Loading...
HomeMy WebLinkAboutMonster Tree Service - 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: 11 I /S Firm or Business Name: V'lotn,S TIC 5 ' c_` Type of tree work to be performed: vi 5�� ,p ' c��'�'�' ' 4 -a G'CI 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. Licenses held in nearby cities: 411 W e '�� j( 0J6J.,4 Has your company ever had a license revoked in any other city? (YES) (NO) cf�,I V If yes,where? p� c�,,' • LICENSE FEE: $30.00 Yv S� " ��`� ��` •u Name of Business or Company /�� _ U)11 �� I COMPLETION OF THE WORKERS L ey `" Y COMPENSATION INSURANCE AND Business Street Address TAX I.D. FORMS IS REQUIRED LtA 0140 IAN 5 ow' BEFORE A LICENSE CAN BE ISSUED. {; G Y•y'" v ` THE FORMS ARE ATTACHED. City �tyy State Zip Code LICENSE EXPIRES THE END OF (( ) /6S— THE CALENDAR YEAR WITHIN Phone Number cJ sA,A.4, tok 1444 S WHICH APPLIED FOR OR UPON CY EXPIRATION OF LIABILITY Email Address INSURANCE OR WORKERS'COMP. COMPENSATION INSURANCE, WHICHEVER OCCURS FIRST. License No.TW: Date: -02C -- 5 ) 19115 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. ZTAAJI ��� �u c R�, Insurance Company(not the Insurance Agent): , Policy Number or Self-Insu nce Permit Number: 144 1•I A(-bODE)C) ce1)--o- , Dates of Coverage: ce pf,Qctot,4-- 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. Sign.re Business Name Date: 5 k l Business Address 51 Telephone Number: O 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 311 Personal Information: (Complete only if applicable) Applicant's Name: t f US IA V't' Seto Applicant's Address: 1 1S' e.Q 7 1 eN CfC gutic9LA sitotio City State State Zip Code Social Security No.: 417--I6- 20'1 Business Information: (Complete only if applicable) Business Name: litn@SOn.Lk IIAI US %-tS O a -4ee 4I2.0 sevu'ci Business Address: R q AV( f City ( State Zip Code Minnesota Tax Identification No.: Federal Tax Identification No.: LE4` 51(D4 12 If a Minnesota Tax Identification number is not required, please explain: 613 Signatu a Title Date } ti , 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 incurre rel tive to such claims and losses. r By: Date Corpo :te officer or Individual Proprietorship Owner 1 ycl 1 C G Subscribed and sworn to before me this I l day of mal , Oo I rJ . kit - veilotiftio , .A Notary Public. V r i► I County. MARY SEIGER — k I County. PUBLIC-MIMEO= I 01TA My commission expires: � Jan 31, 8 S:Shared/Forms/Arborist/Tree Worker's License Application MASON-1 OP ID: HR .4WRLY CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD(YYYY) �• � 05!1112015 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 NAMEEACT Heidi L Robbins,CIC Sandeen Agency,Inc. PHONE 715-386-5825 FAX 715 386 605 Second Street (A/C,No,Ext): (A/C,No): - -1466 Hudson,WI 54016 ADMDRESS:hrobbins @sandeen.com Heidi L Robbins,CIC INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:National Specialty Insurance INSURED Masonick Industries Inc INSURER B: Monster Tree 3687 Layton Ave INSURER C Lake Elmo,MN 55042 INSURER 0: 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 ',S D,V/VD POLICY NUMBER (MM/LDDIYEYYY) (MMIDDIYYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR NSU2117911 06/27/2014 06/27/2015 PREMSES EaoccurrDence) $ 300,000 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 $ I (Ea accident) I 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 OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS LIAB ^CLAIMS-MADE NSU2117911 06/27/2014 06/27/2015 AGGREGATE _$ 1,000,000 DED RETENTION$ $ WORKERS COMPENSATION PER O f H- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE NIA E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ It yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION OAKPA-1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Oak Park Heights ACCORDANCE WITH THE POLICY PROVISIONS. 14168 57th St N PO BOX 2007 AUTHORIZED REPRESENTATIVE Oak Park Heights,MN 55082 ki,-,(4/e.,,,66„:„,) 1 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD • ® DATE(MM/DDMlYY) ACORD CERTIFICATE OF LIABILITY INSURANCE `...►--- 05/12/2015 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 C. I PRODUCER VEINED CONTACT Heidi Robbins NAME: Sandeen Agency Inc PHONE,,E,t:715-386-5825 FAX No): 605 2nd St EMAIL ADDRESS: PO Box 107 MAY 1 5 7015 INSURER(S)AFFORDING COVERAGE NAIL p Hudson,WI 54016 INSURER A: MWCARP c/o RTW,Inc. INSURED Masonick Industries Inc INSURER B: DBA:Monster Tree City of Oak Pads Heights INSURER C: 3687 Layton Ave —....0104 — INSURER D: Lake Elmo,MN 55042 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 ADDL SUBR POLICY EFF POLICY EXP UMITS LTR INSD WVD POLICY NUMBER (MMIDD/YYYY) (MDD/YYYY) COMMERCIAL GENERAL LIABILITY 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 JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE UABIUTY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS (Per accident) $ UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED - RETENTION$ $ WORKERS COMPENSATION I PER I ER OTH- COMPENSATION . STATUTE -I - --- - -- -AND-EMPLOYERS'LIABILITY YIN — - - �..----- - A ANY PROPRIETOR/PARTNER/EXECUTIVE ECUTIVE Y N/A N MNAR-0000036750-1 10/17/201410/17/2015 E.L.EACH ACCIDENT $ 100,000.00 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 100,000.00 If yes,DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 500,000.00 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Officers are excluded from coverage. CERTIFICATE HOLDER CANCELLATION ANY OF City of Oak Park Heights THE ULD EXPIRATION DATE DESCRIBED VTHEREOF, NOTICE I WILL BE CANCELLED DELIVERED RIN PO Box 2007 ACCORDANCE WITH THE POLICY PROVISIONS. 14168 Oak Park Blvd N Oak Park Heights,MN 55082 AUTHORIZED REPRESENTATIVE 1 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD