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Home My WebLink AboutHERRERA, MELINACity of Santa Ana \ Clerk of the Council AGREEMENT TERMINATION FORM • Please complete this form when the attached agreement and all amendments (if any) are no longer in effect. Return form to the Clerk of the Council Office (M-30). Call 647-6520 if you have any questions. COTC Office Use Only 13F THE Comm ) 3121 Pi43:06 The agreement with No. N - 0aM-C17'0I was completed on 06130120fk and final payment has been made. (Ust all amendments. Use space below'rf needed.) Department: QQCk Phone/Ext.: 52101 y Signature: Cp),VIVLO� Yl V4 Date: N— pt 12021 Revised 08-2310 J ON FILE W07. ,. MAY NE PROCEED CLERK OF COUNCIL DATE:jt,iL o 2 2419 1q ; F4s & Vl N-2018-095-01 THIS FIRST AWNDMENT to the above -referenced agreement is entered into on June 12, 2019, by and between Melina Herrera ("Providoe%,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 parties entered into Agreement No. N-2018-095 dated May 10, 2018, to provide Care Bears Academy classes for the City's recreational class program. The term of the Agreement runs from July 1, 2018, continues through June 30, 2019, and is still in effect, B. The classes provided for the Care Bears Academy have proven to be successful and the parties wish to amend the Agreement to increase the overall compensation paid to the Provider by $10,000, The Parties therefore agree: 1. Section 2, Compensation, is therefore increased by an additional $10,000 with the total not -to -exceed amount to be expended during the term of this Agreement to $35,000, 2. Except as modified by this First Amendment, all terms and conditions of the Agreement shall remain in full force and effect. IN WITNESS WHEREOF, the parties hereto have executed this First Amendment to the Agreement on the date and year first written above. ATTE NORMA MITRE Acting Clerk of the Council APPROVED AS TO FORM SONIA R, CARVAT210 City Attorney } By: LAURA A. ROSSINI Senior Assistant City Attorney RECOMMENDED FORr7VAL :ive Director, Z- � Recreation and Community Services Agency CITY OF SANTA ANA CRISTJNE RIDGE City Manager PROVIDER Molina Herrera Page I of I EVANSTON INSURANCE COMPANY CERTIFICATE NO.: 2019-09 CERTIFICATE OF INSURANCE SPECIAL EVENT LIABILITY PROGRAM PRODUCER PUBLIC ENTITY (ADDITIONAL INSURED) Alliant Insurance Services, Tnc, in conjunction with i City of Santa Ann Apex Insurance Services 20 Civic Center Plaza P. O. Box 6450 Santa Ana, CA 92701 Newport Beach, CA 92658 License No: OC 36861 NAMED INSURED (EVENT HOLDER): EVENT INFORMATION: Melina Herrera TYPE: Pre-School/Daycare 783 Olympic Ave DATE(S): 01/01/2019-12/31/2019 Costa Mesa, CA 92626 LOCATION: Santa Ann Corbin Center *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: SEP41028 MASTER POLICY DATES: EFFECTIVE: JANUARY 1, 2019 EXPIRATION: JANUARY 1, 2020 COMMERCIAL GENERAL LIABILITY OCCURRENCE FORM DEDUCTIBLE: NONE General Aggregate Limit $ 2,000,000 Products & Completed Operations 1,000,000 SPECIAL CONDITIONS: Personal & Advertising Injury 1,000,000 The following endorsements altaehed 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 ❑ $1,000,000/$3,000,000 ❑ $2,000,000/$2,000,000 Damage To Property (If purchased) The limits of insurance apply separately to each event insured by this policy ns ife separate policy ofinsurnncc has been issued for that event. OTHER ADDITIONAL INSUREDS CANCELLATION: Should the above described policy be cancelled before the expiration date thereof, notice will be delivered inaccordance with the policy provisions, AUTHORIZED REPRESENTATIVE: DATE ISSUED: +r✓�u WQRKF:RS' COMPENSATION, PLCIARikT10N [ Melina Herrera------ hereby affirm under penalty of perjury, the —1 wine duel following declaration: I certify on behalf of ` Melina Herrera _ that during the tern of my IConsullanr Company Name) contract for Recreation Classes _ 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 haws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 ol'the Labor Code, I shall forthwith comply with those provisions and provide proof of workers' compensation coverage. DATE: By: Name: Melina Herrera Title: Instructor Telephone: 714 955-1979 WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN ENIPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000)• IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. �,aeva� Ms. Melina Herrera 424 S. Center Street Santa Ana, CA 92703 June 24, 2019 City of Santa Ana Risk Management Division 20 Civic Center Plaza, Santa Ana, CA 92702 Re: Auto insurance Requirement Release of Liability. Dear City of Santa Ana Risk Management Division: I, McIina Herrera, Recreation Instructor, hereby release the City of Automobile Liability. I do not use/drive any vehicle during the course and scope of my course/instruction class. During the term June 12, 2019 through June 30, 2020, I will be teaching Care Bears Classes at Corbin Center located at; 2215 W. McFadden Ave., Santa Ana, CA. qc Z..--e a, Recreation Instructor i EJ� R 011Nion a ,qe R�S�, WORKERS' COMPENSATION DECLARATION I Melina Herrera hereby affirm under penalty of perjury, the (Name/Title) following declaration: I certify on behalf of Melina Herrera that during the term of my (Consultant/Company Name) contract for Recreation Classes 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: t_ Name: Title: Recreation Instructor Telephone: 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 COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES.