Loading...
HomeMy Public PortalAboutC-21-082 - AUDIOTECH PRODUCTIONS3 [Enter Date] [Enter Company Name] [Enter Company Address] [Enter City, State ZIP] Insurance Requirements Dear [Enter Provider's Name]: Please be advised pursuant to your desire to work with the City of Carson, you are required to submit the following: ✓ Compliant Certificates of Liability Insurance (to be maintained for the duration of services against claims which may arise from or in connection with the services), evidencing the coverage(s) as indicated below. Certificates of insurance, as well as additional insured and waiver of subrogation endorsements in favor of the City, must be submitted in their entirety before any services are provided or the event takes place. Failure to submit such required forms shall be cause for City of Carson to reject or terminate any service provider application agreement. The City of Carson reserves the right to modify these requirements based on the nature of the risk, prior events, insurance coverage, or other special requirements. MINIMUM SCOPE AND LIMIT OF INSURANCE General Liability Insurance: Coverage shall be at least as broad as Insurance Services Form CG 00 01 covering CGL on an `occurrence" basis, including property damage, bodily injury and personal & advertising injury with limits no less than $1,000,000 per occurrence and $2,000,000 aggregate. Additional Insured Status The City of Carson, and its elected and appointed officials, employees, volunteers and agents, are to be covered as additional insureds with respect to liability arising out of their work or operations performed at or on behalf'of the City -sponsored event including materials., parts, or equipment furnished in connection with the event. 532227,5 CFN 4 City of Carson Community Services Department Service Provider Application Agreement Check one (staff use): ✓ Carson Event Center_ Human Services _ Recreation _ Transportation Event: V1 4,—M FR &DSH W QA Event Location: G • J. I • 0 Event Date: 07 11 Name of Service Provider: AwD i b`Tr�; Cir} Business Form/Entity Type (Ifjndiv*duaL sole proprietorship, corporation, or limited liability company, specify here): Business Form/Entity Type (if general partnership, limited partnership, limited liability partnership, or other, specify here): Business Entity State of Incorporation (if applicable): Type of Service: -PA Sof S -,E� PAlS Contact Person: Phone #: ( 310 ) 453 ` 7025 Emer. Contact: JZM E JN- F-(( J lM EWE Z Phone #: ( W ) 13 `-) - gs200 Billing Address. -LI 2.2.% SK>1Z0F'z PVOE5- Number Street Q A2.SI�O C'31^ C -'?O 7 41 -T- City State ZIP Proof of Insurance (circle one)? Yew No If no, would you like to purchase special event insurance through the City (circle orae)? Yes No Special Instructions / Notes: 532227.5 CFN 5 If Service Provider wishes to request any special accommodation needed to facilitate provision of the services, please identify it here or contact the staff member referenced on page 1 of this application: Total Service Fee $ 11 aFo'. 00 NOTE: If service provider is unable to provide the services as proposed or requested or the City of Carson cancels the service for any reason, the associated fees will not be paid. fremainder ofpage intentionally left blank] 532227.5 CFN 0 Further Terms of Service Provider Application Agreement: The undersigned signatory of Service Provider (Service Provider being the above -referenced person or entity seeking to provide services at the above -referenced event, including all its officers, agents, employees and volunteers) hereby represents and warrants that he or she is duly authorized by Service Provider to execute and deliver this application on behalf of Service Provider, and that by so executing this application, and in consideration for the City's review of this application, Service Provider is bound by these terms. Service Provider understands and agrees to comply with the City's "Service Provider Rules & Regulations," which are set forth below and incorporated herein by this reference. Service Provider agrees to indemnify and release City in connection with its proposed services in accordance with the "Waiver, Release, Hold Harmless, Agreement Not to Sue, Indemnification, and Photo Release" submitted concurrently herewith. Service Provider agrees to maintain all required insurance coverages and comply with all associated insurance requirements as set forth on the above "Insurance Requirements" page, which is incorporated herein by reference. Service Provider agrees that all required policies shall contain, or be endorsed to contain, an agreement by Service Provider to waive all rights of subrogation and contribution against the City, its elected or appointed officers, officials, employees and agents, for all losses and liabilities paid under the terms of any policy which arise from the activities or operations of, or the services performed by, Service Provider, regardless of any prior, concurrent, or subsequent non-active negligence by the City. In the event there is more than one person or entity named in this Service Provider Application Agreement as the Service Provider, then all obligations, liabilities, covenants and conditions hereunder shall be joint and several. This Service Provider Application Agreement, unless and until accepted, approved, and executed by the City Manager or designee, is only an application for provision of services to City, and does not constitute an approval or authorization for Service Provider to perform or provide any service to City. Neither Service Provider nor any of its agents or employees shall be deemed agents or employees of the City, nor a member of a joint enterprise with the City. Neither Service Provider nor any of its agents or employees shall at any time or in any manner represent that Service Provider or Ty of its agents or employees are agents or employees of City, or that it is a member of a joint enterprise with City. Subject to the requirements of this Service Provider Application Agreement, neither the City nor any of its employees shall have any control over the manner, mode or means by which Service Provider, its agents or employees, perform the services set forth herein. In the event that part of this Agreement is declared invalid or unenforceable by a valid judgment or decree of a court of competent jurisdiction, such invalidity or unenforceability shall not affect any of 532227.5 CFN the remaining portions of this Agreement which are hereby declared as severable and shall be interpreted to carry out the intent of the parties hereunder. Service Provider acknowledges that the City of Carson's consideration of Service Provider's application to provide the above -referenced services is on the express condition that Service Provider represents and warrants that it is and will be in compliance with all applicable restrictions on the use of intellectual property, including copyright laws, in connection with the services proposed to be provided. Service Provider shall indemnify, defend, and hold harmless the City against any penalties, claims, or liabilities arising from or in connection with Service Provider's noncompliance with same. The undersigned, on behalf of Service Provider, agrees that Service Provider seeks and is willing to provide the above -referenced service(s) on the date and time of the above -referenced event. This Service Provider Application Agreement has been executed on the dates written below. APPLICATION SUBMISSION (wet signature required; no electronic signatures): SERVICE PROVIDER: PA SysT-F MS seayiLe- Signature of S •c Provider's Au tized Re •esentative P'R-rte, �tmE>4E z Printe ame o Service Provider's Authorized Representative (space below this line for City use only) APPLICATION APPROVAL: CITY OF CARSON _�A� - Signature of City Manager or Designee 532227.5 CFN p7/0/ 1.-7, Date zc2- Date Service Provider Rules & Regulations 1. SERVICE PROVIDER APPLICATION: Upon acceptance, approval, and execution of a service provider application by the City of Carson ("City"), these rules and provisions shall become binding and a part of the Service Provider Application Agreement between the applicant (being the entity providing a service to City as specified in the service provider application), including its officers, employees, agents and volunteers ("Provider"), on the one hand, and the City, on the other hand. Any additions and amendments thereto that may be established or put into effect by the City, and provided in writing to the Provider, shall also become binding and a part of the Service Provider Application Agreement. 2. PAYMENT/CANCELLATION: If the Provider is unable to perform or cannot provide the services as requested, or the City cancels the service for any reason, the associated fees for service will not be paid. 3. CANCELLATION: No refunds will be given unless the subject event is cancelled by the City's Community Services Department. Applications may be denied or events cancelled in favor of City programs. 4. PROPERTY LOSS OR DAMAGES: The City is not responsible for any damage to, loss or theft of the Provider's property, or that of Provider's agents, employees or invitees. 5. CHARACTER OF ENTERTAINMENT: The Provider shall observe, obey and comply with all applicable local, state and federal laws, and all applicable policies, rules, regulations and terms and conditions governing use of City facilities. The Provider will forfeit all rents or other fees paid if ejected from premises for violations of same. Ejection shall not release Provider from any obligations for the payment of rents or other fees not yet paid under such permit or additionally incurred. The policy of the City is to serve the public in the best possible manner. The Provider shall at all times cooperate to this end. The policies, rules, regulations and conditions governing use of City facilities are subject to change without notice to Provider unless the change affects a permit already issued to Provider. Provider shall be solely responsible for the orderly conduct of all persons using the premises by its invitation, either expressed or implied, during all times covered by the Service Provider Application Agreement. The City reserves the right to eject or cause to be ejected from the premises any person or persons due to unlawful conduct. 6. RESPONSIBILITY: The Provider shall provide all material, equipment, and personnel necessary for provision of the service described in this agreement. 7. MOVE-IN/MOVE-OUT: Move -in to the event area will be set for each venue. Unless otherwise stated, Provider will be required to keep its area fully set up and manned until the event is officially over. Please note that these times are subject to change. 8. SAFETY: Standing on chairs, tables or other rental equipment is prohibited. This equipment is not engineered to support your weight. The City of Carson, its employees, agents, or officers will not be responsible for injuries or falls caused by the improper use of furniture. Please assist in our efforts to provide a SAFE WORKING ENVIRONMENT. 532227.5 CFN Z 9. VOLUME/LIGHT CONTROL: The City reserves the right to regulate the volume or intensity of any and all noise or light generating mechanisms (including, but not limited to, loudspeakers, radios, television sets, musical instruments, entertainers, or blinking or flashing lights) in the reasonable judgment of the City. 10. FLAMMABLE MATERIALS — All decorations, props and electrical equipment must be fireproof or of fire retardant materials, must meet City requirements and are subject to removal. Candles and other open flame devices will not be permitted except as authorized on this agreement; subject to Fire Department regulations. 11. COPYRIGHT INFORMATION: Provider is responsible for licensing fees as required by law. Provider may be subject to legal action for the use, display or sale of any item using any copyrighted and/or trademarked name or logo which has not been specifically authorized under license from the trademark holder. 12. PERMITS AND LICENSE: Provider shall procure at its own cost and expense all the required licenses and permits applicable to Provider's use or activity . 13. OBLIGATION FOR CLEANLINESS: Provider agrees that the facility and any other surrounding City property (including parking lots) used by the Provider must be left in a clean and orderly condition (equal to or better than the condition existing prior to the event). If additional maintenance is required, other than the normal cleaning process, the Provider will be charged additional fees based on the cost of such maintenance. 14. DISPUTES: All points not covered by the Service Provider Rules & Regulations are subject to the decision of the appropriate City representative. 15. FLOOR MANAGEMENT: The City will appoint a Floor Manager who is authorized to enforce these rules and regulations. 16. SPACE ASSIGNMENT: Event space is assigned to providers at the sole discretion of the City. Concerns regarding competitive or specific types of providers should be communicated to the City at the time of application. 17. RULE CHANGES: The City reserves the right to make reasonable changes to the foregoing rules, event hours and move-in/move-out arrangements at any time without notice to Provider, unless the change affects a permit already issued to Provider. 532227.5 CFN 10 Waiver, Release, Hold Harmless, Agreement Not to Sue, Indemnification, and Photo Release 1, 6R:l{ `T1MJr -;HE7Z- , ("individual") [on behalf of jAw lyit<G N PiappLe-T t 6 k/ ("Service Provider"), and as a bona fide agent of Service Provider duly authorized to execute this Waiver, Release, Hold Harmless, Agreement Not to Sue and Indemnification agreement ("Agreement") on behalf of Service Provider] (individual and Service Provider hereinafter collectively referred to as "Signatory," and the term "Signatory" includes Service Provider's officers, officials, employees, agents and volunteers), seek acceptance by the City of Carson f an application to provide services in/at QAQ,50q /M7�Y4AnYlKL SC-t44A#Wfvent") on / 2 ("Date"). G,VnO LTJ Signatory understands that accidents and injuries can arise out of the Event; knowing the risks, nevertheless, and in consideration of the acceptance of an application to provide a service at the Event on the Date, Signatory hereby waives, releases and discharges any and all claims for damages for death, personal injury, or property damage which Signatory may have, or which hereafter accrue to Signatory, against the City of Carson, its elected and appointed officers, officials, employees, agents and volunteers (collectively "City"), and from and against any and all liability arising out of or connected in any way with Signatory's participation in or presence at the Event, even though that liability may arise out of negligence or carelessness on the part of City. It is further understood and agreed that this Agreement is to be binding on Signatory's heirs and assigns. Signatory hereby grants City the right to photograph or video -record Signatory during or in connection with the Event, and to use Signatory's photographed or video -recorded likeness, and any image, silhouette, or reproduction of the voice or appearance of Signatory taken during or in connection with the Event ("Likeness"), for any purpose, including publicity and promotion of City and its events, and creation or production of materials in any form for such purpose, with no claim of entitlement to any license fee or royalty of any kind from City. Signatory hereby waives any right to the intellectual property of Signatory's Likeness. The rights granted by Signatory hereunder shall not expire. Signatory further agrees to indemnify, defend and hold harmless City from and against any and all claims, liabilities, losses, damages, expenses, and costs (including without limitation costs and fees of litigation) of every nature (including, but not limited to, property damage, bodily injury, or death), whether imposed by law or otherwise, sustained or alleged to be sustained by any person or entity (whether they be members of the public visiting the Event, employees of the City, other service providers at the Event, or otherwise), occurring at, arising from, or connected with .Signatory's preparation or performance of services at the Event, Signatory's actions, inactions, or use of facilities at the Event, or any equipment, machinery or items displayed or used by the Signatory at or for the Event, except for such claim, liability, loss, damage, expense, or cost which was caused by the sole negligence or willful misconduct of the City. By signing below, I acknowledge and represent that I have read and understand the above, and that I voluntarily agree tp its terms. Signed: NAME: 'f�f Ezi ORGANIZATION: _ ),(,DJD 7EC-H F FZA2�T10H Date: 07/0), % l 532227.5 CFN PRO�UCT�OlV Arjay Jimenez 21227 Shearer Ave Carson, Ca 90745 T: 310.953.7059 E: djarjayl2@gmail.com City of Carson/Attn: Adrian Reynosa 801 E. Carson St Carson, Ca 90745 T: 310.830.7600 E: areynosa@carsonca.gov PA Systems Services for Filipino American Friendship Day Event @ Carson International Sculpture Garden 1. Total payment due in 30 days 2. Please include the invoice number on your check INVOICE DATE: 07/11/21 INVOICE #: 071121 CUSTOMER ID: $ 1,850.00 SUBTOTAL $ 1,850.00 TAXABLE $ - TAX RATE $ - TAX DUE $ - OTHER $ - -OTAL DUE 1 $ 1,850.00 Make all checks payable to: AudioTech Production If you have any questions about this invoice, please contact Arjay Jimenez, P#: 310.953.7059, E: djarjayl2@gmail.com Thank You For Your Business! CERTIFICATE OF LIABILITY INSURANCE DATE(MWDD/YYYY) ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF 05/16/2021 THIS CERTIFICATE IS ISSUED AS A MATTER OF INF RMATI N NLY 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 have ADDITIONAL INSURED provisions or 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 endorsements . PRODUCER CONTACT NAME: Mass Merchandising Underwriting K&Klnsurance Group, Inc. 1712 Magnavox Way Fort Wayne IN 46804 PHONE 1-800-328-2317 1-260-459-5502 Ext): ac No -M IL ADDRESS: entertainers@kandkinsurance.com PRODUCER CUSTOMER ID: 6BRPG0000007507700 INSURER(S) AFFORDING COVERAGE NAIC # 05/17/2022 INSURED INSURER A: Nationwide Mutual Insurance Company 23787 Arjay Ferrer Jimenez INSURER B: DBA: DJ/PA/KJ Service 21227 Shearer Ave INSURER C: INSURER D: Carson, CA 90745 INSURER E: A Member of the Sports, Leisure & Entertainment RPG INSURER F: COVERAGES CERTIFICATE NUMBER: W01946767 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 LTR TYPE OF INSURANCE ADOL INSD SUBR WVD POLICY NUMBER MMIDD/YYYY POLICY EXP MWDD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY X 6BRPG0000007507700 05/17/2021 05/17/2022 EACH OCCURRENCE $1,000,000 CLAIMS- OCCUR MADE 12:01 AM EDT 12:01 AM A N $1,000,000 PREMISES Ea Occurrence MED EXP (Any one person) $5,000 PERSONAL & ADV INJURY GENERAL AGGREGATE $5,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS — COMP/OPAGG $1,000,000 POLICYPRO LOC JECT PROFESSIONAL LIABILITY OTHER: LEGAL LIAB TO PARTICIPANTS $1,000,000 AUTOMOBILE LIABILITY coQffFffff7l77ffTiWiT-- (Ea accident BODILY INJURY (Per person) ANY AUTO OWNED AUTOSSCHEDULED ONLY AUTOS BODILY INJURY (Per accident) HIRED NON -OWNED A AUTOS ONLY AUTOS ONLY Per accident NOT PROVIDED WHILE IN HAWAII UMBRELLA LIAB OCCUR EACH OCCURRENCE EXCESS LIAR CLAIMS -MADE AGGREGATE DED RETENTION WORKERS COMPENSATION AND EMPLOYERS' LIABILITY N/A STATUTE OTHER ANY PROPRIE CR/PARTNER/ Y / N E.L. EACH ACCIDENT EXECUTIVE OFFICER/MEMBER ❑ EXCLUDED? (Mandatory in NH) E.L. DISEASE—EA EMPLOYEE E.L. DISEASE—POLICY LIMIT If yes, describe under DESCRIPTION OF OPERATIONS below A MEDICAL PAYMENTS FOR PARTICIPANTS 6BRPG0000007507700 05/17/2021 05/17/2022 PRIMARY MEDICAL $5,000 12:01 AM EDT 12:01 AM EXCESS MEDICAL DESCRIPTION OF OPERATIONS/ LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached 0 more space is required) Performing as DJ or KJ The certificate holder is added as an additional insured, but only for liability caused, in whole or in part, by the acts or omissions of the named insured. leJa:Ul�ly_\I�ael��la: efill010i=10A_\1Is] 0 City of Carson SHOULD ANY OF THE ABOVE DESCRIBED P LI IES BE AN ELLED BEFORE 801 E. Carson St THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Carson, CA 90745 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE (Owner/Lessor of Premises) Coverage is only extended to U.S. events and activities. " NOTICE TO TEXAS INSUREDS: The Insurer for the purchasing group may not be subject to all the insurance laws and regulations of the State of Texas ACORD 25 (2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 6BRPG0000007507700 COMMERCIAL GENERAL LIABILITY CG 20 26 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Persons Or Organization(s) City of Carson 801 E. Carson St Carson, CA 90745 Named Insured: Arjay Ferrer Jimenez DBA: DJ/PA/KJ Service Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section 11 — Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by your acts or omissions or the acts or omissions of those acting on your behalf: 1. In the performance of your ongoing operations; or 2. In connection with your premises owned by or rented to you. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following is added to Section III — Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. CG 20 26 04 13 0 Insurance Services Office, Inc., 2012 Page 1 of 1