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Home My Public Portal About2023-44 Selecting U.S. Lubricants LLC for Well Maintenance and Cleaning ServicesRE SO L U T IO N N O . 2023-44 A RE SO L U T IO N O F T H E V IL L A G E C O UN C IL O F T H E V IL L A G E O F K E Y B ISC A Y N E , FL O RI D A , SE L E C T IN G U .S . L U B RI C A N T S L L C F O R W E L L M A IN T E N A N C E A N D C L E A N IN G SE R V IC E S IN A N A M O U N T N O T T O E X C E E D $2 11 ,200.00; PR O V ID IN G F O R A U T H O RI Z A T IO N ; A N D P R O V ID IN G FO R A N E F F E C T IV E D A T E . W H E RE A S, the Village of Key Biscayne (the "Village") issued Invitation to Bid No. 2022- 20 (the "ITB") for well maintenance and cleaning services, which services include, but are not limited to, routine cleaning, maintenance, and repair for the Village's existing 35 wells and as needed well restoration services (the "Services"); and W H E RE A S, two sealed bids were received by the 1TB deadline; and W H E RE A S, after review and evaluation of the submitted bids, the Village Manager recommended that U.S. Lubricants LLC (the "Contractor") be selected to perform the Services as the lowest responsive and responsible bidder; and W H E RE A S, the Village Council desires to select the Contractor to provide the Services and authorize the Village Manager to negotiate and execute an agreement with the Contractor in an amount not to exceed $211,200.00, consistent with the Contractor's bid attached hereto as Exhibit "A;" and W H E RE A S, the Village Council finds that this Resolution is in the best interest and welfare of the residents of the Village. N O W , T H E RE F O RE , B E IT RE SO L V E D B Y T H E V IL L A G E C O U N C IL O F T H E V IL L A G E O F K E Y B ISC A Y N E , FL O RI D A , A S FO L L O W S : S ection 1. R ecitals. That each of the above-stated recitals are hereby adopted, confirmed, and incorporated herein. Page I of3 S e c t i o n 2 . Services. Section 3. Selection. That the Village Council hereby selects the Contractor for the Authorization. That the Village Council hereby authorizes the Village Manager to negotiate and execute an agreement with the Contractor in an amount not to exceed $211,200.00, consistent with the Contractor's bid attached hereto as Exhibit "A," and subject to the Village Attorney's approval as to form, content, and legal sufficiency. Section 4. Effective Date. That this Resolution shall be effective immediately upon adoption. PASSED and ADOPTED this 18th day of ~Ju_l , 2023. ATTEST: VILLAGE CLERK WEISS SEROTA HELFMAN COLE & BIERMAN, P.L. VILLAGE ATTORNEY Page 2 of 3 E X H IB IT A C o n tracto r's B id fo r IT B N o. 2022 -20 Page 3 of3 E X H IB IT A Well Maintenance and Cleaning Services - ITB II 2022-20 FORM2 ADDENDUM ACKNOWLEDGEMENT Solicitation Title: WELL MAINTENANCE AND CLEANING SERVICES Solicitation No.: 1TB # 2022-20 Listed below are the dates of issue for each Addendum received in connection with this Solicitation: Addendum No. 1 Dated 01LtbL~l0 • I Addendum No. Dated Addendum No. Dated Addendum No. Dated Addendum No. Dated Addendum No. Dated Addendum No. Dated Addendum No. Dated Addendum No. Dated Addendum No. Dated Addendum No. Dated ! No Addendum issued for this Solicitation Firm's Name: u.~. l,l(b,n'e-a,,rJ-f-5 t-Lf!_ ~ Authorized Representative's Name: 'Jos~ l . r..£..rni!/l#Jtle z__ Title: f//~ Email, ps.,,_f@ US - lub.£S. ~ :::~:,::;:::.'"':+=-•{ I ¥4 - - \ f 21 Well Maintenance and Cleaning Services - ITB # 2022-20 FORMl RESPONSE CHECKLIST Form 1: Response Checklist Form 2: Addendum Acknowledgment Form 3: Certificate of Authority (Complete one of the two forms as applicable) • Form 3A: Certificate of Authority {for Corporations or Partnerships) • Form 38: Certificate of Authority (for Individuals) Form 4: Certification to Accuracy of Proposal Form 5: Company Declaration Form Form 6: Affidavits • • Form 6A: Form 68: Single Execution Affidavits Independence Affidavit ! ! u ! ! Form 7: Proposer's Statement of Organization Form 8: Dispute Disclosure Form 9: Drug Free Workplace Form 10: Scrutinized Companies Form 11: Public Entity Crimes Form 12: List of Proposed Subcontractors Form 13: References Form 14: Form of Performance Bond Form 15: Form of Payment Bond Form 16: Proposal Security Form 17: Certificate of Insurance Form 18: Company Qualification Questionnaire ATTACHMENTS n A. Contract Draft EXHIBITS 0 A. Scope of Services 0 8. Bid Schedule/Price Proposal 20 W e ll M a in t e n a n c e a n d C le a n in g S e r v ic e s - IT B # 2022·20 FORM 3A CERTIFICATE OF AUTHORITY (If Corporation) I HEREBY CERTIFY that a meeting of the [circle one] €'card of Direc~ Partners of (). ~ l,u in--,~fs u.«. ________ a business existing under the laws ofthe State of c/rrr-,' d4 (the "Entity") held on tt a-r7Uaz1{ // #, . 20 ~ the following resolution was duly passed and adopted: "RESOLVED, that, Clo~ l. F.L-,-r}a,r]~ 2- as /J]r ___ of the Entity, be and is hereby authorized to execute this Proposal dated __ (Ja-r,J~ //#. 20 ~3, on behalf of the Entity and submit this Proposal to the Village of Key Biscayne. and this Entity and the execution of this Certificate of Authority, attested to by the Secretary of the Corporation. and with the Entity's Seal affixed, will be the official act and deed of this Entity." I FURTHER CERTIFY that said resolution is now in full force and effect. -ff, IN WITNESS WHEREOF, I have hereunto set my hand and affixed the official seal of the Entity this Jj__ _____ day of ~ a,.,,,,,'Jt) ~ Secretary: _ Print Name: _ ,20~ President: 0 ..A..- l _ t/ Print Name:~e. L.. f-~a:,,,,,,tJ!!e Z.. (Seal) 22 Well Maintenance and Cleaning Services - ITB # 2022-20 FORM 3B CERTIFICATE OF AUTHORITY (if Individual) I, ("Affiant") being first duly sworn, deposes and says: 1. I am the _ [Select and print as applicable: Owner/Partner/Officer/Representative/Agent) of: _ ______________________________ doing the business as __, Contractor that has submitted the attached Proposal. 2. I am fully informed respecting the preparation and contents of the attached Proposal and all of the pertinent circumstances respecting such Proposal. 3. I am authorized to execute the Proposal dated _, and submit this Proposal to the Village of Key Biscayne, and the execution of this Certificate of Authority, attested to by a Notary Public,, will be the official act and deed of this attestation. In the presence of: Signed, sealed and delivered by: Witness ##1 Print Name: _ Print Name: _ Title: _ Witness ##2 Print Name: _ ACKNOWLEDGMENT State of Florida County of _ On this day of __, 20_, before me the undersigned, personally appeared _, whose name(s) is/are subscribed to the within instrument, and he/she/they acknowledge that he/she/they executed it. Witness my hand and official seal: N otary Public (Print, Stam p, or Type as Com m issioned) ___ Personally known to me; or ___ Produced identification (Type of Identification: _ ___ Did take an oath; or ___ Did not take an oath 23 W e ll M a in t e n a n c e a n d C le a n in g S e rv ic e s - IT B ti 2022-20 FORM4 CERTIFICATION TO ACCURACY OF PROPOSAL The pro poser, by executing this fo rm , hereby certifies and attests that all fo rm s, affidavits and docum ents related thereto that it has encl osed in the proposal in support of its proposal are true and accurate. Failure by the pro poser to attest to the truth and accuracy of such fo rms, affidavits and docum ents shall result in the proposal being deem ed non-responsive and such proposal will not be considered. By subm itting a pro posal to do the w ork, the proposer cert ifies that a careful review of the RFP and the Agreem ent has taken place and that the proposer is fully info rm ed and understands the requirem ents of the RFP and the Agreem ent and the quality and quantity of serv ice to be performed. The undersigned individual, being duly sw orn , deposes and says that: 1. H e/She is !J' OS4J L. f ./l..rrl a--rJ£t, 2- of V • S. lu /n? 'c~is LL(!,,, the proposer that has subm itted the att ached proposal; 2. He/She is fully info rm ed respecting the preparation and contents of the att ached proposal and of all fo rm s, aff idavits and docum ents subm itt ed in support of such proposal; 3. A ll fo rm s, aff idavits and docum ents subm itt ed in support of this pro posal and included in this proposal are true and accurate; 4. N o info rm ation that sho uld have been included in such fo rm s, affi davits and docum ents has been om itt ed; and 5. N o info rm ation that is incl uded in such fo rm s, aff idavits or docum ents is false or misleading. STATE O F Fl fJ-('7 ~ ) CO U N TY O F f.l},'a,,m j]J~) -!h The fo regoing instrum ent w as acknow ledged befo re me this // day of ::f a,,,,,,Jv1/'{ . 20.2:!} by Cf'l¼e- l. F...e..t-r1 CYY1tkz_ as__,_M___...,vt[2~-· _ (Name of person acknowledging) [Tltle} fo r {).~. lu bY,UYYJ-/s LL..~ {Company name) Personally know n to m e ! or has produced Identification ______,J type of identification produced a_=..l..-~ (N O TA fil(,$/il'l H ER'il,ABEL B. OR TIZ SI G N A TU RE O F~ .~~"• Commlaalon#GG909732 PRINT, TY PE/STAM P NAM E OF NOTARY , ri Expires October 8, 2023 24 "'t o,.,.rr llon ~tll TitN lwq tl NG!lry 8tnloea Well Maintenance and Cleaning Services - ITB # 2022-20 FORMS COMPANY DECLARATION FORM I certify that any and all information contained in this RFP is true. I certify that this RFP is made without prior understanding, agreement, or connections with any corporation, firm or person submitting a RFP for the same materials, supplies, equipment, or services and is in all respects fair and without collusion or fraud. I agree to abide by all terms and conditions of the RFP and certify that I am authorized to sign for the Proposer's firm. Please print the following and sign your name: v.~. ¼b-n~-fs ~ FIRM NAME ~:8 & Al uJ 4~4 T~ , 1--1, ~ <, Ii. 2131 ¢ ;L. PRINCIPAL BUSINESS ADDRFESS TELEPHONE 1%-e.{@ os-lobes . ld-rY'J FACSIMILE E&,AIL ADDRESS FEDERAL I.D. NO. OR SOCIAL SECURITY NUMBER MUNICIPAL BUSINESS TAX RECEIPT OR OCCUPATIONAL LICENSE NO. NAME f 25 W e ll M a in t e n a n c e a n d C le a n in g S e rv ic e s - IT B I# 2022-20 FO RM 6 A SINGLE EXECUTION AFFIDAVITS THIS FORM MUST BE SIGNED AND SWORN TO IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER OFFICIAL AUTHORIZED TO ADMINISTER OATHS. TH IS FORM COMBINES SEVERAL AFFIDAVIT STATEMENTS TO BE SWORN TO BY THE PROPOSER OR BIDDER AND NOTARIZED BELOW. IN TH E EVENT TH E PROPOSER OR BIDDER CANNOT SWEAR TO ANY OF THESE AFFIDAVIT STATEMENTS, TH E PROPOSER OR BIDDER IS DEEMED TO BE NON-RESPONSIBLE AND IS N O T ELIGIBLE TO SUBMIT A PROPOSAL/BID- THESE SINGLE EXECUTION AFFIDAVITS ARE SUBMITTED TO TH E VILLAGE OF KEY BISCAYNE AND ARE STATEMENTS MADE: C By: ::r o~e.-- l. r ..L-rYJa-r, cf.e z_ For (Name of Proposing or Bidding Entity): tJ . S. Cu /o,n ~-/s LL(!_,, Whose business address is: :?J&?J~ AhJ J_f?-/,,, T~a , f/1/~1~ Ji..JJJJlt./.:J... And (if applicable) its Federal Employer Identification Number (FEIN) is: {1 :J- ?,4- CJ fcJCjJ (if the entity does not have an FEIN, include the Social Security Number of the individual signing this sworn statement. SS#: _,, A m ericans w ith Disabili ties A ct Com pliance Affi davit The above-named firm, corporation or organization is in compliance with and agrees to continue to comply with, and assure that any subcontractor, or third-party contractor under this project complies with all applicable requirements of the laws listed below including, but not limited to, those provisions pertaining to employment, provision of programs and services, transportation, communications, access to facilities, renovations, and new construction. • The American with Disabilities Act of 1990 (ADA), Pub. L. 101-336, 104 Stat 327, 42 USC 1210112213 and 47 USC Sections 225 and 661 including Title I, Employment; Title II, Public Services; Title Ill, Public Accommodations and Services Operated by Private entities; Title IV, Telecommunications; and Title V, Miscellaneous Provisions. • The Florida Americans with Disabilities Accessibility Implementation Act of 1993, Section 553.501- 553.513, Florida Statutes: • The Rehabilitation Act of 1973, 229 USC Section 794; • The Federal Transit Act, as amended 49 USC Section 1612; ,,,... • The Fair Housing Act as amended 42 USC Section 3601-3631. CJ t:· Proposer Initials 26 W e ll M a in t e n a n c e a n d C le a n in g S e rv ic e s - IT B # 2022-20 Public Entity Crimes Affidavit I understand that a "public entity crime" as defined in Paragraph 287 .133{l)(g), Florida Statutes, means a violation of any state or federal law by a person with respect to and directfv related to the transaction of business with any public entity or with an agency or political subdivision of any other state or of the United States, including but not limited to, any bid or contract for goods or services to be provided to any public entity or an agency or political subdivision of any other state or of the United States and involving antitrust, fraud, theft, bribery, collusion, racketeering, conspiracy, or material misrepresentations. I understand that "convicted" or "conviction" as defined in Paragraph 287.133(1)(b), Florida Statutes, means a finding of guilt or a conviction of a public entity crime, with or without an adjudication of guilt, in any federal or state trial court of record relating to charges brought by indictment or information after July 1, 1989, as a result of a jury verdict, non-jury trial, or entry of a plea of guilty or nolo contendere. I understand that an "affiliate" as defined in Paragraph 287.133{l)(a), Florida Statutes, means: 1. A predecessor or successor of a person 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. The term "affiliate" includes those officers, directors, executives, partners, shareholders, employees, members, and agents who are active in the management of an affiliate. The ownership by one person of shares constituting a controlling interest in another person, or a pooling of equipment or income among persons when not for fair market value under an arm's length agreement, shall be a prima facie case that one person controls another person. A person who knowingly enters into a joint venture with a person who has been convicted of a public entity crime in Florida during the preceding 36 months shall be considered an affiliate. I understand that a "person" as defined in Paragraph 287.133(1)(e), Florida Statutes, means any natural person or entity organized under the laws of any state or of the United States with the legal power to enter into a binding contract and which bids or applies to bid on contracts for the provision of goods or services let by a public entity, or which otherwise transacts or applies to transact business with a public entity. The term "person" includes those officers, directors, executives, and partners, shareholders, employees, members, and agents who are active in management of an entity. Based on information and belief, the statement, which I have marked below, is true in relations to the entity submitting this sworn statement. (INDICATE WHICH STATEMENT APPLIES.) Neither the entity submitting this sworn statement, nor any of its officers, directors, executives, partners, shareholders, employees, members, or agents who are active in the management of the entity, nor any affiliate of the entity has been charged with ad convicted of a public entity crime subsequent to July 1, 1989. 27 Well Maintenance and Cleaning Services - ITB # 2022-20 ) The entity submitting this sworn statement, or one or more of its officers, directors, executives partners, shareholders, employees, members, or agents who are active in the management of the entity, or an affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July 1, 1989. [ ] The entity submitting this sworn statement, or one or more of its officers, directors, executives, partners, shareholders, employees, members, or agents who are active in the management of the entity, or an affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July 1, 1989. However, there has been a subsequent proceeding before a Hearing Officer of the State of Florida, Division of Administrative Hearings and the final Order entered by the Hearing Officer determined that it was not in the public interest to place the entity submitting this sworn statement on the convicted vendor list (attach a copy of the fin a I order). I understand that the submission of this form to the contracting officer for the public entity identified in paragraph 1 above is for that public entity only and that this form is valid through December 31 of the calendar year in which it is filed. I also understand that I am required to inform the public entity prior to entering into a contract in excess of the threshold amount provided in Section 287.017, Florida Statutes for category two of any change in the information contained in this form. Gr Proposer Initials No Conflict of Interest or Contingent Fee Affidavit Proposer warrants that neither it nor any principal, employee, agent, representative nor family member has paid or will pay any fee or consideration that is contingent on the award or execution of a contract arising out of this solicitation. Proposer also warrants that neither it nor any principal, employee, agent, representative nor family member has procured or attempted to procure this contract in violation of any of the provisions of the Miami-Dade County conflict of interest or code of ethics ordinances. Further, Proposer acknowledges that any violation of these warrants will result in the termination of the contract and forfeiture of funds paid or to be paid to the Proposer should the Proposer be selected for the performance of this contract. ~f Proposer Initials Business Entity Affidavit Proposer hereby recognizes and certifies that no elected official, board member, or employee of the Village of Key Biscayne (the II Village") shall have a financial interest directly or indirectly in this transaction or any compensation to be paid under or through this transaction, and further, that no Village employee, nor any elected or appointed officer (including Village board members) of the Village, nor any spouse, parent or child of such employee or elected or appointed officer of the Village, may be a partner, officer, director or proprietor of Proposer or Vendor, and further, that no such Village employee or elected or 28 Well Maintenance and Cleaning Services - ITB II 2022-20 appointed officer, or the spouse, parent or child of any of them, alone or in combination, may have a material interest in the Vendor or Proposer. Material interest means direct or indirect ownership of more than 5% of the total assets or capital stock of the Proposer. Any exception to these above-described restrictions must be expressly provided by applicable law or ordinance and be confirmed in writing by Village. Further, Proposer recognizes that with respect to this transaction or bid, if any Proposer violates or is a party to a violation of the ethics ordinances or rules of the Village, the provisions of Miami-Dade County Code Section 2-11.1, as applicable to Village, or the provisions of Chapter 112, part Ill, Fla. Stat., the Code of Ethics for Public Officers and Employees, such Proposer may be disqualified from furnishing the goods or services for which the bid or proposal is submitted and may be further disqualified from submitting any future bids or proposals for goods or services to Village. df Proposer Initials Anti-Collusion Affidavit 1. Proposer/Bidder has personal knowledge of the matters set forth in its Proposal/Bid and is fully informed respecting the preparation and contents of the attached Proposal/Bid and all pertinent circumstances respecting the Proposal/Bid; 2. The Proposal/Bid is genuine and is not a collusive or sham Proposal/Bid; and 3. Neither the Proposer/Bidder nor any of its officers, partners, owners, agents, representatives, employees, or parties in interest, including Affiant, has in any way colluded, conspired, connived, or agreed, directly or indirectly with any other Proposer/Bidder, firm, or person to submit a collusive or sham Proposal/Bid, or has in any manner, directly or indirectly, sought by agreement or collusion or communication or conference with any other Proposer/Bidder, firm, or person to fix the price or prices in the attached Proposal/Bid or of any other Proposer/Bidder, or to fix any overhead, profit, or cost element of the Proposal/Bid price or the Proposal/Bid price of any other Proposer/Bidder, or to secure through any collusion, conspiracy, connivance or unlawful agreement any advantage against the Village of Key Biscayne or any person interested in the proposed Contract. !f- Proposer Initials Scrutinized Company Certification 1. Proposer certifies that it and its subcontractors are not on the Scrutinized Companies that Boycott Israel List. Pursuant to Section 287.135, F.S., the Village may immediately terminate the Agreement that may result from this 1TB at its sole option if the Proposer or its subcontractors are found to have submitted a false certification; or if the Proposer, or its subcontractors are placed on the Scrutinized Companies that Boycott Israel List or is engaged in the boycott of Israel during the term of the Agreement. 2. If the Agreement that may result from this 1TB is for more than one million dollars, the Proposer certifies that it and its subcontractors are also not on the Scrutinized Companies with Activities in Sudan, Scrutinized Companies with Activities in the Iran Petroleum Energy Sector list, or engaged with business operations in Cuba or Syria as identified in Section 287.135, F.S. pursuant to Section 287.135, 29 Well Maintenance and Cleaning Services - ITB # 2022-20 F.S., the Village may immediately terminate the Agreement that may result from this 1TB at its sole option if the Proposer, its affiliates, or its subcontractors are found to have submitted a false certification; or if the Proposer, its affiliates, or its subcontractors are placed on the Scrutinized Companies with Activities in Sudan list, or Scrutinized Companies with Activities in the Iran Petroleum Energy Sector list, or engaged with business operations in Cuba or Syria during the term of the Agreement. 3. The Proposer agrees to observe the above requirements for appllcable-subcontracts entered into for the performance of work under the Agreement that may result from this 1TB. As provided in Subsection 287.13 5(8), F.S., if federal law ceases to authorize the above-stated contracting ':".hibitions then they shall become inoperative. ([t:_ Proposer Initials A cknow ledgm ent, W arranty, and A cceptance 1. CONTRACTOR warrants that it is willing and able to comply with all applicable state of Florida laws, rules and regulations. 2. CONTRACTOR warrants that it has read, understands, and is willing to comply with all requirements of 1T B # 202 2-20 W ELL M A IN T EN A N C E A N D CLEA N IN G SERVICES and any addendum/addenda related thereto. 3. CONTRACTOR warrants that it will not delegate or subcontract its responsibilities under an agreement without the prior written permission of the Village Council or Village Manager, as applicable. 4. CONTRACTOR warrants that all information provided by it in connection with this Proposal is true and sr: Proposer Initials Truth in N egotiation Cert ifi cation The CONTRACTOR hereby certifies, covenants, and warrants that wage rates and other factual unit costs supporting the compensation for this project's agreement are accurate, complete, and current at the time of contracting. The CONTRACTOR further agrees that the original agreement price and any additions thereto shall be adjusted to exclude any significant sums by which the Village determines the agreement price was increased due to inaccurate, incomplete, or noncurrent wage rates and other factual unit costs. All such agreement adjustments shall be made within (1) year following the end of the contract. For purposes of this certificate, the end of the agreement shall be deemed to be the date of the final billing or acceptance of the work by the Village, whichever is later. -::rp- Respondent Initials Sw orn Signatu re of Proposing Entity Representative and Notarization fo r all above A ff idavits fo llow s on the next page 30 W e ll M a in t e n a n c e a n d C le a n in g S e rv ic e s - IT B II 2 0 2 2 -2 0 ACKNOWLEDGMENT State of Florida , -:[). Countyof f/litv,?"11 ~ --lh Onthis // dayof !a,.,,,,l.lm personally appeared 'Cl~-i!.- l.. ~a 2- whose name{s) subscribed to the within instrument, and he/she/they acknowledge that he/she/they executed it. • 20~ before me the undersigned, is/are Witness my hand and official seal: Not~peasCo mmissioned) _V __ Personally known to me; or ___ Produced identification (Type of Identification: _, ___ Did take an oath; or ___ Did not take an oath MABEL B. ORTIZ Commission# GG 909732 Expires Oc lobar 6, 2023 llon4 tdT!W Bud9'1 Nolary SetYicos 31 Well Maintenance and Cleaning Services - ITB II 2022-20 FORM 6B INDEPENDENCE AFFIFAVIT The undersigned individual, being duly sworn, deposes and says that: 1 am <J'ose,,, l, · f./l4Yltfvr1,le..-z_ of tJ. S. luJ.n,,.,'?·a4'Jf .s lJ-{V the proposer that has submitted the attached proposal; I hereby certify to the best of my knowledge that neither I nor any of those persons residing in my household have or have had during the past five years, any relationships (professional, financial, familial or otherw ise) with the VILLA GE (or any of its districts), its elected or appointed officials, its employees or agents, or any member or alternate member of the Selection Committee. A "relationship" for the purpose of this affidavit shall include but not be limited to employer/employee, consultant, contractor, subcontractor, associate, officer, partnership, joint venture, ownership greater than one percent, landlord/tenant, or creditor/debtor, gift donor/recipient (in excess of $100.00), past or on-going personal relationships, or joint involvement with charitable/voluntary activities. Relationship includes having a prior or current contract with the VILlAGE. Except as set forth below, I hereby certify to the best of my knowledge that neither I nor any of those persons residing in my household have received any promise of compensation, remuneration, gift, discount, or other gratuity in exchange for my proposal. I understand and agree that I shall give the VILLA GE written notice of any other relationships (as defined above) that I enter into with the VILLA GE (or any of its districts), its elected or appointed officials, its employees or agents, or any member or alternate member of the Selection Committee during the period of the Agreement. I set forth below any exceptions to the aforementioned (if none, write "None"): Alone,..., 32 Well Maintenance and Cleaning Services - ITB II 2022-20 ~ Sign ture (Blu ink only) 0-os-e.- l-. F~ ~h ~ Print Name Tl;; ti~ l-2) Date! I STATE OF Fl H'l ~ ) COUNTY OF Mi~ if)~ The foregoing instrument was acknowledged before me this by :::fh.se- l. ~~&2- {N am e of p erso n acknow ledging) for tJ. S. /.u ~Uidl-fs ~ (Com pany na m e) J /./1, day of 'J',u,1 V~ 20_28 as_M_~~'-ff-'~----------- -PrntieJ Personally known to me I or has produced Identification __, type of identification produced - . ~- SIGNATURE OF~ /JI ""-1-.d 2; .11-r-lt· 2- PRINT, TYPE/STAMP NAME OF NOTARY (NOTARY SEAL HERE) ,tP-Y Pue. MABEL B. ORTIZ ~o~ •··•· <"-o * ,,,W,. * Commission# GG 909732 ~-~~ Expires October 6, 2023 .,.~_. o, ,._Q'<' Bondtd Tnru Bud;tl No\aty Services 33 Well Maintenance and Cleaning Services - 1TB II 2022-20 FORM7 PROPOSER'S STATEMENT OF ORGANIZATION 1. Full Name of Proposer: • (). S. w&-,;;~-fs l-l~ 2. Principal Business Address, Phone and Fax Numbers & Email Address: Z,&2'C, Nu) {/..8-fh eas«. µ,·a-,,r1,·, FL- ,2JZJ1</:;J... 3. Principal Contact Person(s): :-;:Jos ~ l. .f ~ a,.,,-nb z_ 4. Form of Proposer (Corporation, Partnership, Joint Venture, Other): 1 A. If a corporation, in what state lncoroorated: _ B. Date Incorporated: .._. _ _,,._ _ C. If a joint Venture or Partnership, date of Agreement: _ij/_1--v_d.-1./_;'?V;....__/_() _ D. Name and address of all partners (state whether general or limited partnership): C]b .s.e,.. L. F..ll.rYl &-??~ 2- E. If other than a corporation or partnership describe, organization and name of principals. _ 5. Provide names of principals or officers as appropriate and provide proof of the ability of the individuals so named to legally bind proposer. Name Title Jos.e, L. ?~a-r1 de z.., t-11'1'"'· 34 W ell M aintenance and Cleaning Serv ices - IT B It 2022-20 6. Indicate the number of years' proposer has had current continual successful experience performing work of a similar scope relevant to this RFP Agreement. _ _,\._,,___°'J.,..'-------- 7. List all entities participating in this Agreement (including subcontractors if applicable): Name Address Title A. _ B. _ c.. _ D. _ 8. Outline specific areas of responsibility for each entity listed in Question 7. A. _ B. _ (. _ D. _ 9. County or municipal business tax receipt number (attach copies): County: 7!J 7..3 q D / 10. 11. Municipal: _ Have you ever failed toA:omplete any work awarded to you? Yes__ No_!_ If yes, attach a separate sheet of explanation. Within the last five years, has any officer or partner of your organization ever been an officer or partner of anotherjorganlzatlon that failed to complete an Agreement? Yes_ No _,J_ If yes, attach a separate sheet of explanation 12. Within the last five yea/s, have you ever had a performance, payment or bid bond called? Yes __ No_!_ If yes, attach a separate sheet of explanation. 13. Have you, any officer or partner of your organization, or the organization been involved in any litigation or arbit,ion against the Village? Yes__ No__ If yes, attach a separate sheet of explanation. 14. Within the last five years, have you, any officer or partner of your organization, or the organization or parent company or its subsidiaries been involved in any litigation or arbitration against anybther Florida public entity? Yes__ No _J_ If yes, attach a separate sheet of explanation. 35 Well Maintenance and Cleaning Services - ITB II 2022-20 15 . W ithin the last five years, have you, any officer or part ner of your organization, or the organization or parent com pany or its subsidiaries been involved in any litigation or arbitration against 1 private entity fo r an am ount greater than $100,000? Yes_ No__ If yes, attach a separate sheet of explanation. 16. Has your organizatio n or any of its part ners, off icers, or key personnel, or its subsidiaries or parent com pany beet arged or indicted fo r any crim inal activity w ithin the last five years? Yes__ No__ If yes, attach a separate sheet of explanation. 17. years? Yes H as your organization or any of its part ners, off icers, or key personnel, or its subsidiaries or parent com pany been convicted and/or fined fo r any crim inal activity w ithin the last five Noj If yes, attach a separate sheet of explanation. 18. W ithin the last five years, have you, any offi cer or partner of your organization, or the organization been investigated by any local, state, or federal law enfo rcem ent agency , crim inal justice agency pr inspector general offi ce? Yes__ No :J_ If yes, attach a separate sheet of explanation. 19. W ithin the last five years, have you, any offi cer or part ner of your organization, or the organization com m unicated w ith any local, state, or federal law enfo rcem ent agency, crim inal justice agency or inspector general offi ce relating to goods or serv ices provided or perform ed fo r any goj rn m ental entity ? Yes__ No__ If yes, attach a separate sheet of explanation. 20 . W ithin the last five years, have there been any reports or audits relating to you, any offi ce or part ner of your organizatio n, or the organization issued by any local, state, or federal law enfo rcem ent agency, dim inal justice agency or inspector general off ice. Yes__ No _J_ If yes, attach a separate sheet of explanation. 21. W ithin the last five yea rs, have you, any officer or part ner of your organization, or the organization failed to discl ose or m ade m isrepresentations to any govern m ental entity regarding conflicts of interest or potent'f or apparent confli ct s of interest. Yes_ No__ If yes, attach a separate sheet of explanation. 36 Well M ·ntena~e-rvices - 1TB II 2022-20 Signa ure (Blue in nly) -Oos.e. t.. r...11-rY1 a.r1 k 2- Prin~ame Title 7 Dater ' STATE OF ft(J-r''l4 i COUNTY OF1>~/)oc)r1izt) -1IJ The foregoing instrument was acknowledged before me this // day of "J' a,,,yJI,)~ , 20.£~ by ~ l-. ~a-r,de z. as_f-11--,t-qc-=---------- {Name of person acknowledging) ~) for tJ. ~- luhn·cA--rl-f:s U-~ (Company name) Personally known to me / or has produced Identification_,· type of identification produced _ SIGNATU~ (NOTARY SEAL HERE) MABELB. ORTIZ Commission# GG 909732 Expires October 6, 2023 Bonded Thru Budget Nollr, Se,vlces M~ l). t),,,--fi2- PR1NT, TYPE/STAMP NAME OF NOTARY 37 Local Business Tax Receipt Miami-Dade County, State of Florida -THIS IS NOT A BILL -00 NOT PAY 6800263 BUSINESS NAME/LOCATION U S LUBRICANTS LLC 3636 NW 48TH TER MIAMI. FL 33142-3924 OWNER U S LUBRICANTS LLC C/0 JOSE L FERNANDEZ, MGR Employee(s) RECEIPT NO. RENEWAL 7073901 EXPIRES SEPTEMBER 30, 2023 Must be displayed al place of business Pursuant w County Code Chapter SA - Art. 9 & ·;o SEC. TYPE OF BUSINESS 220 TANGIBLE PERSONAL PROP DLR PAYMENT RECEIVED BY TAX COLLECTOR 93.75 01/11/2023 INT-23-249139 MIAMHlADE mi'J This Local Business Tax Recoipt only confirms poymont ol lho Local Business Tax. Tho Recoipt is not a license, permit. or a certification of the holder's qunlifications, to do businnss. Holder must comply with any govcrnnrnntol or nongovernmental regulatory lows ond rcquiroments which apply to the business. Tho RECEIPT NO. above must he displayed on ult commercial vehicles - Miami-Dade Code Sec 8u-276. For more information, visil~filillillllL!ll!.l'ili ~ Well Maintenance and Cleaning Services - ITB # 2022-20 FORMS DISPUTE DISCLOSURE Answer the following questions by placing an "X" after "Yes" or "No". If you answer "Yes", please explain in the space provided, or on a separate sheet attached to this form. 1. Has your firm or any of its officers, received a reprimand of any nature or been suspended by the Department of Professional Regulations or any other regulatory agency or professional associations within the last five (5) years? YES NO_/ _ 2. Has your firm, or any member of your firm, been declared in default, terminated or removed from a contract or job related to the services your firm provides in the regular course of business within the last five (5) years? j YES NO _ 3. Has your firm had against it or filed any requests for equitable adjustment, contract claims, Bid protests, or litigation in the past five (5) years that is related to the services your firm provides in the regular course of business? J YES NO _ If yes, state the nature of the request for equitable adjustment, contract claim, litigation, or protest, and state a brief description of the case, the outcome or status of the suit and the monetary amounts of extended contract time involved. I hereby certify that all statements made are true and agree and understand that any misstatement or misrepresentation of falsification of facts shall be cause for forfeiture of rights for further consideration of this Bid for the Village of Key Biscayne. Firm: U.S. lu,{n,,," Authorized Signature: --tt------1 ------w Print or Type Name: Q''D-S€- l., r4YJa?"Jtf!ez_ Title: __ f./J_~-A---------------- Date:_0~~1-0-/-+-'-~-~-------- 38 W ell M aintenance and Cleaning Serv ices - IT B II 2022-20 FORM9 DRUG FREE WORKPLACE The undersigned proposer in accordance with Chapter 287.087, Florida Statutes, hereby certifies that V.$. {,uftr?"c.a-?1 f5 l,~ does: (Name of proposer) 1. Publish a statement notifying employees that the unlawful manufacturing, distribution, dispensing, possession, or use of a controlled substance is prohibited in the workplace and specifying the actions that will be taken against employees for violations of such prohibition. 2. Inform employees about the dangers of drug abuse in the workplace, the business's policy of maintaining a drug-free workplace, any available drug counseling, rehabilitation, and employee assistance programs, and the penalties that may be imposed upon employees for drug abuse violations. 3. Give each employee engaged in providing the contractual services described in the RFP document a copy of the statement specified in subsection (1). 4. In the statement specified in subsection (1), notify the employee that, as a condition of working on the contractual services described in the RFP or the Agreement, the employee will abide by the terms of the statement and will notify the employer of any conviction of, or plea of guilty or nolo contendere to, any violation of Chapter 893 or of any controlled substance law of the United States or any state, for a violation occurring in the workplace no later than five (5) days after such conviction. 5. Impose a sanction on or require the satisfactory participation in a drug abuse assistance or rehabilitation program if such is available in the employee's community, by any employee who is so convicted. 6. Make a good faith effort to continue to maintain a drug-free workplace through implementation of this section. 7. As the person authorized to sign the statement, I certify that this firm complies fully with the above requirements. 39 Well Signa ure (Blue ink only) <;l"S.e,. l.. r-1/YJ wr,de Z- Print Name r;uttfri ~ ~ ?J Date I STATE OF F/o-Tl'd.t ) COUNTY OF~;~;'])~ ./,, The foregoing instrument was acknowledged before me this // day of -:[' d'i41U~ 20~ by -:::Jt>se. l. r..#.rn ~h 2- as ---=-/JI.___,&:~-•:....__ _ (Name of person acknowledging) ~) for tJ.S./,u~~-fs ~ (Company name) Personally known to me / or has produced Identification___, type of identification produced _ SIGNATURE 0~ (NOTARY SEAL HERE) MABEL B. ORTIZ Commission# GG 909732 Expires October 6, 2023 Bonded ThN Budget Notary Servlc4• PRINT, TYPE/STAMP NAME OF NOTARY 40 Well Maintenance and Cleaning Services - 1TB II 2022-20 FORM 10 SCRUTINIZED COMPANIES The undersigned proposer in accordance with Section 287.135, Florida Statutes, hereby certifies that: Proposer is not participating in a boycott of Israel; Proposer is not on the Scrutinized Companies with Activities in Sudan List or the Scrutinized Companies with Activities in the Iran Petroleum Energy Sector List; oser does not have business operations in Cuba or Syria. Print Name 1;t:17 Date I 1 STATE or ~lcr,i/4 l COUNTY OF Mta,,,,?i 'l)~ ~ The foregoing instrument was acknowledged before me this / / day of 'J' U:,,.,,,,t,/~ 20..!-, .!J by ~ose. l. ~4,,y1 d.t "2- as_~-~f-'---------- (Name of person acknowledging) rnve) for l).S. luh-,1~-h;; U~ (Company name) I Personally known to me or has produced Identification___, type of identification - produced _ (NOTARY SEAL HERE) MABEL B. ORTIZ commission# GG 909732 Expires October 6, 2023 90Mtd Tnrv Bvdgtl Notary Servlcos PRINT, TYPE/STAMP NAME OF NOTARY 41 Well Maintenance and Cleaning Services - ITB # 2022-20 FORM 11 PUBLIC ENTITY CRIMES Sworn Statement Under §287.13 3(3)(a), Florida Statutes (T his fo rm m ust be signed in the presence of a notary public or other officer authorized to adm inister oaths.) .JI. 1. This sworn statement is submitted with Bid, Proposal or contract No. ":J T..E; 1C -;;-o,;;;7. - ~ 2. This sworn statement is submitted by: (}. S . 1,a,/;;riC,A41fs L l-~ (name of entity submitting sworn statement) w ho se business address is: Fede ral Identifi cation N u m ber (FEIN ) is: (if applicable) Soci al Security N um ber: (if the entity has no FEIN, include the Social Security Number of the individual signing this sworn statement) 3. My name is: (print name of individual signing this document) and my relationship to the entity is: __ f-/J __ vp-:.,.__· _ 4. I understand that a "public entity crime" as defined in §287.133(1)(g), Florida Statutes means 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 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 an agency or political subdivision of any other state or of the United States and involving antitrust, fraud, theft, bribery, collusion, racketeering, conspiracy, or material misrepresentation. 5. I understand that a "convicted" or "conviction" as defined in §287.133(1)(b), Florida Statutes, means a finding of guilt of a conviction of a public entity crime, with or without an adjudication of guilt, in any federal or state trial court of record relating to charges brought by indictment or information after July 1, 1989, as a result of a jury verdict, non-jury trial, or entry of a plea of guilty or nolo contendere. 6. I understand that an "affiliate" as defined in §287.13 3(1)(a), Florida Statutes means: (a) A predecessor or successor of a person or a corporation convicted of a public entity crime; or 42 Well Maintenance and Cleaning Services - ITB # 2022-20 (b) 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. The term "affiliate" includes those officers, directors, executives, partners, share holders, employees, members, and agents who are active in the management of an affiliate. The ownership by one person of shares constituting a controlling interest in another person, or a pooling of equipment or income among persons when not for fair market value under an arm's length agreement, shall be a prima-facie case that one person controls another person. A person who knowingly enters into a joint venture with a person who has been convicted of a public entity crime in Florida during the preceding 36 months shall be considered an affiliate. 7. I understand that a "person" as defined in §287.133(1)(e), Florida Statutes, means any natural person or entity organized under the laws of any state or of the United States with the legal power to enter into a binding contract and which binds or applies to bids on contracts for the provision of goods or services let by a public entity, or which otherw ise transacts or applies to transact business with a public entity. The term "person" includes those officers, directors, executives, partners, shareholders, employees, members, and agents who are active in management of an entity. 8. Based on the information and belief, the statement that I have marked below is true in relation to the entity submitting this sworn statement. (Please indicate which statement applies) a. __ Neither the entity submitting the sworn statement, nor any officers, directors, executives, partners, shareholders, employees, members or agents who are active in management of the entity nor any affiliate of the entity have been charged with and convicted of a public entity crime subsequent to July 1, 1989. b. __ The entity submitting this sworn statement, or one or more of the officers, directors, executives, partners, shareholders, employees, members or agents who are active in management of the entity, or an affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July 1, 1989, and (Please indicate which additional statement applies) 1) __ There has been a proceeding concerning the conviction before a hearing officer of the State of Florida, Division of Administrative Hearings. The final order entered by the hearing officer did not place the person or affiliate on the convicted vendor list. (Please attach a copy of the final order) 2) __ The person or affiliate was placed on the convicted list. There has been a subsequent proceeding before a hearing officer of the State of Florida, Division of Administrative Hearings. The final order entered by the hearing officer determined that it was in the public interest to remove the person or affiliate from the convicted vendor list. (Please attach a copy of the final order) 43 Well Maintenance and Cleaning Services - ITB II 2022-20 3) __ The person or affiliate has not been placed on the convicted vendor list. ~ase describe any action taken by or pending with the Department of General Se ices) Date STATE OF -f/lh'?~ ) COUNTY OF /-41~i '])~) --/7, The foregoing Instrum ent w as acknow ledged befo re m e this / f day of ::f a,,itl 41 • 20 ~ by ;:Jo~l- r~~b-2- as_M,_47-r...._. _ (Name of person acknowledging) ?Title) for {).s. l«/rr/~ L.t...~ (Company name) Personally known to me _/ __ or has produced Identification___, type of identification produced - _ (NOTARY SEAL HERE) SIGNATURE~- ~o"ti;~.~~~"c> MABEL B. ORTIZ '/J _ I'.. 11 4. n'1 ,.1....- • .. W_. * Co mmlssion#GG909732 /'-' ((,,O(,,,C., rJ. ~112- <>.,.~~ Expir es0cl ober6,2023 PRINT, TYPE/STAMP NAME OF NOTARY ~>~o,r,.O~ IIGndeclTIWBud911N011rySerrion 44 Well Maintenance and Cleaning Services - ITB II 2022-20 FORM 12 LIST OF PROPOSED SUBCONTRACTORS The undersigned Proposer hereby designates, as follows, all major subcontractors whom they propose to utilize for the major areas of work for the project. The bidder is further notified that all subcontractors shall be properly licensed, bondable and shall be required to furnish the Village with a Certificate of Insurance in accordance with the contract general conditions. Failure to furnish this information shall be grounds for rejection of the bidder's proposal. (If no subcontractors are proposed, state "None" on first line below.) No. Subcontractor Name & Address Scope of Work License Number - - -- -- Title:_f-1.--'--,lt.7=f-·------- Date:_/J l-1-/-'--! l-4--/_:;JrJ--:.fA_~---- r J 45 W ell M aintenance and Cleaning Serv ic es - IT B II 2022-20 FORM 13 CLIENT REFERENCES IN ADDITION TO THE INFORMATION REQUIRED ON THIS FORM, CONTRACTOR TO PROVIDE A MINIMUM OF THREE REFERENCE LETTERS. PRINT CLEARLY . , I REFEREN_CE #1 Public Entity Name: VI /14f)_e- _gJ_l!!!J_ ~s'!!rn e,,,, Reference Contact Name: :Na~d Tua 2- Contact Title: ~/-Y?ie-f- H~ Contact Department: /1! U, 'c. tJ ;.;Jc.s Contact Telephone: ~..r. q~(;, . (:J,.ZJ q? Contact Email: nt4 t:i2. @ 4¥bts~~ fl r(; Public Entity Size/Number of Residents/Square Mileage: o/~ 17?1 /e,::;,~ Contract Start Date:________ Contract End Date: _ Is the Contract still Active? Yes ! No Scope of Work (be as detailed as possible)W __ 12,__/_{_d_=,,,,r11 .' .5-'hnn t,Ja/~ REFERENCE #2 Public Entity Name: ([}~ 0/ vh Reference Contact Name: A--r-n? IV'Y1 t{,(J }/u rJ -? 2.... Contact Title: (h,,,/y;;rd. H re, Contact De pa rtme nt: f// U,f rJ f ~ t!i,,r?U- Contact Telephone: ;? J'C, - ~/ · 0 f I/ Contact Email: Cf nv11-e2:- oce,._.,,-,c/ ,Ji, H~ Ile, - ~ Public Entity Size/Number of Residents/Square Mileage: /4 ?tl1I /? ~·~ Contract Start Date:----~-- Is the Contract still Active? Yes j No Scope of Work (be as detailed as possible) _W_e-_l l-m-(&&11b1&:J. u ,£.. d-17· Contract End Date: _ 46 Well Maintenance and Cleaning Services - ITB # 2022-20 REFERENCE #3 Public Entity Name:------------------------------ Reference Contact Name: _ Contact Title:-------------------------------- Contact Department: _ Contact Telephone: _ Contact Email:-------------------------------- Public Entity Size/Number of Residents/Square Mileage: _ Contract Start Date: _ Is the Contract still Active? Yes No _ Scope of Work (be as detailed as possible) _ Contract End Date: _ REFERENCE #4 Public Entity Name: _ Reference Contact Name: _ Contact Title:-------------------------------- Contact Department: _ Contact Telephone: _ Contact Email:-------------------------------- Public Entity Size/Number of Residents/Square Mileage: _ Contract Start Date:_________ Contract End Date: _ Is the Contract still Active? Yes No _ Scope of Work (be as detailed as possible) _ 47 W ell M aintenance and Cleaning Serv ices - 1TB # 2022-20 REFERENCE #5 Public Entity Name: _ Reference Contact Name: _ Contact Title:-------------------------------- Contact Department: _ Contact Telephone: _ Contact Email: _ Public Entity Size/Number of Residents/Square Mileage: _ Contract Start Date: _ Is the Contract still Active? Yes No _ Scope of Work {be as detailed as possible) _ Contract End Date: _ 48