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Home My WebLink AboutInstant Green Tree Planting, Inc. 4 CITY OF OAK PARK HEIGHTS RECEIVED 14168 OAK PARK BOULEVARD-Box 2007 OAK PARK HEIGHTS,MINNESOTA 55082 (651)439-4439 APR 16 2015 CITY OF OAK PARK HEIGHTS w Oak FyHeights 2015 -- \A NS WORKER'S LICENSE APPLICATION Date:X--\\\ N S Firm or Business Name:--7Y i"\ `-� Pr � f-( Q•V\�VZ `��(1C Type of tree work to be performed: .— `l -e-( �ovv\. 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 I _I liability that may come against the license/permit holder. C ♦ Proof of WORKERS COMPENSATION INSURANCE.'/ _ I —I —I go ♦ State and Federal Tax Identification numbers pursuant to MN STATE STATUTE 270.72. I� ♦ 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? T LICENSE FEE: $30.00 �r 3 V\r �C�e�'- \C e k)V.ti\-\■r( Name of Business or Company COMPLETION OF THE WORKERS Cic‘1\ - \ d" COMPENSATION INSURANCE AND Business Street Address TAX I.D. FORMS IS REQUIRED _ BEFORE A LICENSE CAN BE ISSUED. s',� r Y \l'J� THE FORMS ARE ATTACHED. City State Zip Code i 1 LICENSE EXPIRES THE END OF S .I )_ --A --1 .5c 1 THE CALENDAR YEAR WITHIN Phone Number ` \ WHICH APPLIED FOR OR UPON Av.��m e \�°54of\'�C,t�(teyAcel.Q 0, \t.��j, L V+°v1 EXPIRATION OF LIABILITY Email Address ( INSURANCE OR WORKERS'COMP. COMPENSATION INSURANCE, WHICHEVER OCCURS FIRST. License No.TW: Date: 2 Za15 j`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. _ _— n3%033354 - Sri Under the Minnesota Government Data Practices Act and the Federal Privacy Act of 1974,we are required t 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: Applicant's Address: City State Zip Code Social Security No.: Business Information: (Complete only if applicable) Business Name: � 2 Business Address: ("\�J `adder \13-17- City 1/4)\—\ State Zip Code Minnesota Tax Identification No.: \0\ 01-1 Federal Tax Identification No.: � ' \, LA CIS If a Minnesota Tax Identification number is not required, please explain: Signature Title Date ' 0. . 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): T i f .\ �t- Policy Number or Self-Insurance Permit Number: k A.D N 5)-- 4(4 ° \ Dates of Coverage: OR - - , wed to have rkers'Compensation Insurance because: (check one) wpb 31. A*0181A2 Nosio%h;ve no em oyees covered by law vg to Othe •- • I have read and understand my rights and obligations with regards to business licenses, permits and Workers'Compens • verage and hereby certify by my signature below that to the best of my k dge,the informat n provided is true and correct. r ..j.-1,44-rp.,,,pr- ye, vq.......... ii i Z./ Signature Business Name Date: 4--li1.3/I- Fa--4'1 vim-- S1-0 Business Address Telephone Number: *Si)7 1 ? --2-5-0"1 Si .Y 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 attorne es and costs incurred relative to such claims and losses. Date Corporate Officer or Individual Proprietorship Owner Subscribed and sworn to before me CG`S this I'D day of A�. . kA4444 '�` veA- , Notary Public. SAMNA JERLOW • �` County. a W min My commission expires: lip , c�01 S:Shared/Forms/Arborist/Tree Worker's License Application 1'52l,IN1a.o. ® ACORD CERTIFICATE OF LIABILITY INSURANCE l2/i/20114) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS `.''V CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES rit .. U-. BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED N REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. p IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to cA 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 1-800-851-7740 CONTACT Cindy Felchner (Account #219661) Florists' Mutual Insurance Company/Hortica, PHONE FAX N Florists' Insurance Services Inc IAIC.No,Extl; 800-851-7740 ext 1940 WC,Nol: 866-819-9256 P O Box 428 ADDRESS: cfelchnerehortica.com W 1 Horticultural Lane Edwardsville, IL 62025 ___ _ INSURER(S)AFFORDINGCOVERAGE _ _NAICS Maguire Agency INSURERA: FLORISTS MUT INS CO 13978 INSURED INSURER B: Instant Green Tree Planting Inc, St Croix Tree Service Inc INSURER C: 943 120th Street INSURERD: Roberts , WI 54023 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 42370658 REVISION NUMBER: THIS IS-TO CERTIFY-THAT THE POLICIES-OF INSURANCE LISTED BELOW.BAVE-BEEN ISSUED_TOSHE INSURED NAMED ABOVE FOR THE POLICY_PERIOQ___ 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 SUER POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER IMM/DDIYYYYI (MMIDDIYYYY) A GENERAL LIABILITY BP13127 01/01/15 01/01/16 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED I COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) $1,000,000 CLAIMS-MADE I X I OCCUR MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 — !POLICY PRO- --JFCT LOC S A AUTOMOBILE LIABILITY FMA009091 01/01/15 01/01/16 COMBINED DSINGLELIMIT 1,000,000 X ANY AUTO BODILY INJURY(Per person) S _ _ ALL OWNED SCHEDULED BODILY INJURY(Per accident) S HIRED AUTOS X NON-OWNED PROPERTY DAMAGE S X_ AUTOS (Per accident) S A X UMBRELLA LIAB X OCCUR EX10336 01/01/15 01/01/16 EACH OCCURRENCE $2,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $2,000,000 DED X RETENTIONS 10,000 S A WORKERS COMPENSATION WCN32669 01/01/15 01/01/16 X WCSTATU- OTH- AND EMPLOYERS'LIABILITY TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE Y] N/A E.L.EACH ACCIDENT $500,000 OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $500,000 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Ramat*.Schedule,N more space Is required) Evidence of Insurance CERTIFICATE HOLDER CANCELLATION MINI SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Oak Park Heights THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 14168 Oak Park Boulevard Box 2007 AUTHORIZED REPRESENTATIVE 4 Stillwater, MN 55082 tn'��U I USA ®1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD df ant 42370658