HomeMy Public PortalAboutC-23-186 - NORMAN HUTCHINS - 2023 FAMFEST SPAParks
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> City of Carson a,�
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, Community Services Department
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Service Provider Application Beiferle'
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: _Kenny Harris
(Event Coordinator's Name)
18601 S. Main Street. Carson Ca. 90248
(Enter Event Coordinator's address (i.e., city hall, corporate yard, or specific park address)
Email: kharris(�,)carsonca.gov
(Enter event coordinator's email address)
Should you have any questions, please feel free to contact the staff member listed below .
Truly,
Kenny Hams
(Name)
RCS. II
(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)
XService Provider Application Agreement
4 Invoice for Future Event Date'
— ik Business License (if applicable)
+�cProof of Insurance/Certificate of Insurance
X 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 3/14/2023
8/4/2023
(Date)
Impact Entertainment Media Group
(Company) --
516 E. Carson St.
(Company Address)
Carson, CA 90745
(City, State ZIP)
Insurance Requirements
Dear Norman Hutchins
(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.
5322275 CFN AS OF 3/14/2023
4
City of Carson
Community Services Department
Service Provider Application Agreement
Check one (staff use):
Carson Evcnt Center❑ Human Services W1 Recreation ❑ Transportation
Event: Famfest 2023 Event Location: Stevenson Park Event Date: 8/26/2023
Name of Service Provider: Norman Hutchins
Business Form/Entity Type (if individual, sole proprietorship, corporation, or limited liability
company, specify here):
Impact Entertainment Media Group
Business Form/Entity Type (if general partnership, limited partnership, limited liability partnership,
or other, specify here):
LLC
Business Entity State of Incorporation (if applicable): CA
Type of service: Live Music and Vocal Perfomance
Contact Person: Norman Hutchins
Emer. Contact. N/A
Billing Address: 516 E
Number
Carson
City
Phone #: n 399-5100
Phone #: (__-)N/A
Carson St. #233
Street
Ca. 90745
State
Proof of Insurance (check one)? ❑Yes QNo
If NO, please complete the attached insurance waiver form.
ZIP
Special Instructions/Notes:
(Norman Hutchins) will provide one 40 min live music and vocal set for the event mentioned above. (Norman Hutchins) should
be on site at least 75 min before scheduled start time(TDS) for check in and load in. Stage plot and Rider need to be submitted
for the usage of the Sound Co. Payment will be paid in check for to (Norman Hutchins) on the day of the event.
532227.5 CFN AS Of 3/24/2023
Please list any special request In highlighted section below. Please Note that the City of Carson
will note be responsible for any Hotel, Transportation, or Per Diem expense. All these cost should be handled by the Performer.
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 $5000.00
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 3-10-2023
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):
SERVICEPROYMER: Norman Hutchins
L/
(Signature eider's Authorized Representative)
(Printed Name of service Provider's Authorized Representative)
(Space below this line for City use only)
APPLICATION APPROVAL:
CITY OF CARSON_
Signat_= of City Manager or Designee)
817 -kJ -13 ot-�� I &,L�
6, /,.2 3
(D=)
k=22 -z3
532227.5 CFN AS OF 3.14-M
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.
5322275 CFN AS OF 3-142023
Waiver, Reltesee. Hold Hlinul s, Alreement Not to Sac and indemaMcation 10
1s Nomwn flutelike _, ("individual") (on hrhalf of
("Fxhihitnr'�, and as a hona fide agent of F.xhihitnr duly authorized to execute tilt)
Waiver, Release, Hold listmless, Agreement Not to Sue and indcmnificntion agreement ("Agretm�t") on behalf of Fxltibi?orJ
(tind.vtduel
and Exhibitor hcsLinattcs collectively tcfcttc(t to as " Silyratory," and the torn "SiMli ory" includes Exhibitor's officers,
officials, employees, agents and volunteers), seek acceptance by the ('ity of Carson of an spplic.16on to provide ser+iccs in/at
Fay 2023 ("L'vetn") on
Signatory under, 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 pmvide a service at the Event on the Date, Signatory hereby waives, releases
and discharges the City of Carson, iLs elected and RPp0inted officers, officials, employees, ngrnis and voluntccra (collectively
"City," and individually, "City Party's, and from and against any and all claims or liabilities to Signatory Or any Other perm of
entity, including but not limited to claims or liabilities for bodily injury, illness, death, or property damage, arising Out of at
connected in any way with Signatory's participation in, presence at, or performance of services at or for the Evcnt, 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 rue
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 Cit}' and each City Party from and against any and all claims,
liabilities, losses, damages, expenses, and costs (-mcluding 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 claire, liability, loss, damage, expense, or cast 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 genual release does not extend to claims that the creditor or releasing party does not ]mow or suspect to exist in his or her favor
at the time of executing the rrleasc 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, naurre 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 representation,
statements or inducements, apart from this written form, have been made with regatta 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,
gig below, {gry ac/� nowledges and represents that it has read and understands the above, and that is voluntarily
By si�A
aim
OR(LAN1ZATiON`:,Norman Hutchins _
DATE:!
01007.00011181805.1 AS OF 3-14-2023
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 tarry
insurance. We must require this because it Is a condition of the City's Excess insurance polio.
Acknowledgement:
1. 1 am an entertainer that will perform at the City of Carson
Famfest 2023
event.
2. 1 am conflrming 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
Famfest 2023
event.
3. 1 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. 1 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 My of Cayson may approve this request or may reject it at its discretion.
Signed:
Date:
W-9
p�yrt tient o: the Treasury
t rtsrna.' Rrvrnue Se cm
Request for Taxpayer
Identification Number and Certification
► t30 t0 KN'W.flS.gov/FormtY9 for ktstructfons and the latest iflfOrTMOOn.
1 Nft * (n% thn'A'- On WNW KNN.." tAY rNAM-)IC ra"Tr -dron INA tom, dM not Maya this Rrvt Mm k.
it RintrKae nane�dta•egarcSed en�t4ty� nsme. " d'ftenr-R item above
Z�/IDiQr✓� �V/E�%Ii�N
Give Form to the
requester. Do not
send to the IRS.
S Cts WXworAwte box few federal tax claasMcxtbn of the ty one the , cyrm crus !codrrd a
a person whose retro M entered on fra 1. Check on of Ph OvY ww !o
following 4"VM boxaa certaln entiflon, not 'rddv6 all; see
iA'tirUUiOfS on pecan �):
❑ trdN4A�aysole pray w r or El Cerpweeon El Corporation ElPrtrwship 11 TnaUsatste
aktgle-rnrart. LLC Exempt payee code (if my)
ElUmltwd habPlty carcary. Ent« tha tax classi"ion (C -C roiWalion, S -S comoration, P-Partn rship)►
Note: Check the appropriate box In the line above for the tax classification of the single -member owner. Do not check Fxamptlon from FATCA rep0►enq
LLC If ttw LLC Is cl:caslned as a single -member LLC that is disregarded from the owner unless tt•.e owner of the LLG is code (if anti
_ nath•r LLC that Is not dkregarded from ttte owner for U.S. federal tax purpoxas. Oiherwise, a single-mernber LLC that
EEE is dleregarded tram the owner ahoukt chock the epprop sale bon to the ion cies""tion of Its owner.
Other (see inetructionsi ► POPM a.ow,m mY Oned& trM• car USi
5 Address (number, is ,, " apt. or suite no.) See Instrycilons. Requester's name end address (spheral)
/ / 5 / A-G,e� o .34 X o
a CI . state. and Zip cod
iIffo
7 list aocourt nu ber(s) here (optional)
LEUJL Taxpayer identification Number MN)
Ente, your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid Social sec'r` number
backup withholding. For individuals, this is generally your social security number (SM. However, for a _
resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later.
- r. For other �. � M-4,
entities, it Is your employer identification number (EIN). If you do not have a number, see How to get a
TIN, later, or
Nato: it the account is In more than one name, see the Instructions for line 1. Also see Whet Name and I Emptoper Iderrtlncation numbw
Number To Give lt►e Requester for guidelines on whose number to enter. FT --1
■i"U certmcanon
Under penalties of perjury. I certify that
1. The number shown on this forth 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 Intenal 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 1 am
no longer subject to backup withholding; and
S. 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.
Cer9ficalbn tnsmictlons. 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 faked 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 ORA), and generally, payments
other than interest and dividend, you are not required to sign the certification, but you must provide your correct TiN, See the instructions for Part Il, later.
11 �
sign w7mirt r. of
Hera Us person ► ti-a�►��
General lns;ucti s
Section raforenc," aro 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 wwwJrs.9ov1FormW9.
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 (UN) which may be your social security number
(SSN), individual taxpayer Identification number pTIN), adoption
taxpayer identification number (ATIN), or employer identification number
(9% 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 we not limited to, the following.
• Forth 1099 -INT Interest earned or paid)
nate►
- Form 1099-0N (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 interwe ,
1098-T (tuitlon)
• Form 1099-C (canceled debt)
• Form 1099-A (acquisition or abandorunent 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 71N, you m/9ht
be subject to backup withholding. See What is backup withholding,
later.
Cat No. 10231X Form W-9 ow. 10-2016)
-E-V.Oerferycr"E Through Mwi,
615 E. Carson Street
#233
Carson, CA 90745
Office: (302) 734.4500
Cell: (302) 399.5169
TO:
City of Carson
Attn: Mr. Kenneth Harris
18601 S. Main Street
Carson, CA 90248
INVOICE
fNVOICE: 20012
DATE: 08/04/2023
FOR:
Music Performance
DESCRIPTION
HOURS RATE AMOUNT
Norman Hutclii-ns,--
(Artist) will provide 40 minutes— --T
Of Live Music & Vocal performance 40 Minutes 5,000.00 $5,000-00
WE APPRECIATE YOUR SUPPORTITOTAL $5,000.00
Make all checks payable to Norman Hutchins