HomeMy WebLinkAboutMCINTOSH, DEBORAH F. (2)City of Santa Ana
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Clerk of the Council coffomc
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AGREEMENT TERMINATION FORM
N
9 All 19 PI) 3: 10
Please complete this form in its entirety when the attached agreement 'hd
amendments (if any) are no longer in effect.
Note: If your agreement is grant related, please ensure that all grant retention requirements CITY OF SANTA ANA
have been satisfied prior to signing the termination form. CLERK OF COUNCIL
Is the agreement(s) a permanent record? Yes No
Return form to the Clerk of the Council Office (M-30).
Call 647-1520 if you have any questions.
The agreement with
No, N-20118424 was completed on 7PAS' and final payment has been made.
(List all amendments. Use space below if needed.)
Department:
Phone/Ext.: 53-sz�
Signature: S-� Q x 1 o'
Date: 'go, z
Revised: 10-18-16
INSURANCC NO (ON FELE WC Declaration on tla.
WORK MAY RLT PROCEED
CLERK OF COUNCV#eeda)
DATE: t I- T
0:PROS (/)
Silvia Cuevas
June 14,2018
Deborah F. McIntosh ("Speaker/Performer")
23454 Darcy Lane
Newhall, California 91321-3924
Re: Speaker/Performer Engagement Agreement
N-2018-124
This letter represents your agreement with the City of Santa Ana ("City' as entered into on the above date for the
engagement described below:
i. Event Description: Historical Re-enactment.Services, Character: Betsy Ross (as described in the attached invoice
— Exhibit A)
2. Date(s): Tuesday, July 4, 2018
3. Event Time(s): 5:30 p.m. to 9:30 p.m.
4. Location; Show will be presented at the Centennial Park, Santa Ana CA ("Property")
5. Compensation: $225 (payable by check within 30 calendar days of event) provided agreement is fully executed;
Speaker/Performer must provide IRS form W-9 before payment can be made.
6. Equipment provided by City: 2 tables.
7. Equipment provided by Speaker/Performer: all supplies, costumes, and equipment, required for the performance
8. City Contact Person (for coordinating purposes only): Sonia Batres (714) 571-4227
9. Independent Contractor: Speaker/Performer shall, during the entire term of this Agreement, be construed to be an
independent contractor and not an employee of the City. This Agreement is not intended nor shall it be construed
to create an employer -employee relationship, a joint venture relationship, or to allow the City to exercise
discretion or control over the professional manner in which Speaker/Performer performs the services that are the
subject matter of this Agreement; however, the services to be provided by Speaker/Performer shall be provided in
a manner consistent with all applicable standards and regulations. Speaker/Performer shall pay all salaries and
wages, employer's social security taxes, unemployment insurance and similar taxes relating to employees and
shall be responsible for all applicable withholding taxes.
1,0, Indemnification: Speaker/Pcrformer, his or her agents, or employees (if applicable) agrees to and shall indemnify,
defend, and hold harmless the City, its officers, agents, employees, consultants, special counsel, and
representatives from and against all loss, expenses, or liability (including costs and attorney's fees) arising from
the negligence or willful misconduct of Speaker/Perfonner, his or her agents, or employees.
It. Release: Speaker/Performer accepts the Property and any City -provided equipment used in connection with the
performance in their "as -is" condition, with all faults. Speaker/Performer fully releases, waives and discharges
forever any and all claims, demands, rights, and causes of action of any kind or nature against, and covenants not
to sue, City, its elected officials, officers, employees, agents and volunteers, and all persons acting on behalf of,
by, through or under each of them, under any present or future laws, statutes, or regulations for any claim or event
relating to the condition of the Property or City -provided equipment or Speaker/Performer's use thereof.
N-20i sA 24
Low Agrca-marma - L cborah F. Nicintasli
paste 1
12. Conimxreiat General Limbibly lrr uaaxee. Speaker-Tetfonnee€ %Ml mairltvin emnamial Scriml liability,
ansurame naming the oily, ils OLYKVM. Cmployeas, agms, voEurifters and mprescnealhes as aaidttimraal ntWcrks)
and shaill imctude, but not be limited ur prolecsion, agoirim claitm arising fr im bodily peal Itilwy,
inetuding deathns+ulu og thercNii rr are daau rgv to pmpwty, w-whiag frrant trity tat c>r oc:unr.m a arising mitt or
Spmkcr,Pcrfarmer's otteral:iaxss fn the perfalms:ince of this Ai re mcw, ine.ludir , wiltmi: limilation, -cis
irrm c hing r,zhiclos. Ilm ammunaac or imuralice shall be m,-t Icss than the foLlowving; singte limit mveraV. applying
to Nxidy anti pgmull injury, including &-wh rviuhislp fligmfrxu, myJ prapwrty darmuge., in the total amouma of
51,0}1001) per mcurreixc, wish $2.WO,000 in the :ag i:$2te.. Sue.13 inturarwe, shall,: (1) ra mw 97u City, i4.4
olisc+^rK eartpferYrvs, agc^Tus, volurgecus. and rLIxesw-niatives, as additional insureds; (21 be lxrntsry and not
wrtributc+t), with mgxp �t to iftsunos-v ae its minim-d by -Ow Ciry, avid O7 eomtain mzrtdard
sgvr,.rtKm ofinslind prrn ision&
13. Ei'or'ncr`s Compensation limuramee. In accordarxe with ilk- California Labor Crime, SpeakeraPerfonner, if
Spsmiker crfonvier htta any c npl x},ems, is rquircd tar be hssuired apinst liability, for worker`s cam3 as<ition or to
underat-c self-bksuramice.
1,L Tbc City €lmll have dic right arul rill flay'-t're4 Hasse io simuk2st of produce and show- a wpc-Mawd bmidcast
of Speaker:7'erlbraier's po sxnt:aiic-1ra to tlw. Ciry conarmeitiay at mineral public, lhrwugh. wdx—' st or any ather
nx.ena This lieens4 ahatl 174 mmu gawp ve m4 th4 c+ip)Tight slIall rrmin wide the Sp mkcr- Prrfvrrter. Copies of
Speaker;Perfarmer's prc mai: en mly be 11nintaioLd by atw Cil:v. aatj conselara t w uw of stu'li
mxurdilags..
15. S}xakertPerfcumtux shall not disk imainaw becatuse of rage: coW, creed. religiatra, wx, rmr. l status, sextwil
orienrrrraa age, matirnral origin, amp, try+, dmlhilily, nr tally ottIcT lmsis prastaticd by al4sl,iOdWc bw 6; emnrwelinn
with a}ny a4tKilics rcGiW to this Agincuaent.
16, Tbis Agreensent shall in all ms pccts shall be imurpreh-d, cofbiitcdi and govem d exclusively kayr and under tlw
Lvmi of t re sulk or C°alifomia, [job parlias agree tliat Ckrarsge County, Odifonia shall b4 thC a'4raac for any
attia`ra kW fCn-rC1!ding INN n12;a, lac b€rx#,1 e1r aan,.a; astn of, ira raoussr.!,'9iam with or ll;y re:t mzyta mfthis ACTc--2rimt.
17. TbiAgreNnnevi r p-~smmts ih4 mrpicte rind cxclusivc statcrivm tw-ccm ilm City acrsa3 Spcak4r.'PctrrOmIrr
rega:i ag. the subject maitcr herein and supersedes any and all rasher agrecratenls, oral or wfitrrark klwem lli
pames. Vets Agrcenscnt miay, no be rprdiru tl ass4pt by writu4% inswumcm sigmcwl by brat city mild by an
ovdI rived rcFescritatiw of 5piaker.1'erforner,
i*icasc exc` ge this letter to relfect yarn agrecrrment la the lentil and coodiziora set fanh hercin
CH OF S,iIVA itio SPEAkERrPERECyRMER
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% Clerk of the Council Sexalor Assistant City Allonvy
R1:.i'MIX kri`CaED FOR ApPIK VAV
7 .ANNIF IL ili.4DO llc lit xcti aivc Direckur, hunks, RA, natuar, mW Cdrmmunit-r Scr%ites Agcocv
N-2018-124
Motor%
of Women
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r
Invoice #001:7-4-2018
To: Sonia Batres, Community Events Supervisor
City of Santa Ana, Parks, Recreation & Community Services Agency
20 Civic Center Plaza, P.O.Box 1988
Santa Ana, CA 92702
Program: Independence Day Program as Betsy Ross
Performance Date: Wednesday, July 4, 2018
Performance Time: Approximately 5:30 p.m. — 9:30 p.m.
Arrival Time: Approximately 5:30 p.m. (could be earlier, traffic allowing)
Address: Centennial Park — 3000 W. Edinger Avenue, Santa Ana
• Portrayal of Betsy Ross, telling how she came to sew
the "Stars and Stripes."
• Platform stage presentation and booth presentation
including showing how Betsy cut a perfect 5-pointed
star with a snip of a scissors.
• Display booth will include a sign and flags used
during our history,
• An appliqued star, and a 42-ft red stripe to illustrate
how big the "Star-Spangled Banner" was.
Fee: $225 payable to: Deborah F. McIntosh
(History Through the Eyes of Women)
23454 Darcy Lane
Newhall, CA 91321-3924
N-2018A 24
I _Deborah F, McIntosh _ hereby af0rna under penalty of perjuy, the
tNMIw Fats}
following declaration
I certify cart behalf of )History Through the Eyes of Women_ that during the tent
of any
(V:W184apnU�t'utn(gny N'+rncp
contract for _4P Of July Entertainment _ sen-ices wAith the City of Santa Ana, I will not
employ any person in any manner so as to bccome subject to the workers` compensation
laws orcat I rorma. and agree that irI should become subject to the Workers'
compensation provisions of Section 37DO of the Labor Code, I shalt forthwith comply
with those provisions and provide proof of work -cm' compensation coverage.
BATE: ,lam' el/
8va? "
Name: —Deborah F. McIntosh
"Bike; �1�raAaitlarrattl�ouna?t~r - G,��,�1�'��'.�u�2'�C�
"Telephone: (1) 803-224(t Ca 6-
WARNING: F+ IT-IURf TO SECIIIRG k&'ORKE.RS° CO PFNiSATION Ct VF} ,R.At;r IS
UNLAWFUL, AND SHALL 5UBJI-CI' AN EIMPLOYER TO CRIMINAL PEN'ALTIrs
AND CIVIL HNES Urro ONE 14UNDRED THOUSAND DOLLARS tSI O0,Lt00). IN
,ADDITION TO THE COST OFCOMPENSATION, DAMAGES AS PROVIDED FOR
IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATFORN13Y' 4 I I GS,.
EVANSTON INSURANCE COMPANY
CERTIFICATE NO.:
CERTIFICATE OF INSURANCE
SPECIAL EVENT LIABILITY PROGRAM
PRODUCER
PUBLIC ENTITY (ADDITIONAL INSURED)
Alliant Insurance Services, Inc. in conjunction with
Apex Insurance Services
P. O. Box 6450
Newport Beach, CA 92658
License No: OC 36861
NAMED INSURED (EVENT HOLDER):
EVENT INFORMATION:
City of Santa Ana
TYPE: 4" of July Celebration
P O Box 1988
DATE(S): July 4, 2018
Santa Ana, CA 92702
LOCATION: Centennial Park
*Liquor Liability Yes ❑ No
"Liquor Liability after 12 am ends before 2 am ❑
This is to certify that the insurance policy listed below has been issued to the above insured named (event holder) for the policy
period indicated. The insurance described herein is subject to all the terms, exclusions and conditions of such policy(ies) unless
amended as described in Special Conditions.
INSURANCE CARRIER: Evanston Insurance Company
MASTER POLICY NUMBER: SEP41026
MASTER POLICY DATES: EFFECTIVE: JANUARY I, 2018 EXPIRATION: JANUARY I, 2019
COMMERCIAL GENERAL LIABILITY
OCCURRENCE FORM
DEDUCTIBLES NONE
General Aggregate Limit $ 2,000,000
Products & Completed Operations 1,000,000
SPECIAL CONDITIONS
Personal & Advertising Injury 1,000,000
The following endorsements attached to
Each Occurrence Limit 1,000,000
the Master Policy do not apply to this
Damage To Premises Rented To You (Any One Premises) 100,000
Certificate Of Insurance:
Medical Payments (Any One Person) 5,000
MEGL643
Liquor Liability (If purchased) 1,000,000
Optional Limits Purchased
❑ $1,000,00043,000,000
❑ $2,000,000/$2,000,000
Damage To Property (If purchased)
The limits of insurance apply separately to each event insured by this policy as if a separate policy of insurance has been issued for that event.
OTHER ADDITIONAL INSUREDS
Robert Broski
AWRS-7 El Toro Lady Marines
Peter Small
Deborah McIntosh
Go On Wheels/Ernesto Rivas
Gay Storm
CANCELLATION. Should the above described policy be cancelled before the expiration date thereof, notice will be delivered in accordance with the policy
revisions.
AUTHORIZED REPRESENTATIVE:
DATE ISSUED:
&A lban t
Alliant Insurance Services, Inc.
Newport Beach -Alliant Insurance Services, Inc.
1301 Dove Street, Ste. 200
Newport Beach
CA 92660-2436
Phone: (949) 756-0271
City of Santa Ana
Po Box 1988
Santa Ana, CA 92702
Invoice # 869837
Page 1 of 1
ACCOUM NUMBER
DATE _
_ _
SANTANA-08
6/28/2018
BALANCE OUEON
, AGENCVCODE
7/28/2018 — - -
200
AMOUNT PAID --
AMOUNTDUE
T
$1,395.00
Special Events Program
Client:
City of Santa Ana
Policy: Special Event Liability
Policy Number:
SEP41026
Insurance Carrier:
Evanston Insurance
Company
Effective: 1/1/2018 to 1/1/2019
Item #
Trans Eff Date
Due Date
Trans '
Description
Amount
3279214
1/1/2018
7/28/2018
ENDT
Premium 4th of July Celebration
$1,298.611
3279215
1/1/2018
7/28/2018
SURT
Surplus Lines Taxes
$38.96
3279216
1/1/2018
7/28/2018
SURF
Surplus Lines Stamping Fees
$2.60
3279217
1/1/2018
7/28/2018
OFEE
Other Fees & Services
$12.98
3279218
1/1/2018
7/28/2018
BNKF
Bank Fee
$41.85
Total Invoice Balance: $1,395.00
IMPORTANT NOTICE: The Nonadmitted & Reinsurance reform act (NRRA) went into effect July 21, 2011. Accordingly, surplus lines tax rates and
regulations are subject to change which could result in an increase or decrease of the total surplus lines taxes and/or fees owed on this placement. If a
change is required, we will promptly notify you. Any additional taxes and/or fees owed must be promptly remitted to Alliant Insurance Services, Inc.
IMPORTANT NOTICE: The Foreign Account Tax Compliance Act (FATCA) requires the notification of certain financial accounts to the United States Internal
Revenue Service. Alliant does not provide tax advice. Please contact your tax consultant for your obligations regarding FATCA.
Alliant embraces a policy of transparency with respect to its compensation from insurance transactions. Details on our compensation policy, including the
types of income Alliant may earn on a placement, are available at www.alliant.com. For a copy of our policy or for inquiries regarding compensation issues
pertaining to your account contact: Alliant Insurance Services, Inc., Attn: General Counsel, 701 B St., 6th Floor, San Diego, CA 92101
I ,Deborah F. McIntosh _ hereby affirm under penalty of perjury, the
(NMWTOC)
following declaration
I certify on behalf of History Through the Eyes of Women_ that during the term
of my
"WIN"Mmopony NORM)
contract for —41h of July Entertainment _ services with the City of Santa Ana, I will not
employ any person in any manner so as to become subject to the workers' compensation
laws of California, and agree that if I should become subject to the workers'
compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply
with those provisions and provide proof of workers' compensation coverage.
DATE: ea & yyg
Name: Deborah F. McIntosh l /f ,-_ %qc� 1'
Title: _Pre sidcaToundcr ,7 %' 44 ,a"
Telephone: (661) 803-2240 fo40/-&-3 ' 2 Z ¢O
WARNING: FAILURE. TO SECURE WORKERS' COMPENSATION COVERAGE IS
UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES
AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000). IN
ADDITION TO THE COST OF COMPEENSATION, DAMAGES AS PROVIDED FOR
IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES,
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