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Home My WebLink AboutRIVERA, RODRIGO SALOMON 4ACity of Santa Ana ® � Clerk of the Council AGREEMENT TERMINATION FORM COTC Office Use Please complete this form in its entirety when the attached agreement and allr19 Mr, 2 E ?� 5 amendments (if any) are no longer in effect. MAI Note: If our agreement is rant related, lease ensure that all rant retention requirements Y or S A OF r colICIL have been satisfied prior to signing the termination form. CLERK 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-2016-025-001 was completed on (List all amendments. Use space below if needed.) 12 L�j JQj�:j and final payment has been made. Department: PRc LA Phone/Ext.: L1910. Signature: ( ��sri1/cZ+ IY//i Date: �31Iq 1ROIQ, Revised: 10-18-16 IN— 0 RV4U K, ttf.0. C s:i 1+tf�� 1 Iiri a l' l� MAYOR tkil IRPS Miguel A. Puildo a� MAYOR PRO TEM,Q�P s Vicente Sarmlanto dY" [ tLRI4 OP Cf1lfNUll."'�' �- COUNCILMEMBERS @11 2 '1 2016 Angelloa Arrazcua P. David Benavides Michele Martinez O: PRCS (/ ) Roman Reyna Sal Tlnajern Silvia Cuevas CITY OF SANTA ANA PARKS, RECREATION, AND COMMUNITY SERVICES AGENCY 20 Chic Canter Plaza M-23 + P.O. Box 1988 M-23 Santa Ana, California 92702 MW Sanfa-ana.org November 23, 2016 Rodrigo Salomon Rivera 709 S. Parton Street Santa Ana, CA 92701 Re; Extension of Recreation Services Agreement Agreement No. N-2026-025 Dear Mr. Rivera: CITY MANAGER David Cavazos CITY ATTORNEY Sonia R. Carvalho CLERK OF THE COUNCIL Maria D. Huizar Pursuant to Section 3 of the above -referenced agreement between you and the City of Santa Ana, the term of such Agreement is hereby extended for an additional one (1) year period, from January 1, 2017 through December 31, 2017, All insurance certificates are required to be extended and/or renewed to cover this extension. All other terms and conditions of the Agreement remain unchanged and in full force and effect. Sincerely, Gerardo Monet, Executive Director Parks, Recreation, and Community Services Agency C111Y gF SANTA NA C/` J David Cavazos City Manager APPROVED AS TO FORM J n M. Funk Assistant City Attorney ATTEST 4. f ' Maria D. Huizar Clerk of Council SANTA ANA CITY COUNCIL Miguel A. RuUdo Vincenta. Sarmlento Michele MaNnea Angelica Aa,=W P. Da�tl nenamdes I Raman Reyoa ` Sal Tinaiero Mayor t May., Pro Tee, Wahl Were Were WerdA Ward I Ward MWIMnta:Sat+ta-ana oro VSacraenfs toadE na care, I RRevnata~senta-ana o,(g 1 §TjnNero sania- EXHIBIT A SCOPE OF SERVICES Salomon Rivera/Salsa Provider shall provide Salsa Dance for 18 years -75 years old A. Salsa Beginning I, class is one day, per week, 1 hour per day - $30.00/6weeks B. Salsa Beginning II, class is one day, per week, 1 hour per day - $30.00/6weeks C. Salsa Intermediate, class is one day, per week, 1 hour per day - $30.00/6weeks D. Provider will provide and be responsible for equipment, records, and personnel and cleanup of the facilities and materials necessary to ensure the safety and effectiveness of said instruction. E. If Provider allows others to teach his/her class, those teachers must be over 21, have obtained and maintain an instructor rating, and be covered by Provider's insurance. Provider shall provide City with documentation to verify instructor and insurance requirements. CLASS SIZE A. Each class shall have a minimum of 10 and maximum of 40, registered and paid participants B. No registration will be accepted after the second meeting of class. C. In the event the minimum number of enrollees is not realized by the second meeting of the class, the class shall be canceled. Provider will be under no obligation to provide services and the City will have no obligations to pay Consultant compensation CLASS FEES A. Each participant shall pay a $30.00 class registration per 6 weeks. Anticipated revenue not to exceed $25,000.00 B. No refunds shall be made to participants after the first week of class unless the class is canceled by the Parks, Recreation, and Community Services Agency. C. The City shall collect the class fees from each participant during the registration period. D. City agrees to pay Provider seventy percent (70%) of the total fees within thirty (30) working days after completion of the class session. City shall receive thirty per cent (30%) of the fees collected. E. Provider agrees that City representative shall be entitled to audit Providers records to insure compliance with this Agreement and that all participants are registered. F. Provider may not waive class participation/registration fees. G. City shall prepare class rosters and provide a copy to Provider. Only registered participants, listed on roster may participate in class. EVANSTON INSURANCE COMPANY CERTIFICATE NO,: 635907136500162265 CERTIFICATE OF INSURANCE SPECIAL EVENT LIABILITY PROGRAM PRODUCER PUBLIC ENTITY (ADDITIONAL INSURED) Alliant Insurance Services, Inc. In conjunction with City of Santa Ana Apex Insurance Services P. O. Box 6450 Newport Beach, CA 92658 License No: OC 36861 NAMED INSURED (EVENT HOLDER): EVENT INFORMATION: Salamon Rivera TYPE: Dance (Various) 709 S Parton St. DATE(S): 02124/2016-1212612016 Santa Ana, CA 92701 LOCATION: Southwest Senior Canter *Liquor Liability Yes No(j) **Liquor Liabiliafter 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: $EP41020 MASTER POLICY DATES: EFFECTIVE: January01, 2016 EXPIRATION: January 01, 2017 COY&MRCIAL GENERAL LIABILITY &rural OCCURRENCE FORM DEDUCTIBLE: NONE A$grogute Limit $ 2,000,000 Products & Completed Operations 1,000,000 SPECIAL CONDITIONS: Personal & Advertising Injury 1,000,000 The following endorsements attached or Each Occurrence Limit L0001000 the Master Policy do not apply to this Damage To Premises Rented To You (Any One Premises) 100,000 Certificate O£Inamorace: Medical Payments (Any One Person) 3,000 Liquor Liability (If purchased) 1,000,000 Optional Limits Purchased( I ❑ S1,000,0003,000,000 ❑ $2,000,000/$2,000,000 Property Damage (If purchased) No Property Damage Coverage Ua5 The limits of insurance apply separately to each event insured by this policy as if a separate policy of in -aP19 osued:for' th d event, OTHER ADDITIONAL INSUREDS CANCELLATIONShould the above described policy be cancelled before the expiration dale thereof, notice will be delivered inaccordance with the policy rovisions. AUTHORIZED REPRESENTATIV.C: DATE ISSUED: 02/1012016 EVANSTON INSURANCE COMPANY CERTIFICATE NO.: 2017-33 CERTIFICATE OF INSURANCE SPECIAL EVENT LIABILITY PROGRAM PRODUCER PUBLIC ENTITY (ADDITIONAL INSURED) Alliant Insurance Services, Inc. in conjunction with City of Santa Ana Apex Insurance Services 20 Civic Center Plaza P. O. Box 6450 Santa Ana, CA 92701 1 Newport Beach, CA 92658 License No: OC 36861 NAMED INSURED (EVENT HOLDER): EVENT INFORMATION: Salamon Rivera TYPE: Dance (Various) 709 S Parton St. DATE(S): 2/27/17 — 12/31/17 Santa Ana, CA 92701 LOCATION: Southwest Senior Center *Liquor Liability Yes El No "Liquor Liability after 12 am ends before 2 amE] 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(ics) unless amended as described in Special Conditions. INSURANCE CARRIER: Evanston Insurance Company MASTER POLICY NUMBER: SEP41023 MASTER POLICY DATES: EFFECTIVE: JANUARY 1, 2017 EXPIRATION: JANUARY 1, 2018 COMMERCIAL GENERAL LIABILITY OCCURRENCE FORM DEDUCTIBLE: NONE General Aggregate Limit $2,000,000 Products & Completed Operations 1,000,000 SPE( ' 'lAl, CONDITIONS: Personal & Advertising Injury 1,000,000 The following endorsements attached to Each Occurrence Limit l'oo0,000 the Master Policy do not apply to dais Damage'To Premises Rented To You (Any One Premises) 100,000 Certificate 01'Insurance: Medical Payments (Any One Person) 5,000 Liquor Liability (If purchased) 1 '000,000 Optional Limits Purchased bY'. F-1 $1,000,0001$3,000,000 Re'JleNN d [] $2,000,000/$2,000,000 ' Damage To Property (If purchased) well� Av w. up,\Ja The limits of'insurance apply separately to each event insured by this policy as ifa paratep0liCy0finSUranoRgs Aa TA, evern. OTHER ADDITIONAL INSUREDS CANCELLATION: Should the above described policy be cancelled before the expiration date thereof', notice will be delivered in accordance with the policy provisions. AUTHORIZED REPRESENTATIVE: DATE ISSUED: February 27, 2017 By Stella Fajardo WORKERS' COMPENSATION DECLARATION hereby of under penalty of perjury, the following declaration I certify on behalf of P that during the ten-n of my (IC011SUN 1 nt/C&l pa Name contract for s rvices 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: \L2Z B Narne;, Title. 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 TOTHE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. Reviewed I* -,1 � 1\jl 3' FC �,u, Pe- \\,i a �s PRCSAJAdM!11-