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HomeMy WebLinkAboutRainbow Tree Care faD, (6L 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: 1),13 1� Firm or Business Name: al N ,\001/0 ytt- �fNr Type of tree work to be performed: V'�-Qi coif 1s L-(, 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. er Licenses held in nearby cities:l` I lk1lO (,(.Y-e& - yA j D �U►���� Has your company ever had a license revoked in any other city? (YES) (NO) If yes,where? IOENSEFEE: —$311 D_ Name of Business or Company lJ N� lid y COMPLETION OF THE WORKERS LekilOQ )L COMPENSATION INSURANCE AND Business Street Address I TAX I.D. FORMS IS REQUIRED 1, �3L/3 p1 BEFORE A LICENSE CAN BE ISSUED. kh /71 poi-e Y i n THE FORMS ARE ATTACHED. City State/ Zip Code LICENSE EXPIRES THE END OF (i ) lad r I THE CALENDAR YEAR WITHIN Phone Number WHICH APPLIED FOR OR UPON AA,CY- Q( Q v"G• e ,G()/ri EXPIRATION OF LIABILITY Email Address INSURANCE OR WORKERS'COMP. COMPENSATION INSURANCE, WHICHEVER OCCURS FIRST. License No.TW: Date: X015 – a S (/36//5— 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: 'NO\ Applicant's Address: City State Zip Code Social Security No.: Business Information: (Complete only if applicable) Name: Zav1 1L �L ' VrQk Business Address: City State Zip Code Minnesota Tax Identification No.: Vti 3L\ Federal Tax Identification No.: "1 (0� _-I If a Minnesota Tax Identification number is not required, please explain:%IV sji0.,(t( cr/kj-ditbr eSignature Title D to CITY OF OAK PARK HEIGHTS 14168 OAK PARK BOULEVARD-Box 2007 OAK PARK HEIGHTS,MINNESOTA 55082 (651)439-4439 PROOF FWORKERS' O O 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): JI.Q ,trk ,0 0,11%Adol M W Policy Number or Self-Insurance Permit Num.er: ( ,[ ` 1pq-i `Lo' D' - Dates of Coverage: ) 1 OR I am not required to have Workers'Compensation Insurance because: (check one) r- ,, - •loyees covered by law 03M3AFOI M 3T:31431.� A:O PAAT()Pt t , £ ) .V- -.i • • u • - .n• 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..kn wledge,the information provided is true and correct. -P- i\_/LO lir .e_cez-r-C.,. (_. Signature Business Na e \C5 1\ ---\---4.4 , Date: A \ 'c inN.t., 1 .—a-( YV C. S3 .J Business Address �l7 � Telephone Number: l _I 3c2)0 RECEIVED CITY OF OAK PARK HEIGHTS JAN 3 1 ?01,-,- • 14168 H GHTS,MINN SOTA Box 55082 CITY OF MARK HEIGHTS (651)439-4439 —pM 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. i S By: 1 � -22A A Date Corporate Officer or Individual Proprietorship Owner Subscribed and sworn to before me this 2$ day of Ja.nucl✓L„ , 2-0 t�� 1W/ , Notary Public. Re/1r1 Q piv• County. .c JEANETTE M.KRAEMER NOTARY PUBLIC-MINNESOTA My commission expires: 01 13 1 / MyCaw_ianNam r, S:Shared/Forms/Arborist/Tree Worker's License Application Client#: 15516 RAITR ACORDT. CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 12/03/2014 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 NAME: Jeanette Kraemer J.A.Price Agency,Inc. PHONE 952 944-8790 FAX(A/C,No) 952 944-0097 (A/C,No,Ext): 6640 Shady Oak Road E-MAIL ADDRESS: mk P a rlce.com Suite 500 INSURER(S)AFFORDING COVERAGE NAIC# Eden Prairie,MN 55344-6176 INSURER A:Western National Insurance Grp INSURED INSURER B:Markel Inurance Co/Builders Grp Rainbow Tree Company INSURER C: 11571 K-Tel Drive INSURER D: Minnetonka,MN 55343 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 INSR WVD POLICY NUMBER (MM/DDYIYYYY) (MM/DDS) LIMITS A GENERAL LIABILITY CPP105916802 06/01/2014 06/01/2015 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES(EaEocccur ante) $300,000 CLAIMS-MADE X OCCUR MED EXP(Any one person) $5,000 X PD Ded:1,000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 —1 POLICY X JECT- LOC $ A AUTOMOBILE LIABILITY CPP107720601 06/01/2014 06/01/2015(EeaocdeDISINGLELIMIT $1,000,000 ANY AUTO BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS X HIRED AUTOS X AUTOSWNED (Per a cid nt)DAMAGE A X UMBRELLA LIAB X OCCUR UMB100963802 06/01/2014 06/01/2015 EACH OCCURRENCE $2,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $2,000,000 DED X RETENTION$10,000 $ B WORKERS COMPENSATION 020001740 06/01/2014 06/01/2015 X WC STATU- OTH- ER EMPLOYERS'LIABILITY TORY LIMITS Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? N N/A (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/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space Is required) Certificate holder included as additional insured on the general liability, including primary and non-contributory,if required by written con CERTIFICATE HOLDER CANCELLATION City of Oak Park Heights SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Y g THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 14168 Oak Park Boulevard ACCORDANCE WITH THE POLICY PROVISIONS. Box 2007 Oak Park Heights, MN 55082 AUTHORIZED !REPRESENTATIVE I ` �/1/f I S°C..c, A.."- " - ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #S148264/M138162 JMK Client#: 15516 RAITR ACORDTM CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 5/19/2015 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 CON TACT NAME: Jeanette Kraemer J.A.Price Agency,Inc. PHONE RECEIVED PHONE,Ext):952 944-8790 FAX 6640 Shady Oak Road (A/C,No): 952 944-0097 Suite 500 ADDRESS: JmkCd /japrice.com INSURER(S)AFFORDING COVERAGE NAIC# Eden Prairie,MN 553444176 INSURED NAY 1 I` 2 2 7 6'[ INSURER A:"Western National INSURER B:*The Builders Group Rainbow Tree Company INSURER C: 11571 K-Tel Drive Minnetonka,MN 55343 City of Oak Park Weights INSURER D: PM INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW h#AVE-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 POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS A GENERAL LIABILITY CPP105916803 06/01/2015 06/01/2016 EACH OCCURRENCE _ $1,000,000 PREMISES( X COMMERCIAL GENERAL LIABILITY Ea oocccurrrence) $300,000 CLAIMS-MADE X OCCUR MED EXP(Any one person) $5,000 _ X PD Ded:1,000 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 H( JECT LOC $ A AUTOMOBILE LIABILITY CPP107720602 06/01/2015 06/01/2016(Ea accidentSINGLE LIMIT $1,000,000 ANY AUTO BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS ( ) X HIRED AUTOS X N -OWNED PROPERTY DAMAGE AUTOS (Per accident) $ $ A X UMBRELLA LIAB X OCCUR UMB100963803 06/01/2015 06/01/2016 EACH OCCURRENCE $2,000,000 _ EXCESS LIAB CLAIMS-MADE AGGREGATE $2,000,000 DED X RETENTION$10,000 $ B WORKERS COMPENSATION 030001740 06/01/2015 06/01/2016 X WC STATU- 0TH- AND EMPLOYERS'LIABILITY Y/N TORY LIMITS ER ANY OFFICER/MEMBER EXCLUDED?ECUTIVE N N/A E.L.EACH ACCIDENT $1,000,000 (Mandatory in NH) ---.-- -_..—._-._ ___--E.L,GISE�ASE MX , --------- - tf yes,describe under - _ -- ----- ---- - — -- uESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) *Insurer A:Western National Mutual Insurance Company *Insurer B: Markel Insurance Company/The Builders Group Certificate holder included as additional insured on the general liability,including primary and non-contributory,if required by written c CERTIFICATE HOLDER CANCELLATION City of Oak Park Heights SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 14168 Oak Park Boulevard ACCORDANCE WITH THE POLICY PROVISIONS. Box 2007 Oak Park Heights, MN 55082 AUTHORIZED REPRESENTATIVE I ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #S158173/M158097 JMK 1