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Home My WebLink AboutM & S Tree Removal - Expired 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: ) , j�./: Firm or Business Name:,..A.;"7„9":::-; Type of tree work to be performed: 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: <,7,- Has your company ever had a license revoked in any other city? (YES) If yes,where? LICENSE FEE: $30.00 _, '' ,r; r Name of Business or Company COMPLETION OF THE WORKERS . /ZJc 1(MJ /Cie l) COMPENSATION INSURANCE AND Business Street Address TAX I.D.FORMS IS REQUIRED _ BEFORE A LICENSE CAN BE ISSUED. Ii'LCJj 4E>r /"j c THE FORMS ARE ATTACHED. City State Zip Code / ,e 7 ' LICENSE EXPIRES THE END OF (f j '` ) J�— THE CALENDAR YEAR WITHIN Phone Number WHICH APPLIED FOR OR UPON EXPIRATION OF LIABILITY Email Address INSURANCE OR WORKERS'COMP. COMPENSATION INSURANCE, 9-I WHICHEVER OCCURS FIRST. License No.TW: Date: A - 5.. 01�— Zel 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 315t) Personal Information: (Complete only if applicable) c./' Applicant's Name: /":� ✓�",--�' � l,'�-a�. ( /, Applicant's Address: /) City State Zip Code Social Security No.: 67//— /' - _>/! Business Information: (Complete only if applicable) Business Name: /%'f". :) 'fr'!G Business Address: � � ."'�%/< .�� U /Li _ City State Zip Code Minnesota Tax Identification No.:`�?,- ?��l r' Federal Tax Identification No.: Y .,''�9'9�-'/ If a Minnesota Tax Identification number is not required, please explain: Signature Title Date pA. V., 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 not 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. Signature Business Name /1.1(3c.:( d At..J '> /kJ Date: , �t Business Address Telephone Number: ( ) 5 / 7 T 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. By: Date Corporate Officer or Individual Proprietorship Owner Subscribed and sworn to before me this day of I(Y\C,rCleN, , 070 5 . �M • '_ >,. 11 4. A Notary Public. - �� _ MARY SEIGER 1 County. Nd�M1l 1C•M dfA My commission expires: �V1 , 3 yr lai6�YUJ�n 81.2016 S:Shared/Forms/Arborist/Tree Worker's License Application MAR-9-2015 09:34 FROM: _ T0O6514390574 P. 1/1 1 DATE tMMmon*+rw1 ACO d CERTIFICATE OF LIABILITY INSURANCE os/lsnola CHIT IFICAT DOE IS ISSUED AFFIRMATIVELY A 1AATTEO pNEGAT VELY AMEND, EXTEND OR ALTER THE COVERA E AFF CERTIFICATE HOLDER.THIS BELOWCATE DCES NOT OF INSUR OR AUTHORIZED BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER. IMPORTANT: conditions lof the polliicy,I certain DponO s may require on endorsement.must A statement on this certificate doss not confer rights to the the tams and certificate holder In lieu of such endorseme •. Bruce Wegner —' PRODUCER MnM6 PAR... (851)738.1554 w�ALt�ws- (651)758.1217 Lint,we. Clair Wagner and Sons Insurance Agency,Ltd. yybITlpta(�Qmetl.00IT1 --• 0082 12th Street NoAh NA►c 0 Oakdale,Mn 55128 INSUR RI9)AIoRDINO.covERAOE . ir9uR9RA: Wit Bend Mutual Ins.Co. _— INeun80 INsuseR a: - ...- Mathew P.Schmidt dba amuses c M 8 S Tree Removal INSURER Q: - „ 1067 Nolan Ave N .yien BR tl) Stlliwater.Mn 55082 Rea P• REVISION NUMBER: COV ERAGES CERTIFICATE NUMBER: R FOR THE POLICY PERIOD INDICATED.CNOIWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OFBANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. HEREIN IS SUBJECT TO ALL THE TERMS, "lhOUCY,so rOUCY Ear tJMITe INaR Y NUMB +•• S 1,000,000.00 Type on GENERAL EACH OCCURRENCE X cnMMERCU1l bl!11ERAL LIABtLRY EACH g too.000,00__ PPEMIS�• a 5,000.00 �_ CI,AIMS•MADE OCCUR MED ExP(Anyone parson), S -- 05/14/2014 05/14/2015 PERSONAL a AOV INJURY $ 1,000,000.00 NSN 1878271 01 A __ GENERAL AGGREGATE $ 2,000,000.00 06NL gryCRE4VRE PRO-APPLIES PER: PRODUCTS-COMPIOP ADO s 2,000,000.00 U LOC S — POLICY, J6C s • QNPO oLIaluEO t;n+DLgI..IwT - AUTOMOBILE LWaILmr e0fndeMl BODILY INJURY(Ph parson) S ANY AUTO �_ BODILY INJURY(Per Bement) S SCHEDULED —AUTOS -- NON•OWNED Ca S —� I HIRED AUTOS AUTOS C�I0f�1 EACH OCCVRRENCE S .....� UMBRELLALW5 _ OCCUR EACH AGGREGATE S excuse LIAR ,(. CIAIM$-MATE i , � DEO 1 RETENTION t, .. 1Y7 X —.. W D OIMPL YNTu UAIIII ON EL.EgCM ACCIDENT = .. AND CMPLOrTOR ARTNn'r Y J N BA ANY(Ms PROPRifiTORIPARTNERtEXECUTIVB N i A EL.DISEASE•EA EMPLOYEE 6 ._� OFFICER/MUeOCR EXCLUDED? (Mendelory M NH) E.L.DISEASE•POLICY LIMIT S H Ss,001601101 ton:," •:3CRIJ •N OF OP.' • 'twlow DESCRIPTION OP OPERATIONS I LOCATION!I VEHICLES(ACORD 10',ALIOl001'SI Ren.ert.echsdUM,may bo attached If more epees I.',gutted) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL Be DEUVCREO IN ACCORDANCE WITH TNG POLICY PROVISIONS. City of Oak Park Hgts 14168 Oak Park Blvd-Box 2007 Jamm ano�Pnesewrsters Oak Park Hgta,Mn 55082 a• W C Attention Julie Hultman 4104..4-"C-4-- I 0 1988.2014 ACORD CORPORATION. All rights reserved. ACORD Z5(2014101) The ACORO name and logo are registered marks of ACORD