The URL can be used to link to this page

Home My Public Portal AboutC-23-034 - SPA RAPHA MUSIC - '23 BLACK HISTORY CELEBRATION City of Carson Community Services Department Service Provider Application Dear Applicant, On behalf of the City of Carson, [ 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 you seek. 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 attachments directly to the following address: City of Carson Attn: Dani Cook (Event Coordinator’s Name) 801 E. Carson St., Carson, CA 90745 (Enter Event Coordinator’s address (i.e., city hall, corporate yard. or specific park address) Email: dcook@carsonca.gov (Enter event coordinator’s email address) Should you have any questions, please feel free to contact the staff member listed below . Truly, Dani Cook (Name) Human Services Program Manager (Tide} 532227,.5 CEN AS OF 4-11-2022 oad , Keg Aloe VA Ls “py, . (Company) [9707 2 Cagtboee, AYE (Company Address) (pre6o7, Ca Fo2¢f (City, Sate ZIP} insurance Requirements Dear Lim Williams (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: 1 against claims which may arise from or in connection with the services), evidencing the coverage(s) as indicated below. ¥ Compliant Certificates of Liability Insurance (to be maintained for the duration of services 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 G0 Of caverine 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 er operations performed at or on behalf of the Cin-sponsored event including materials, parts, or equipment furnished in connection with the event, ace ; AS OF 4-11-2022 City of Carson Community Services Department Service Provider Application Agreement Check one (staff use): [| Carson Event Center{7] Human Services [| Recreation [| Transportation 2/17/23 _Black History Month Celebration Carson Event Center u Event Date: Even Event Location: Name of Service Provider: Raha Muse / Tren bhe, KA Lape / / . Business Form/Entity Type (if individual, sole proprietorship, corporation, or limited liability company, specify here): x type if) v5/i Business Form/Entity Type (if general partnership, limited partnership, limited Hability partnership, or other, specify here): Business Entity State of Incorporation (if applicable): Type of Service: Nose Stay tees ( o Inge + Bary d | Contact Person: [10 thy, Ki Witenes Phone #: SBA _&7?2- SZ eo Emer. Contact: Phone#:(__) Billing Address: 19707 S- Cewtaal Ave Number Street [q2202 Cis 10246 City State valu Proof of Insurance (check one)? [Xlres [No Ifno, would you like to purchase special event insurance through the City (check one)? [Wes [No Special Instructions / Notes: Rapha Music will provide musicians and singers for the 2023 Black History Month Celebration on February 17, 2023. 532227.5 CEN AS OF 4-11-2022 MAY 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: $2,500 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. Total Service Fee [remainder of page intentionally left blank] AS OF 4-11-2022 the ponding -\rtt « fo spy : , me remaming 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 ta be provided. Service Provider shall indemnity, 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: eghs vse NN { ~" Gigngtire of Service Proviger’s Authorized Representative) (Printed Ngfite of Service Provider’s Authorized Representative) (Space below this fine for City use caly) APPLICATION APPROVAL: CITY OF CARSON Whechasl Whitteerr, Ca. February 9, 2023 {Signature of City Manuger or Designee) C — —————~ eee ~ 3322275 CEH AS OF 3-11-2022 Waiver, Release, Hold Harmless, Agreement Not to Suc and Indemnification i C ExT itor” M and as ¢ bun fide agent ul Exhibitor daly ent Not to Sue ly referred Ui seck acceptance by ("Event") on aan a _Lypeoldy, hile _Cindividaal M) fon behalf of xd Indernai “Stanatory,” and the term” 7 he City of Carson of ani appl Healion to provi J Hannless, Agree vitor hereinalier ce le employees, agents and volunteers), allon agreement (’Aureenie: wpe ignatory understands that accide us, illnesses, and injuries can arise out of the Event; Knowing the 7 consideration of the acceptance of an application to provide a service at the Event on the Date, Sienatory nis and vo oe and discharges the City of Carson, its elected and appointed officers. officials, employees, a “City” and J individually, “City Party’), and from and against any and all claims or liabilities to Signatory ar ¢ entity, including but not limited to claims or [abilities for bodily injury, illness, death, or property dama ng connected in any way with Sienatory’s participation in, presence af, or performance of servic that Hability may arise cut of negligence or carelessness on the par of City, and Signatory agree such claims through any action or proceeding against the City or any City Party. However, Signatory underst: ands the is not intended to release any party from any act or omission of “aross negligence." 5 tO WAVE he Event, and to use enatory hereby grants City the right to photograph or video-record Signatory during or in connection with th Sig Signatary’s photographed or video-recorded likeness, and any image, silhouette, or reproduction of the voice or appea Signatory taken during or in connection with the Event (“Likeness”), for any purpose, including publicity and promotion On and its events, and creation or production of materials in any form for such purpose, with no claim of entitleme aT tO of royalty of any kind from City. Signatory hereby waives any right to the intellectual property of Signatory’s L. ikeness. Signatory further agrees to indemnify, defend and hold harmless City and each City Party from and against any and all liabilities, losses, damages, expenses, ‘and costs (including without limitation costs and fees of | itigation) of every nature (ine but not limited to, property damage, bodily injury, or death), whether imposed by law or otherwise, sustained of all sustained by any person or entity (whether they be members of the public visiting the Event, employees of the City, othe at the Event, or otherwise), occurring at, arising from, or connected with Signatory’s preparation or perform: aT Event, Signatory’s actions, inactions, or use of facilities at the Event, or any equipment, machinery or items displ ayed dor 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. in giving the foregoing releases and waivers, Signatory expressly waives any and all rights conferred upon it by the provisions of California Civil Code Section 1542, which Signatory understands reads as follows: “A general release does not extend to claims that the creditor or releasing party does not know or suspect to exist in his or her Liver t at the Ume of executing the release and thal, if known by him or her, would have materially affected his or her settlement with the debtor or released party.” This waiver shall be effective as a bar to any and all actions, fees, damages, losses, claims, liabilides and demands of whatsoever character, nature and kind, that are known or unknown, or suspected or unsuspected, that may arise from or relate in any way to Signatory's participation in the Event. . This Agreement shall be binding on Signatory’s successors, heirs and assigns, and shall not expire. No oral represcoraens statements or inducements, apart from this written form, have been made with regard to the subject matter of this form. [fan portion of this form is declared invalid by a court of competent jurisdiction, the remainder shall continue in full force and effect, eps By signing below, Signatory acknowledges and represents that iChas read and understands the above, and that it voluntarily agrees fo its terms. By signing below, Signatory acknowledges and represents that it has read and understands the above, and that is yeluntarily agrees to its terms. SIGNED: ‘ aE eteesennntenn LOSES | AS OF 4-11-2022 INVOICE Rapha Music RaphaMuzic@gmail.com 1567 High Meadow Drive +1 5622774630 Beaumount, Ca 92223 City of Carson/BIk History Bill to Invoice details City of Carson/Bik History Invoice no.: 1127 City of Carson/Black History Invoice date: 2/8/23 Celebration 2022 Terms: Net 30 701 E. Carson, Carson California Due date: 2/17/23 90745 Product or service Production Services 1 unit x $2,500.00 Musicians and Singers for Black History Program Total Ways to pay VISA Gee ose, re BANK Note to customer Thank you for trusting us with your entertainment needs. Amount $2,500.00 $2,500.00 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. INSURER(S) AFFORDING COVERAGE INSURER F : INSURER E : INSURER D : INSURER C : INSURER B : INSURER A : NAIC # NAME:CONTACT (A/C, No):FAX E-MAILADDRESS: PRODUCER (A/C, No, Ext):PHONE INSURED REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES 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 endorsement(s). THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. OTHER: (Per accident) (Ea accident) $ $ N / A SUBR WVD ADDL INSD 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. $ $ $ $PROPERTY DAMAGE BODILY INJURY (Per accident) BODILY INJURY (Per person) COMBINED SINGLE LIMIT AUTOS AUTOSAUTOS NON-OWNEDHIRED AUTOS SCHEDULEDALL OWNED ANY AUTO AUTOMOBILE LIABILITY Y / N WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OFFICER/MEMBER EXCLUDED? (Mandatory in NH) DESCRIPTION OF OPERATIONS below If yes, describe under ANY PROPRIETOR/PARTNER/EXECUTIVE $ $ $ E.L. DISEASE - POLICY LIMIT E.L. DISEASE - EA EMPLOYEE E.L. EACH ACCIDENT EROTH-STATUTEPER LIMITS(MM/DD/YYYY)POLICY EXP(MM/DD/YYYY)POLICY EFFPOLICY NUMBERTYPE OF INSURANCELTRINSR DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) EXCESS LIAB UMBRELLA LIAB $EACH OCCURRENCE $AGGREGATE $ OCCUR CLAIMS-MADE DED RETENTION $ $PRODUCTS - COMP/OP AGG $GENERAL AGGREGATE $PERSONAL & ADV INJURY $MED EXP (Any one person) $EACH OCCURRENCE DAMAGE TO RENTED $PREMISES (Ea occurrence) COMMERCIAL GENERAL LIABILITY CLAIMS-MADE OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO-JECT LOC CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) CANCELLATION AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. CERTIFICATE HOLDER The ACORD name and logo are registered marks of ACORD MTTU Hiscox Inc. d/b/a/ Hiscox Insurance Agency in CA 520 Madison Avenue 32nd Floor New York, New York 10022 (888) 202-3007 contact@hiscox.com Hiscox Insurance Company Inc 10200 Timothy A Williams 19707 S Central Ave Carson, CA 90746 The City of Carson 701 E Carson St Carson, CA 90745 The City of Carson, and its elected and appointed officials, employees, volunteers and agents, are to be covered as additional insured with respect to liability aris ing 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. 01/01/202401/01/2023P100.027.096.4YY X A X X Each Claim: $ 1,000,000 Aggregate: $ 1,000,000 Professional LiabilityA 01/01/202401/01/2023P100.026.410.4Y 1,000,000 100,000 5,000 1,000,000 2,000,000 S/T Gen. Agg. 11/17/2022