HomeMy Public PortalAboutJohnny On The Spot Portable ToiletsCITY
OF
C
R
E
S
T
V
I
E
W
Department of Public Services
DIRECTOR - WAYNE STEELE
ASSISTANT DIRECTOR — CARLOS JONES
The Public Services Department's mission is to develop and maintain
the optimum public infrastructure system, secure adequate resources
and foster planned quality growth, to promote the welfare of the
community.
CONTRACT DOCUMENTS
for
"PORTABLE TOILET RENTALS
CONTRACT" #12-0223A
s
y
CITY OF CRESTVIEW
Director Department of Public Services Telephone No. (850) 682-6132
Brona D. Steele 715 Ferdon Boulevard North Fax No. (850) 682-7359
E-Mail: steeleacitvofcrestview.orq Crestview, Florida 32536 E-Mail: oublicservicesecvflora.accoxmail.com
January 16, 2012
INVITATION TO BID
The Department of Public Services is soliciting competitive sealed proposals for Portable Toilet Rentals
Contract #12-0223A for the City of Crestview. Bid documents are available at our office on 715 North
Ferdon Boulevard, Crestview, FL between the hours of 6:30 AM to 5:00 PM, Monday — Thursday.
Bids will be publicly opened and read in the Council Chambers at City Hall, 198 N. Wilson Street,
Crestview, Florida 32536, at 2:00 P.M. local time, February 23, 2012. Bids received after 2:00 P.M. will
not be accepted. Bids should be submitted on the bid documents provided by the City in a sealed
envelope with the following clearly typed or printed on the outside: Project Name and Submitting
Company Name, address, and license number. Bid can be mailed to: Betsy Roy, City Clerk, P.O. Box
1209, 198 N. Wilson Street, Crestview, FL 32536.
Bid documents are available at the Department of Public Services at 715 N. Ferdon Boulevard,
Crestview, FL or if you have any questions, contact Carlos Jones, Assistant Director at
(850) 682-6132.
The scope of work includes the rental of approximately 30 to 35 units at different sites and at different
times of the year depending on events held or hosted by the City of Crestview. Some units will need to be
handicap accessible.
The term of the contract will be a two (2) year contract; with a renewable clause of a one (1) year period;
upon such terms and conditions as both parties may agree.
The successful bidder will be required to sign a standard City Contract, furnish a Certificate of Insurance
and be licensed with the city.
Award will be made to the lowest responsible and responsive bidder. The City of Crestview reserves the
right to reject any or all bids, to waive technicalities, and to make an award as deemed in its best interest.
Either party may terminate the Contract resulting from this bid by giving the other party hereto sixty (60)
days written notice of termination. The City shall not be required to give Contractor such written notice if
in the opinion of the City, the Contractor is unable to perform its obligations hereunder, or if in the
City's opinion, the services being provided are not satisfactory. In such case, the City may immediately
terminate the Contract by mailing a notice of termination to the Contractor.
The City of Crestview will in no way be liable for any costs incurred by any bidder in the preparation of its
Bid in response to this Invitation to Bid.
The CITY OF CRESTVIEW, FLORIDA does not discriminate on the basis of race, color, national origin,
sex, religion, age, and handicapped status in employment or provision of service.
Department of Public Services
Brona D. Steele, Director
y
CITY OF CRESMEW
Director Department of Public Services Telep•tone No. (850) 682-6132
Brona D. Steele 715 Ferdon Bculevard North Fax No. (850) 682-7359
E-Mail: staelei3citvofcrectview.orfa Crestview, Florida 32536 E-Mall: oublicservlcesticvflnra.qs um II .corn
PROPOSAL
_ 1
BIDDERS NAME: �{�1yI.� bit +L ` rytt k' (RoATDLL�+Ijj
51 �>,t
PROJECT: PORTABLE TOILET RENTALS CONTRACT #12-0223A for the City of Crestview, Florida
The Bidder proposes (to furnish all material and equipment and perform all Work) for the following price:
Item No.
Description
Quantity
Unit
Time
Total Price
1
Standard Portable Toilet
1
each
1 Day Event
5o.00
2
Handicap Portable Toilet
1
each
1 Day Event
75.00
3
Standard Portable Toilet
1
each
2 Day Event
50, 0-K)
4
Handicap Portable Toilet
1
each
2 Day Event
-15.. po
5
Standard Portable Toilet
1
each
3 Day Event
5b. Oo
6
Handicap Portable Toilet
1
each
3 Day Event
-7 S. l`) 10
7
Standard Portable Toilet
1
each
Week Event
5b. 00
8
Handicap Portable Toilet
1
each
Week Event
'76. 0 0
9
Standard Portable Toilet
1
each
Monthly Event
5o. 00
10
Handicap Portable Toilet
1
each
Monthly Event
-7 S. 00 -
11
Sanitation Station
1
each
1 Day Event
'7 5 ,00
Grand
Total
5?C11- DD
TOTAL BASE BID $(Numerals)jOD—
(Written)1111-4.chi4;20.14 L i:11 415 pet.. Ar uoLAR•cc u rit F aAlix 41.413, 0.
Provides pricing for all required labor, equipment and materials to complete all the work indicated for the city as
indicated in these specifications. If there is a difference between the numerical or written values, the written will take
presidence or whichever is In the best interest of the City of Crestview, Florida.
Mint Name of Contractor
6Yz-7
Phone
2' 10•7Cix.
leftentative of Contractor Signature Date
P - I
CITY OF CRESTVIEW
Director Department of Public Services Telephone No. (850) 682-6132
Brona D. Steele 715 Ferdon Boulevard North Fax No. (850) 682-7359
E-Mail: steeleOcitvofcrestview.ora Crestview, Florida 32536 E-Mail: oublicservicesOcvflora.accoxmail.com.
March 13, 2012
aJOHNNY ON THE SPOT
P.O. Box 746
Crestview, FL 32536
Re: NOTICE OF AWARD - "Portable Toilets Rental Contract #12-0223A"
Dear Mr. Grant,
Bids were received on Feb. 23, 2012 in the Council Chambers, and publicly opened and read. Your firm
has been determined to be the low and responsive bidder for the subject project.
At the City Council meeting on Mar. 12, 2012 the Council approved your bid in the amount of the unit
prices in your bid proposal.
The City is ready to structure and execute a "Contractual Agreement' with your firm. We are supplying
you with four (4) sets of contract documents in which we have inserted copies of your bid proposal and a
copy of this Notice of Award. Please return these documents within ten (10) days of your receipt of the
contract documents. Will you please:
1. Sign all four sets in the required spaces.
2. Please insert a copy of your Certificate of Insurance in each of the four contract documents.
3. Please insert a copy of your city license in each of the four contract documents
4. Return all four sets to us for signature of the Mayor and the Clerk.
Once the contract has been executed and signed by the City of Crestview, we will issue a Notice to
Proceed.
Regards,
Wayne Steele
Director
Department of Public Services
STANDARD FORM OF AGREEMENT
BETWEEN OWNER AND CONTRACTOR
(This document has important legal consequences; consultation with an attorney is encouraged
with respect to its completion or modification).
THIS AGREEMENT made as of the 01 day of APRIL in the year 2012 by and between,
the CITY OF CRESTVIEW, FLORIDA, (hereinafter called OWNER) and
JOHNNY ON THE SPOT — Crestview, Florida (hereinafter called CONTRACTOR),
WITNESSETH THAT OWNER and CONTRACTOR in consideration of the mutual covenants
hereinafter set forth, agree as follows:
1. WORK. The CONTRACTOR shall perform all Work as specified or indicated in the
Contract Documents for the completion of the Project generally described as follows:
PORTABLE TOILET RENTALS CONTRACT
Bid # 12-0223A
2. The CONTRACTOR will furnish the materials, supplies, tools, equipment, labor, and
other services necessary to perform the PROJECT described herein.
3. CONTRACT TIME. The contract will be a two (2) year contract; with a renewable clause
of a one (1) year period, upon such terms and conditions as both parties may agree.
4. The CONTRACTOR agrees to perform all of the work described in the CONTRACT
DOCUMENTS as reflected in the Bid form and to comply with the terms and conditions thereof, for the
total of prices per unit as shown in the BID PROPOSAL FORM.
5. CONTRACT PRICE. Owner shall pay Contractor for performance of the Work in
accordance with the Contract Documents in current funds as follows: Unit Prices per Bid Proposal
included.
6. CONTRACT DOCUMENTS. The Contract Documents which comprise the Contract
between Owner and Contractor are attached hereto and made a part hereof and consist of the
following:
7.1 Invitation to Bid
7.2 Contractor's Bid Proposal
7.3 Notice of Award, (dated 13 March 2012 )
7.4 Standard Form of Agreement
7.5 Insurance Requirements
7.6 Public Entity Crimes
PORTABLE TOILET RENTALS CONTRACT
-1-
STANDARD FORM OF AGREEMENT BETWEEN OWNER AND CONTRACTOR
7. This Agreement shall be binding upon all parties hereto and their respective heirs,
executors, administrators, successors, and assigns.
IN WITNESS WHEREOF, the parties hereto have executed this Agreement the day and year first
above written.
OWNER:
CITY OF CRESTVIEW, FLORIDA
CONTRACTOR:
Skrtr..1aA +Tn. l �- RR(s, l rK -
David Cadle, Mayor Print/Type
Attest Attest
By_.1
Attest
gr:Lz, // ( K�? J
Elizabeth M. Roy, City Clerk
PORTABLE TOILET RENTALS CONTRACT
-2-
Insurance Requirements
Contractor shall procure and maintain, for the duration of the contract, insurance against
claims for injuries to persons or damages to property which may arise from or in connection with
the performance of the work hereunder by the contractor, his/her agents, representatives,
employees, or subcontractors. The cost of such insurance shall be borne by the contractor.
A. Minimum Scope of Insurance:
Coverage shall be at least as broad as:
1. Insurance Services Office Form No. CG 0001 (11/85) or CG 0002 (2/86)
Commercial General Liability; and Insurance Services Office Form No. GL 0404 (5181) Broad
Form Comprehensive General Liability ; endorsement, and
2. Insurance Services Office form No. CA 0001 (Ed. 1/87) covering Automobile
Liability, code 1 "any auto", and CA 0002 (1/87), and
3. Workers' Compensation as required by the State of Florida and Employers'
Liability insurance:
B. Minimum Limits of Insurance:
Contractor shall maintain coverage's and limits as follows:
1, General Liability:
Aggregate Limit: $1,000,000.
Products and completed operation aggregate limit: $500,000.
Personal and advertising injury limit: N/A.
Each occurrence limit: $500,000.
Fire damage limit: $50,000 any one fire.
Medical expense limit: $5.000 per person.
Owner's and contractor's protective: yam.
Pollution - limited form: N/A.
Pollution: N/A.
Premises and Operations: N/A.
Contractual: y
Blanket: no
(1) Designated contractors (specify): City of Crestview.
2. Automobile Liability:
(a) Business auto with symbol(s): one (1)
(b) Limit per accident: 1,000,000.
3. Workers' Compensation as required by Florida laws, and Employer's Liability
with the following minimum limits:
(a) Each accident: $100,000.
Appendix 18-1c
(b) Per employee disease: $100,000.
' (c) All claims disease: $500,000.
C. Deductibles and Self -Insured Retentions:
Any deductible or self -insured retention must be declared to and approved by the City. At
the option of the City, either the insurer shall reduce or eliminate such deductibles or self insured
retentions as respects the City, its officials and employees, or the contractor shall procure a bond
guaranteeing payment of losses and related investigation, claim administration and defense
expenses.
D. Other Insurance Provisions:
The policies are to contain or be endorsed to contain the following provisions:
1. General Liability and Automobile Liability Coverage's:
(a) The City, its officials, employees and volunteers are to be covered as
additional insured's as respects: liability arising out of activities performed by or on behalf of the
contractor; products and completed operations of the contractor; or automobiles owned, leased,
hired, or borrowed by the contractor. The coverage shall contain no special limitations on the
scope of protection afforded to the City, its officials, employees or volunteers.
(b) The contractor's insurance coverage shall be primary insurance as
respects the City, its officials, employees and volunteers. Any insurance or self-insurance
maintained by the City, its officials, employees or volunteers shall be excess of contractor's
insurance and shall not contributed with it.
(c) Any failure to comply with reporting provisions of the policies shall
not affect coverage provided to the City, its officials, employees and volunteers.
(d) Coverage shall state that the contractor's insurance shall apply
separately to each insured against whom claim is made or suit is brought, except with respect to the
limits of the insurer's liability.
2. Workers' Compensation and Employer's Liability Coverage: The insurer
shall agree to waive all rights of subrogation against the City, its officials, employees and
volunteers for losses arising from work performed by the contractor for the City.
3. Each insurance policy required by this clause shall be endorsed to state that
coverage shall not be suspended, voided cancelled, reduced in coverage or in limits except after
thirty (30) days prior written notice by certified mail, return receipt requested, has been given to the
City.
E. Acceptability of Insurers: Insurance should be placed with insurers having a Bests'
rating of A -Excellent and Xiii Financial Size.
F. Verification of Coverage: Contractor shall furnish the City with certificates of
insurance and with original endorsements affecting coverage's required by this appendix. The
certificates and endorsement for each insurance policy are to be signed by a person authorized by
that insurer to bind coverage on its behalf. The certificate and endorsement are to be on forms
provided or approved by the City and are to be received and approved in final form by the City
before work commences.
Appendix 18-2c
G. Subcontractors: Contractor shall include all subcontractors as insured's under
its policies or shall furnish separate certificates and endorsements for each subcontractor. All
coverage's for subcontractors shall be subject to all of the requirements stated herein.
H. Bidder's Qualifications: If insurance is required pursuant to an invitation for bid
or request for proposal (RPP), bidder shall submit with his/her bid or proposal evidence that
he/she can meet the requirements of this appendix. Such evidence may be in the form of an
insurance binder; however, prior to work commencing, bidder must comply with paragraph F
above.
ALL QUESTIONS REGARDING INSURANCE MUST BE DIRECTED TO THE
CITY CLERK, TELEPHONE 850-682-6131 OR FAX 850-689-4575.
Appendix 18-3c
Bid or Contract No. #12-0223A
SWORN STATEMENT UNDER SECTION 287.133(3)(A) FLORIDA STATUTES, ON
PUBLIC ENTITY CRIMES.
(To be signed in the presence of a notary public or other officer authorized to administer oaths.)
STATE OF FL00-I04
COUNTY OF OKAW2S A
Before me, the undersigned authority, personally appeared -3 -3(0 LS
who, being by me first duly sworn, made the following statement:
1. The business address of .inir/N y 04 Wig $P01 feNPfcr r .rivc ,.
(Name of bidder or contractor) is /you "1-4yvars LErE OLIO (statement).
CilaSTYIC'✓ /rk i Zr T`�!
2. My ationship to _Jokie +i -Pk( Slor To. Ca7 ,reri-. (contractor) is
/t10/DEN (relationship such as sole Proprietor,
partner, president, vice president, etc.)
3. I understand that a public entity crime as defined in Section 287.133 of the Florida Statutes
includes a violation of any state or federal law by a person with respect to and directly related
to the transaction of business with any public entity in Florida or with an agency or political
subdivision of any other state or with the United States, including but not limited to, any bid
or contract for goods or services to be provided to any public entity or such an agency or
political subdivision and involving antitrust, fraud, theft, bribery, collusion, racketeering,
conspiracy, or material misrepresentation.
4. I understand that "convicted" or "conviction" is defined by the statute to mean a finding of
guilt or a conviction of public entity crime, with or without an adjudication of guilt, in any
federal or state trial court or record relating to charges brought by indictment or information
after July 1, 1989, as a result of a jury verdict, nonjury trial, or entry of a plea of guilty or
nolo contendere.
5. I understand that "affiliate" is defined by the statute to mean (1) a predecessor or successor of
a person or a corporation convicted of a public entity crime, or (2) an entity under the control
of any natural person who is active in the management of the entity and who has been
convicted of a public entity crime, or (3) those officers, directors, executives, partners,
shareholders, employees, members, and agents who are active in the management of an
affiliate, or (4) a person or corporation who knowingly entered into a joint venture with a
person who has been convicted of a public entity crime in Florida during the preceding 36
months.
6. Neither the bidd r or the contractor nor any facer, director, executive, partner, shareholder,
e plo ee, me : r or agent o is active ' t e management f the bidder or contractor r
a 'Hate • he bidde o contrac •r ha been cony' te• of a pub entity rim
s • s q ent to ul 1, 198 •
(Draw a line thr• . h paragraph 6 if paragraph 7 below applies).
7. There has been a conviction of a public entity crime by the bidder or contractor, or an officer,
shareholder, employee, member or agent of the bidder or
co tractor • is active in a management o e bidder or co ractor or an affiliate of th
director, executive, partner,
b'
0
n
0
• der o
der o
me
th
con ractor. A
the D
f the co
convicte
vision o r Ad
victe• person
rson or a
rmination has
inistrative
r affilia
s
made purl .n to Section :7.133(3 .y
arings that it is of i the publi• in rest '•r the
to appea on t convic ed ven•.r list. The name
. A copy of
ee
th = •rder of the Division of Administrative Hearings is attached to this statement.
(Draw a line through paragraph 7 if paragraph 6 above applies)
As the person authorized to sign the statement, I certify that this firm complies fully with the
above requirements.
Date
Sign
(Contractor)
Print/Type�su: )61-)OL.i
Sworn to and subscribed before me in the state and county first mentioned above on the
� day of c_orc_V--,
Notary Public
My Commission expires
AFFIX SEAL
P,,e,X. RUSHING
' ,'a°. —•1,`� ; Notary Public • State of Florid
• 3 My Comm. Expires Sep 23, 2014
Pam: Commission # EE 29090
1 ��4%'°' '�''', Bonded Through National Notary Assn. 0
f00,1 • •
."
44/1"1111." Yer-,-ft..411110.411P.NIP•4111..41410"41
City of Crestview
P.O. BOX 1209
CRESTVIEW, FL 32536
LICENSE NO. 12-00002657
LICENSE YEAR: 2011-2012
BUSINESS CLASSIFICATION: UNCLASSIFIED
LOCATION 201 VALLEY RD
ISSUE JOHNNY ON THE SPOT TOILET RENT
TO
P.O. BOX 746
CRESTVIEW FL 32536
SUBJECT TO FLORIDA STATUES
FOR LOCAL BUSINESS TAX
RECEIPTS
DATE ISSUED: January 19, 2012
LICENSE VALID THROUGH: September 30, 2012
AMOUNT PAID: 0.00
LOCAL BUSINESS TAX RECEIPT
J atiacia heette
DEPUTY CLERK
THIS MUST BE POSTED CONSPICUOUSLY IN YOUR PLACE OF BUSINESS. PENALTY FOR FAILURE TO DO SO.
1
i
"
f z
J O H N O N T - 0 1
G O N Z A L E Z V
' ��` . �� ` �� C E R T I F I C A T E O F L I A B I L I T Y I N S U R A N C E
D A T E ( N M I D D / W Y Y )
2 / 1 3 / 2 0 1 2
T H I S C E R T I F I C A T E I S I S S U E D A S A M A T T E R O F I N F O R M A T I O N O N L Y
C E R T I F I C A T E D O E S N O T A F F I R M A T I V E L Y O R N E G A T I V E L Y A M E N D ,
B E L O W . T H I S C E R T I F I C A T E O F I N S U R A N C E D O E S N O T C O N S T I T U T E
R E P R E S E N T A T I V E O R P R O D U C E R , A N D T H E C E R T I F I C A T E H O L D E R
A N D C O N F E R S N O R I G H T S U P O N T H E C E R T I F I C A T E
E X T E N D O R A L T E R T H E C O V E R A G E A F F O R D E D
H O L D E R . T H I S
B Y T H E P O L I C I E S
A U T H O R I Z E D
A C O N T R A C T B E T W E E N T H E I S S U I N G I N S U R E R ( S ) ,
I M P O R T A N T : I f t h e c e r t i f i c a t e h o l d e r I s a n A D D I T I O N A L I N S U R E D , t h e p o l l c y ( i e s ) m u s t b e e n d o r s e d . I f S U B R O G A T I O N I S W A I V E D , s u b j e c t t o
t h e t e r m s a n d c o n d i t i o n s o f t h e p o l i c y , c e r t a i n p o l i c i e s m a y r e q u i r e a n e n d o r s e m e n t A s t a t e m e n t o n t h i s c e r t i f i c a t e d o e s n o t c o n f e r r i g h t s t o t h e
c e r t i f i c a t e h o l d e r i n l i e u o f s u c h e n d o r s e m e n g s ) .
P R O D U C E R
I n s u r a n c e O f f i c e o f A m e r i c a , I n c .
P . O . B o x 1 6 2 2 0 7
A l t a m o n t e S p r i n g s , F L 3 2 7 1 6 - 2 2 0 7
I N ��T A C T
P H O N E
M e ' ( 8 0 0 ) 2 4 3 - 6 8 9 9 ( u c N o ) : ( 4 0 7 ) 7 8 8 - 7 9 3 3
A D D R E s s :
I N S U R E R S ) A F F O R D I N G C O V E R A G E
N A I C N
I N S U R E R A : M i d - C o n t i n e n t C a s u a l t y C o m p a n y
2 3 4 1 8
I N S U R E D
J o h n n y O n T h e S p o t T o i l e t R e n t a l s , I n c .
1 7 0 2 E . J a m e s L e e B l v d
C r e s t v i e w , F L 3 2 5 3 9
I N S U R E R B : P r o g r e s s i v e E x p r e s s I n s u r a n c e C o m p a n y
1 0 1 9 3
I N S U R E R C :
I N S U R E R D :
I N S U R E R E
I N S U R E R F :
"
. . . . . . . . . .
T H I S I S T O C E R T I F Y T H A T T H E P O L I C I E S O F I N S U R A N C E L I S T E D B E L O W H A V E B E E N I S S U E D T O T H E I N S U R E D N A M E D A B O V E F O R T H E P O L I C Y P E R I O D
I N D I C A T E D . N O T W I T H S T A N D I N G A N Y R E Q U I R E M E N T , T E R M O R C O N D M O N O F A N Y C O N T R A C T O R O T H E R D O C U M E N T W I T H R E S P E C T T O W H I C H T H I S
C E R T I F I C A T E M A Y B E I S S U E D O R M A Y P E R T A I N , T H E I N S U R A N C E A F F O R D E D B Y T H E P O L I C E S D E S C R I B E D H E R E I N I S S U B J E C T T O A L L T H E T E R M S ,
E X C L U S I O N S A N D C O N D I T I O N S O F S U C H P O L I C I E S . L I M I T S S H O W N M A Y H A V E B E E N R E D U C E D B Y P A I D C L A I M S .
L T R
T Y P E O F I N S U R A N C E
A D D L
I N S R
��V D
W
P O L I C Y N U M B E R
P O L I C Y E F F
( M M I D D / Y Y Y Y )
P O L I C Y E X P
( M M I D D / Y Y Y Y )
L I M I T S
A
G E N E R A L
X
L I A B I L I T Y
C O M M E R C I A L G E N E R A L L I A B I L I T Y
0 4 G L 0 0 0 8 4 2 3 0 9
2 / 1 8 / 2 0 1 2
2 / 1 8 / 2 0 1 3
E A C H O C C U R R E N C E
S 1 , 0 0 0 , 0 0 0
p D R M S E S E a N T h o
r r e n c e )
$ 1 0 0 , 0 0 0
C L A I M S - M A D E n O C C U R
M E D E X P ( A n y o n e p e r s o n )
S E x c l u d e d
P E R S O N A L & A D V I N J U R Y
S 1 , 0 0 0 , 0 0 0
G E N E R A L A G G R E G A T E
S 2 , 0 0 0 , 0 0 0
G E N ' L A G G R E G A T E U M I T A P P L I E S P E R :
P R O D U C T S - C O M P / O P A G G '
S 2 , 0 0 0 , 0 0 0
S
B
A U T O M O B I L E
X
L I A B I L I T Y
A N Y A U T O
A L L O W N E D
X
X
S C H E D U L E D
A U T O S
N O N - 0 W N E D S
A U T O
0 6 2 8 3 6 1 8 - 4
2 / 7 / 2 0 1 2
2 / 7 / 2 0 1 3
C O M B I N E D S I N G L E L I M I T
( E a a c a d e n t )
S 1 , 0 0 0 , 0 0 0
B O D I L Y I N J U R Y ( P e r p e r s o n )
S
B O D I L Y I N J U R Y ( P e r a c a d e n t )
S
P R O P E R T Y D A M A G E
( P e r a c c i d e n t )
S
S
U M B R E L L A L I A B
E X C E S S L I A B
_
O C C U R
C L A I M S - M A D E
E A C H O C C U R R E N C E
S
A G G R E G A T E
S
D E D R E T E N T I O N S
S
W O R I O R S C O M P E N S A T I O N
A N D E M P L O Y E R S ' L I A B I L I T Y
A N Y P R O P R I E T O R / P A R T N E R / E X E C U T I V E
O F F I C E R M I E M B E R E X C L U D E D ?
( M a n d a t o r y I n N H )
I 1 y e a , d e s c r i b e u n d e r
Y / N
N / A
W C S T A T U - O T H -
T O R Y L I M I T S E R
E . L . E A C H A C C I D E N T
S
E . L . D I S E A S E - E A E M P L O Y E E
S
E . L . D I S E A S E - P O L I C Y L I M I T
S
D E S C R I P T I O N O F O P E R A T I O N S / L O C A T I O N S / V E H I C L E S ( A t t a c h A C O R D 1 0 1 , A d d i t i o n a l R a m a d a S c h e d u l e , I f m o r e s p a c e I s r e q u i r e d )
"
C A N C E L L A T I O N
( P r o o f o f C o v e r a g e
S H O U L D A N Y O F T H E A B O V E D E S C R I B E D P O L I C I E S B E C A N C E L L E D B E F O R E
T H E E X P I R A T I O N D A T E T H E R E O F , N O T I C E W I L L B E D E L I V E R E D I N
A C C O R D A N C E W I T H T H E P O L I C Y P R O V I S I O N S .
A U T H O R I Z E D R E P R E S E N T A T I V E
A C O R D 2 5 ( 2 0 1 0 / 0 5 )
� 1 9 8 8 - 2 0 1 0 A C O R D C O R P O R A T I O N . A l l r i g h t s r e s e r v e d .
T h e A C O R D n a m e a n d l o g o a r e r e g i s t e r e d m a r k s o f A C O R D
,MHY-5-2011 01:41P FROM:CVIEW PMI
6897556
TO:6544791
P.1/1
ACORO®
CERTIFICATE OF LIABILITY INSURANCE
PRODUCER
INSURED
Insurance Associates of Dustin, Inc
127 Miracle &no Parkway, Suite N-7
Fort wake Bead). FL 32548
PAYROLL MANAGEMENT, INC
127 MIRACLE STRIP PKWY, S W , SUITE 7
FT WALTON BEACH, FL 32548
FAX:850-275-5438
COVERAGES
5422
THIS CERTIFICATE IS ISSUED AS A
ONLY AND CONFERS NO RIGHTS
HOLDER. THIS CERTIFICATE DOES
ALTER THE COVERAGE AFFORDED
INSURERS AFFORDING COVERAGE
DATE (MMYDDIYYYY)
04/29/2011
MATTER OF INFORMATION
UPON THE CERTIFICATE
NOT AMEND, EXTEND OR
BY THE POLICIES BELOW.
INSURER A NATIONAL UNION FIRE INS., CO. PITTSBURG,
INSURER B.
NAIC *
10445
INSURER C
INSURER D;
INSURER E.
THE
ANY
MAY
POLICIES.
POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
REOUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LIMITS SHOWN ARE AS REQUESTED
IADD'L
INSR
I TE_ML.1Rq
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE
PATE INYfDDIVYM
POLICY EXPIRATION
DATP IMMC07YYYYL
LIMITS
GENERAL
LABILITY
COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE
S
DAMAGE TO RENTED
PREMISES NS occurrence)
S
CLAIMS MADE U OCCUR
MED EXP IAIy ono Poison)
S
L_
Gfr11
PERSONAL a ADV INJURY
S
GENERAL AGGREGATE
S
AGGREGATE LSAT APPPLLIIEjS PER
POLICY .Ear I I Wt.
PRODUCTS - COMP/OP AGO
S
AUTOMOBILE
~^
�--
^_
__
ANYAUIOABILITY
ALL OWNED AUTOS
SCHEDLLEDAUTOS
HIRED AUTOS
COMBINED SINGLE UNIT
(Ea accident)
1
i
BODILY INJURY
(Per person)
S
BODILY INJURY
(Per accident)
S
PROPERTY DAMAGE
(ar ac NW)
S
GARAGE
UASILITY
ANY AUTO
AUTO ONLY - EA ACCIDENT
S
OTHER THAN EA ACC
i
AUTO ONLY. AGO
S
ERCESS
77
I UMBRELLA UABILITY
EACH OCCURRENCE
i
AGGREGATE
S
S
S
E
A
WORKERS
AND EMPLOYERr
ANY PROPRIETORMARTNERtEXECUTIVE
OFFICERMEMBER
(AMandatary
M yes, climbs
COMPENSATION
LIABILITY YIN
488'04-31
RETENTION:500,000
5/01/11
r6/Dv12
WCSTATU• IOTH-
X ?RR,'1 minx I ER
EXCWDED7 N
E.L. EACH ACCIDENT
S 1,000,000
In NH)
unG;
Wow
E.L. DISEASE - EA EMPLOYEE
S 1,000,000
E.L. DISEASE - POLICY LIMIT
$ 1,000,000
OTHER
DESCRIPTION OF OPERATIONS I LOCATION!, VEHICLES! EXCLUSION! ADDED BY ENDORSEMENT, SPECIAL PROVISIONS
PROVIDING LEASED EMPLYEES TO: JOHNNY ON THE SPOT TOILET RENTALS, INC. COVERAGE FOR 6
EMPLOYEES. *FOR STATE OF FLORIDA WORK COMP COVERAGE ONLY. "DOES NOT COVER USL&H"
5422
SHOULDANY OF THEABOVE DESCRIBED POUCEA BECANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 60 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY IOND UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
I
.:41)6p6 , r , re. I I 1 (. - I, .
01988.2009 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
q d
..
Form W-9
(Rev. December 2011)
Department of the Treasury
Internal Revenue Service
Request for Taxpayer
Identification Number and Certification
Give Form to the
requester. Do not
send to the IRS.
N
N
c
fe
a
c
0
c
oc
o2
" a
c
a o
t
u
0
to
m
m
Name (as shown on your income tax retum)
JOHNNY ON THE SPOT TOILET RENTALS, INC.
Business name/disregarded entity name, if different from above
Check appropriate box for federal tax classification:
❑ Individual/sole proprietor ❑ C Corporation ✓❑ S Corporation ❑ Partnership ❑ Trust/estate
❑ Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership) ►
❑ Other (see instructions) ►
❑ Exempt payee
Address (number, street, and apt. or suite no.)
1702 E. JAMES LEE BLVD.
City, state, and ZIP code
CRESTVIEW, FL 32539
Requester's name and address (optional)
List account number(s) here (optional)
Part I
Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. The TIN provided must match the name given on the "Name" line
to avoid backup withholding. For individuals, this is your social security number (SSN). However, for a
resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other
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 chart on page 4 for guidelines on whose
number to enter.
Social security number
Employer identiRcabon number
2
0
1
0
9
0
7
4
9
Part II
Certification
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and
2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal 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 I am
no longer subject to backup withholding, and
3. I am a U.S. citizen or other U.S. person (defined below).
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 and dividends, you are not require o sign the certification, but you must provide your correct TIN. See the
instructions on page 4.
Sign
Here
Signature of
U.S. person ►
J
Date ► I - • 2,0 )
General Instruction
Section references are to the I al Revenue Code unless otherwise
noted.
Purpose of Form
A person who is required to file an information return with the IRS must
obtain your correct taxpayer identification number (TIN) to report, for
example, income paid to you, real estate transactions, mortgage interest
you paid, acquisition or abandonment of secured property cancellation
of debt, or contributions you made to an IRA.
Use Form W-9 only if you are a U.S. person (including a resident
alien), to provide your correct TIN to the person requesting it (the
requester) and, when applicable, to:
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 if 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' share of
effectively connected income.
Note. If a requester gives you a form other than Form W-9 to request
your TIN, you must use the requester's form if it is substantially similar
to this Form W-9.
Definition of a U.S. person. For federal tax purposes, you are
considered a U.S. person if you are:
• An individual who is a U.S. citizen or U.S. resident alien,
• A partnership, corporation, company, or association created or
organized in the United States or under the laws of the United States,
• An estate (other than a foreign estate), or
• A domestic trust (as defined in Regulations section 301.7701-7).
Special rules for partnerships. Partnerships that conduct a trade or
business in the United States are generally required to pay a withholding
tax on any foreign partners' share of income from such business.
Further, in certain cases where a Form W-9 has not been received, a
partnership is required to presume that a partner is a foreign person,
and pay the withholding tax. Therefore, if you are a U.S. person that is a
partner in a partnership conducting a trade or business in the United
States, provide Form W-9 to the partnership to establish your U.S.
status and avoid withholding on your share of partnership income.
Cat. No. 10231 X Form W-9 (Rev. 12-2011)