HomeMy Public PortalAboutC-21-152 - CPVA_ALMA DE ORO - COUNTRY WESTERN FAIR SPACity of Carson
Community Services Department
Service Provider Application
Dear Applicant,
Onbehalf of the City of Carson,I would like to thank you for taking the time to explore business
opportunities with the City by applying to provide services for an event at a City facility.As part
of our application process,you must complete,sign,and return the following forms.Submission
of these forms does not guarantee that you will be provided the business opportunity youseek.
Your prompt assistance in submitting the requested documentation to the City staff member
listed below will be appreciated and will help expedite the application process.Please send your
completed application and attachmentsdirectly to the following address:
City of Carson
Attn:Jose Pifa
(Event Coordinator’s Name)
Dominguez Park -21330 Santa Fe Ave.Carson,CA.90810
(Enter Event Coordinator’s address (i.e.,city hall,corporate yard,or specific park address)
Email:jpina@carsonca.gov
(Enter event coordinator’s email address)
Should you have any questions,please feel free to contact the staff memberlisted below .
Truly,
Jose Pifia
(Name)
Recreation Center Supervisor II
(Title)
532227.5 CFN AS OF 1-22-2020
Checklist
Before submitting your application packet make sure each of the below
indicated items have been attached or completed.
(FOR COMMUNITY SERVICES OFFICE USE ONLY)
Service Provider Application Agreement
Invoice for Future Event Date’
Business License (if applicable)
Proof of Insurance/Certificate of Insurance
Waiver,Release,Hold Harmless,Agreement Not to
Sue,Indemnification,and Photo ReleaseS
I
R
I
Current Copy of W-9 Form (if not on file already)
The date of the Event shall be listed on the invoice for Future Event Date (IFED).If the Service Provider Application is
approved,then the IFED will be processed as an invoice for services rendered for the Event.No payment will be made
until the conclusion of the Event,at earliest.
532227.5 CFN AS OF1-22-2020
|%[aI
(Date)C P V A /A l a w c e D e o
(Company)
(06.220 St.
(Company Address)
C h i n ,G h 9s(City,State ZIP)
Insurance Requirements
p e r COVA [Pina de O v o
(Enter Provider’s Name)
2
Please be advised pursuant to your desire to work with the City of Carson,you are required to
submit the following:
Y 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 OI 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 appointedofficials,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 furnishedin connection withthe event.
532227,5 CFN AS OF 1-22-2020
City of Carson
Community Services Department
Service Provider Application Agreement
Check one (staffuse)
[
|Carson Event Center|_|Human Services OKcreation [|Transportation
event COWuMTY Keston autre Event Location:Daningaee
Fle
even Date:_upole'
Name of Service Provider:CevA fein ae O®
Business Form/Entity Type (if individual,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:eniertam Nord
Contact Person:KAY ey)Ruan Phone #:(Ab)¢f 3 HIS¥
Emer.Contact:Phone#:()
Billing Address:L&D é.a0"SF
(-WSO)G W7US
City State
Proof of Insurance (check one)?[Wes [No
If no,would youlike to purchase special event insurance through the City (check one)?[ves [INo
Special Instructions /Notes:
532227.5 CFN .AS OF 1-22-2020
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 |of this application:
Total Service Fee $200 >JO
NOTE:If service provider is unable to providethe services as proposed or requested or the City
of Carson cancels the service for any reason,the associated fees will not be paid.
[remainder ofpage intentionally left blank]
532227.5 CFN AS OF 1-22-2020
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 appointedofficers,officials,employees and agents,for all
losses and liabilities paid under the terms of any policy whicharise 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 Manageror designee,is only an application for provision of services to City,and does not
constitute an approval or authorization for Service Provider to performor 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 mannerrepresent that Service Provider or any of its
agents or employees are agents or employees of City,or that it is a memberof 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,performthe 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 competentjurisdiction,such invalidity or unenforceability shall not affect any of
$32227.5 CFN AS OF 1-22-2020
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,orliabilities 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 proviper:(PVA |Mimatde,Oro
MyisZed eg 222
(Sighatureot Sérvice Provider's Authorized Representative)(Date)
Caren Soles.
(Printed Name ofService Provider’s Authorized Representative)
(Space below this line for City use only)
APPLICATION APPROVAL:
CITY OF CA //-
(Signature of CHY Manageror Designee):(Date)
§32227.5 CFN AS OF 1-22-2020
Service Provider Rules &Regulations
1,SERVICE PROVIDER APPLICATION:Upon acceptance,approval,and execution of aserviceproviderapplicationbytheCityofCarson(“City”),these rules and provisions shall
become binding and a part of the Service Provider Application Agreement betweenthe 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 orput
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 theservicesasrequested,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 orinvitees.
5.CHARACTER OF ENTERTAINMENT:The Provider shall observe,obey and comply withallapplicablelocal,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 otherfeespaidifejectedfrompremisesforviolationsofsame.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 tochangewithoutnoticetoProviderunlessthechangeaffectsapermitalreadyissuedtoProvider.
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 personor 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 equipmentis 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 AS OF 1-22-2020
9.VOLUME/LIGHT CONTROL:The City reserves the right to regulate the volume orintensity
of any and all noise orlight 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 orof 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 oractivity .
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 onthe 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 changesto 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.
$32227.5 CFN AS OF 1-22-2020
10 |
Waiver,Release,Hold Harmless,Agreement Not to Sue,Indemnification,and Photo Release
I,(Gi fren Ja las ,(“individual”)fon behalf ofCPVP{AWA,he Ceo (“Service Provider”),and as a bona fide agent of Service ProviderdulyauthorizedtoexecutethisWaiver,Release,Hold Harmless,Agreement Not to Sue and Indemnificationagreement(“Agreement”)on behalf of Service Provider](individual and Service Provider hereinaftercollectivelyreferredtoas“Signatory,”and the term “Signatory”includes Service Provider’s officers,officials,employees,agents and volunteers),seek acceptance by the City of Carson of a application to provide servicesin/at Cunr Outer NY AuY (“Event”)on
_
||P20 ho (“Date”).
Signatory understands that accidents and injuries can arise out of the Event:knowing the risks,nevertheless,and in consideration of the acceptance ofan 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 ofCarson,its elected and appointed officers,officials,employees,agents and volunteers (collectively “City”),and from and against any andall liability arising out of or connected in any way with Signatory’s participationinorpresenceattheEvent,even though that liability may arise out of negligence or carelessness on the part ofCity.It is further understood and agreedthatthis Agreementis 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 withtheEvent,and to use Signatory’s photographed or video-recorded likeness,and any image,silhouette,orreproductionofthevoiceorappearanceofSignatorytakenduringorinconnectionwiththeEvent(“Likeness”),for any purpose,including publicity and promotion of City and its events,and creation orproductionofmaterialsinanyformforsuchpurpose,with no claim of entitlement to any license fee or royaltyofanykindfromCity.Signatory hereby waives any right to the intellectual property of Signatory’s Likeness,The rights granted by Signatory hereundershall not expire,
Signatory further agrees to indemnify,defend and hold harmless C ity from and against any and all claims,liabilities,losses,damages,expenses,and costs (including without limitation costs and fees of litigation)ofeverynature(including,but not limited to,property damage,bodily injury,or death),whether imposed by laworotherwise,sustained oralleged to be sustained by any person or entity (whether they be membersof thepublicvisitingtheEvent,employees of the City,other service providers at the Event,or otherwise),occurringat,arising from,or connected with Signatory’s preparation or performance of services at the Event,Signatory’sactions,inactions,or use of facilities at the Event,or any equipment,machinery or items displayed or used bytheSignatoryatorfortheEvent,except for such claim,liability,loss,damage,expense,or cost which wascausedbythesolenegligenceorwillfulmisconductoftheCity.°
By signing below,I acknowledge and represent that I have read and understand the above,and that Ivoluntarilyagreetoitsterms.j 2ae
Aid KEnbe-
Grnn Safad.
ORGANIZATION:CP Vtt /Alng lo,Ore)
Date:{l-$-262
Signed:
532227.5 CFN AS OF 1-22-2020
ron W-9
(Rev.October 2018}
Deparmentof the TreasuryInternalRevenusService
Request for Taxpayer
Identification Number and Certification
>Go to www.irs.gov/FermW$9for instructions and the latest information.
Give Form to the
requester,Do not
send to the IRS.
Calas vark
2 Business name/disregarded entity name,if different from above
1 Narne (as shownon your incame tax relurm).Name is required on this fine,da nol leave this line blank.\dlunheor AscocecMery
following seven boxes.
Cc individualsole proprietor or vf C Corporation
single-member LLC
Print
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type.
[1]Other isee instructions)&
O S Corporation
CT Limited liability company,Enter the tax classification (C=C corporation,S=S corporation,P=Partnership)»
Note:Checkthe appropriate box in the line above for the tax classification of the single-member owner,Do not check Exemption from FATCA reportingLLCiftheLLCisclassifiedagasingle-member LLC that is disregarded frorn the owner unless the owner of the LLG isanotherLLCthatisnotdisregardedframtheownerforU.S.federal tax purposes,Otherwise,a single-mamber LLC that18disregardedfromtheownershouldchecktheappropriateboxforthetaxclassificationofitsowner,
3 Check appropriate box for federal tax classification of the person whose narne is entered on line 1.Check only one of tha
|
4 Exemptions (codes apply only tocertainentities,nat individuals;see
instructions on page 3):
oO Partnership Oo Trust/estate
Exempt payeo code {if any)
code (if any) CAppies te accautits maintomed culsicte ie US!
5 Address (number.street.and apt.or suite ne.}st instructions,(OCO_E.DBOSee
Specific
Instructions
on
pa
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3.
Requester’s name and address (optiynal)
—CLOT<&Cily,state.and ZIP codeCarscyy,CA 7 List account numberts)here (optional)
Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box.The TIN provided must match the name given on line 1 to avoidbackupwithholding.For individuals,this is generally your social security number (SSN).However,foraresidentalien,sole proprietor,or disregarded entity,see the instructions for Part /,laler.For other -~entities,it is your employer identification number (EIN).if you do not have a number,see How to getaTIN,later.
Note:If {he account is in more than one name,see the instructions for line 4.Also see What Name andNumberToGivetheRequesterforguidelinesonwhosenumbertoenter.
Social security number }
or
|Employer Identification number
AL]-|Si Fel g|2
Certification
Under penalties of perjury,|certify that:
1.The number shown on this form is my correct laxpayer identification nurnber (or |am wailing for a number to be issued to me};and2.1 am not subject to backup withholding because:(a)lam exempt from backup withholding,or (6)|have not beer notified by the internal RevenueService(IRS)that |am subject to backup withholding as a resull of a failurenolongersubjecttobackupwithholding;and
3.fama U.S.citizen or other U.S.person (defined below);and
to report all interest or dividends,or (c)the IRS has notified me that !am
4.The FATCA code(s)entered on this form (it any)indicating that |am exempt from FATCA reporting is correct.Certification instructions.You must cross out item 2 above if you have been notified by the IRS that youare currently subject to backup withholding becauseyouhavefailedtoreportallimerestanddividendscnyourtaxreturn,For real estate transactions,item 2 does not apply.Far mortgage interest paid,acquisition or abandonment of sec ed property,cancellation of debt,contributions to an individual retirement arrangement (IRA),and generally,paymentsotherthaninterestanddividendseiapnotrequiredtosignthecertification,but you must provide your correct TIN.See the instructions for Part fl,later.. Sign Signature of ~
Here U.S.person Date >\\F-2\
General Instructions
Section references are to the Internal Revenue Code unless otherwisenoted,
Future develapments,For the latest information about developmentsrelatedtoFormW-S and its instructions,such as legislation enacted
after they were published,go to www.irs.gov/FormW9.
Purpose of Form
An incividuai ar entity (Form W-9 requester)who is required to file aninformationreturnwiththeIRSmustobtainyourcorrecttaxpayeridentificationnumber(TIN)which may be your social security number(SSN),individual taxpayer identification number (ITH).adoption
taxpayer identification number (ATIN),or employer identification number(EIN),to reoort on an information return the amount paid to you,or otheramountreportableonaninformationreturn,Examples of informationreturnsinclude,but are not limited to,the following,
*Form 1099-INT {interest earned or paid)
+Form 1099-DIV (dividends,including those fram stocks or mutualfunds)
*Form 1099-MISC (various types of income,prizes,awards,or grossproceeds}
*Form 1099-B (stock or mutual fund sales and certain othertransactionsbybrokers)
*Form 1099-S (proceeds from real estate transactions)
*Form 1099-K (merchant card and third parly network transactions)
«Form 1098 (home mortgage interest),1098-E (student loan interest),1098-T (tuition)
*Form 1099-C (canceled debt)
+Form 1099-A (acquisition or abandonment of secured property)
Use Form W-9 only if vou are a U.S.person (including a residentalien).to provide your correct TIN,
ff you do not return Form W-9 to tha requesterwith a TIN,you mightbesubjecttobackupwithholding.See What is backup withholding,later.
Cat.Ne,10291x Form W-9 iRav.10-2018)
Calas Park V.A.,Alma De Oro
1000 E.220th St Phone:(310)413-3454
Carson,CA 90745 Office:C10)318-3565
E-rnail:mechas3 lO@sgmail.con
Quoted by:Karen Ruan
involee for Future Performance
Statement #1104202]Bill To:City of Carson
Date:November 4,2021 701 E.Carson St.
Customer 1D:CWF 2021 Carson,CA.90745
(310)830-7600
Date Type Description|‘Amount ‘Payment Balance
:Ballet
AlmaDeOro —Folklorico oe DONUT ey hy11/20/2021 |Performance $200.00 ==$-200.00 .
Total =$200.00.
Reminder:Please make check payable to CALAS PARK VOLUNTEER ASSOCIATION
Terms:Check due on day of performance
CuIstomerNameCity of Carsoncuustomerio:Cwr2021,see nanan
_November4,4,2¢2AmountDue:$200.00.
|_(PerformancedateSaeurday11/20/2021),
Page |