FAX 8615 Eagle Pant Blvd. (A/C.No.Ext): (A/C,No): Lake Elmo,MN 55042 E-MAIL Jeff Zignego SS:Deb@eaglepointins.com INSURERS)AFFORDING COVERAGE NAIC# INSURER A:Secura Insurance 22543 INSURED Woodchuck Tree Care LIc INSURER B: Tyler: 7310 Jocelyn Road N INSURER C 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. INSR ADDL SUBR POUCY EFF POLICY EXP L7R TYPE Of INSURANCE JNSO WVD POLICY NUMBER (MMIDD/YYYY) (MMIDD(YYYY) LIMITS A X COMMERCIAL GENERAL UABIUTY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR X CP3227904 08/27/2014 08/27/2015 DAMAGE TO RENTED 100,000 PREMISES(Ea occurcence) $ MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GE 'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY JECT PRO LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE UABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) A ANY AUTO 3227905 08/27/2014 08/27/2015 BODILY INJURY(Per person) $ ALL OWNED X AUTOS X SCHEDULED BODILY INJURY(Per accident) $ AUTOS X NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS (Per accident) _ $ X UMBRELLA UAB X OCCUR EACH OCCURRENCE $ 2,000,000 A EXCESS LIAB CLAIMS-MADE CU3227906 08/27/2014 08/27/2015 AGGREGATE _ $ 2,000,000 DED X RETENTION$ 10,000 $ WORKERS COMPENSATION AND EMPLOYERS'UABIUTY Y/N STATUTE ER ANY PROPRIETOR/PARTNERJEXECUTIVE 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/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION CITYOAK SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Oak Park Heights THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ty g ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 2007 14168 Oak Park Blvd N AUTHORIZED REPRESENTATIVE Oak Park Heights,MN 55082 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD • ® DATE(YM/DD/YYYY) AC ORE CERTIFICATE OF LIABILITY INSURANCE 12/18/2014 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 POUCIES 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(es)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 Northern Capital Insurance Group NAME: SFM Risk Solutions PO Box 5396 No.Era: 438 FAX,Not: 952-838-2000 Minneapolis,MN 55440-9396 ADDRESS: arpj>hsrlsfmic.com INSURERS)AFFORDING COVERAGE NAIC# INSURER A: MWCARP c/o SFM Risk Solutions INSURED Woodchuck Tree Care LLC INSURER B: 7310 Jocelyn Rd N Stillwater,MN 55082-8324 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 Afxx..SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD V/VD POLICY NUMBER IMMIUOIYYYY).(MM PD/YYYYI UNITS COMMERCIAL GENERAL UABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GE 'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY P'E LOC PRODUCTS-COMP/OP AGG- $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accidera) — 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 LAB _ OCCUR EACH OCCURRENCE _ $ EXCESS LAB CLAIMS-MADE AGGREGATE $ DEC RETENTION$ $ WORKERS COMPENSATION El A AND EMPLOYERS'LIABILITY Y/N STATUTE ER TH- EACH ACCIDENT $ $100,000 OFFICER/MEMBER EXCLUDED?PROPRIETOR/PARTNER/EXECUTIVE N/A 48706.804 07/26/2014 07/26/2015 EL. (Mandatory In NH) EL.DISEASE-EA EMPLOYEE $ $100,000 N yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ $500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Sc h dde,may be aid I more space is required) Special provision:WC 00 03 08.Partners,Officers,and Others Exclusion Endorsement is attached to the policy. An ownerfofficer/other has rejected coverage. CERTIFICATE HOLDER CANCELLATION City of Oak park Heights SHOULD ANY OF THE ABOVE DESCRIBED POUCIES 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 01988-2014 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. WOODTRE OP ID: DE '4+��.---RL CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 08/24/2015 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(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:CONTACT Deb Erickson Eagle Point Insurance 8615 Eagle Point Blvd. (A/CC,Nr o.Ext):651-209-9330 FAX No): 651-209-9332 Lake Elmo,MN 55042 E-MAIL ESS:deb©eaglepointins.com Jeff T.Zignego RECEIVED INSURER(S)AFFORDING COVERAGE NAIC# INSURER 4:Secura Insurance 22543 INSURED Woodchuck Tree Care LIc INSURER a:SFM Mutual Insurance Company Tyler: AL r: Z 4 7310 Jocelyn Road N 1 INSURER C Stillwater,MN 55082 INSURER D: INSURER : City of Oak Park Heights INSURER : COVERAGES CERTIFACME NUMBERQM -PM 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 SUBR POLICY EFF POLICY EXP LTR INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR X CP3227904 08/27/2015 08/27/2016 DAMAGE-Sr O PREMISE (Ea RENTED 100,000 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GE 'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000 POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 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) $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 2,000,000 A EXCESS LIAB CLAIMS-MADE CU3227906 08/27/2015 08/27/2016 AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER Y/N B ANY PROPRIETOR/PARTNER/EXECUTIVE 048706.804 07/26/2015 07/26/2016 E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? N/A --- - (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 --- -_...-- If yes,describeander_ --- _ -- --. - - - ------ ------ — DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 Commercial Applica DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION CITYOAK SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Oak Park Heights THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN tY 9 ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 2007 14168 Oak Park Blvd N AUTHORIZED REPRESENTATIVE Oak Park Heights, MN 55082 Jeff T.Zignego i ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD