Loading...
HomeMy Public PortalAboutC-23-095 - ROYAL DIVAZZ 2023 YOUTH CONFERENCE 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 anuha- ly Ai Attn: (Event Coordinator’s Name) VA E. Flemour Cf. Cnbwal, &. Yoldy (Enter Event Coordinator’s address (i.e., city hall, corporate yard, or specific park address) (ou A dw AL Email: fod AL spa q mara COM (Enter event coordinator’s email address) Should you have any questions, please feel free to contact the staff member listed below . Truly, () neorg WV Pole (Name) pa 4 (Title) 532227.5 CFN AS OF 3/14/2023 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! Vv Business License (if applicable) v 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) ow file * 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 3/14/2023 iyear d pursuant to vour desire to work with the City of Carson, you are required [6 f Leability Insurance (to be maintaines ay anise from or in connection with the services), evidencing Lac seca, t ee d u r a t i o n of ser vic es against claims whic coverage’s) as indicates Certifieates of insurance, as well as additional insured and waiver ot 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 mod fy these requirements based an the nature of the: risk, prior events, insurance coverage, or other special requirernen!s. AND LIMIT OF INSURANCE MINIMUM SCOE General Lighitity Insurance: Coverage shall be af least as broad ay Insurance Services Form CG OG GT covering COL ov en “oeourrence’ Basis, includurg property damage, bodily injury ertising injury with Limits no less fiuin $1,000,000 per occurrence and and personal & Ge $2,000, 000 ageregate. Additonal Insured States the City af Carson, and its elected and appotned of to be covered ax additional insureds with resp tals, emplovees, volunteers aml agents, are to liabiliry arising out of their work or operations performed at or on behalf af the City-sponsored event including materiats, parts, or equipment furnished in connection with the event Bu727,5 CEN AS GE 4/14/2023 = if 2 t (OnumGA ity Se rvi ce Pro v e e e te ider Application Agreement Check one (staff tse}: peeeneennng | | Carson Event Center| _. | biuman Services OFLAOt e023 Yout in Gonferen nce 022 Na me o f Se rv ic e P rovi d er: (< o ygea i Business ‘Fort ity Type (if individual, sole propricto ship, corporation, of Antec babili ty rf Q v ¥ Pa irtners sha ed Habiln: p. wEnt ity Type (if ge ne ra l partnership, limi ted part ners hip, limat Busimess Fort or other, specify here): T y p e o f S e r v i c e : Contact Person: geet’ Phone th 63 Emer. Contact: ie PR Coe Phone #: (x, Bill ing Address: (0 4 Che Nuanber Stree Proof of Insurance (check one)? iv Yes No IF NO, please complete the attached insurance waiver form. Special Instructions/Notcs: pr \ we SARE? 5 CFM . AS OF SPAS IS Provider wishes lo request any special accommodation nceded to faciihite provision ¢ enced on Page Poof this applicatic Total Service Fee > NOTE: Tf service provider is usable to provide the services as proposed of reque sted or the City of Carson cancels ihe service for any reason, the associated fees will not be paid. fremainder of page intentionally left blank] 5998078 CER AS OF 4/14/2073 sep be gibcd 32 y igthy ase ES oasete BAPTA PS OPN EAA APE E ment) on bel shal? coblior’s ¢: s u i d e : s e g v i c e s a v a l Waiver, Release, Hold Ha condita al asd Eadhitor bencin al officials, employecs, agents and volun 323 ouls Contarence awaer, Re on of. an "at ate Alon Date") ver, kaowiig the rsh at accidents, dlsessas, and inqurits can arse oul of the E aguvation to provide a service a Ue Ey vent on tie Date, 8 hpealary * Zarson, ifs elected an souled atficers, affict foyees, agents and ty Paty” jared Trem a rany and all ceainss or sabi etics : ‘ines for bodily injury, Winess. Geath, 3 toty's qarlicipation in, presence at, or performance sfiese on the part af Cry. and ¢ inns hi roug ah any action or proceat y against the City or any City Party Howe ay yw polease any party frum any act ar omuision of “20 , Sipnaiory wens: v £ s (collechivel ¥ ay PeTSOn o or y volo connec’ in any way wit tes y grants Cay the night to pl Cys - phot graphed of viGen-secomded Leeness, and any wage, & Signatory taken duriag or im connection with the by }ikeness” i for any purpose, tretue 6d sts events, and creation or production of male: nose, with ne cl or royalty af any kind from Cry. Suenatory hereby wa notograph of vadeo-record Signatory during or int cormection with the Event. Sor reproduction of the voice Gf appe g public Signatory further ageees to wk City aad each City Party from and ai arty and all claints, cs, losses, damages. expenses, “and costs E lon costs and [ees of ltigason} of every nature (ind but not Hmited to, propery damage, bodily ingury at death), whether imposed by law or otherwise, sustained cher he public visiting (he Event, 27 oft: sustained by any person or entity Owh hey at the Event, ar otherwise), cccurnmg al, ansing from, of connect Evem, Signatory’s actions, imactlons, or use fi cilities at the Ever, or the Signatory at or lor she Event, exc pt fo Haim, Labekty, loss, di wt ted with Signtory’s preparation or "perform ny equipraent, machinczy or ile : re, expense, of cost which was cau neglipence or willfil misconduct of the Cty. in giving tie foregoing releases and waivers. Signatory expressly waives any and all rights coslerred upon at by ihe provisians of Section, £543, which Sigmatory anderstands reads as follows California Civil Code , does net know or suspect to exist in fis or her favor have materially affected his or her seulement with the $ thet the creditor or that, if Keown by fant Ge her, wos “A general release does not extend at the time of executing the release an debtor or released party” ns, Habilites and dersands of whatsoever ay arise frora or relate aa any way by “This waiver shall be effective as a bar te any and all actions, fees, damages, i085 character, nature and kind, Ghat are known or unknews, of suspectec OF LESUSpecles deh Signatory’s participation in the Event, This Agreement shall be binding Gn Sipnatery’s successors, heirs and ass statements Or coments apart from this writes form, have been made with f portion of this form is declared invaid by a coun cof competent surisdiclion, the ce gna, and shall nat expt re No ofa ropresentainons, the ser of shis form. Lf any jnder shall continue in full force and affect Ry signing below, Signatory ackaowiedges and cjpreserits that it has read and understands the above, and that voluntarily agrees 10 its Lorms. Hy signing below, Signatory acknowledges and represents that it has read and understands the above, and that is voluniarily aprees to its terms. io SIGNEDY NAME, oy t Z . ORGANIZATION: EQ cdt | od { ; LA w e my D AT E ! t e o w AS OF 3-14-2603 SOOT COOLS 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. |am anentertainer that will perform at the City of Carson 2023 Youth Conference event. 2. 1am confirming that | 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 event. 3. lacknowledge 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. | 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. | 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 Kamishia Wekks nate: 05/09/2023 ‘CITY OF C A R S O N B U S I N E S S T A X C E R T I F I C A T E to conduct Lo . evidence that all taxes required by the City of Carson a 2 A aa a e e e paid by the listed person, company, or organization Iss uance of this License N u m b e r : 0 8 5 8 1 | iness activi certificate is not a City endorsement or ass urance of the a e , ot business . 7 ivity, y Expiration Date: F e b r u a r y 2 9 , 2 0 2 4 po bee _ B u s i n e s s N a m e : R O Y A L D I V A Z Z K I D Z M O B I L E S P A L L C . o e oe a E f f e c t i v e D a t e : M a r c h 0 1 ' 2 0 2 3 . Business Location; 624 E T U R M O N T ST C A R S O N ; ‘cA 90746-3806. * 3 Description; 9 V W H E E L E D V E H I C L E S 0-4 _ Business Owner: R O Y A L DIVAZZ KIDS MOBILE S P A L Llc: it . , j a e ! ane [oh \ at ve - Notify the Revenue Division in writing of any changes. RO Y AL DIVAZZ KI DZ M O B I L E SPA, LL C License renewal is the taxpayer's responsibility. 624ETURMONTST © + , A L C : C A R S O N , CA 9 0 7 4 6 - 3 8 0 6 | POST IN A CONSPICUOUS PLACE- NOT TRANSFERABLE , Revenue Manager ROVALIG fale di RL AGO CBIS ED ; o CERTIFICATE OF LIABILITY INSURANCE angio. THIS CERTIFICATE 1S ISSUEOQ AS 4 MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGAYIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFACATE OF INSURANCE GG8S NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S) AUTHORIZED REPRESENTATIVE OR PRODUCER. ONO THE CERTIFICATE HOLDER, (MPORTANT: |€ the certificate Folder is an BDEITIS NAL, t SUBROGATION LS WAIVE, guinjer i this certificate does not confar rights to the. C ontiivate hoi BIS-291-7 PTF visions or be endorsed. sarment. A dialement on PRODLE Halfernan Kelfering-Rase i zance Servicws, LLC : Fuerte Or, #104 La Mesa, CA 91944 Robyn Kettorhag NSURED Royal Devers Kidz Motille Spa, LEC dha Royal Divagz Kid Spa 624 E Turraant Straat ee 25898 Catsan, CA SFS$ EERT RICATE NUMBER: ie LIRETS ASE GOD “00 ood "4.000 4,056,000 296,000 “dneluced wal SLATS 1865 BRAS ORI GORE. S } 4,006,000 IMAPMG2501 8-04 OWOBRO2I OVO 2024 eid rec ulead) TBHP OO OF OPESLATIONMS | LOCATHOMS PYERCILES UAC ai flemmres Sot edule may he Miached if mare ansc CERTIFICATE HOLDER TAN CE. LATION CTP YAR SHOUL0 AMY GF THE ABOVE DEUCKIBED POLICIES 88 CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED iN ACCORDANCE WATH FRE POLICY PROVISIONS, City of Carsen Atin-Carlos Gonzalez 701 E. Carson Street, Po. Box Garson, GA SO7T4s AGRI 23 (A016/00) 4aGb-2015 ACORD CORPORATION. Al rights reserved, The ACQRD name and loco are registered marks of ACORD