HomeMy Public PortalAboutC-23-044 - NATALIE FRAGOSO - CESAR CHAVEZ TRIBUTE SPACity of Carson
Community Services Department
Service Provider Application
Dear Applicant,
On behalf 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 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: Cristina Herrera & Nichols
(Event Coordinator's Name)
(Enter Event Coordinator's address (i.e., city hall, corporate yard, or specific park address)
Email: cherreraRcarsonca.gov & nrey
(Enter event coordinator's email address)
Should you have any questions, please feel free to contact the staff member listed below .
Truly,
Cristina Herrera
(Name)
Senior Recreation Center Superv.
(Title)
532227.5 CFN AS OF 4-11-2022
2
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)
n/a
n/a
Service Provider Application Agreement
Invoice for Future Event Datel
Business License (if applicable)
Proof of Insurance/Certificate of Insurance
Waiver, Release, Hold Harmless, Agreement Not to
Sue, Indemnification, and Photo Release
Current Copy of W-9 Form (if not on file already)
1 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 OF 4-11-2022
3
1/27/23
(Date)
(Company)
(Company Address)
(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 AS OF 4-11-2022
4
City of Carson
Community Services Department
Service Provider Application Agreement
Carson Event Center
Check one (staff use):
Human Services
✓
Recreation 1 Transportation
Event:Tribute to Cesar Chavez Event Location: Carson Event Center Event Date:3/24/23
Name of Service Provider: Natalie Fragoso
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: �I
Contact Person: \41 dIL , CCAOL2S 3 Phone #: ((d4\) ?j 3-5'
Emer. Contact:
Phone #: (6e) '1J 3 • lD (D I -
Billing Address:
Street
Number
State ZIP
City
Proof of Insurance (check one)?
Yes
✓
No
If no, would you like to purchase special event insurance through the City (check one)? EYes ✓QNo
Special Instructions / Notes:
532227.5 CFN AS OF 4-11-2022
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
$2,000
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.
[remainder of page intentionally left blank)
532227.5 CFN AS OF 4-11-2022
6
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 terns.
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 any 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 AS OF 4-11-2022
February 21, 2023
8
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 AS OF 4-11-2022
9
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 naive 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 AS OF 4-11-2022
Waiver, Release, Hold Harmless, Agreement Not to Sue and Indemnification 10
I, AAr/tl l.{i lr , ("individual") [on behalf of
("Exhibitor"), and as a bona fide agent of Exhibitor duly authorized to execute this
Waiver, Release, Hold Harmless, Agreement Not to Sue and Indemnification agreement ("Agreement") on behalf of Exhibitor]
(individual and Exhibitor hereinafter collectively referred to as "Signatory," and the term "Signatory" includes Exhibitor's officers,
offf�i Is,
mpllooyeees� pa ee�nts as d, volunteers), seek acceptance b the C'ty of Carson of an application to provide services in/at
I '1 — uty,r owes es ("Event") on by
("Date").
Signatory understands that accidents, illnesses, 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 the City of Carson, its elected and appointed officers, officials, employees, agents and volunteers (collectively
"City," and individually, "City Party"), and from and against any and all claims or liabilities to Signatory or any other person or
entity, including but not limited to claims or liabilities for bodily injury, illness, death, or property damage, arising out of or
connected in any way with Signatory's participation in, presence at, or performance of services at or for the Event, even though
that liability may arise out of negligence or carelessness on the part of City, and Signatory agrees to waive its rights to make any
such claims through any action or proceeding against the City or any City Party. However, Signatory understands that this paragraph
is not intended to release any party from any act or omission of "gross negligence."
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.
Signatory further agrees to indemnify, defend and hold harmless City and each City Party 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 Exhibitors
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.
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 favor
at the time of executing the release and that, 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, liabilities 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 representations,
statements or inducements, apart from this written form, have been made with regard to the subject matter of this form. If any
portion of this form is declared invalid by a court of competent jurisdiction, the remainder shall continue in full force and effect.
By signing below, Signatory acknowledges and represents that it has read and understands the above, and that it voluntarily agrees
to its terms.
By signing below, Signa acknowledges and represents that it has read and understands the above, and that is voluntarily
agrees to its terms.
SIGNED:
NAME:
1\1,PI, AkZ ^rr�SO
ORGANIZATION:
DATE:
01007.0001/781805.1 AS OF 4-11-2022
INVOICE
Name: Natalie Fragoso Date 2/15/23
Address: 2226 Via Lazio Ave
Delano, Ca 93215
Phone: 661.333.5082
Invoice # 324
Payment due: March 24, 2023
BILL TO
City of Carson
| ie DESCRIPTION
3/24/2023 Entertainment Provide keynote speech for Tribute 1.00: $2,000 2000.00:
to Cesar Chavez Event on Friday, March 24, 2023
Payment Instructions (Check Payable to) Natalie Fragoso Balance Due = § 2,000.00
Please note: The City of Carson's own insurance will cover the City's liability but will not cover an
Entertainer's liability. All service providers (including entertainers) are still required to carry insurance.
We must require this because it is a condition of the City's Excess insurance policy.
Acknowledgement:
1. I am an entertainer that will perform at the City of Carson (Tribute to Cesar Chavez) event.
2. I am confirming that I and my business do not have commercial general liability insurance as
required by the City of Carson but am still interested to provide services at the (Tribute to
Cesar Chavez) event.
3. I acknowledge and agree that in the event of a loss the City of Carson or its insurance carrier will
not provide coverage to me or to my business.
4. I further acknowledge and agree that in the event of a loss resulting from my or my business
wrongful or negligent acts, the City of Carson or its insurer will seek to recover its financial loss
from me or my business. I will cooperate in every way with the said recovery efforts.
5. The City of Carson may approve this request or may reject it at its discretion
Signed:____Natalie Fragoso______________________________________
Thanks!
From:Anuar Lopez Ocampo
To:Anuar Lopez Ocampo
Subject:FW: Tribute to Cesar Chavez Waiver
Date:Thursday, March 9, 2023 7:20:40 AM
Attachments:image001.png
Waiver_Verbiage_Natalie F.docx
From: Natalie Fragoso <nfragoso@djuhsd.org>
Sent: Monday, March 6, 2023 8:17 AM
To: Cristina Herrera <cherrera@carsonca.gov>
Subject: Re: Tribute to Cesar Chavez Waiver
CAUTION: This email originated from outside of the organization. Do not click links or open attachments
unless you recognize the sender and know the content is safe.
Thank You,
Natalie Fragoso
Senior Counselor
Cheerleading Advisor
Robert F. Kennedy High School
1401 Hiett Avenue
Delano, CA 93215
P: 661-720-5114
F: 661-721-0833
E: nfragoso@djuhsd.org
From: Cristina Herrera <cherrera@carsonca.gov>
Sent: Thursday, March 2, 2023 3:42 PM
To: Natalie Fragoso <nfragoso@djuhsd.org>
Subject: Tribute to Cesar Chavez Waiver
CAUTION: This email originated from outside your organization. Exercise caution when
opening attachments or clicking links, especially from unknown senders.
Hello Natalie,
Can you please sign and return our waiver form.
Thank you,
Cristina Herrera
City of CarsonSr. Recreation Center Supervisor21411 S. Orrick Ave,Carson, CA 90745(310) 830-4925 Tuesday-Saturday
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Form W-9
r 2014)
;Rev. December
Department of ther201 Treasury
Internal Revenue Service
Request for Taxpayer
Identification Number and Certification
Give Form to the
requester. Do not
send to the IRS.
Print or type
See Specific Instructions on page 2.
1 Name ( s sho n
o your inctljle tax m)). Name is required on this line; do not leave this line blank.
2 Business name/disregarded entity name, if d rent from above
3 Ch k appropriate
Individual/sole
single -member
box for federal tax classification; check only one of the following seven boxes:
4 Exemptions
certain entities,
instructions
Exempt payee
Exemption
code (if any)
(Applies to accounts
(codes apply only to
not individuals; see
on page 3):
code (if any)
proprietor or . C Corporation E S Corporation iii Partnership
. Trust/estate
LLC
company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership)
-member LLC that is disregarded, do not check LLC; check the appropriate box in
of the single -member owner.
I.
I.
Limited liability
Note. For a single
the tax classification
Other (see instructions)
from FATCA reporting
the line above for
maintained outside the U.S.)
5 Address (number, street, nd apt. or suite no.)
222 L vka t4.7,to 40x -rue,
Requester's name and address (optional)
6 City, state, and ZIP code
DO(,. O, 3Z I
7 List account number(s) here (optional)
Part 1 Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid
backup withholding. For individuals, this is generally your social security number (SSN). However, for a
resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other
entities, it is your employer identification number (EIN). If you do not have a number, see How to get a
TIN on page 3.
Note. If the account is in more than one name, see the instructions for line 1 and the chart on page 4 for
guidelines on whose number to enter.
Social security number
(D
or
2
Ip
Employer identification number
Part 11
Certification
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and
2. 1 am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue
Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am
no longer subject to backup withholding; and
3. I am a U.S. citizen or other U.S. person (defined below); and
4. The FATCA code(s) entered on this form (if any) indicating that I 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 you are currently subject to backup withholding
because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage
interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and
generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the
instructions on page 3.
Sign
Here
Signature of
U.S. person ►
General Instructions
Section references are to the Internal Revenue Code unless otherwise noted.
Future developments. Information about developments affecting Form W-9 (such
as legislation enacted after we release it) is at www.irs.gov/fw9.
Purpose of Form
An individual or entity (Form W-9 requester) who is required to file an information
return with the IRS must obtain your correct taxpayer identification number (TIN)
which may be your social security number (SSN), individual taxpayer identification
number (ITIN), adoption taxpayer identification number (ATIN), or employer
identification number (EIN), to report on an information return the amount paid to
you, or other amount reportable on an information return. Examples of information
returns include, but are not limited to, the following:
• Form 1099-INT (interest earned or paid)
• Form 1099-DIV (dividends, including those from stocks or mutual funds)
• Form 1099-MISC (various types of income, prizes, awards, or gross proceeds)
• Form 1099-B (stock or mutual fund sales and certain other transactions by
brokers)
• Form 1099-S (proceeds from real estate transactions)
• Form 1099-K (merchant card and third party network transactions)
Date ► r/ / / / /� �3
• 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 you are a U.S. person (including a resident alien), to
provide your correct TIN.
1f you do not return Form W-9 to the requester with a TIN, you might be subject
to backup withholding. See What is backup withholding? on page 2.
By signing the filled -out form, you:
1. Certify that the TIN you are giving is correct (or you are waiting for a number
to be issued),
2. Certify that you are not subject to backup withholding, or
3. Claim exemption from backup withholding if you are a U.S. exempt payee. If
applicable, you are also certifying that as a U.S. person, your allocable share of
any partnership income from a U.S. trade or business is not subject to the
withholding tax on foreign partners' share of effectively connected income, and
4. Certify that FATCA code(s) entered on this form (if any) indicating that you are
exempt from the FATCA reporting, is correct. See What is FATCA reporting? on
page 2 for further information.
Cat. No. 10231X Form W-9 (Rev. 12-2014)