HomeMy Public PortalAboutC-23-104 - DEMBREBRAH W. AFRICAN DRUM 2023 JUNETEENTH SPAChecklist
Before submitting your application packet make sure each of the below
indicated items have been attached or completed.
(FOR COMMUNITY SERVICES OFFICE USE ONLY)
xf Service Provider Application Agreement
xP Invoice for Future Event Date!
NA Business License (if applicable)
\N&NCT Proof of Insurance/Certificate of Insurance
X IZ Waiver, Release, Hold Harmless, Agreement Not to
Sue, Indemnification, and Photo Release
X 5s 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
City of Carson
Community Services Department
Service Provider Application Agreement
Check one (staff use):
[| Carson Event Center| _ | Human Services Recreation [] Transportation
Event: 2223 Juneteenth Celebration Event Location: Mills Park Event Date: 6/17/2023
Name of Service Provider: Dembrebra West African Drum and Dance Ensemble
jn or ual, sole proprietorship, corporation, or limited liability
con ere):
Refer to W9
uusiness Form/Entity Type (if general partnership, limited partnership, limited liability partnership, GREE
Refer to W9
aTypeof Service: Deum and Danse Performance
, Bayette “Ndella” Davis-Diassy s h o n e #2 3 1 0 ) 8 0 8 -5 2 5 6
Na P h o n e #: ( ) N/A
Number Street
Compton Ca. 90222
City State ZIP
Proof of Insurance (check one)? [_ lves [V No
If NO, please complete the attached insurance waiver form.
Special Instructions/Notes:
(Dembrebra West African Drum and Dance Ensemble) will perform one 25 minute Drum and Dance presentation
for said event mentioned above. (DWADDE) should arrive at least one hour before scheduled performance time
due to limited parking availability. Check-in and changing areas will be located backstage for(DWADDE).
532227.5 CFN AS OF 3/14/2023
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Payment will be in check form which will be distributed on the day of the event at the conclusion of performance.
* Please list any other request in section below.
Total Service Fee $600.00
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
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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):
Dembrebra West African Drum Dance Ensemble
SERVICE PROVIDER:
Dt Ay De 5-3-2023
Y “Gignature of Bvice Provider's Authorized Representative) (Date)
Bay cette Davis - D033
(Printed Namie of Service Provider's Aujhorized Representative)
(Space below this line for City use only)
APPLICATION APPROVAL:
CITY OF a)
LS 6 pd / 23
a of City Manager or (2 / @ate)
532227.5 CFN AS OF 3-14-2023
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 3-14-2023
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
1, Bayete “Ndella” Davis-Diassy , (“individual”) [on behalf of
Dembrebra West African Drum and Dance Ensamble (“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, officials, employees, agents and volunteers), seek acceptance by the City of Carson of an application to provide services in/at 2023 Junateenth Celebration (“Event”) on Saturday , June 17th, 2023 (“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, Signatory acknowledges and represents that it has read and understands the above, and that is voluntarily agrees to its terms.
stone Dyrt Dro Day
ame: d AY ette Davis -D IRSSY
ORGANIZATION: Dembrebra West African Drum and Dance Ensemble
DA T E, O U -%-2 023
01007.0001/781805.1 AS OF 3-14-2023
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Yy inciirance 2 lity insur aCe as.
2023 Juneteenth Celebration event.
3. 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. | 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.
‘Date:) 5 -$- 2023
+4 FSIO
Give Form to the
requester. Do not
send to the IRS.
Request for Taxpayer
Identification Number and Certification
> Go to www.irs.gov/FormW9 for instructions and the latest information.
1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.
Dembrebrah West African Drum and Dance Ensemble
2 Business name/disregarded entity name, if different from above
= Form W g)
(Rev. October 2018)
Department of the Treasury Internal Revenue Service
3 Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the | 4 Exemptions (codes apply only to following seven boxes. certain entities, not individuals; see instructions on page 3):
C S Corporation O Partnership | Trust/estate Individual/sole proprietor or Lle Corporation
single-member LLC Exempt payee code (if any)
CL] Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership) >
Note: Check the appropriate box in the line above for the tax classification of the single-member owner. Do not check Exemption from FATCA reporting
LLC if the LLC is classified as a single-member LLC that is disregarded from the owner unless the owner of the LLC is
another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single-member LLC that
is disregarded from the owner should check the appropriate box for the tax classification of its owner.
[-] Other (see instructions) >
5 Address (number, street, and apt. or suite no.) See instructions.
1401 West Piru Street
6 City, state, and ZIP code
Compton, CA 90222
7 List account number(s) here (optional)
code (if any)
Print
or
type.
See
Specific
Instructions
on
page
3.
(Applies to accounts maintained outside the U.S.) Requester’s name and address (optional)
G0 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 instructions for Part |, later. For other - - entities, it is your employer identification number (EIN). If you do not have a number, see How to get a
TIN, later. or
Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and _{ Employer identification number | Number To Give the Requester for guidelines on whose number to enter.
| Social security number |
9/2] -1| 1/9) 3/1/6)6)2 Part Il 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 Internal 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 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 for Part Il, later.
Sign Signature of 2 . |. . Here | us. patenn Oygidn he
General Instructions
Section references are to the Internal Revenue Code unless otherwise
noted.
Future developments. For the latest information about developments
related to Form W-9 and its instructions, such as legislation enacted
after they were published, go to www.irs.gov/FormW9.
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)
Date > yy 7 /-2023
° 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)
¢ Form 1098 (home mortgage interest), 1098-E (student loan interest),
1098-T (tuition)
e 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.
If 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,
later.
Cat. No. 10231X Form W-9 (Rev. 10-2018)
March 21, 2023
Dembrebrah West African Drum and Dance Ensemble
1401 W. Piru Street
Compton, Ca 90222
INVOICE
Date of Event: June 17, 2023 Time: 1:00 pm * (TBA)
GROUP NAME: City of Carson
CONTACT PERSON: Kenny Harris
ADDRESS: —Mills Park 1340 E. Dimondale Dr. Carson, CA 90746
TELEPHONE: 310-631-3130
E-MAIL: kharris@carson.ca.us
Parking provide or available (permits where applicable) *******
Dressing rooms (not a public restroom)
Refreshments (fruit, juice —at least water)
Clean stage or Marley covered floor ( Dancers perform without shoes)
Clean stage or Marley covered floor ( Dancers perform wit Eee BEEBE EB BEBE BEEBE
PAYEE: Dembrebrah West African Drum and Dance Ensemble
Tax ID# 92-1931662
AMOUNT: §$ 600.00
PRESENTATION: Drum Call, 2 drum compositions, and 2 ballets
Drummers 3 Dancers 2-3 (depending on availability that will be confirmed before event
date)
Coordinator: Bayette “Ndella” Davis-Diassy 310-808-5256 or diassy@att.net
Signed Date