HomeMy Public PortalAboutC-23-203 - KHADIJAH BLANCHE-DIOP - 2023 WHITE LINEN SPAV e n d o r 1 0 7 5 9 2
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Coxe Service Provider Application Bet
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: Aundrea E. Rockhold
(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: arockhold@carsonca.qoy
(Enter event coordinsior’s em21! address)
Should you have any questions, please feel free to contact the staff member listed below .
Truly.
Aundrea Rockhold
(Name)
Rec. Center Supervisor II
(Title)
§32227.5 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)
Service Provider Application Agreement
Invoice for Future Event Date!
f A Business License (if applicable)
Proof of Insurance/Certificate of Insurance
X Waiver, Release, Hold Harmless, Agreement Not to
Sue, Indemnification, and Photo Release
Xone current Copy of W-9 Form (if not on file already)
ee
‘ 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
VL 7 [a013,
(Date)
ompany WA w. [6% Sp (Company Address) fraw thro ne CH JolSO
(City, State ZIP)
Insurance Requirements 4
deer Khadumndn boy ihs LLC dba BeigaulS dy. Monk
(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 (tc be maintained for the duration of services
against claims which may arise from or in conngetior: 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.
F 3/14 §32227.5 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
Cajun&Blues White Linen Affair 701 E Carson St. Carson September 9, 2623 Event Location: Event Date:
Name of Service Provider: Khadim Enterprises LLC, dba Beigents du Monde
Event:
Business Form/Entity Type (if individual, sole proprietorship, corporation, or limited liability company. specify here):
LLC
Business Form/Entity Type (if general partnership. timited partnership, limited liability partnership, or other, specify here):
LL
; . - — . CA Business Entity State of Incorporation (if applicable):
Type of Service: Beignets NOLA
Contact Person: Khadijah Blanche-Diop Phone #: (424) 227-0352
Emer. Contact: Tai Waller Phone #: (424) 227-0392
Billing Address: 2602 vi. il oe or.
Number treet Hlawttnerme ,CA 10250
City State Z1e
Proof of Insurance (check one)? [Vlves [No
If NO, please complete the attached insurance waiver form.
Special Instructions/Notes:
() will provide Beignets 400 serving, for upcoming White Linen Cajun Blues Fest . ( ) should arrive at least 2.0 hours before
opening (approximately 4:00pm) for load in and setup. () will receive
Payment will be in check made to Vendor name above. _
§32227.5 CFN AS OF 3/14/2023
ws
Please list any special concerns in the section below. Please note, that the City of Carson is not responsible
for any Hotel, Transportation, or Per Diem expense. All these cost fall under the responsibility of the Performer.
If Service Provider wishes to request any special accommodation needed to facilitate provision of the ‘ ns de
services, please identify it here or contact the staff member referenced on Page 1 of this applic: i> ue \
Last year the sprinkler system at the event site turned on while x@** *
while we were preparing and serving, ruined a lot of the product.
| ask that you please have us in a place that is accessible, convenient and with no surprises.
Total Service Fee $1375.00 _
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 ramed in this Service Provider Application
Agreement as the Service Provider, then all cbligations. 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
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):
SERV JIDER: Beignets du Monde
Ze 08/17/2023
(Signature of Service Pray ider's Authorized Representative} (Date) Khadijah Blanche-Diop
(Printed Name of Servic sider’ orizes Rep
taive)
(Space below this line for City use only)
APPLICATION APPROVAL:
ON Lif q eo i088
(Signature of Cuy Manager or Destance) er (Date)
“Tm Gaiersan. on BatKUE
$32227.5 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 1 serve the public in the best possible manner. The Provider shall at all times cooperate to this es.
The policies, rules. reguiations 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 our efforts to provide a SAFE WORKING ENVIRONMENT. assist in
532227.5 CFN AS OF 3-14-2023
j pile intensit 9. VOLUME/LIGHT CONTROL: The City reserves the right to regulate the ro ofenealet -
of any and all noise or light generating mechanisms (including. but not Tia ° i el in the
radios. television sets. musical instruments, entertainers, OF blinking or flashing lig
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
copytighted 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 spaze is assigned to providers at the sole discretion of the
City. Concems regarding competitive ar spscific types of providers should be communicated to
the City at the time of apptication.
17. RULE CHANGES: fhe City reserves the right to make reasonable changes to the foregoing
rules, event hours and move-in/move-cut 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
|, Khaayah Blanche-Diop individual’) fon behalf al
iBespiets cui Morice. —("Pyhibitor”), and as a bana fide agent of Exhibitor duly authorized to execute this
Waiver. Release. Hold Harmless. Agreement Not to Sug and Indemnification agreement (“Agreement”) on behalf of Exhibitor]
(individual and E-vhibitor hereinatter collectively referred to as “Signatory.” and the term “Signatory” includes Exhibitor's officers.
officials, employees. arents and volunteers). seek acceptance by the City of Carson of an application to provide services invat
anin Blues (hsent’) on 9292023 - Date”).
and injuries can arise out of the Event: knowing the risks. nevertheless, and in
consideration of the acceptanee 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
“Cnty.” 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 lo 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 ol gross negligence.”
Signatory understands that accidents. illnesses.
Si enatory 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
Signaiory 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 ail claims.
liabilitie . 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 othenvise, 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 othenvise), occurring al, 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
Calitornia 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 io exist in his or her favor
at the time of executing the release and that, if known by hiza or her. would have materially affected his or her settlement with the
debtor or released party.”
This waiver shall be eifective as a bar damages. losses. claims, liabilities and demands of whatsoever
character. nature and kind. that are known or unknown, of <uscected 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
lo its terms.
By signing below, Signatory acknowledges and represents that it has read and understands the above, and that is voluntarily
agrees Lo its t
SIGNED:
NAME: Khadijah Blanche-Diop
ORGANIZATION: Beignets du Monde
D A T E : 0 8 /1 7 /2 0 2 3
Q1G07. GOOL:7B18U5 | AS OF 3-14-2023
ee a ae re
Khadim Enterprises LLC
dba Beignets du Monde
2803 West 116th Street
Hawthorne, CA 90250
(424) 227-0352
Invoice
Invoice for Payable to Invoice #
Aundrea Rockhold Khadim Enterprises LLC 911
City of Carson
Project Event date
Cajun & Blues White Linen Event 9/9
ARockhold@carsonca.gov . : _ - _ — a oo
Description Qty Unit price Total price
Beignets - NOLA, single serve 400 $3.00 $1,200.00
Service Fee (per hour) 2 $75.00 $150.00
Notes: Subtotal $1,350.00
Location: Travel / Delivery $25.00
Tax $0.00
Arrival time: Deposit Received
$1,375.00
•
I
Please note : The City of Carson 's own insurance will cover the City's liability but will not cover an
I
Entertainer's liability. All serv ice providers (Including entertainers) are still required to carry
Insurance . We must require this because It ls a condition of the City's Exce ss insurance rolicy.
Acknowledgement :
1. I am an entertainer that will perform at the City of Carson
___________________________ _ _:_ ___ 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 sti ll intereste~ to-provide services at the J
/'/ I /, I --------------~::::..._ ____________ +-_..::.._ __ event.
3. I a""owledge a,d "'~ <ha< I L, of a losuhe Ctty ofCa"°" o, Its ,~i ra,re ~""' ,.;11
not provide coverage to e or to my business . 1
4. I further ack no dge and agree that in the event of a loss resulting from mJ or my business'
I
negligent acts, the City of Carson or its ins urer will see k to recover its financial loss
e or my busin ess. I will cooperate ir; ;,~ery way with the said recovery el orts.
5. The City of Carson may approve this request or may reject it at its disc retion .
Signed :
Date :
I
2023 White Linen
2023 White Linen
9/7/23