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HomeMy WebLinkAboutBEGINNER'S EDGE SPORTS TRAINING, LLC�� . City of Santa Ana e 11 Clerk of the Council COTC Office ..... ....- AGREEMENT TERMINATION FORM Please complete this form in its entirety when the attached agreement and all amendments (if any) are no longer in effect. Note: If your agreement is grant related, please ensure that all grant retention requirements �';i L T COi F X--:, have been satisfied prior to signing the termination form. r,€,= Is the agreement(s) a permanent record? Yes No V L Return form to the Clerk of the Council Office (M-30). Call 647-1520 if you have any questions. The agreement with R)%1DM 'e Qqft 5pa ba lao% l.L ►r, Onty N-2019-047 was completed on 1q 1Al i_ _101a and final payment has been made. (List all amendments. Use space below if needed.) Department: MC Phone/Ext.: Signature: I Date: not 12A 1201 Revised: 10-18-16 INSURANCE ON FILE WORK MAY PROCEED UNPL i4 9UNCE EXPIRES CI.ER f 0 UNCIL. RECREATION SERVICES AGREEMENT oNYE MAR 1 1 2oig THIS AGREEMENT is rruade and entered into 27th day of February 2019 by and 4 AVlw. CK^etween Beginner's Edge Sports ']'raining, LLC, a California Limited Liability Company ("Provider") and the City of Santa Ana, a charter city and municipal corporation organized and existing under the Constitution and laws of the State of California ("City"), RECITALS A. The City desires to retain a recreation service provider having special skills, resources and knowledge to provide various sports classes in its recreation class program. B. Provider represents that it is able and willing to provide such services to the City. C. In undertaking the performance of this Agreement, Provider represents that it is knowledgeable in its field and that any services performed by Provider under this Agreement will be performed in compliance with such standards as may reasonably be expected. NOW THEREFORE, in consideration of the mutual and respective promises, and subject to the terms and conditions hereinafter set forth., the parties agree as follows: SCOPE OF SERVICES Provider shall perform those services as set forth in Exhibit A to this Agreement. 21 COMPENSATION In consideration for the provision of the programs set forth in Exhibit A, City agrees to pay the Provider seventy percent (70%) of all gross revenue received from program participants. Total revenue to Provider shall not exceed $25,000.00 annually. Payment to Provider shall be made monthly within thirty (30) days following completion of the last class taught by Provider the prior month. City shall be responsible for collecting all fees from program participants, Provider shall not collect fees but will refer all interested participants to City for registration information. Provider agrees that City shall retain thirty percent (30%) of all gross revenue received from program participants as an administrative fee. 3. TERM This Agreement shall continence on April 1, 2019 and end on December 31, 2019 unless tenninated earlier in accordance with Section 12 below. The terns of this Agreement may be extended by a writing executed by the City Manager and the City Attorney. 4. INDEPENDENT CONTRACTOR Provider 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 manner in which Provider performs the services which are the subject matter of this Agreement; however, the services to be provided by Provider shall be provided in a manner consistent with all applicable standards and regulations governing such services. Provider 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. Provider is not an agent, representative or employee of City and Provider shall have no authority to act on behalf of the City. 5. INSURANCE Prior to undertaking performance of work under this Agreement, Provider shall maintain and shall require its subcontractors, if any, to obtain and maintain insurance as described below: a. Commercial General Liability Insurance. Provider shall maintain commercial general liability insurance which shall include, but not be limited to protection against claims arising from bodily and personal injury, including death resulting therefrom and damage to property, resulting from any act or occurrence arising out of Provider's operations in the performance of this Agreement, including, without limitation, acts involving vehicles. The amounts of insurance shall be not less than the following: single limit coverage applying to bodily and personal injury, including death resulting therefrom, and property damage, in the total amount of $1,000,000 per occurrence and $2,000,000 in the aggregate. Such insurance shall (a) name the City, its officers, employees, agents, volunteers and representatives as additional insured(s); (b) be primary and not contributory with respect to insurance or self-insurance programs maintained by the City; and (c) contain standard separation of insured's provisions. b. Worker's Compensation Insurance. In accordance with California State law, Provider, if Provider has any employees, is required to be insured against liability for worker's compensation or to undertake self-insurance. Prior to commencing the performance of the work under this Agreement, Provider agrees to obtain and maintain any employer's liability insurance with limits not less than $1,000,000 per accident. c. The following requirements apply to the insurance to be provided by Provider pursuant to this section: (i) Provider shall maintain all insurance required above in full force and effect for the entire period covered by this Agreement. Certificates of insurance shall be furnished to the City upon execution of this Agreement and shall be approved in form by the City. (ii) Certificates and policies shall state that the policies shall not be canceled or reduced in coverage or changed in any other material aspect without thirty (30) days prior written notice to the City. d. If Provider fails or refuses to produce or maintain the insurance required by this section or fails or refuses to furnish the City with required proof that insurance has been procured and is in force and paid for, the City shall have the right, at the City's election, to terminate this Agreement. Such termination shrill not affect Provider's right to be paid for its time and materials expended prior to notification of termination. Provider waives the right to receive compensation and agrees to indemnify the City for any work perfortned prior to approval of insurance by the City. G. INDEMNIFICATION Provider agrees to and shall indemnify, defend and hold harmless the City, its officers, agents, employees, consultants, special counsel, and representatives from liability: (1) for personal injury, damages, just compensation, restitution, judicial or equitable relief arising out of claims for personal injury, including death, and claims for property damage, which may arise from the negligent operations of the Provider or its contractors, subcontractors, agents, employees, or other persons acting on their behalf which relates to the services described in section 1 of this Agreement; and (2) from any claim that personal injury, damages, just compensation, restitution, judicial or equitable relief is due by reason of the terms of or effects arising from this Agreement, to the extent that the injury, damages, just compensation, restitution, judicial or equitable relief is caused by the negligence of the Provider. This indemnity and hold harmless agreement applies to all claims for damages, just compensation, restitution, judicial or equitable relief suffered, or alleged to have been suffered, by reason of the events referred to in this Section or by reason of the terms of, or effects, arising from this Agreement. City may make all reasonable decisions with respect to its representation in any legal proceeding. In no case will Provider be required to indemnify or hold harmless the City from injury, damages, just compensation, restitution, judicial or equitable relief caused by the negligence of the City. CONFLICT OF INTEREST Provider covenants that it presently has no interests and shall not have interests, direct or indirect, which would conflict in any manner with performance of services specified under this Agreement. 8. LIVE SCAN BACKGROUND CHECK Provider, and any employees, subcontractors or substitutes, in contact with minors under eighteen (18) years of age shall arrange for and submit to a Live Scan electronic background check for criminal history available through the California Department of Justice as a condition of this Agreement and provide proof of compliance prior to performing services hereunder. 9. NOTICE Any notice, tender, demand, delivery, or other communication pursuant to this Agreement shall be in writing and shall be deemed to be properly given if delivered in person or mailed by first class or certified mail, postage prepaid, or sent by fax or other telegraphic communication in the manner provided in this Section, to the following persons: To City: Clerk of the Council City of Santa Ana 20 Civic Center Plaza (M-30) P.Q. Box 1988 Santa Ana, CA 92702-1988 Fax(714) 647-6956 With copy to: Executive Director of Parks, Recreation and Community Services City of Santa Ana 20 Civic Center Plaza (M-23) P.O. Box 1988 Santa Ana, California 92702 Fax (714) 571-4211 And City Attorney 20 Civic Center Plaza (M-29) P.O. Box 1988 Santa Ana, California 92702 Fax (7t4) 647-6515 To Provider: Mr. Mitchell Goldberg Beginner's Edge Sports Training, LLC. 29634 N. 126°i Ave. Peoria, AZ 85383 Phone: (623) 748-9453 Email: directoriibcstsportsca.corn And Ms. Janice Grodsky, Agent for Service of Process 2230 North El Camino Real, SP 15 Oceanside, California 92058 A party may change its address by giving notice in writing to the other party. Thereafter, any communication shall be addressed and transmitted to the new address. If sent by mail, communication shalt be effective or deemed to have been given three (3) days after it has been deposited in the United States mail, duly registered or certified, with postage prepaid, and addressed as set forth above. If sent by fax, communication shall be effective or deemed to have been given twenty-four (24) hours after the time set forth on the transmission report issued by the transmitting facsimile machine, addressed as set forth above, For purposes of calculating these time frames, weekends, federal, state, County or City holidays shall be excluded. 10. EXCLUSIVITY AND AMENDMENT This Agreement represents the complete and exclusive statement between the City and Provider regarding the subject matter herein, and supersedes any and all other agreements, oral or written, between the parties. In the event of a conflict between the terms of this Agreement and any attachments hereto, the terms of this Agreement shall prevail. This Agreement may not be modified except by written instrument signed by the City and by an authorized representative of Provider. The parties agree that any terms or conditions of any purchase order or other instrument that are inconsistent with, or in addition to, the tenns and conditions hereof, shall not bind or obligate Provider or the City. Each party to this Agreement acknowledges that no representations, inducements, promises or agreements, orally or otherwise, have been made by any party, or anyone acting on behalf of any party, which is not embodied herein. 11, ASSIGNMENT/SUBSTITUTES a. Assignment. The experience, knowledge, capability and reputation of Provider were a substantial inducement for City to cater into this Agreement. Therefore, Provider may not assign, transfer, delegate, or subcontract any interest herein without the prior written consent of the City and any such assigntnent, transfer, delegation or subcontract without the City's prior written consent shall be considered null and void. b. Substitutes. In the event Provider is not able to teach a class due to illness or some other cause beyond Provider's reasonable control, Provider must procure, at its sole expense, a qualified substitute instructor to teach the class at its regular time and place. Provider shall ensure that substitute instructors are at least twenty-one (21) years of age and comply with the City's insurance and live scan requirements contained herein. Evidence of compliance with City's insurance and live scan requirements shall be provided upon request. Provider must immediately notify the City of the substitute instructor's name, qualifications, address and phone number. If Provider cannot procure a qualified substitute and the City is unable to assist in this regard, then the class shall be canceled and a make-up class must be added to the session. Provider must notify participants as soon as possible of any class cancellation and make-up class. Provider must personally teach at least seventy-five percent (75%) of its offered classes. 12. TERMINATION a. This Agreement may be terminated by the City upon thirty (30) days written notice of termination. In such event, Provider shall be entitled to receive, and City shall pay Provider, compensation for all services rendered prior to the effective date of termination. b. Termination or cancellation of classes by the Provider outside of Section I I.b. must be given to the City at least thirty (30) days prior to ternination/cancellation. Failure to provide adequate cancellation notice to the City may put future contracting of business with the City at risk and will result in the City's retention of ten (10%) percent of the final payment to Provider. 11 RECORDS Provider shall use attendance sheets generated and supplied by the City to record. attendance in each class. Provider shall keep these and any other records in connection with the work to be performed under this Agreement and shall permit City, upon request, to review such records for a period of three (3) years from the date of final payment to Provider under this Agreement. 14. NON-DISCRJMINATION Provider shall not discriminate because of race, color, creed, religion, sex, marital status, sexual orientation, age, national origin, ancestry, or disability, as defined and prohibited by applicable law, in the recruitment, selection, teaching, training, utilization, promotion, tennination or other employment related activities or any services provided under this Agreement. Provider affirms that it is an equal opportunity employer and shall comply with all applicable federal, state and local laws and regulations. 15. JURISDICTION —VENUE This Agreement has been executed and delivered in the State of California and the validity, interpretation, performance, and enforcement of any of the clauses of this Agreement shall be determined and governed by the laws of the State of California. Both parties further agree that Orange County, California, shall be the venue for any action or proceeding that may be brought or arise out of, in connection with or by reason of this Agreement. 16. LICENSES Provider shall, throughout the term of this Agreerent, maintain all necessary licenses, permits, approvals, waivers, and exemptions necessary for the provision of the services hereunder and required by the laws and regulations of the United States, the State of California, the City of Santa Ana and all other governmental agencies. 17. SEVERABILITY In the event that one or more of the phrases, sentences, clauses, paragraphs or sections contained in this Agreement shall be declared invalid or unenforceable by valid judgment or decree of a court of competent jurisdiction, such invalidity or unenforceability shall not affect any of the remaining phrases, sentences, clauses, paragraphs or sections of this Agreement, which shall be interpreted to carry out the intent of the parties hereunder. 1.8. EXHIBITS All Exhibits referenced herein and attached hereto shall be incorporated as if fully set forth in the body of this Agreement. 19. AUTHORITY The persons) executing this Agreement on behalf of the parties hereto warrant that they are duly authorized to execute this Agreement on behalf of said parties and that by so executing this Agreement, the parties hereto are formally bound to the provisions of this Agreement. IN WITNESS WHEREOF, the parties hereto have executed this Agreement the date and year first above written. APPROVER AS TO FORM: SONIA R. CARVALHO City Attorney By: r1L 2�X� t t Laura Rossini Senior Assistant City Attorney AL: Q CITY OF SANTA ANA Steven Mendoza Acting City Manager "'" lvarr e: Mr. Mitchell Goldberg, Owner xecutive Director of Parks, Beginner's Edge Sports Training, LLC. Recreation and Community Services Agency 26-2932264 Exhibit A SCOPE OF SERVICES A. Provider shall conduct sports classes including soccer, baseball, softball and track for ages 16 months - 10 yrs. old. B. Provider shall teach such or similar classes (1) at the times below at facilities to be designated by the City or (2) on a schedule agreed upon by the parties for each class session or tern, including the location, specific days and hours when classes will be held, and holidays to be observed, in accordance with City's needs. Beginners Edge Sports Training Our industry -leading weekly soccer class will teach your kids the skills of soccer by offering activities such as: dribbling, kicking, throw-ins, goalie skills, ( age pennitting: scrimmaging) and more! Our goal and focus is to maintain an energetic & highly active program that will teach, encourage and advance you young players regardless of their skill level. • Soccer Skills Training classes that will consist of monthly sessions, held 2 days per week, 45 minutes per class, per day. 4-Sport Multi Sport Our industry -leading 4-Sport program brings you multiple weeks of fantastic sports: Soccer, Basebalt/Softball, Basketball & Track. We will teach your player how to kick and control a soccer ball, how to hit, catch, thro and run the bases, shoot and dribble a basketball and running, jumping and building strength + endurance in our Track & Field program. Our goal and focus is to maintain an energetic & highly active program that will teach, encourage and advance your young players regardless of their skill level. • 4-Sport Multi Sport training classes will consist of monthly sessions, held 2 days, per week, 45 minutes, per class, per day. INSTRUCTOR: Mitch Goldberg LOCATION: Jerome Community Center, 726 S Center St., Santa Ana, (714) 647-6556 C. Provider shall provide all materials, supplies, equipment, records and personnel. Provider shall be responsible for clean up of the facilities and materials and shall ensure the safety and effectiveness of instruction. CLASS SIZE A. Each class must have a minimum of 4 paid students and no more than 16 students. B. No registration will be accepted after the second meeting of classes. C. If the minimum registration has not been reached by the second class, the class shall be canceled. Provider will be under no obligation to provide services for the cancelled classes, and the City will have no further obligations to pay Provider compensation for the retraining classes that were cancelled in that session. CLASS FEES A. Each participant shall pay class registration fees as established by City. B. Provider may not waive class participation/registration fees, C, Only registered participants may participate in class. D. Any refunds to participants will be made in accordance with City policy. E. Any materials fee shall be established by mutual agreement of City and Provider and shall be payable directly to Provider. SOCC-91 OP 10: XJ '4i- R CERTIFICATE OF LIABILITY INSURANCE D10/2912018ATE Y) 10/29/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER RPS Bollinger $ orts & Leisure PO Box 390 p Short Hills, NJ 07078 AJ Morgan CONTACT NAME: PHONE F C Nu IAIC, No. Exit EMAIL -- ADDREBE: INSURER $ AFFORDING COVERAGE NAIC N INSURER A: `Minkel insurance Company 38970 INSURED Beginners Edge Sports Training 29634 North 126th Avenue INSURER s: INSURER C : Peoria, AZ 85383 INSURER D : INSURER E : INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILSR TYPE OF INSURANCE AODL POLICY NUMBER MOLICY EFF MM DAY EXP LIMITS A X COMMERCIAL GENERAL �LIABILITY GLAIMS-MADE �rJ OCCUR X 3602AH025251 11/05/2018 11/05/2019 EACH OCCURRENCE $ 1,000,00 PREMISES Ea occurrence 100,00 X MED EXP(My one person) _$_ $ 5,00 Inel Participenta X SexualAbuse7Mol PERSONAL A ADV INJURY $ 1,000,00 A $1 MILL I $2MILL 11/05/2019 11/05/2019 AGGREGATE LIMIT APPLIES PER: POLICY [,—]PE0 LOC GENERAL AGGREGATE $ 3,000,00 G EN'L PRODUCTS - COMPIOP AGO $ 1,000,00 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ ANY AUTO ALLOWNED SCHEDULED A AUTOS UTOS BODILY INJURY (Per accident) $ HIRED AUTOS N--OWNED POaEden DAMAGE $ UMBRELLA LIAB Ll OCCUR EACH OCCURRENCE AGGREGATE $ EXCESS LIAR CLAIMS -MADE DED I I RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORIPARTINEWEXECUTIVE OFFICEMMEMBER EXCLUDE04 ❑NIA PER OTH- STATUTE ER E.L. EACH ACCIDENT $ E.L. DISEASE -EA EMPLOYEE $ (Mandatary in NH) If yes, describe under DESCRIPTION OF OPERATIONSbu. E.L DISEA E 104 ICY LIMIT $ A Accidentinsurance 4102AH025250 11/05/2018 11/05/2019 �$d: 25,00 Full Excess ge e50 DESCRIPTION OF OPERATIONS f LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required ,ram,,,.•-- Certificate holder is included as an additional insured. Coverage is provided under these policies only for sponsored/supervised activities of the named insured for which a premium has been paid. G0c�.fa R.SNgeeceatlC)� City of Santa Ana Parks, Recreation and Community Services Agency 1825 W Civic Center Dr Santa Ana, CA 92703 COSANTA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25 (2014101) R The ACORD name and logo are registered marks of ACORD riahts reserved POLICY NUMBER: 3602AH025251 - 11 COMMERCIAL GENERAL LIABILITY CG 20 26 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): City of Santa Ana Parks, Recreation and Community Services Agency 1825 W Civic Center Dr., Santa Ana, CA. 92703 A. Section II - Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by your acts or omis- sions or the acts or omissions of those acting on your behalf: 1. In the performance of your ongoing opera- tions; or 2. In connection with your premises owned by or rented to you. However: 1. The insurance afforded to such additional in- sured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the in- surance afforded to such additional insured will not be broader than that which you are re- quired by the contract or agreement to pro- vide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following is added to Section III - Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Availabl�t e applicable Limits of Insur- i e in the Declaratons; whichever is less. This endorsements �otwi in a applica- ble Lsc�'��?Pcs s n the Declarations. �-COgtc`? �aa�° CG 20 26 04 13 Copyright, Insurance Services Office, Inc., 2012 Page 1 of 1 POLICY NUMBER: 3602AH025251 - 11 COMMERCIAL GENERAL LIABILITY CG 20 01 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTORY - OTHER INSURANCE CONDITION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART The following is added to the Other Insurance Con- dition and supersedes any provision to the con- trary: Primary And Noncontributory Insurance This insurance is primary to and will not seek contribution from any other insurance available to an additional insured under your policy pro- vided that: (1) The additional insured is a Named Insured under such other insurance; and (2) You have agreed in writing in a contract or agreement that this insurance would be primary and would not seek contribution from any other insurance available to the additional insured. ?,P,Nj CG 20 01 04 13 Copyright, Insurance Services Office, Inc., 2012 Page 1 of 1 Policy Change Number THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. POLICY CHANGES THIS ENDORSEMENT FORMS A PART OF THE POLICY NUMBERED BELOW: POLICY NUMBER POLICY CHANGES COMPANY EFFECTIVE 3602AH025251 • 11 11-05-2018 Markel Insurance Company NAMED INSURED AUTHORIZED REPRESENTATIVE Beginners Edge Sports Training dba SoccerTots Bruce A. Kay Lil Sluggers Baseball & Slam Dunkerz Basketball COVERAGE PARTS AFFECTED CHANGES The following has been added to the policy as an additional insured: City of Santa Ana Parks, Recreation and Community Services Agency 1825 W Civic Center Dr. Santa Ana, CA 92703 Form CG2001 is added to the policy, but only with respect to the above additional insured. All other terms and conditions remain unchanged. t� (;B,CiYIG'O(?,eCC��ttO� ,,CS The above amendmentls) result in a change in premium as follows: NO CHANGES ❑ TO BE ADJUSTED ADDITIONAL RETURN PREMIUM AT AUDIT PREMIUM S 0.00 $ Bruce A, Kay Authorized Representative S nature AU IL 12 01 11 85 Copyright, ISO Commercial Risk Services, Inc., 1983 10-31-2018 4WRKERS' C049PF,NSA 1'ION DECLARATIQN hereby affirm under penalty ofpeijury, the following declaration: I certify on n behalf ofduring the torra of m}` —(Cnusui�a -Coi MY Namo contract for _ Recreation Classes services with the City of Santa Ana, 1 will not employ an) 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 Codc,1 shall forthwith eomply with those provisions and provide proof of workers' compensation coverage, B Y: It// q1 —'ffiv- —, Name: _l Title:(' " Telephone: 1� Z- WARcNiNG: FAILURE TO SECURE WORKERS' COivIPCNSAI]ON COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CIUMINAL PEti AL' IES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COrNIPENSA`I'ION, DAMAGES AS PROVIDED FOR IN SECTION a?Ob OF THE LABOR CODE, INTEREST, AND ATTORNEY'S PEES.