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Home My Public Portal AboutC-23-099 - YVETTE MAO SAMOAN HERITAGE DAY SPA City 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: Janny Noa (Event Coordinator’s Name) 23410 Catskill Ave., Carson, Ca 90745 (Enter Event Coordinator's address (i.e., city hall, corporate yard, or specific park address) Email: Jnoa@carsonca.gov (Enter event coordinator’s email address) Should you have any questions, please feel free to contact the staff member listed below . Truly, Janny Noa (Name) Sr. Recreation Center Supervisor (Title) 532227.5 CFN AS OF 3/14/2023 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) V Service Provider Application Agreement yf SN Invoice for Future Event Date! NN | /< Business License (if applicable) S E bo 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) ‘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 03/18/23 (Date) £ Z ATuratace Piuecsan Soaaeee ompany lAZip ‘Sew beset, ies. : (Company Address) is Owem , CA. Ford. pene neni araey teen ata (City, State zip) insurance Requirements Dear Wetre Ma%e i (Enter Provider's Name) nee Please be advised pursuant to your desire to work with the City of Carson, you are required to submit the following: 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 ure 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 tisk, 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 OF covering CGL on an “occurrence” basis, including property damage, hodily injury and personal & advertising injury with limits no less than $1,000,000 per occurrence and 32,000,000 ageregate, Additionat Insured Status The City of Carson, and its elected and ppointed officials, emplovees, vol S and agents, are to be covered as additional insureds with respect to lability arising out of their work or operations performed at or on hehalf of the City-sponsored event including materials, parts, or equipment furnished in connection with the event, 532227.5 CEN : ASOF 3/14/2023 City of Carson ee : Community Services Department Mei a Service Provider Application Agreement sags Check one (staff uses, ees ted Geaa Event Center|] Human Services [WZ] Receaion{] P ae Bren Seton oe page Event Location: ara ~ Event Date: Name of Service Provider: Tupul aga 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: Fee includes the traveling expences and daily stipends as requested. Total Service Fee $1,500.00 _ 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. [remainder of page intentionally left blank] 532227.5 CFN AS OF 3/14/2023 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 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 3-14-2023 7 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: __| H@uLAeA- Pelnesinn Lace G ek. The 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 AS OF 3-14-2023 Waiver, Release, Hold Harmless, Agreement Not to Sue and Indemnification 10 LYvelte Ma'o , Cisdividual”) fon behalf of Tuoubaa CExhibitor”), and as a bona fide agent of Exhibitor duly authorized to execute this Waiver, Releasc, Hold Harmicss, Agreement Not to Sue and Indemnification agrecment (“Agreement”) on behalf of Exhibitor] Cadividual and Exhibitor hereinafter collectively referred to as “Signatory,” und the term “Signatory” includes Exhybitor’s officers, officials, eraployees, agents and volunteers), seck acceptance by the City of Carson of an application to provide services in/at Sanesn Montego Day Colseratan ——— C Event} on Saurdoy. na 24.2023 ("Date"), Signatory understands (hat accidents, iNnesses, and injuries can arise out of the Event; knowing the risks, nevertheless, and in consideration of the seceplance of an application lo provide a service at the Eventon the Dale, Signatory hereby waives, releases and discharges the City of Carson, its clected and appointed officers, officials, employees, agents and volunteers {collectively “City,” and individually, “City Party”), and from and against any and oll claims or liabilities to Signatory or any other person or entity, including but not limited to claims or liabiitics for bodily injury, iiness, death, or property duninge, arising out of or comnected in any way with Signatory’s participation in, presence al, ar 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 tights 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 {o release any party from any act or omission of “gross negtigence.* Signatory hereby grants City the right to photogreph or video-record Signatory during or in connection with the Event, and to use Signatory's photographed or vidco-recorded likeness, and any imate, silhouctte, of 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 cvents, and creation or production of materials in any fonn for such parpost, with no claim of catitlement to any License feo or royalty of any kind from City, Signatory hereby waives any right to the intellectual Property of Signutory’s Likeness. Signatory further agrees to indemnify, defend aud hold harmtess City and each City Party from and against any and all claims, liahilicies, losses, damages, ex, 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 of alleged to be Sustained by any person or eatity (whether they be members of the public visiting the Ryent, employees of the City, other Exhibitors at the Event, or otherwise), occurring at, arising from, or cannected with Signatory’s preparation or performance of services at the Event, Signatory’s actions, insetions, 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, liabifity, loss, damage, expense, or cost which was caused by ihe sole negligence or willful misconduct of the City, fn giving the foregoing réteases and waivers, Signatory expressly waives any and all rights conferred upan it by the provisions of Califomia Civil Code Section 1542, which Signatory understands reads us follows: “A general release does not extend to claims that the creditor or releasing party does not know or Suspect fo exist in bis or her favor at the time of executing the release and thst, 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 «bar to any and all actions, fees, damages, losses, claims, liabilities and demands oF whatsoever s Dature and kind, that arc known or unknown, ot 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 Signatary's Successors, heirs and assigns, and shall not expite. No oral Tepresentations, Statements or inducements, apart from this written form, have been made with tepard to the Subject matter of this form. tfany Portion of this form is declared invalid by s court of carmpetent jurisdiction, the remainder shall Continue in full force and effect, By signing below, Signatory 1icknowledges and represents that it has read and understandy the above, and that it voluntarily agrees to its forms, By signing below, Sigastory acknowledges and represents that it hus read and understands the above, and that is Yoluntarily agrees to its Ey x SIGNED: b : NAME: M4 Welle T: Mao ‘ ORGANIZATION: TkguLAch "Palynecran Dance Emp DATE: Moxy 27, A022 wv G1007.0001/781805. 1 Please note: The City of Carson's own insurance will cover the City's liability but will not cove Wiability. All service providers (including entertainers) . urance, We must require this because it is a condition of ie City’s Exe Acknowledgement: 1. lam an entertainer that will perforri at the City c _Samoan Heritage Day Celebration rom W=-9 (Rev. December 2014) Department of the Trea: internal Revenue Servica vetbe ao Request for Taxpayer Identification Number and Certification 2 Business name/disregarded entity name, if different from above Tupulaga “Polynesian Rance Grup AU349 Give Form to the requester. Do not send to the IRS. 1 Name {as shown on your income tax retum). Namo |s required on this Iing; do not leave this line blank. O Individual/sole proprietor or CO C Corporation sing'e-member LLC the tax classification of the single-member owner. C1 other (see instructions) > 3 Check appropriate box for federa! tax classification; check only one of the following saven boxes: S Corporation Oo Partnership O Umited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership) > Note. For a single-mombor LLC that is disregarded, do not check LLC; check tha appropriate box in the line above for 4 Exemptions (codes apply only to certain entities, not individuals; see LJ Trust/estate | instructions on'pago 3): Exempt payee code (if any) Exemption from FATCA reporting code (if any) poties to accounts maintained cutuda the US) 5 Address (number, street, and apt. or suife no.) IQ210 bunbro alee Ave Requester's namo and address (optional) CITY OF CARSON Print or type See Specific Instructions on page 2. 6 City, state, and ZIP code a Carem, Ch. 907 701 E. CARSON ST. CARSON, CA 90745 7 Ust account number(s) 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 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 | instructions on page 3. For other 1S s: Y -|8 FS) -|7\e\|2 4g 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 ‘| or Employer Identification number | Certification Under penalties of perjury, | certify that: 1. The number shown on this form is my correct taxpayer identification number (or | am waiting for a number to be issued to me); and 2. |am not subject to backup withholding because: (a) | am exempt from backup withholding, or (b) | have not been notified by the Intemal Revenue Service (IRS) that | 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 |! am no longer subject to backup withholding; and 3. lama U.S. citizen or other U.S. person (defined below); and 4. The FATCA code(s) entered on this form (if 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 you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax retum. 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 v dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions on page 3. Sh Sign Signature of t yy « Here | US. person> Ariin) Date > Apr; | \7, 2022 General Instructions/ a (home mortgage interest), 1098-E (student loan interest), 1098-T Section references are to the Internal Revenue Code unless otherwise noted. Future developments. Information about developments affecting Form W-9 (such as legisiation enacted after we release it) is at www.irs.gov/fw9. Purpose of Form An individual! or entity (Form Wi-9 requester) who is required to file an information return with the [RS 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 arnount reportable on an Information retum. 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 1099-8 (stock or mutual fund sales and certain other transactions by brokers) © Form 1099-S (proceeds from rea! estate transactions) * Form 1099-K (merchant card and third party network transactions) * Form 1099-C (canceled debt) * Form 1099-A (acquisition or abandonment of secured property) Uso Form W-9 only if you are a U.S. person (including a resident allen), to provide your correct TIN. if you do not retum Form W-9 to the requester with a TIN, you might be subject to backup withholding. Soe 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 Hf 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’ sharo of effectively connected Income, and 4. Cartify that FATCA code(s) entered on this form (if any) indicating that you are exempt from the FATCA reporting, is correct. Seo What is FATCA reporting? on pago 2 for further Information. Cat. No. 10231X Form W-9 (Rov. 12-2014) anal ALE LE EIA HEAT a Lata DL STEELS UH COUP INE MINS SANA MEL HST AKAMA EMO T DVD DUAMY LAM EUSA a RONDA DSA Set EO —- S S S E R E N E M E E R SE L e s bw ee ee | INVOICE TUPULAGA Tupulaga Polynesian Dance Group Date: Date INVOICE # SHD 052323 To City of Carson Foisia Park- Janny Noa 23410 Catskill Ave Carson, Ca 90745 310-830-8310 Customer ID FoisiaJN Salesperson Job Payment Terms Due Date Yvette Ma'o | Dance Group 6.24.23 Due on receipt 06/24/23 Qty Description Unit Price Line Total 4d _ Polynesian Dance Performance for 30 Mins to perform $1,500 $1,500 _ For the Samoan Heritage Day Celebration on Saturday | . | | | June 24, 2023 Subtotal $1,500 Sales Tax | - | Total | $1,500 | Make all checks payable to Yvette Ma'o Thank you for your business! Yvette Ma'o 13910 Dunbrooke Ave., Carson, Ca 90746 Phone:310-626-3141 MrsMao@hotmail.com