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Home My WebLink AboutPalmer Arborist Services LLC k ��• #. f 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 Q Date: v -/C Firm or Business Name: fit-// i ñc /7 '—/ f�iV/ cf LLC Type of tree work to be performed:#/4/7/17" rie-717, />7,9, 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: f/ '//&✓a-, //" Has your company ever had a license revoked in any other city? (YES) (10 If yes,where? LICENSE FEE: $30.00 Pfn «� Name of Business or}Company COMPLETION OF THE WORKERS /2 /7e 7 /7/ 1 ,' /i /I/ COMPENSATION INSURANCE AND Business Street Address TAX I.D. FORMS IS REQUIRED /VA/ /'4iZ BEFORE A LICENSE CAN BE ISSUED. l C�i/// THE FORMS ARE ATTACHED. City State Zip Code LICENSE EXPIRES THE END OF (6c/ ) y?/ - /730 THE CALENDAR YEAR WITHIN Phone)Number WHICH APPLIED FOR OR UPON /�G�/�L�/� f 2/1/Z/ /9 a/ i 1 7 EXPIRATION OF LIABILITY 'Email Address INSURANCE OR WORKERS'COMP. COMPENSATION INSURANCE, WHICHEVER OCCURS FIRST. License No.TW: Date: zo is 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: ( A//43-e-1' 7 , Applicant's Address: 1 � / 7 4 / /'t14/ 5'9g'2 City State Zip Code Social Security No.: Business Information: (Complete only if applicable) Business Name: $[of nib `ff 1-e/k'7 C"er (� Business Address: I Z Y 3& / / c/ (11/ /I/ I'll(/ cos?'2 City State Zip Code Minnesota Tax Identification No.: / Federal Tax Identification No.: V 7 3/7/ 0 e"' If a Minnesota Tax Identification number is not required, please explain: Xe/71.'e-4-E_ 7 A41-ems Signature Title Date #: 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) KI have no employees covered by law Other(specify) -7''llyalicreadArtclunderstand 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 knowledg ,the information provided is true and correct. /4A-- b/44-67‘ /97.bd.-/"'il fie.- /' .e_.c-IL(' Signature Business Name Date: �,- g /c /7 V / 771'4 r/; cf/V f/S"4"csele, - /1/Ssoez Business Address 7 Telephone Number: ( /) '�7�r'/j 3' ry � 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. B y: /"" t4411- t' Date Corporate Officer or Individual Proprietorship Owner Subscribed and sworn to before me this zi\fi day of ilk Lit� t)(5 • Notary Public. t JC1s k,l VICZY1 County. JENNIFER M.QINSKI .•. My commission expires: i i S i ) ' 1 7 Aq �s y MINNESOTA ; ; ccamission Expitesan.31,2017 S:Shared/Forms/Arborist/Tree Worker's License Application ActREI CERTIFICATE OF LIABILITY INSURANCE OATS(MM/DD/YYYY) 5/8/2015 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 pollcy(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 Petersen Associates NAME: American Advantage — Petersen & Associates, Inc. PHONE (262)432-0789 (AJAx C,No): (262)492-0790 J A/C A No,Ext): 15171 W National Ave ADD ee:info @petersenassoa.aom INSURER(S)AFFORDING COVERAGE NAIC S New Berlin WI 53151 INSURER West Bend Mutual In 15350 INSURED INSURER B: Palmer Arborist Services LLC INSURER C: 12430 77th CT N INSURER D: INSURER E' Stillwater MN 55082 INSURER F: COVERAGES CERTIFICATE NUMBER:CL1522400449 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 AWL• :. POLICYEFF POLICY EXP LIMITS LTR TYPE OF INSURANCE (�D YND POLICY NUMBER (MMiDD/YYYY),(MM!OD!YYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 TO Reii ED A - CLAIMS-MADE X OCCUR DAMAGE ES(Ea occurrence) $ 100,000 115V19416692 6/11/2014 6/11/2016 MEDEXP(Any oneperson) $ 5,000 PERSONAL&ADVINJURY $ 1,000,000 GE 'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 — X POLICY _PRO-T n LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: Property dam eye-Slnple limit $ AUTOMOBILE LIABILITY CO MBIINgDtSINGLELIMIT $ ?Fa ANY AUTO BODILY INJURY(Per person) $ — ALL OWNED —SCHEDULED BODILY INJURY(Par accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS _ AUTOS (Parscoldent) $ UMBRELLA LIAB _OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION 1 PER 0iH- AND EMPLOYERS'LIABILITY Y N STATUTE FR ANY PROPRIETOR/PARTNER/EXECUTIVE — N iA E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED/ (Mandatory In NH) — E.L.DISEASE-EA EMPLOYE $ It yes,describe under DESCRIPTION OF OPERATIONS bolow E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS!LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more apace Is required) CERTIFICATE HOLDER CANCELLATION (651)439-0574 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Oak Park Heights THE EXPIRATION DATE THEREOF, NOTICE WILL CE DELIVERED IN 14168 Oak Park Blvd N ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 2007 Oak Park Heights, IV 55082 AUTHORIZED REPRESENTATIVE Eric Petersen/KGA < t/' ,, JA, °'=" ®1988-2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014/01) The ACORD name and logo are registered marks of ACORD INS025(20)4011 --� lrC1% 11r-IIaM I C Jr L1HDILI I T IIVOURHIVLCI 10/26/2015 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 certIfIcata does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER CONTACT Kim Gard.yr ecki NAME: American Advantage - Petersen & Associates, Inc. PHONE (262)432-0789 FAX (262)492-0790 (A/C,Na.Ertl: (A/C,Not; 15171 W National Ave A►DDIEee;kim@petersenassoa.00m INSURER(S)AFFORDING COVERAGE NAIC it New Berlin WI 53151 INSURERA West Bend Mutual Ins 15350 INSURED INSURER B: Palmer Arborist Services LLC INSURER C: . 12430 77th St Court N INSURGRO: INSURER E: . Stillwater MN 55082 INSURER F: COVERAGES CERTIFICATE NUMBER:CL15102600613 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 AOPI.5UER POLICY EFF POLICY EXP LIMITS LTR INC1WD POLICY NUMBER IMM/DOMYYY) IMM/ODIYYYYI X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 100,000 A CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ 1346692 05 6/11/2016 6/11/2016 MED EXP(Any one person) 3 5,000 PERSONAL&ADV INJJRY $ 1,000,000 GENt AGGREGATE LIMIT APPLIESIE ECT I '1PER: GENERAL AGGREGATE $ 2,000,000 X POLICY PRO I I LOC PRODUCTS-COMP/OP AGG $ 2,000,000 Property damn/411%11e limit $ OTHER, AUTOMOBILE LIABILITY E a a COMBIED(SINGLE LIMIT $ ANY AUTO BODILY INJURY(Per person) 3 ALL OWNED —SCHEDULED BODILY INJURY(Per accident) 3 AUTOS — NON-OW'ED PROPERTY DAMAGE $ HIRED AUTOS AUTOS (Per accident) $ UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADEAGGREGATE 3 DED RETENTION$ PtH 0TH-WORKERS COMPENSATION STATUTE ER AND EMPLOYERS'LIABILITY Y I N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT 3 OFFICER/MEMBER EXCLUDED? N IA (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remartl a Schedule,may be attached If mere apace le required) CERTIFICAT,E HOLDER CANCELLATION (651)439-0574 SHOULD ANY OP THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Oak Park Heights THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 14168 Oak Park Blvd N ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 2007 Oak Park Heights, MN 55082 AUTHORIZED REPRESENTATIVE Eric Petersen/KGA e,. " � '" �'`' Y 61988-2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014101) The ACORD name and logo are registered marks of ACORD IN8025(201401)