HomeMy WebLinkAboutItem 06.iMay 16, 2011
Proposed Action
Overview
APPROVAL OF TREE WORK LICENSE
FOR ST. CROIX TREE SERVICE, INC.
Item No.
Staff recommends adoption of the following motion: Approve tree work license for St.
Croix Tree Service, Inc.
Passage of this motion will result in issuing a tree work license for St. Croix Tree
Service, Inc.
The City of Lakeville licenses companies that provide tree care (Le. pruning, removal,
trenching and injections) in the city.
St. Croix Tree Service, Inc. has submitted an application for a tree work license.
Staff is recommending approval of a tree work license for St. Croix Tree Service Inc.
Primary Issues to Consider
d Applicant paid fee and submitted Certificate of Insurance.
Q Staff contacted the applicant and verified they are knowledgeable about arbor
practices and proper tree care.
Supporting Information
O Copy of Application for Tree Work License submitted by St. Croix Tree Service Inc.
J6hn Hennen
Park Maintenance & Operations Mgr
Financial Impact: $ Budgeted: YIN Source:
Related Documents (CIP, ERP, etc.):
Notes:
APPLICATION FOR TREE WORK LICENSE
CITY OF LAKEVILLE
20195 Holyoke Avenue, Lakeville, MN 55044
Phone: 952 -985 -4400
1. Business name: 5.\-. -C
2. Phone no: (Cfj cj - ` 317 : 115 3 ( 'jt�
Fax: �- S
3. Contact person: Q -2_0, b( . t fl t Title: 'C
4. Mailing address: (ill
] �'�Q i'
Street City Zip
i'1 ON
5. Person to be contacted in emergency:
6. Business ownership:
7. Number of employees:
9. Number of vehicles:
Individual
- -- Partnership Corporation
List names of employees, partners or officers below:
8. Minnesota Tax Identification No. of business
(or Social Security No. if applicant is an individual): ,t o �.: n CF
10. Type of equipment to be used in business: \ LC &- \ , }fit AY Lit[ f� J
c. \ - - , , c A_,. Y'` •f]i :, 1 %\vv ', Y (Ci, 9 it ` } k"GI C ,")
11. Will you be using chemical substances in any activity related to treatment or disease
control? YES , NO (If YES, certification by the Agronomy Division of the
Minnesota Department of Agriculture as a "commercial pesticide applicator" must be attached.)
12. Please provide the following information related to workers' compensation insurance,
or certify the precise reason your business is excluded from compliance with the
insurance coverage requirement for workers' compensation.
Insurance company name (NOT agent): ( G�-k
Policy number or self - insurance permit. number: .N Ni Ct 1 1 J 1 ot u f
APPLICATION FOR TREE WORK LICENSE Pa _2_
1 (CONTINUED)
Dates of coverage: to } —
(or)
I am not required to have workers' compensation liability coverage because:
( ) 1 have no employees covered by the law,
( ) Other (Specify)
13. Proof of public liability insurance, covering all operations, for the sum of $300,000
combined single limit coverage must be attached.
14. Is your company licensed in any other city? If so, please list:
If not licensed in other cities, please use the spaces alcove to list references and phone numbers.
I, the undersigned, hereby certify that the above information, furnished by me, is true and
correct to the best of my knowledge. 1 further acknowledge that 1 have read and
understand the attached "Tree Preservation" and "Shoreland Impact" guidelines.
h o r ed Si�.nat�u•e
Aut g
D Title ��
TP.E1 APPL.doe(11.!22102)
MAW
.` Pct. LA
Date:
ANNUAL FEE: $25.00
A.11 Licenses. Expire December 31st
FOR CITY USE :ONLY:
Approved By: Date Fee Paid:
Date: Amount Paid: S
Receipt No:
License No: