HomeMy WebLinkAbout2007-11-28 Set Agenda
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'Estabfisfid 1857
CITY COUNCIL WORK
SESSIONS & MEETING
AGENDA
COUNCIL MEETING
Wednesday, November 28,2007
6:30 p.m.
_~dr~
L CALL TO ORDER
1. Roll Call
II. PUBUC HEARINGS
llL APPROVALOFAGENDA
IV. APPROVAL OF COUNCIL MINUTES
1. November 14, 2007 City Council Work Session Meeting Minutes (page 1-2)
2. November 14, 2007 City Council Meeting Minutes (pages 3-10)
3. November 14, 2007 EDA Meeting Minutes (pages 11-13)
V. CONSENT AGENDA
1. City or Centerville November 15, 2007 through November 28, 2007 Claims
(page 14 & 14a)
2. Centennial Fire District Claims Through November 15, 2007 (page 15)
3. Pay Estimate #4, PrKision Excavating & Grading LLC - Old Mill Road
Improvements - $104,751.17 (Pages 16-19)
4. Successful Performance Review Publie Works Maintenance Worker - Mr.
Tedd Peterson & Completion or Year 8 or Employment
5. Release of Easement to Anou County HRAlNew Easement Granted to
Correct Errors in Description (pages 20 -24)
VI. A W ARDSIPRESENTATIONS/APPEARANCES
1. Ms. Connie Moore, Alexandra House (pages 25-27)
2. Mr. Mike Thinesin, Centerville Lions Accounting ror Fete des Lacs City
Donation (pages 28-29)
3. Ms. LacheUe Williams, YMCA Update (pages 30.33)
VIL OLD BUSINESS
1. Environmental Assessment Worksheet Response & Comments (Binder)
a. Res. #07-OXX - Adopting Findings of Fact & Record of Detision -
EA W Downtown Redevelopment (page 34) **Replace wlNew
Versionu
2. 2009 Street & Utility Improvements Project
a. Preliminary Survey Scope & Fee Proposal- Bonestroo (pages 35-36)
b. Schedule Input Meeting - 2009 Street Reconstruction Project
3. Items/Structures Placed in Easements - Snowplow Hazards
4. Res. #07-0XX: - Westview Street Watermain Assessment (Page 36a)
5. Res. #07-0XX: - Fairview Street Assessments (Page 36b)
vm. NEW BUSINESS
1. Alexandra House Request Funding for 2008 - $2,074
2. Consider Granting Tobacco Licensing for 2008:
a. Comer Express
b. CenterMart
Co Sagers Bar & Grill
d. Trio Inn
4. Consider Granting On-Sale & Sunday Liquor Licensing for 2008:
a. Sagen Bar & Grill
b. Trio Inn
eo Wiseguy Pizza
4. Consider Granting OfT-Sale Liquor Licensing for 2008:
a. Trio Inn
b. Centerville Liquor Barrel
5. Eagle Pass Twin Townhome Association Request for Screening
6. Anoka County Historical Society Request for Take on Loan for Public
Safety Display: Centerville Horse Drawn Fire Tanker & Bars from Jail
IX. ANNOUNCEMENTSIUPDA TES
1. City Administrator, Mr. Dallas Lanon
2. Downtown Redevelopment
X. ADJOURNMENT
**REMINDERS * *
Thanksgiving Day - November 22,2007 & November 23,2007 - City Hall Closed **HAPPY
THANKSGIVING**
Planning & Zoning Commission Meeting - December 4, 2007, 6:30 p.m. Council Chambers
Parks & Recreation Committee Meeting- December 5, 2007, 6:30 p.m. Council Chambers
EDA Meeting - December 12, 2007, Following Regularly Scheduled Council Meeting Council
Chambers
City Council Meeting - December 12, 2007, 6:30 p.m. Council Chambers
CITY OF CENTERVILLE
11/28/07 12:39 PM
Page 1
tervi{{e
*Check Summary Register@
UPDATE
(E....ta$sh-e.{ 18.:"7
NOVEMBER 2007
Name
Check Date
Check Amt
10100 MAIN STREET BANK
Paid Chk# 022903 ASSURANT EMPLOYEE BENEFIT 11/28/2007
Paid Chk# 022904 BURSTEIN - GLASER 11/28/2007
Paid Chk# 022905 CITY OF ST. PAUL 11/28/2007
Paid Chk# 022906 LAUGHLlNS PEST CONTROL 11/28/2007
Paid Chk# 022907 MEADER, MARK 11/28/2007
Paid Chk# 022908 MENARDS - FOREST LAKE 11/28/2007
Paid Chk# 022909 MINN. DEPT. OF HEALTH 11/28/2007
Paid Chk# 022910 NCPERS LIFE INSURANCE 11/28/2007
Paid Chk# 022911 PETERSON, TEDD 11/28/2007
Paid Chk# 022912 PRESS PUBLICATIONS 11/28/2007
Paid Chk# 022913 QWEST 11/28/2007
Paid Chk# 022914 SPRINT 11/28/2007
Paid Chk# 022915 SWEENEY, KRIS 11/28/2007
Paid Chk# 022916 S.T. SERVICES INC. OF BUFFAL 11/28/2007
Total Checks
$121.50 12-1-07 THRU 1-1-08 SHORT TERM
$13.061.41 COMDEMNATION MATTER - SERV THR
$44.71 ASPHALT
$154.43 PEST CONTROL - CITY HALL
$372.93 OVER PYMT ON UT BILL
$17.99 6' BULL FLOAT EXT HANDLE
$23.00 J. MCPHERSON CLASS D #9528 CER
$32.00 T. BENDER & J. MEYER ADDN LIFE
$50.01 REIMBURSE FOR BOOT ALLOTMENT
$33.30 ORD. AMEND SECT. 51.09
$475.29 651-429-4750 PH SERV THRU 12-1
$244.73 CELL PHONE SERVTHRU 11-14-07
$42.20 MILEAGE REIMBURSEMENTS
$698.00 METER DEPOSIT LESS WATER USAGE
$15,371.50
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~ta6(i.sliuf 1.857
STATE OF MINNESOTA
COUNTY OF ANOKA
CITY OF CENTERVILLE
1880 ~tJin $met, Cenumffe. ~ 55038
651-429-3232",. 'FtJJ(6S1-429-86Z9
RESOLUTION ## 07-_
A RESOLUTION ADOPTING FINDINGS OF FACT AND RECORD OF
DECISION ON ENVIRONMENTAL ASSESSMENT WORKSHEET FOR
CENTERVH..LE DOWNTOWN REDEVEWPMENT
WHEREAS, subsequent to duly given mailed and published notice, the City Council
held a public hearing on November 14,2007 and considered public comments received
during the comment period and during the public hearing, regarding the Environmental
Assessment Worksheet for the Downtown Redevelopment Project; and
WHEREAS, subsequent to the pub1ie hearing the City's engineer bas prepared a
response to comments as well as recommended "Findings of Fact and Record of
Decision" on the subject Environmental Assessment Worksheet.
NOW THEREFORE, BE IT RESOLVED BY THE CITY COUNCn. OF
CENTERYaLEt MINNESOTA:
1. The Findings of Fact and Record of Decision dated November 28,
2007, together with the addendum. dated November 26, 2007, is
hereby adopted.
2. The CenterviUe Downtown Redevelopment Project as described in the
EA W does not have potential for significant environmental effects.
3. An Environmenta11mpact Statement (ElS) will not be required for the
Centerville Downtown Redevelopment Project defined in the EAW.
4. That the City Administrator shall file the final document in his office
as well as file copies with the Environmental Quality Board and with
agencies on the EA W distribution list.
PASSED AND ADOPTED by the City Council this 28th day of November,
2007.
Mayor, Mary Capra
Attest:
Teresa Bender, City Clerk
@
Minnesota Department of Public Safety
Alcohol and Gambling Enforcement
444 Cedar Street, Suite 133
S1. Paul, MN 55101-5133
651-201-7501- TIY 651-282-6555 - Fax 651-297-5259
iJ 2007
RENEWAL OF LIQUOR, WINE, CLUB OR 3.2% LICENSES
'. .' ,N~;jk#1:~ ~~~or~:#t:~~S20~ IDCud{~~~~bY.MNLiiiuoiCoolr1li'~.(3.2% ~~)
Licensee: Please verify your license information contained below. Make corrections if necessary and sign. City
Clerk/County Auditor should submit this signed renewal with completed license and licensee liquor liability for the new license
period. City Clerk/County Auditor are also required by M.S. 340A.404 S. 3 to report aDY Hcense
cancellatioD.
License Code
City/County where license approved.
OFSL
License 1?t:1i.Pd Ending
L:enterVl!!e
12/31/20~
15089
Centerville Liquor Barrel
Licensed Location address
Licensee Name
Trade Name
GNAW Inc.
*7093 20th Ave S
City, State, Zip Code
Cente~ville. MN 55038
Business Phone
651/426-6674
LICENSE FEES: Off Sale $
On Sale $
Sunday $
100.00 0.00 0.00
By signing this reDewal appHcatioD, appUcant certifies that there has beeD DO chaDge iD ownership on the above named
licensee. For changes in ownership, the Ucensee named above, or for new licensees, full applications should be used. See
back of this application for further information Deeded to complete this renewaL
AnolicaDt's siJ:nature on this renewal confirms the foUowiD,: Failure to report any ofthe followml: will result in fines.
1. Ucensee confirms it has no interest whatsoever, directly or indirectly in any other liquor establishments in
Minnesota. If so, give details on back of this application.
2. Ucensee confirms that it has never had a liquor license rejected by any city/township/county in the sate of
Minnesota. If ever rejected, please give details on the back of this renewal, then sign below.
3. Ucensee confirms that for the PlUit five years it has not had a liquor license revoked for any liquor law violation
(state or local). If a revocation has occurred, please give details on the back of this renewal, then sign below.
4. Ucensee confirms that during the past five years it or its employees have not been convicted of any criminal
violations or imposed with any civil penalties. If so, please report on back of this application.
5. Licensee confirms that during the past license year, a summons has not been issued under the Liquor Uability
Law (Dram Shop) MS 340A.802. If yes, attach a copy of the summons, then sign below.
6. Licensee confirms that Workers Compensation insurance is in effect for the full license period.
LiceDsee has attached a Hquor liability insurance certificate tbat corresponds witb the license period iD city/county
where license is Issued $100,000 in cash or securities or $100,000 surety bond may be submitted in lieu of liquor liabU-
lty. (3.2% liquor IiceDses are exempt ifsales are less thaD $25,000 at on sale, or $50,000 at oft'sale).
licenseesiinahlre~ r-//l/~ DOB 7.;,y.7L ss# 1/7'1 Jl) b/(f'l Dale /b:J,. 7
(Signature certifies ~ be correct and license bas been approved by CIty/COunty.)
aty nerlr/CQunty AlIdilnr Si21'ature
Date
(Signature certifies that renewal of a liquor, wine or club license has been approved by the city/county as stated above.)
(Signature certifies licensee or associates have not been cited during the past five years for any stateJ1oca1liquor
(criminaUcivil). Report violations on back, then sign here.
PS 9093-05
IlJdtcat~l2f'llw cJ!,wges 'If COl]Wratc ()lfictDdlJ:lrtners,hSHTIe addresse'iJlf tg'ephOlli~_number~
llUlicntdLeJow ,my inJPJ"t'st wJla!sOe~Le~direct'rQrlI19jr.ITthjll othecliili!Qr estahlisl!!nents:
Kepor-t heir)\' dl.'tails oUiquOXJil.J.L}}I)JationsJchil 01" CrimillalUhaUline Qccllrred~rithin th!::.tlst fin: 'ears. (Pates, offenses.
tJ n e~JlIJ.Ltl}tll"j)-'~llJJJti C "'Lilll:' u d i nlUJml()J~un tD211~J1al tie,sl;
lkJ2QItDJ:lml.rlIt;J ib_DJ,nlUJJ).Ull!llic eJN~ l'"j ~UiQll'i J}l" req'mtlons;
LLtl!l:ml)~t}. i'mD~Ui'llb.;
CITY OF CENTERVILLE
GENERAL AUTHORIZATION AND RELEASE
Pursuant to Minnesota State Statute ~13.05, Sabel. 4
Minnesota Data Praetices Act
TO: City of Centerville
1, }/{ t C. ~ / r W A-l/V1 A7l _ hereby authorize and grant my informed consent to
permit you, BCA, FBI, NCIC. Department of Motor Vehicles, and the City ofCenteMlle
to release to and make available to the City of CentervillelCentennial Lakes Police
Department or their agents as assigned, data classified as private which concerns me and
which may be in your possession. The data which I authorize to be released consists of
private data, as defined by Minnesota State Statute iI3.02. Subd. 12, and has been
collected by you as a result of my contacts and/or associations with you and/or your
agents and representatives. The information for which release is authorized includes all
data which has been collected, created, received, retained or disseminated in whatever
fo~ which in any way relates to my dealings witb you or your agency. I understand
that the purpose of permitting the City of CentervillelCentennial Lakes Police
Department or their agents to have access to this information, is to determine my
qualification for a city license.
This authorization shall be valid for a period of one (I) year, but I resenre the right to, at
any time prior to that expiration, cancel tbe written authorization by providing written
notice to the City of Centervi11elCentennial Lakes Police Department or their agents as
{f ~ 15-1
I 0 . 5 I. 7
Date
.
~~. I
/1, c/~( 1lIoMII1
Full Name Printed: First
&~
Middle
Last
7-l-r,7L-
Date of Birth
(.:".' , "'1': ( ",. ..; )",; ....~. !_'.ccnse)
SWORN TO AND ATTESTED BEFORE ME THIS liL-ttbAY OF >;t~/Jtk
20 '1.
e TERESABENDER
WJr/IRI P\aIC ....SOTA
.' My CoMiaIclIl EJprea JIn. 31. 2010
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CITY OF CENTERVILLE
RENEWAL APPLICATION FOR LICENSE TO SELL
TOBACCO PRODUCTS AT RETAIL
The undersigned, residing at 1('1'9 1- era ~A ,+"., in the City of
0&1. ld'1 / ~
in the County of w/rSH>~ 17),1\1 . State of Minnesota, Residence Telephone: (
>6fL-)1'if kf/Z- HEREBY MAKES APPLICATION FOR LICENSE to be issued to MICHAEL.
WAL.MAR, GNAW INC. DBA CENTERVILLE LIQUOR BARRE~ to sell tobacco products at retail at
7093 ~ 20TH AVENUE SOUTHt Business Telephone: (VI ) Ifll ."1"1 in the City ofCenterville, Ano/az
County, Minnesota for the term of one (1) year beginning with the 1st tlJzy of JlllUlory, 2H8 , subject to the
laws of the State of Minnesota and the ordinances and regulations of said CJIy of~ pertaining tberetot
and herewith deposit S85. ()() in payment of the fee therefore.
Report below details of tobacco law violations that have occurred within the last five years. (Dates,
offenses, fines or other penalties):
Report below details involving any license rejections or revocations:
By signillg this relleWOl flJIplktlJiOIl, opplicant certifies tlult there Iuu beell lID cluutge ill tMllenldp,
corp01Yl1e oJJicers, ",. panrans. If cluuaga '-'e occurMl ""rillg die pIl5I11 ""'IItIts, complete ill its entirety
the atItIclaed TtIX Oetl1'tUlCe Illfo17lUltio1l, sigll below.
Date:
/6'3,.,
~" w.J?--
Si re
)//ec~f r Vv-e;(~
Name (Print)
FOR OmCE USE ONLY (Do not write below this 1iDe)
Report by Police DtpartmeDt
This is to certify that the applicant and the associates, named herein have not been convicted within the past five years of
8Ily vioIaIiaa of li:denlI, - at ~JE. pIOYisioo, at - Iq!UIatioa rcIaIins to -- at__
:::~1& y," :.lasttoacridl oP f!rJ,t<L
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CERTIFICATE OF COMPLIANCE
DEPARTMENT OF REVENUE
Pursuant to Minnesota Statute 270.72 Tax Clearance; Issuance of Licenses, the licensing
authority is required to provide to the Minnesota Commissioner of Revenue your. Minnesota
Business Tax Identification Number and the social seeuritv number of each license
applicant (penon si2nilU! the application).
. -Under the Minnesota Government Data Practices Act and the Federa"i?rivacy Act of 19.74, we
are r~quired 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, ~nalties, or interest;
2. Upon receiving this information, the license authority will supply it only to the
Minnesota Department ~f 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 license issuance.
Please supply the following information and return along with your application:
TYPE OF LICENSE BEING APPLIED FOR OR RENEWED: fLEN6vv ITF ~ArAe
PERSONAL INFORMA nON:
Applicant's Name:
;t1l-f>!v.vf 7 Iff; ,.fA fl
'18'12- C,~ M
fJtklot Ie ~J\J
,
[City] [State]
W/lttMA?--
Applicant's Address:
Social Security Number:
BUSINESS INFORMATION:
Business Address:
()q k,~~/Ie
71i~3 . ~~
a-/e-.r~k
[City]
L'1V~' i5~~(
A.e-)'
Business Name:
Federal Tax Identification Number:
-AMI
[State]
61/107f,
~~#oJ }i5Y6Y
5~~?
[Zip]
Minnesota Tax Identification Number:
If a Mmne30ta Tax Identification Number is n
!D.J/'7
Date
I , I' , ,
Signature and Position (Officer, Owner, Partner)
CITY OF CENTERVILLE
INTOXICATION MALT LIQUOR LICENSE
APPLICATION
DRAM SHOP INSURANCE EXEMPTION
I hereby certify under penalty of perjury that I have applied for an intoxicating liquor/on-
sale wine license and that the sales of such beverages are less than $10,000 per year. In
addition, I certify that the attached list of my wholesale suppliers is true and correct. If
necessary, these suppliers may be contacted in order to confirm this declaration.
!o . J (, I
Date
Signature, Notary Public
Date
NOTE: A LIST OF YOUR WHOLESALE SUPPLIERS MUST ACCOMPANY THIS
DRAM SHOP EXEMPTION FORM.
CERTIFICATE OF COMPLIANCE
MINNESOTA WORKERS' COMPENSATION LAW
Minnesota Statute, Section 176.182 requires every state and local licensing agency to withhold
the issuance or renewal of a license or pennit to operate a business or engage in an activity in
Minnesota until the applicant presents acceptable evidence of compliance with the workers'
compensation insurance coverage requirements of MSS Chapter 176. The infonnation 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 City and retained in the files.
This infonnatioo is required by law, and licenses and pennits to operate a business may oat be
issued or renewed if it is not provided and/or is falsely reported. Furthermore, if this
information is not provided or falsely stated, it may result in a $1,000 penalty assessed against
the applicant by the Commissioner of the Department ofuibor and Industry.
Insurance Company Name:
(NOT the insurance agent)
BIAC
Policy Number:
we - ~Z- 0.4-- I r~ 7 Z~ -OJ
Dates of Coverage:
l(b!1-c6r
TO 1/6/:;eo ~
{ r
(OR)
I am not required to have workers' compensation liability coverage because:
o
I have no employees
o
o
I am self-insured (include permit to self-insure)
Ihave no employees who are covered by the workers' compensation law
(these include: spouse, parents, children and certain farm employees)
I certify that the information provided above is accurate and complete and that a valid
workers' compensation policy will be kept in effect at all times as required by law.
Name:
M(t/fuel
[First]
Tko II/t4-f
[Middle]
{fh-l 4",.'11~
709 3 ?O~
Ce'1~,:lk
[City]
C51. l.{ U 'C67~
it'? vC/r
A~ 5
wAtA#-
[Last]
6cz,;/<2 (
Name of Business:
Business Address:
}ltJJ
[State]
~3;-
[Zip]
Business Phone:
(0 .~/. 7
Date
Signature
TAX CLEARANCE INFORMATION
TO LICENSE APPLICANT:
Pursuant to Minnesota Statute 270.72 Tax Clearance: Issuance of Licenses, the licensing authority is
required to provide to the Minnesota Commissioner of Revenue your Minnesota Business Tax
Identification Number and 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 infonnation:
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
Inforn1ation 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 supply the following information and return along with your application to the agency issuing the
license. DO NOT RETURN TO THE DEPARTMENT OF REVENUE.
LICENSE TYPE: () ff ~ A l.,C' - L1 &. Ij 0 I-
NEW [ ]
RENEWAL [v(
LICENSING AUTHORITY:
City of CenterviIIe
LICENSE RENEWAL DA TE:
/-/- ~
BUSINESS INFORMA nON:
Business Name: ~ +e-I'lrli {LL l (4 vo.r
Business Address: 70 t) 3 d-cv ih ~
C~ 4-vJk !
[City]
"3 a,.,-1
)'
j/JjJ
(State]
j)O 3 $;
[Zip]
Business Telephone Number:
j;-::;c ~ Li'"2-G - ~ 6'7 '-1
Title:
Social Security Number:
Full Name:
Title:
Social Security Number:
Full Name:
Title:
Socia! Security Number:
IF A CORPORATION:
G /r-Avv :C/'w C
10'7; 1-0 'f1 ~)'
dba
C~n..ivvll iL 47,;/111 &,,- /
Corporation Name:
Business Address:
Incorporation Date:
List of Directors:
List of Stockholders:
PERSONi\L INFORMATION (if sole proprietor):
Applicant's Name: J1a ku,/ 7 Lv A-c,,N'I.,f?L-
Applicant's Address: l{ g 9 z, G rtt ~ Av
a tJ Ih I.R f'TA,v
[City] [State]
b)/- L(},~ - (;,6 71( Wo-'~
5' 57. ~~
[Zip]
Social Security Number:
t-H- """"
6'); ~ L-79'- ?,Y;72-
Home Telephone Number:
ALL APPLICANTS:
List all persons or entities with either a direct or indirect interest in the applicant or the applicant's business
to be conducted under the license for which this application is made and describe their interest in detail
below.
MlCtwl
- I., ~ 1.,./1' /.
I vv f ,,,'AI"\.A1L- ... vv / .
Addresses:
Assumed or Trade Names, jf any:
Business Telephone Number: b~r -l{2{. 6{7 'f Home Telephone Nwnber: 6(1'17;:-' f~7L-
Has any person named in the application ever been convicted ofa felony? 0 Yes e( No
If yes, set forth the offense, date, county and stated of conviction:
Applicant agrees that any manager employed in the licensed premises will have all qualifications of a
licensee and that the manager will not violate any city or state laws.
Minnesota Tax Identification Number: b ~ 10 7 r>
Federal Tax Identification Number: K J .... OJ <g S- V ~ ~
If. M"~on Number is ootroquirod, pJea.a explain on tho""""" .ide.
Signature: /l M Position (Office, Partner, etc.): ~
Print Name: (b " .3 , . 7 Date:
m I C/ ha,( i W kV.A-t~
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,.
CENTER.YILL.E UqUORBARREL.
MICHAELW AlMAR
\ .
. .PH.651-426-6674
. '7093 . 20TH AVE S
CENTERVILLE, MN 55038
/ J' /.7
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PAY
TO THE
ORDER OF
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DATE
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IlookIoy Ri6l AdmiI1iolJabs Company. LLC
Minnesota Workers' Compensation Assigned Risk Plan
Standard Workers' Compensation and Employers' Liability Policy
Contract Administrator
Berkley Risk Administrators Company, LLC
P.O. Box 59143 Minneapolis, Minnesota 55459-0143
Phone (612) 766-3000 NCC! Carrier Code 21466
Enclosed is your:
~ Coverage Document for Minnesota Worker's Compensation
Please carefully review your policy or Agreement, the Information Page and any Endorsements to
ensure that the coverages you want or need are included and that they are accurately prepared.
Your agent will also receive copies of your Information Page and any Endorsements. Please
communicate with your agent or Berkley Risk Administrators Company, LLC if there are errors
or if changes are necessary. Also included for your review are the forms and instructions
you need to report all workers' compensation claims to us.
~ Minnesota Workers' Compensation Renewal Document
Please carefully review your renewal Policy or Agreement, the Information Page and any
Endorsements to ensure that the coverages you want or need are included and that they are
accurately prepared.
D New supply of First Report of Injury forms andlor the other information you requested.
MANDATORY FRAUD NOTICE
A person who submits an application or files a claim with intent to defraud or helps
commit fraud against an insurer is guilty of a crime. Minnesota Status 60A.955.
I
I
I
YOU MUST MAINTAIN AN ADEQUATE SUPPLY OF FIRST REPORT OF INJURY FORMS.
They should be kept where they are accessible to the person who is responsible for completing the form and
sending it to us. If you run out of forms or can't find your supply, please complete the form below and return
it to Berkley Risk Administrators Company, llC. We will gladly send you a supply of forms and provide any
other information you request. Please do it today because you never know when an injury might be reported
by one of your employees.
CUT ON LINE
, WC-22-04-159728-03
GNAW INC
Centerville Liquor Barrel
7093 20th Ave
Centervllle, MN 55038
L
I
Please send the following information to the
attention of:
at the address at left
--.J
o First Report of Injury Forms
o Supervisor's Report of Accident forms
o Deductible Information
o Employer's Injury Management Guide
o MN Worker's Compensation System
Employee Information Sheet
Clip and mail to:
BERKLEY RISK ADMINISTRATORS COMPANY, lLC
PO BOX 59143
MINNEAPOLIS, MN 55459-0143
BA3110 (11/01)
3836 639064
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Minnesota Workers' Compensation Assigned Risk Plan
Standard Workers' Compensation and Employers' Liability Policy
Contract Administrator
Berkley Risk Administrators Company, LLC
P.O. Box 59143 Minneapolis, Minnesota 55459-0143
Phone (612) 766-3000 NCCl Carrier Code 21466
INFORMATION PAGE
Bcri<ley RisI< IIOrruno.aIcI1l Coiwany. LLC
Renewal Of No. WC-22-04-159728-02
1. The Insured:
GNAW INC
dba: Centerville LIquor Barrel
7093 20th Ave
Centerville, MN 55038
WCIP
Policy Number: WC-22-04-15972S-Q3
Association File Number: 3201395
Other workplaces not shown above:
Tax 10#: F 830385468
UIC#: 068707550000
Date of Mailing: 11/2/2007
~ Individual C Partnership
c2<~ Corporation =:J Other
2. The policy period is from 12:01 a.m.1/6f2008 to 12:01 a.m.1/6f2009 at the insured's mailing address.
3.A. Workers' Compensation Insurance: Part One of the policy applies to the Workers' Compensation Law of the states listed here:
MN
B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3A
The limits of our liability under Part Two are: Bodily Injury By Accident $100,000 each accident.
Bodily Injury By Disease $500,000 policy limit.
Bodily Injury By Disease $100,000 each employee.
C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here:
D. This policy includes these endorsements and schedules:
WC000403 WC000414 WC000419 WC000422 WC220000 WC220301 WC220601D WC220620 WC990001A WC990809
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans.
All information required below is subject 10 verification and change by audit.
PREMIUM BASIS RATES ENTRIES IN THIS ITEM, EXCEPT AS SPECIFICALLY PROVIDED ESTIMATED
ESTiI'MTED TOTAL PER $100 OF CODE ELSEWHERE IN THIS CONTRACT; DO NOT MODIFY ANY OF ANNUAL
ANNUAL REMUNERATION NO. THE OTHER PROVISIONS OF THIS POLICY. PREMIUM
REMIINERl1,T!ON
Manual Premium $106.00
See Schedule Standard Premium $106.00
Merit Rating (B) 0.67 ($35.00)
Minimum Premium: $226.00 Adjusted Standard Premium $71.00
Expense Constant $170.00
Foreign Terrorism Stat Code 9740 $1.00
Special Compo Fund Surcharge Stat Code 0174 1.029 $3.00
Policy Total Estimated Cost $245.00
Net Deposit Premium Required $245.00
Aqency Name and Address Premium Paid to Date ($245.00)
Total Premium Due $0.00
Ross Nesbit Agencies Inc
Paulet Slater Agency
2610 University Ave W
St Paul, MN 55114
DATE: 11/2/2007
Signature:
~~
~ "< .p'...nte"~.
Includes copyright material of the National Council on Compensation Insurance used with its pennission.
@1983 .@ 1991 National Council Compensation Insurance
we 99-00-01
3836 639064
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1lorIIoy1W<_~.LLC
Minnesota Workers' Compensation Assigned Risk Plan
Standard Workers' Compensation and Employers' Liability Policy
Contract Administrator
Berkley Risk Administrators Company, LLC
P.O. Box 59143 Minneapolis, Minnesota 55459-0143
Phone (612) 766-3000 NCCI Carrier Code 21466
Sched ule for MN
Renewal Of No. WC.22-()4-159728-G2
1. The Insured:
WCIP
Policy Number: WC.22-G4-159728-G3
Association File Number: 3201395
GNAW INC
dba: Centervllle Liquor Barrel
7093 20th Ave
Centervllle, MN 55038
Tax 10#: F 830385468
UIC #: 068707550000
Policy Period: From: 1/6/2008
To: 1/6/2009
Endorsement Eff. Date: 1/6/2008
Date of Mailing: 11/212007
PREMIUM BASIS RATES ENTRIES IN THIS ITEM, EXCEPT AS SPECIFICALLY PROVIDED ESTIMATED
ESTIMATED TOTAL ANNUAL PER $100 OF CLASS ELSEWHERE IN THIS CONTRACT; DO NOT MODIFY ANY OF ANNUAL
REMUNERATION REMUNERATION CODE THE OTHER PROVISIONS OF THIS POLICY. PREMIUM
GNAW INC
7093 20th Ave
Centerville MN. 55038
$4,750 2.23 8017 STORE RISKS - RETAIL NOC $106
Manual Premium
Short Rate
Increased Limits
EXperience Modification
Merit Rating
MCPAP (Obsolete)
Standard Premium
$106.00
$0.00
$0.00
$0.00
$0.00
$0.00
$106.00
Aaencv Name and Address
Ross Nesbit Agencies Inc
Paulet Slater Agency
2610 University Ave W
5t Paul, MN 55114
WC990001A
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Minnesota Workers' Compensation Assigned Risk Plan
Standard Workers' Compensation and Employers' Liability Policy
Contract Administrator
Berkley Risk Administrators Company, LLC
P.O. Box 59143 Minneapolis, Minnesota 55459-0143
Phone (612) 766-3000 NCCI Carrier Code 21466
Minnesota Amendantorv Endorsement
Beo1<Iey Posk MmiAslraiofs COmpany. LLC
1. The Insured:
WCIP
Policy Number: WC-22-C4-159728-03
Association File Number: 3201395
Tax 10#: F 830385468
UIC #: 068707550000
Policy Period: From: 1/6/2008
To: 1/6/2009
Endorsement Eff. Date: 1/6/2008
Date of Mailing: 1112/2007
This endorsement applies only to the insurance provided because Minnesota is shown in Item 3A of the information page.
GNAW INC
dba: Centerville Liquor Barrel
7093 20th Ave
Centervil/e, MN 55038
PART TWO - EMPLOYERS LIABILITY INSURANCE
E. We will Also Pay is amended to read:
We will also pay these costs, in addition to other amounts payable under this insurance, as part of any claim,
proceeding, or suit we defend:
1. reasonable expenses incurred at our request, but not loss of earnings;
2. premiums for bonds to release attachments and for appeal bonds in bond amounts up to the limit of our
liability under this insurance;
3. litigation costs taxed against you;
4. your share of pre- or post-judqment interest assuminq that the principal amount of that iudoment is within
the applicable policy limits under this insurance: and
5. expenses we incur.
H. Recovery From Others is amended to read:
Our ability to exercise your rights to recover our payment from anyone liable for an injury covered by this
~__. ........._............ ...1__... __4. ___I.. ;. "'1-.._' _..""...... ....._.._...._ ;.... :......, ,......-11-... "'''''.... ...._..-..... I............ 1...... ..... T....:.... 1:.-:......4.;-..... _...._1:-..... ........1., :&
II I;:'Uldl II...I:: UUI::;:' 'IUL d!JfJlY II LlldL ULIII::I !-'I::I;:'UIII;:' III;:'UII::U IVI LlII:: ;:'dllll:: IV;:';:' uy U;:'. III';:' IIl1l1LdLlUIJ dfJfJIIO:;;:> VII'Y II
the loss was caused by the non-intentional acts of the person against whom subrogation is sought.
PART FIVE - PREMIUM
G. Audit is amended to read:
You will let us examine and audit all your records that relate to this policy. These records include ledgers,
journals, registers, vouchers, contracts, tax reports, payroll and disbursement records, and programs for storing
and retrieving data.
We may conduct the audits during regular business hours during the policy period and within three years after the
policy period ends, except as it pertains to Part Two - Employer's Liability rnsurance which shall be one vear.
Information developed by audit will be used to determine final premium. Insurance rate service organizations
have the same rights we have under this provision.
All other terms and conditions of this policy remain unchanged.
Aqency Name and Address
Ross Nesbit Agencies Inc
Paulet Slater Agency
2610 University Ave W
St Paul, MN 55114
WC 22-00-00
3836 639064
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IlorIIoy Ri. MnriI_ Comporr,.lLC
Minnesota Workers' Compensation Assigned Risk Plan
Standard Workers' Compensation and Employers' Liability Policy
Contract Administrator
Berkley Risk Administrators Company, LLC
P.O. Box 59143 Minneapolis, Minnesota 55459-0143
Phone (612) 766-3000 NCCI Carrier Code 21466
MINNESOTA ENTITY AND ADDRESS SCHEDULE
1. The Insured:
WCIP
Policy Number: WC-22-04-159728-o3
Association File Number: 3201395
GNAW INC
dba: Centervllle Liquor Barrel
7093 20th Ave
Centerville, MN 55038
Tax 10#: F 830385468
UIC #: 068707550000
Policy Period: From: 1/6/2008
To: 1/612009
Endorsement Eff. Date: 1/6/2008
Date of Mailing: 111212007
Entity Information:
Insured Name: GNAW INC
FederallD Number: F - 830385468
UIC Number. 068707550000
dba: Centerville Liquor Barrel
o Individual
[K] Corporation
o Partnership
o Other
7093 20th Ave
Centerville, MN 55038
Aaencv Name and Address
Ross Nesbit Agencies Inc
Paulet Slater Agency
2610 University Ave W
St Paul. MN 55114
WC220620
3836 639064
1. The Insured:
Minnesota Workers' Compensation Assigned Risk Plan
Standard Workers' Compensation and Employers' Liability Policy
Contract Administrator
Berkley Risk Administrators Company, LLC
P.O. Box 59143 Minneapolis, Minnesota 55459-0143
Phone (612) 766-3000 NCCI Carrier Code 21466
MINNESOTA CANCELLATION AND NONRENEWAL ENDORSEMENT
Page 1 of 2
WCIP Policy Number: WC-22-Q4-159728-03
Association File Number: 3201395
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Berldey R.k ~",n15"'''''' Company. LLC
Tax 10#: F 830385468
UIC #: 068707550000
Policy Period: From: 1/6/2008
To: 1/6/2009
Endorsement Eff. Date: 1/6/2008
Date of Mailing: 1112/2007
This endorsement applies only to the insurance provided because Minnesota is shown in Item 3A of the information page.
GNAW INC
dba: Centerville Liquor Barrel
7093 20th Ave
Centerville, MN 55038
CANCELLATION OF A NEW POLICY
If this policy is a new policy and has been in effect for fewer than 90 days, we may cancel for any reason by giving you notice
at least 60 days before the effective date of cancellation.
CANCELLATION OF OTHER POLICIES
If this Policy has been in effect for 90 days or more, or if it is a renewal of a policy we issued, we may cancel for one or more
of the following reasons:
(1) Nonpayment of Premium;
(2) Misrepresentation or fraud made by you or with your knowledge in obtaining the policy or in pursuing a claim under
the policy;
(3) An Act or omission by you that substantially increases or changes the risk insured;
(4) Refusal by you to eliminate known conditions that increase the potential for loss after notification by us that the
condition must be removed;
(5) Substantial change in the risk assumed, except to the extent t,hat we should reasonably have foreseen the change or
contemplated the risk in writing this policy;
(6) Loss of reinsurance by us which provided coverage to us for a significant amount of the underlying risk insured. Any
notice of cancellation pursuant to this item shall advise you that you have 10 days from the date of receipt of the
notice to appeal the cancellation to the commissioner of commerce and that the commissioner will render a decision
as to whether the cancellation is justified because of the loss of reinsurance within 30 business days after receipt of
the appeal;
(7) A determination by the commissioner that the continuation of the policy could place us in violation of the Minnesota
insurance laws; or
(8) Nonpayment of dues to an association or organization, other than an insurance association or organization,
payment of dues is prerequisite to your obtaining or continuing this policy. This item shall not apply to persons who
are retired at 62 years of age or older or who are disabled according to Social Security standards.
If we cancel your policy for any of the reasons listed in (2) through (8), we will give notice at least 60 days before the effective date of
cancellation.
NOTICE OF CANCELLATION
Any notice of cancellation under this endorsement shall be in writing and shall be sent by first class mail or delivered to you
and any agent, to the last mailing addresses known to us. A cancellation notice for nonpayment of premium must be sent at least
30 days before the actual date of cancellation and shall state the amount of premium due and the due date, and shall state the effect
of nonpayment by the due date. Cancellation shall not be effective if payment of the amount due is made prior to the effective date
of cancellation in the notice. A cancellation notice for some other reason shall state the specific reason for cancellation and shall
state the effective date of cancellation. The policy will end on that date.
All other terms and conditions of this policy remain unchanged.
Aqencv Name and Address
Ross Nesbit Agencies lnc
Paulet Slater Agency
2610 University Ave W
5t Paul, MN 55114
WC 22-06-01 D
3836 639064
1. The Insured:
Minnesota Workers' Compensation Assigned Risk Plan
Standard Workers' Compensation and Employers' Liability Policy
Contract Administrator
Berkley Risk Administrators Company, LLC
P.O. Box 59143 Minneapolis, Minnesota 55459-0143
Phone (612) 766-3000 NCCI Carrier Code 21466
MINNESOTA CANCELLATION AND NONRENEWAL ENDORSEMENT
Page 2 of2
WCIP Policy Number: WC.22-04-159728-03
Association File Number: 3201395
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llorkIoy Risk Ildmill8ln1lln OInpony. LLC
GNAW INC
dba: Centerville Liquor Barrel
7093 20th Ave
CenterviJIe, MN 55038
TaxlD#:F830385468
UIC #: 088707550000
Policy Period: From: 1/612008
To: 1/612009
Endorsement Eff. Date: 1/612008
Date of Mailing: 11/212007
REFUNDS DUE YOU
If this policy is cancelled, we will send you any premium refund due. If we cancel, the refund will be pro rata. If you cancel,
the refund may be less than pro rata. The cancellation will be effective even if we have not made or offered a refund.
NONRENEWAL OF YOUR POLICY
Any notice of non renewal shall be in writing and shall be sent by first class mail, or delivered to you and any agent. to the
last mailing addresses known to us, at least 60 days before the expiralion dale.
We need not mail or deliver this nonrenewal notice if you have:
(1) Insured elsewhere;
(2) Accepted replacement coverage; or
(3) Requested or agreed not to renew this policy.
This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.
All other terms and conditions of this policy remain unchanged.
AQencv Name and Address
Ross NesbIt Agencies Ine
Paulet Slater Agency
2610 University Ave W
SI Paul, MN 55114
we 22-06-01 D
3836 639064
ti> Minnesota Workers' Compensation Assigned Risk Plan
~a C Standard Workers' Compensation and Employers' Liability Policy
~ I ' Contract Administrator
SerkleyRisl\Adroo.stra\orsCcmpany.lLC Berkley Risk Administrators Company, LLC
P.O. Box 59143 Minneapolis, Minnesota 55459-0143
Phone (612) 766-3000 NCCI Carrier Code 21466
EXPERIENCE RATING MODIFICATION FACTOR ENDORSEMENT
1. The Insured:
welP
Policy Number: WC-22-o4-159728-03
Association File Number: 3201395
GNAW INC
dba: Centerville Liquor Barrel
7093 20th Ave
Centerville, MN 55038
Tax 1D#: F 830385468
UIC #: 068707550000
Policy Period: From: 1f6f2008
To: 116/2009
Endorsement Eft. Date: 1/6/2008
Date of Mailing: 11f2f2007
The premium for the policy will be adjusted by an experience rating modification factor. The factor was not available
when the policy was issued. The factor, if any, shown on the Information Page is an estimate. We will issue an
endorsement to show the proper factor, if different from the factor shown, when it is calculated.
All other terms and conditions of this policy remain unchanged.
Aqencv Name and Address
Ross Nesbit Agencies Inc
Paulet Slater Agency
2610 University Ave W
St Paul, MN 55114
WC 00-04-03
3836 639064
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Iler'dIyPiok~~.LLC
Minnesota Workers' Compensation Assigned Risk Plan
Standard Workers' Compensation and Employers' Liability Policy
Contract Administrator
Berkley Risk Administrators Company, LLC
P.O. Box 59143 Minneapolis, Minnesota 55459-0143
Phone (612) 766-3000 NCel Carrier Code 21466
NOTIFICATION OF CHANGE IN OWNERSHIP ENDORSEMENT
1. The Insured:
WCIP
Policy Number: WC.22-04-159728-o3
Association File Number: 3201395
GNAW INC
dba: Centervllle LIquor Barrel
7093 20th Ave
Centerville, MN 55038
Tax 10#: F 830385468
UIC #: 068707550000
Policy Period: From: 1/612008
To: 1/612009
Endorsement Eff. Date: 11612008
Date of Mailing: 11/212007
Experience rating is mandatory for all eligible Insureds. The experience rating modification factor, if any, applicable
to this policy, may change if there is a change in your ownership or in that of one or more of the entities eligible to be
com bined with you for experience rating purposes. Change in ownership includes sales, purchases, other transfers,
mergers, consolidations, dissolutions. formations of a new entity and other changes provided for in the applicable
experience rating plan manual.
You must report any change in ownership to us in writing within 90 days of such change. Failure to report such changes
within this period may result in revision of the experience rating modification factor used to determine your premium.
All other terms and conditions of this policy remain unchanged.
Agencv Name and Address
Ross Nesbit Agencies Inc
Paulet Slater Agency
2610 University Ave W
St Paul, MN 55114
WC 00-04-14
3836 639064
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Minnesota Workers' Compensation Assigned Risk Plan
Standard Workers' Compensation and Employers' Liability Policy
Contract Administrator
Berkley Risk Administrators Company, lLC
P.O. Box 59143 Minneapolis, Minnesota 55459-0143
Phone (612) 766-3000 NeCI Carrier Code 21466
Beri:.my Risk Admimstralors Company. LLC
MINNESOTA EXTRATERRITORIAL COVERAGE ENDORSEMENT
1. The Insured:
WCIP
Policy Number: WC-22-04-159728-03
Association File Number: 3201395
GNAW INC
dba: Centerville Liquor Barrel
7093 20th Ave
Centervil/e, MN 55038
Tax 10#: F 830385468
UIC #: 068707550000
Policy Period: From: 1/6/2008
To: 1/6/2009
Endorsement Eff. Date: 1/6/2008
Date of Mailing: 11/212007
1. This Insurance applies to:
A. An employee who regularly performs the primary duties of employment within Minnesota who receives an injury
while outside of Minnesota in your employ.
B. An employee hired in Minnesota who receives an injury while temporarily employed outside of Minnesota.
C. An employee who regularly performs the primary duties of employment outside of Minnesota, or is hired to perform
the primary duties of employment outside of Minnesota, who receives an injury within Minnesota while employed by
you but only if the employee chooses to forego any workers' compensation claim resulting from the injury that the
employee may have a right to pursue in some other state.
D. An employee who is a resident of Minnesota and is transferred outside the territorial limits of the United States and
remains your employee.
2. Except as specifically provided by Section 1. A-D above, this insurance does not apply to injuries occurring outside of
Minnesota.
3, No coverage is provided under this policy for claims filed in a state other than Minnesota and this policy does not pay the
benefits required by the laws of any state other than Minnesota.
IMPORTANT! IF YOU BEGIN WORK IN ANY STATE OTHER THAN MINNESOTA, YOU MUST OBTAIN INSURANCE
COVERAGE IN THAT STATE AND DO WHATEVER ELSE MAY BE REQUIRED UNDER THAT STATE'S LAW. THIS
INSURANCE DOES NOT SATISFY THE REQUIREMENTS OF THAT STATE'S WORKERS' COMPENSATION LAW.
All other terms and conditions of this policy remain unchanged.
AgencY Name and Address
Ross Nesbit Agencies Ine
Paulet Slater Agency
2610 University Ave W
St Paul, MN 55114
we 99-08-09
3836 639064
1. The Insured:
Minnesota Workers' Compensation Assigned Risk Plan
Standard Workers' Compensation and Employers' Liability Policy
Contract Administrator
Berkley Risk Administrators Company, LLC
P.O. Box 59143 Minneapolis, Minnesota 55459-0143
Phone (612) 766-3000 NCCI Carrier Code 21466
PREMIUM DUE DATE ENDORSEMENT
WCIP Policy Number: WC-22-()4.159728-03
Association File Number: 3201395
ti>rae
BorIcIoyRi&l.__~.LlC
GNAW INC
dba; Centerville Liquor Barrel
7093 20th Ave
Centerville, MN 55038
Tax 10#: F 830385468
ule #: 068701550000
Policy Period: From: 1/812008
To: 1/8/2009
Endorsement Eft. Date: 1/8/2008
Date of Mailing: 111212007
This endorsement is used to amend:
Section D. of Part Five of the policy is replaced by this provision.
PART FIVE
PREMIUM
D. Premium is amended to read:
You will pay all premium when due. You will pay the premium even if
part or all of a workers compensation law is not valid. The due date
for audit and retrospective premium is the date of the billing.
All other terms and conditions of this policy remain unchanged.
Aaencv Name and Address
Ross Nesbit Agencies Inc
Paulet Slater Agency
2610 University Ave W
St Paul, MN 55114
we 00-04-19
3836 639064
1. The Insured:
Minnesota Workers' Compensation Assigned Risk Plan
Standard Workers' Compensation and Employers' Liability Policy
Contract Administrator
Berkley Risk Administrators Company, LLC
P.O. Box 59143 Minneapolis, Minnesota 55459-0143
Phone (612) 766-3000 NCCI Carrier Code 21466
FOREIGN TERRORISM PREMIUM ENDORSEMENT
Page 1 of 1
welP Po/icy Number: WC-22-04-159728-03
Association File Number: 3201395
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Berney Risk Administrators Company. LtC
GNAW INC
dba: Centerville Liquor Barrel
7093 20th Ave
Centerville, MN 55038
Tax 10#: F 830385468
ule #: 068707550000
Policy Period: From: 1/6/2008
To: 1/6/2009
Endorsement Eff. Date: 1/6/2008
Date of Mailing: 11/2/2007
This endorsement is notification that your insurance carrier is charging premium for losses that may occur in the event of an act
of foreign terrorism
Your policy provides coverage for workers compensation losses caused by acts of foreign terrorism, including workers
compensation benefit obligations dictated by state law. Coverage for such losses is still subject to all terms, definitions,
exclusions, and conditions in your policy, and any applicable federal and/or state laws, rules, or regulations.
For purposes of this endorsement, an "act of foreign terrorism" is defined as:
a. Any act that is violent or dangerous to human life, property or infrastructure; and
b. The act has been committed by an individual or individuals acting on behalf of any foreign person or foreign
interest, as part of an effort to coerce the civilian population of the United States or to influence the policy or
affect the conduct of the United States Government by coercion.
The premium charge for the coverage your policy provides for workers compensation losses caused by an act of foreign
terrorism is shown in Item 4 of the Information Page or in the Schedule below.
Schedule
Rate per $100 of
State Remuneration
MN 0.02
This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.
Aqency Name and Address
Ross Nesbit Agencies Jnc
Paulet Slater Agency
2610 University Ave W
St Paul, MN 55114
we 00-04-22
3836 639064
9 Minnesota Workers' Compensation Assigned Risk Plan
. ~a C Standard Workers' Compensation and Employers' Liability Policy
I I Contract Administrator
lloIIIoyRiIIk__OJmilonyLLC Berkley Risk Administrators Company, LLC
P.O. Box 59143 Minneapolis, Minnesota 55459-0143
Phone (612) 766-3000 NCCI Carrier Code 21466
MINNESOTA COMPLIANCE WITH APPLICABLE TRADE SANCTIONS LAWS
1. The Insured:
WCIP
Policy Number: WC-22-04-159728-03
Association File Number: 3201395
GNAW INC
dba: Centervllle liquor Barrel
7093 20th Ave
Centervi/le, MN 55038
Tax 10#: F 830385468
UIC #: 068707550000
Policy Period: From: 11612008
To: 1'612009
Endorsement Eff. Date: 11612008
Date of Mailing: 1112/2007
Under Part Six - Conditions, the following condition is added:
This insurance does not apply to the extent that trade or economic sanctions or other laws or regulations prolubit us from providing
insurance.
All other terms and conditions remain unchanged.
Nothing herein contained shall be held to vary, alter, waive or extend any of the terms, conditions, provisions, agreements or limitations
of the above mentioned policy, other than as stated above.
Aaencv Name and Address
Ross Nesbit Agencies Inc
Paulet Slater Agency
2610 University Ave W
St Paul, MN 55114
WC 220301
3836 639064
Minnesota Department of Labor and Industry
Workers' Compensation Division
443 Lafayette Road North
5t. Paul, MN 55155-4305
(651) 284-5030
FIRST REPORT OF INJURY
See Instructions on Reverse Side.
Please PRINT or TYPE your responses.
Enter dates in MM/DDfYYYY format.
111111111111111111111111111111
'" FRO 1 .,.
1. EMPLOYEE SOCIAL SECURITY # /2. OSHA Case # DO NOT USE THIS SPACE
3. DATE OF CLAIMED INJURY 14. Time of DAM 5. Time employee began DAM
injury DPM work on date of injury DPM
6. EMPLOYEE Name (last, first, middle) 7. Gender 18. Marital o Married
OM OF Status o Unmarried
9. Home address 10. Home phone # u111. Date of birth 1
City State Zip Code 12. Occupation 113. Regular department \14 Date hired
15. Average weekly wage 116. Rate per hour 117. Hours per day 118. Days per week 19. Employment o Full time o Part time
Status o Seasonal o Volunteer
20. Weekly value of: I Meals I Lodging 2nd income 21. Apprentice DYes DNa
22. Tell us how the Injury occurred and what the employee was doing before the Incident (gIve details). Examples: 'Worker was driving lift truck with a pallet of boxes
when the truck lipped, pinning worker's left leg under drive shaft," "Worker developed soreness in left wrist over time from daily computer key entry."
23. What was the Injury or illness (Include the part(s) of body)? Examples: 24. What tools, equipment, machines, objects, or substances were Involved?
chemical burn left hand, broken left leg, carpal tunnel syndrome in left wrist. Examples: chiorine, hand sprayer, pallellift truck, computer keyboard.
25. Did injury occur on DYes DNo 26. Date of first day of any lost time 27. Employer paid for lost time on day of injury (DOl)
employers premises? DYes ONo D No lost time on DOl
If no, indicate name and address of place of 28. Date employer notified of injury 29. Date employer notified of lost time
occurrence
30. Return to work date 31_ Date of death
32. TREATING PHYSICIAN (name, address, and phone) 33. HOSPITAUCLlNIC (name and address) (if any) 34. Emergency Room Visit
DYes DNo
35 Overnight in-patient
DYes UNO
36. EMPLOYER Legal name 37. Employer DBA name (if different)
GNAW lNC Centerville Liquor Barrel
39. Employer FEIN 40. Unemployment ID #
38. Mailing address 830385468 068707550000
7093 20th Ave 41. Employer's contact name and phone #
Centerville, MN 55038
43. Witness (name and phone)
42. Physical address (if different)
7093 20th Ave 44. NAICS code 45. Date form completed
Centerville, MN 55038
46. INSURER name 51 CLAIMS ADMIN COMPANY (CA) name (check one) o Insurer
MN Workers Compensation Assigned Risk Plan Berkley Risk Administrators Company LLC I8l TP A
47. Insured legal name 52. CA Address
GNAW INC PO Box 59143
48. Policy # or self-insured certificate # City State Zip Code
WC-22-04-159728-03 Minneapolis MN 55459-0143
49. Insurer FEIN 150. Date insurer received notice 53_ CA FEIN 154. Claim #
41-1429211 41-1887666
MN FR01 (09/02) Copies to: Insurer, Employer, Employee, and Woikers' Compensation Division (if no insurer)
BRAe 2510 (05/03)
GENERAL INSTRUCTIONS TO THE EMPLOYER
Filing this form is not an admission of liability. You must report a claim to your insurer whenever anyone believes that a work-
related injury or illness that requires medical care or lost time from work has occurred. If the claimed injury wholly or partially
incapacitates the employee for more than three calendar days, the claim must be made on this form and reported to your insurer within
ten days. Your insurer may require you to file it sooner. Failure to file within the ten days may result in penalties. Self-insured
employers have 14 days to file this form with the Department of Labor and Industry (Department). It is important to file this form quickly
to allow your insurer time to investigate the claim. Your insurer will forward a copy of this form to the Department, if necessary.
If the claim involves death or serious injury (including injuries that later result in death), you must notify the Department and your insurer
within 48 hours of the occurrence. The claim can be reported initially to the Department by telephone (651-284-5041), fax (651-284-
5731), or personal notice. The initial notice must be followed by the filing of this form within seven days of the occurrence.
Employers are required to complete this form. Each piece of information is needed to determine liability and entitlement to benefits.
Failure to complete the form may result in delayed processing and possible penalties. You must file this form with your insurer, and give
a copy to the employee and the employee's local union office. You are required to provide the employee with a copy of the Employee
Information Sheet, which is available on the Department's web site at www.doli.state.mn.us. Employees are not responsible for
compleling this form.
SEND REPORT TO INSURER IMMEDIATELY...; DO NOT WAIT FOR DOCTOR'S REPORT
SPECIFIC INSTRUCTIONS FOR COMPLETING THIS FORM
. Item 2: OSHA Case #. Fill in the case number from the OSHA 300 log. This form contains all items required by the OSHA form 301.
Items 15-20: Fill in all the wage information. If the employee does not work a regularly scheduled work week, attach a 26 week
wage statement so your insurer can calculate the appropriate average weekly wage.
Items 22-24: Be as specific as possible in describing: the events causing the injury; the nature of the injury (cut, sprain, burn, etc.),
and the part(s) of body injured (back, arm, etc.); and the tools, equipment, machines, objects or substances involved.
Item 26: Fill in the first day the employee lost any time from work (including time lost for medical treatment), even if you paid the
employee for the lost time.
Item 27: Check the appropriate box to indicate if there was losltime on the date of injury and whether you paid for that lost time.
Item 28: Fill in the date you first became aware of the injury or illness.
Item 29: Fill in the date you became aware that the lost time indicated in Item 26 was related to the claimed injury.
Item 30: Leave the box blank if the employee has not returned to work by the time you file this form. If the employee has returned to
work, fill in the date and notify your insurer if the employee misses time due to this injury after that date.
Item 39: Fill in your Federal Employment 10 number (FEIN). For information on this number, see www.firstqov.QOv and click on
Employer ID Number under Business.
Items 40 and 44: Fill in your Unemployment 10 number and North American Industry Classification System (NAICS) code which are
both assigned by the Minnesota Unemployment Insurance Program (651-296-6141).
Items 46-54: Your insurer or claims administrator will complete this information.
INSTRUCTIONS TO THE INSURER/CLAIMS ADMINISTRATOR/SELF-INSURED EMPLOYER
The following data elements must be completed on this form prior to filing with the Department of Labor and Industry: employee's
name and social security number; date of injury; and the names of the employer and insurer. If any of this information is missing, the
First Report will be rejected and returned to you (per Minn .Stat. 9 176.275). Providing the name of the third party administrator does
not meet the statutory requirement to provide the name of the insurer. NOTE: If the claim does not involve lost time beyond the waiting
period or potential PPD, the form does NOT need to be filed with the Department.
Item 46: Fill in the name of the insurance company. If the employer is self-insured, indicate the name of the licensed or public self-
insured company or group.
. Items 47-48: Fill in the legal name of the employer who purchased the policy from the insurer (named in Item 46) and the policy
number. If the employer is licensed to self-insure, fill in the certificate number.
. Item 49: Fill in the insurer's Federal Employment ID number (FEIN) number.
. Item 51: Fill in the name and address of the company administering the claim (either the insurer or third party administrator). Be
sure to mark either the "Insurer" or "TPA" box.
Item 53-54: Fill in the claims administrator's FEIN and claim number.
This material can be made available in different forms, such as large print, Braille or on a tape. To request, call (651) 284-5030
or 1-800-342-5354 (DIAL-DLI)Noice or TOD (651) 297-4198.
ANY PERSON WHO, WITH INTENT TO DEFRAUD, RECEIVES WORKERS' COMPENSATION BENEFITS TO WHICH THE
PERSON IS NOT ENTITLED BY KNOWINGLY MISREPRESENTING, MISSTATING, OR FAILING TO DISCLOSE ANY MATERIAL
FACT IS GUlL TV OF THEFT AND SHALL BE SENTENCED PURSUANT TO SECTION 609.52, SUBDIVISION 3.
BRAC 2510 (05/03)
Minnesota department of Labor and \ndustr,'
Workers' Compensation Division
443 Lafayette Road North
St. Paul, MN 55155-4305
(651) 284-5030
FIRST REPORT OF INJURY
See Instructions on Reverse Side.
Please PRINT or TYPE your responses.
Enter dates in MMJDDfYYYY format.
111111111111111111111111111111
." FRO '1 ."
1. EMPLOYEE SOCIAL SECURITY # 12 OSHA Case # DO NOT USE THIS SPACE
3. DATE OF CLAIMED INJURY 14. Ti~e of DAM 5. Time employee began DAM
Injury DpM work on date of injury DPM
6. EMPLOYEE Name (last, first, middle) 7. Gender 18. Marital o Married
OM OF Status o Unmarried
9. Home address 10 Home phone # /11. Date of birth
City State Zip Code 12 Occupation 113. Regular department \14. Date hired
15, Average weekly wage 116 Rate per hour 117 Hours per day 118 Days per week 19 Employment o Full time o Part time
Status o Seasonal o Volunteer
20. Weekly value of: I Meals I Lodging 2nd income 21. Apprentice DYes o No
22. Tell us how the injury occurred and What the employee was doing before the Incident (give details). Examples: "Worker was driving lift truck with a pallet of boxes
when the truck lipped, pinning worker's left leg under drive shaft" "Worker developed soreness In left wrist over time from daily computer key entry."
23. What was the Injury or illness (include the part(s) of body)? Examples: 24. What tools, equipment, machines, objects, or substances were Involved?
chemical burn left hand, broken I ell leg, carpal tunnel syndrome in left wrist. Examples: chlorine. hand sprayer, pallet Iill truck, computer keyboard.
25 Did injUry occur on DYes DNa 26. Date of first day of any lost time 27. Employer paid for lost time on day of injury (001)
employers premises? DYes DNo o No lost time on 001
If no, indicate name and address of place of 28. Date employer notified of injury 29. Date employer notified of lost time
occurrence
30, Return to work date 31. Date of death
32. TREATING PHYSICIAN (name, address, and phone) 33. HOSPITAUCLlNIC (name and address) (if any) 34. Emergency Room Visit
DYes DNo
35. Overnight in-patient
DYes ONo
36. EMPLOYER Legal name 37. Employer DBA name (if different)
GNAW INC Centerville Liquor Barrel
39. Employer FEIN T40 Unemployment 10 #
38. Mailing address 830385468 068107550000
7093 20th Ave 41. Employer's contact name and phone #
Centerville, MN 55038
43. Witness (name and phone)
42. Physical address (if different)
7093 20th Ave 44. NAICS code \45, Date fomn completed
Centerville, MN 55038
46. INSURER name 51. CLAIMS ADMIN COMPANY (CA) name (check one) o Insurer
MN Workers Compensation Assigned Risk Plan Berkley Risk Administrators Company LLC l8J TPA
47 Insured legal name 52. CA Address
GNAW INC PO Box 59143
48 Policy # or self-insured certificate # City State Zip Code
WC-22-04-15972S-03 Minneapolis MN 55459-0143
49 Insurer FEIN 150. Date insurer received notice 53. CA FEIN ~ 54. Claim #
41-1429211 41-1887666
MN FROl (09/02) Copies to: Insurer, Employer, Employee, and Workers' Compensation Division (if no insurer)
BRAG 2510 (05/03)
GENERAL INSTRUCTIONS TO THE EMPLOYER
Filing this form is not an admission of liability. You must report a claim to your insurer whenever anyone believes that a work-
related injury or illness that requires medical care or lost time from work has occurred. If the claimed injury wholly or partially
incapacitates the employee for more than three calendar days, the claim must be made on this form and reported to your insurer within
ten days. Your insurer may require you to file it sooner. Failure to file within the ten days may result in penalties. Self-insured
employers have 14 days to file this form with the Department of Labor and Industry (Department). It is important to file this form quickly
to allow your insurer time to investigate the claim. Your insurer will forward a copy ofthis form to the Department, if necessary.
If the claim involves death or serious injury (including injuries that later result in death), you must notify the Department and your insurer
within 48 hours of the occurrence. The claim can be reported initially to the Department by telephone (651-284-5041), fax (651-284-
5731 ), or personal notice. The initial notice must be followed by the filing of this form within seven days of the occurrence.
Employers are required to complete this form. Each piece of information is needed to determine liability and entitlement to benefits.
Failure to complete the form may result in delayed processing and possible penalties. You must file this form with your insurer, and give
a copy to the employee and the employee's local union office. You are required to provide the employee with a copy of the Employee
Information Sheet, which is available on the Department's web site at www.doli.state.mn.us. Employees are not responsible for
completing this form.
SEND REPORT TO INSURER IMMEDIATELY - DO NOT WAIT FOR DOCTOR'S REPORT
SPECIFIC INSTRUCTIONS FOR COMPLETING THIS FORM
Item 2: OSHA Case #. Fill in the case number from the OSHA 300 log. This form contains all items required by the OSHA form 301.
Items 15-20: Fill in all the wage information. If the employee does not work a regularly scheduled work week, attach a 26 week
wage statement so your insurer can calculate the appropriate average weekly wage.
Items 22-24: Be as specific as possible in describing: the events causing the injury; the nature of the injury (cut, sprain, bum, etc.),
and the part(s) of body injured (back, arm, etc.); and the tools, equipment, machines, objects or substances involved.
Item 26: Fill in the first day the employee lost any time from work (including time lost for medical treatment), even if you paid the
employee for the lost time.
Item 27: Check the appropriate box to indicate if there was lost time on the date of injury and whether you paid for that lost time.
Item 28: Fill in the date you first became aware of the injury or illness.
Item 29: Fill in the date you became aware that the lost time indicated in Item 26 was related to the claimed injury.
Item 30: Leave the box blank if the employee has not returned to work by the time you file this form. If the employee has returned to
work, fill in the date and notify your insurer if the employee misses time due to this injury after that date.
Item 39: Fill in your Federal Employment ID number (FEIN). For information on this number, see www.firstqov.qOv and click on
Employer 10 Number under Business.
Items 40 and 44: Fill in your Unemployment ID number and North American Industry Classification System (NAICS) code which are
both assigned by the Minnesota Unemployment Insurance Program (651-296-6141).
Items 46-54: Your insurer or claims administrator will complete this information.
INSTRUCTIONS TO THE INSURER/CLAIMS ADMINISTRATOR/SELF-INSURED EMPLOYER
The following data elements must be completed on this form prior to filing with the Department of Labor and Industry: employee'S
name and social security number; date of injury; and the names of the employer and insurer. If any of this information is missing, the
First Report will be rejected and returned to you (per Minn .Stat. S 176.275). Providing the name of the third party administrator does
not meet the statutory requirement to provide the name of the insurer. NOTE: If the claim does not involve lost time beyond the waiting
period or potential PPO, the form does NOT need to be filed with the Department.
Item 46: Fill in the name of the insurance company. If the employer is self-insured, indicate the name of the licensed or public self-
insured company or group.
Items 47-48: Fill in the legal name of the employer who purchased the policy from the insurer (named in Item 46) and the policy
number. If the employer is licensed to self-insure, fill in the certificate number.
Item 49: Fill in the insurer's Federal Employment ID number (FEIN) number.
lIem 51: Fill in the name and address of the company administering the claim (either the insurer or third party administrator). Be
sure to mark either the "Insurer" or "TPA" box.
Item 53-54: Fill in the claims administrator's FEIN and claim number.
This material can be made available in different forms, such as large print, Braille or on a tape. To request, call (651) 284-5030
or 1-800-342-5354 (DIAL-DLI)No/ce or TDD (651) 297-4198.
ANY PERSON WHO, WITH INTENT TO DEFRAUD, RECEIVES WORKERS' COMPENSATION BENEFITS TO WHICH THE
PERSON IS NOT ENTITLED BY KNOWINGLY MISREPRESENTING, MISSTATING, OR FAILING TO DISCLOSE ANY MATERIAL
FACT IS GUll TV OF THEFT AND SHALL BE SENTENCED PURSUANT TO SECTION 609.52, SUBDIVISION 3.
BRAC 2510 (05/03)
tervi{{e
~isfied 1857
STATE OF MINNESOTA
1880 !Main Street, CentemlU, !M!N 55038
651-429-3232 or <FQJ(651-429-8629
COUNTY OF ANOKA
CITY OF CENTERVIlLE
RESOLUTION #07 -_
A RESOLUTION AOOP11NG ASSESSMENTS ASSOCIATED wmt WESTVIEW WATER IMPROVEMENTS
WHEREAS, pursuant to proper notJce duly given as required by 'aw, the councU has met and heard and passed
upon aD objecUons to the proposed assessment for the Westview Street Water Improvements as follows; and,
Pm1!
R2+31-22-22-0008
ADDRESS
1124 Main Street
AMOUNT
$9,&12.18
NOW THEREFORE, BE IT RESOLVED BY mE CITY COUNQL OF THE CITV OF CENTERVllLE,
MINNESOTA:
1. Such proposed assessment, a copy of which is attached hereto and made a part hereof, Is
heIebv aa:epted and shaIICXX1StIt:ute the special assesso1ent aganst the lane!; named
therein, and each tract of land therein included Is hereby Ibund to be benefited. by the
proposed Improvement In the amooot of the assessment levied against It.
2. SUch assessment shall be payable in equallnstanments extending over a period of om
W years, the first of the InstaIments to be payable on or before the first Monday In
January 2008, and bear Interest at the rate of fiJl per annum form the date of the
adoption of this assessmentresolutJon. To each subsequent Installment when due shall
be added Interest far one (1) yeM on all unpaid Installments.
3. The owner of any poperty so assessed may, at any tine prior to <:ert.IffcaUon of the
assessment to the County Auditor, pay the whole of the asscnnent on such property,
with late fees acaued to the date d pavment, to the Cly CIerlc, no cetifIcatIon fee wiD be
charged If the entire assessment Is paid wtthln thbty (30) days from the adoption of this
resolution; and he/she may, at any time thereafter, pay to the Q:y Clerk the entft
amount of the assessment remaining unpaid, with Interest aa:rued on December 31 of
the year In which 5UCh payment is made. Such payment must be made befClre November
15 or IntereSt wnl be charged through December 31 of the ned: sucxeedlng year.
4. The Clerk shaD furthwIth tJansmit a cetlfled duplicate of this asse&Slnest to the County
AudItor to be extended on the property tax lists of the County. Such assessments shan be
collected and paid ates h the same mamer as other municipal taxes.
PASSED AND ADOPTED by the City CouncH this 28th day of November, 2007.
Attest
CIty Oetk
Mayor
ASSESSMENT SCHEDULE
Constant Annual Payment Method
Brilowski Water Improvement
Parcel Number 23-31-22-22-0008
Street Address 7124 Main Street
Initial Assessment Amount: $
Assessment Term (Years):
Assessment Interest Rate:
Assessment Date:
Assessment Start Date:
Pre-assessment Interest Due: $
9,042.18
9
6.00%
1-Jan-08
Beginning Assessment Total Annual
Number Year Principal Interest Principal Payment 12/31 Payoff
2007 $ 9,042.18 $ $ $ $ 9,042.18
1 2008 $ 9,042.18 $542.53 $786.87 $1,329.40 $ 8,255.31
2 2009 $ 8,255.31 $495.32 $834.08 $ 1,329.40 $ 7,421.23
3 2010 $ 7,421.23 $445.27 $884.13 $ 1,329.40 $ 6,537.10
4 2011 $ 6,537.10 $392.23 $937.18 $ 1,329.40 $ 5,599.92
5 2012 $ 5,599.92 $336.00 $993.41 $ 1,329.40 $ 4,606.52
6 2013 $ 4,606.52 $276.39 $1,053.01 $ 1,329.40 $ 3,553.51
7 2014 $ 3,553.51 $213.21 $1,116.19 $ 1,329.40 $ 2,437.31
n r'\f'\Ar-' '" 2,437.31 "" A A,... ,.... A t'!\,.iI ...,.."n ...,... '" 1 ,329.40 '" 1,254.15
0 LVIO ;p 'I> 1<+0 .L<+ 'I> I, I O,j. 10 'I> 'I>
9 2016 $ 1,254.15 $75.25 $1,254.15 $ 1,329.40 $ 0.00
Total $ 2,922.43 $ 9,042.18 $ 11,964.61
tervi{{e
~sfzed 1857
STATE OF MINNESOTA
1880 !Main Street, CmterfliJli, !M?{ 55038
651-429-3232 or'FtVC.6J1-429-8629
COUNTY OF MOKA
Q1Y OF CEtm:RV1UE
RESOLUTION #07 - _
A RESOLUTION ADOPt1NG ASSESSMENTS ASSOCIATED WI1'H 2007 FADMEW STREET
IMPROVEMENtS
WHEREAS, ~ to proper notICe duty given as requi'ed by law, the coondI has met andheaRI and passed
upon aU objections to the proposed assessment for the Improvement of FaIrvfew Street as foIbws; and,
em.! ADDRESS AMOONT
R24-31-22-32-0002
R24-31-22-33-0007
R24-31-22-33-QOm
2034 falrvlew Street:
2062 Falrvlew Street
$169,604.00
$37,689.67
$37,689.01
NOW THEREFORE, BE IT RESOLVED BY THE CITY COUNCIL OF THE arv OF CENTERVIUJ!,
MINNESOTA:
1. SUch proposed assessment, a mpy of which Is attached heretO anti made a P.Crt hereof, Is
hertV/ accepted and shaH oonstitute the speclaI asses5VlIent against the lands named
therell\ iIld each tract of land therein Jnduded Is hereby found to be benefited by the
proposed Improvement in the aR10lIlt of the assessment levied against It
2. Such assessment: shall be payable In equal Installments edendlng over a period of 1m
!1O.l years, the ftrst: of the Installments to be payable on or before the first Monday 1n
January 2()(11, anti bear Interest at the rate of fi.S per annum fa1n the dale of the
adoption of this assessment resolution. To the first InstaIln1entshall be added Jnb!n!st on
the entire assessment from September 1, 2007. To each subSequent Installment when
due shall be added 1n1ereSt for one (1) yell" 00 all ~Instalhlents.
3. The owner of any property so assessed may, at any time prior to certItk::atfon of the
assessment to the County AudItor, pay the whole of the assessment on such PfOI*lY,
with late fees attrUed to the date of payment, to the CIty Clerk, no certIfICatIon fee will be
dlarged ,the enure assssment Is paid within thKy (30) days from the adoption of this
resolution; and helshe may, at any time theIeaft8', pay to the CIty Clerk the entire
amount of the asscSSluent remaining UJY,JaId, with Intt!reSt <<DUed OR December 31 of
the year In which such payment Is made. Such payment nut be made before November
15 or InlereSt wUt be dlarged through Deanlber 31 of the ned: sucx:eedlng year.
4. The CfeI1( shall forthwith transmit a certified duplicate of this. assessnaent: to the Qronty
Aud/lQ'to be exI81ded on the property laX lIStS of the County. SUch assessments shall be
collected and paid over '" the same mamer as other munICIpal taxes.
PASSED AND ADOPTED bV the City CDuncJI this 28th day eX November, 2001.
Attest
Mayor
City Oerk
ner: Rehbein Properties
cription: Unplatted
'mber: 24-31-22~32-0002
Initial Principal: $169,604.00
Term: 10
Interest Rate: 6.50%
Interim Interest: $ 3,674.75
Total Assessed: $173,278.75
Special Conditions: None
Year Levy Collect Principal Interest Total Balance
$173,278.75
1 2007 2008 $12,840.77 $11,263.12 $24,103.89 $160,437.99
2 2008 2009 $13,675.42 $10,428.47 $24,103.89 $146,762.57
3 2009 2010 $14,564.32 $ . 9,539.57 $24,103.89 $132,198.25
4 2010 2011 $15,511.00 $ 8,592.89 $24,103; 89 $116,687.25
5 2011 2012 $16,519.22 $ 7,584.67 $24,103.89 $100,168.03
6 2012 2013 $17,592.97 $ 6,510.92 $24,103.89 $ 82,575.06
7 2013 2014 $18,736.51 $ 5,367.38 $24,103.89 $ 63,838.56
8 2014 2015 $19,954.38 $ 4,149.51 $24,103.89 $ 43,884.17
9 2015 2016 $21,251.42 $ 2,852.47 $24,103.89 $ 22,632.76
10 2016 2017 $22,632.76 $ 1,471.13 $24,103.89 $ (O.OO)
$173,278.75 $ 67,760.12 $241,038.87
----'ner Royal Oaks Industrial Park
Property C cription Lot 2 Block 1
Legal Of .&Jer: 24-31-22-33-0007
Pln~', jJrincipal $ 37,689.67
Term 10
Interest Rate 6.50%
Interim Interest $ 816.61
Total Assessed $ 38,506.28
Special Conditions: None
Year Levy Collect Principal Interest Total Balance
$ 38,506.28
1 2007 2008 $2,853.50 $ 2,502.91 $5,356.40 $ 35,652.78
2 2008 2009 $3,038.97 $ 2,317.43 $5,356.40 $ 32,613.81
3 2009 2010 $3,236.51 $ 2,119.90 $5,356.40 $ 29,377.30
4 2010 2011 $3,446.88 $ 1,909.52 $5,356.40 $ 25,930.42
5 2011 2012 $3,670.93 $ 1,685.48 $5,356.40 $ 22,259.50
6 2012 2013 $3,909.54 $ 1,446.87 $5,356.40 $ 18,349.96
7 2013 2014 $4,163.66 $ 1,192.75 $5,356.40 $ 14,186.30
8 2014 2015 $4,434.29 $ 922.11 $5,356.40 $ 9,752.01
9 2015 2016 $4,722.52 $ 633.88 $5,356.40 $ 5,029.49
10 2016 2017 $5,029.49 $ 326.92 $5,356.40 $ (0.00)
$ 38,506.28 $ 15,057.76 $53,564.04
11/21/07
To: Dallas Larson
City of CentervilIe, MN
Subject: Trees for Eagle Pass Twin Townhome Assoc.
Just a note to tell you I talked to AI LaMotte about prices for pine trees. The ones he has
& could handle are about 10ft. tall. His price will be $175.00 ea. We will need 8 total for
the 2 sites, 1759 Ojibway & 7059 & 81 Dupre back yards. He can move them as long as
the ground is not frozen.
I need your O.K. that the city will pay for these. I will have AI bill the city directly.
I will have to call Gopher 1.
If possible we would like to complete this project before freeze-up.
Ray onnelly
7059 Dupre Road
651-762-3902