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HomeMy WebLinkAboutCAZALES, RODOLFO DBA TOYAMA KARATE-DO ORGANIZATION 2-2017 • :0 : E e : E ` , o a) N, :0 - a ,\ i0 C a :§ c a)= cj k E It 0_ m- - * o m �... .. �..... \ a _ % / , 31 _ g ' . , o Gel \ / !� E �� @ 2 , E \ ! E d ) 0-) a ! 0 c 0 6 -c \ o ` 0 / 0 U ° 9 '`,.= _ �� § • • ƒ / as LED U . 2 \ 2 c • \ 0 �ƒ O > . / ' 0 x o / a ' 0 2 C Z_ ( �co = U • �` 0 / ▪ § / - cu / / 43 D uls k U 0 0 Lu 2 ƒ -2 2 e t U - 0 5 = T $ / C ƒ a \ a 0 @ ' = 2 E e - g \ / 3 o O ) e \ % / 2 w Lu z \ - £ c 2 w 0 f f \ \ - / j ƒ CD § - E ® ~ ® \ 0• 0 « @ � \ \ - 2e 9 0 \� 2% \ E / E E _o 0 ) \\ \ \ \ 2 ``t om U)- / c 7 0) % ti - - ' \. oo ae o » = ' ; ° - ` . / az ƒ \ ƒ U / Z } INSURANCE ON FILE'. WORK MAY PROCEED l�NTILINSURANCE EXPIRES c;_ lam' /^/—/$ CLERK OF COIj9 29 2017 w)ATE: e� S RECREATION SERVICES AGREEMENT M11FAKIn. O. PRC {I 1 THIS AGREEMENT is made and entered into this 23rd day of August, 2017 by and Silvia Cuevagetween Rodolfo Cazales dba Toyama Karate —Do Organization ("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 Toyama Karate -Do Martial Arts classes in its recreation class program. B. Provider represents that he/she/it is able and willing to provide such services to the City. C. In undertaking the performance of this Agreement, Provider represents that he/she/it is knowledgeable in their 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. 2. 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 commence on September 1, 2017 and end on August 31, 2018 unless terminated earlier in accordance with Section 12 below. The term 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 shall 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 performed prior to approval of insurance by the City. 6. 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. 7. 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 Linder this Agreement. 8. LIVE SCAN BACKGROUND CHECK Provider, and any employees, subcontractors or substitutes, in contact with minors Linder 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.O. Box 1988 With copy to: Santa Ana, CA 92702-1988 Fax (714) 647-6956 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 To Provider: Rodolfo Cazales 2525 N. Grand Avenue, Suite Z Santa Ana, CA 92705 Cell: (714) 474-4737 toyamausa(c�yahoo. com 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 shall 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 terms 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 enter 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 assignment, 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 (2 1) 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 -tip 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 l Lb. must be given to the City at least thirty (30) days prior to termination/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. 13. 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-DISCRIMINATION 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, termination 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 Agreement, 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 cavy out the intent of the parties hereunder. 18. 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 person(s) 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. ATTEST: F"Gj On Mi a 10 L916MM CITY OF SANTA ANA ynthia Kiiqz Interim City Manager [signatures continue on next page APPROVED AS TO FORM: SONIA R. CARVALHO City Attorney By:--' �4 JohJunk, Assistant City Attorney RECOMMENDED FOR APPROVAL: Gerardo fqouct - 1 ' Executivd Director of Parks, Recreation and Cbmmunity Services Agency PROVIDER: game: Rodoll eZza4je—sa Toyama Kal4te-Do Exhibit A SCOPE OF SERVICES A. Provider shall conduct Toyama Karate Do classes for ages 5yrs old and up. 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 term, including the location, specific days and hours when classes will be held, and holidays to be observed, in accordance with City's needs. Toyama Karate Do will consist of monthly sessions held two days per week, for 50 minutes. 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 5 paid students and no more than 20 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 cancelled. 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 remaining 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. 4C4r_>RI7 CERTIFICATE OF LIABILITY INSURANCE � DATE(MM0/22017017 Y) 3/1 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(lea) must have ADDITIONAL INSURED provisions or 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 Reindeer Insurance Services 14037 Pioneer Blvd Norwalk CA 90650 CONTACT NA E: PHONE (562)906-8838 Fax (562)406-8837 s INC Noj;,_ EMAIL esr@truckbypass. com ARPgg@.aL_.._._._....._........ _..._ ..... ..__ INSURER($) AFFORDING COVERAGE NAIC# INSURER A; United States fire insurance Company $2,000,000 INSURED Toyama Karate DO t Rodolfo Ca2alez INSURER B: INSURER G: 01/01/2017 1030 Moore Street INSURER D: S 100,000 Santa Ana, CA 92104 INSURER E: INSURER F: 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. NSR T TYPE OF INSURANCE ADOL INSD SUER VAG POLILYNUMBER POLICY EFF MleurnyYYYl POLICY EXP (MMIDONyWI LIMITS .a. COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $2,000,000 CLAIMS4ADE 1zOCCUR AH-OA26932-002 01/01/2017 01/01/2018 DAMAGE TO RENT Pffg I SEa occurrence S 100,000 MED EXP (Any one person) $5,000 PERSONAL a ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $4,000,000 _ POLICY F—] JECPROT D LOC PRODUCTS - COMP/OP AGO 5 S OTHER: AUTOMOBILE LIABILITY _.._.._ COMBINED SINGLE LIMIT Ea accident S BODILY INJURY (Per person) S i ANYAUTO -.OWNED. SCHEDULED AUTOS ONLY € AUTOS _.�..-.... INJURY( BODILY INJURY Per accident Per _____m__._.....�..__.. $ _ . �` NON -OWNED ! AUTOS ONLY ''. AD7GB ONLY PROPERTY DAMAGE Ver accident S UMBRELLA LIAR_ OCCUR EXCESS LIAR._ CLAIMS -MADE �y y4�1. EACH OCCURRENCE S AGGREGATE S �'\Q/ OED I RETENTION S � S WORKERS COMPENSATION PER OTH� AND EMPLOYERS' LIABILITY YIN "�, STATUTE ER E.L. EACH ACCIDENT S ANY PROPRIETORIPARTNERIEXECUTNE OFFICERIMEMBER EXCLUDED' 1� N f A ('.V V �� E,I I. DISEASE - EA EMPLOYEE 5 (Mandatory In NH) If yes, deserts under DESCRIPTION OF OPERATIONS below ' y�� .. \ E.L. DISEASE POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS( VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more apace Is required) Karate School -certificate Holder is Listed as Additional Insured CERTIFICATE HOLDER CANCELLATION CITY OF SANTA ANA 20 CIVIC CENTER PLAZA M-16 PO BOX 1988 SHOULD ANY OF THE ABOVE DESCRI RED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF. NOTICE W ILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. ADDITIONAI. INSURED ENDORSEMENT Insurance Company United States Fire Insurance Company This endorsement modifies such insurance as is afforded by the provisions of Policy # AH-GA2692-002 relating to the following: 1. The City of Santa Ana, 20 Civic Center Plaza, Santa Ana, California 92701; it officers, employees, agents and representative are named as additional insureds ("additional insureds") with regard to liability and defense of suits arising from the operations and uses performed by or on behalf of the named insured. 2. With respect to claims arising out of the operations and uses performed by or on behalf of the named insured, such insurance as is afforded by this policy is primary and is not additional to or contributing with any other insurance carried by or for the benefit of the additional insureds. 3. This insurance applies separately to each insured against whom claim is made or suit is brought except with respect to the company's limits of liability. The inclusion of any person or organization as an insured shall not affect any right which such person or organization would have as a claimant if riot so included. 4. With respect the additional insureds, this insurance shall not be cancelled, or materially reduced in coverage or limits except after thirty (30) days written notice has been given to the City of Santa Ana, 20 Civic Center Plaza, Santa Ana, California 92701. (Completion of the following, Including countersignature, is required to make this endorsement effective.) Effective 01/01/2017 , this endorsement form as part of Policy # AH-GA26932-002 Issued to Toyama Karate Do Name Insured Countersigned by. ( POLICY NUMBE :AH-GA26932-002 NAME INSURED : Toyama Karate Do COMMERCIAL GENERAL LIABILITY CG 20 15 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - VENDORS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organizations) (Vendor) Your Products City of Santa Ana, product made intentionally by the vendor; its officers, agents, and employees d. Repackaging, except when unpacked solely 20 Civic Center Plaza Santa Ana , CA 92701 0d •r , i "your products" shown in the Schedule which are 90C-,ft�.JJ distributed or sold in the regular course of the ven- dor's aGNye� pig business, subject to the following additional .RAN, exclusions: 1� ..Information required to complete this Schedule, if not shown above will be shown in the Declarations. A. Section II — Who Is An Insured is amended to c. Any physical or chemical change in the include as an additional insured any person(s) or product made intentionally by the vendor; organization(s) (referred to below as vendor) shown in the Schedule, but only with respect to d. Repackaging, except when unpacked solely "bodily injury" or "property damage" arising out of for the purpose of inspection, demonstra- "your products" shown in the Schedule which are tion, testing, or the substitution of parts un- distributed or sold in the regular course of the ven- dor's der instructions from the manufacturer, and then repackaged in the original container; business, subject to the following additional exclusions: e. Any failure to make such inspections, ad - 1. The insurance afforded the vendor does not justments, tests or servicing as the vendor apply to: has agreed to make or normally undertakes a. "Bodily injury" or "property damage" for to make in the usual course of business, in connection with the distribution or sale of which the vendor is obligated to pay dam- the products; ages by reason of the assumption of liability in a contract or agreement. This exclusion f. Demonstration, installation, servicing or does not apply to liability for damages that repair operations, except such operations the vendor would have in the absence of the performed at the vendor's premises in con - contract or agreement; vection with the sale of the product; b. Any express warranty unauthorized by you; CG 20 15 07 04 © ISO Properties, Inc., 2004 Page 1 of 2 13 g. Products which, after distribution or sale by you, have been labeled or relabeled or used as a container, part or ingredient of any oth- er thing or substance by or for the vendor; or h. 'Bodily injury" or "properly damage" arising out of the sole negligence of the vendor for 2. its own acts or omissions or those of its employees or anyone else acting on its be- half. However, this exclusion does not apply to: (1) The exceptions contained in Sub- paragraphs d. or f.; or (2) Such inspections, adjustments, tests or servicing as the vendor has agreed to make or normally undertakes to make In the usual course of business, in connec- tion with the distribution or sale of the products. This insurance does not apply to any insured person or organization, from whom you have acquired such products, or any ingredient, part or container, entering into, accompanying or containing such products. Page 2 of 2 0 ISO Properties, Inc., 2004 GG 2015 07 04 0 WORKERS' COMPENSATION DECLARATION 1, Rodolfo Cazales dba Toyama Karate -Do, hereby affirm under penalty of perjury, the following declaration : I certify on behalf of _Toyama Karate -Do that during the term of my (Consultant/Company Name) contract for Karate 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: Title: WARNING: FAILURE TO SECURE WOR UNLAWFUL, AND SHALL SUBJECT AN AND CIVIL FINES UP TO ONE HUNDR.E ADDITION TO THE COST OF COMPENS IN SECTION 3706 OF THE LABOR CQ Policy Number: Date Entered: 02/07/2018 '`�C �® CERTIFICATE OF LIABILITY INSURANCE z/�mm0 ' 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 have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on PRODUCER INSURED Reindeer Insurance Services 14037 Pioneer Blvd Norwalk CA 90650 Rodolfo Cazalez 1030 Moore Street Santa Ana. CA 92704 I PHONE No EAh (562) 406-8838 (AXc Noe (562) 406-8837 EMAIL .....e«�, esr@truckbypass. cow Insurance Company 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. INSR ADOLISUBR. POLICY EFF POLICY EXP TYPE OF LTR D' POLICY NUMBER MM/DOIYYYV MMNOP/YYY LIMITS A X COMMERCIAL GENERAL UABILITY EACH OCCURRENCE $ 2 r OOO, 000 AH-GA2692-004 01/01/2018 01/01/2019 DAMAGETO RENTED 100, DOD CLAIMS -MADE OCCUR PREMISES(Ea occurrence $ j MED EXP (Any one person) $5,000 _ PERSONAL &ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $4,000,000 POLICY PRO LOC JECT _ __PRODUCTS-COMPIOP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) _ ANYAUTO BODILY INJURY (Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS - BODILY INJURY (Per accident) $ HIRED NON -OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per acadenl $ UM BRELLA LIAR OCCUR EACH OCCURRENCE $ ```` EXCESS LIAR CLAIMS -MADE N i AGGREGATE ., $ DED RETENTION $ Pl $ MPIRISATION OTOR/PARTEWEXECUTIVE PER TIT ER AORPROPRIEKERS AND EMPLOYERS' LIABILITYY/N p� /.' �✓ VV !�JV ri -` E. L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? � N/A `—STATUTE V — _ _.- _- (Mandatory In NH),\"r" ,n ` E. L. DISEASE - EA EMPLOYEE $ It yes, describe under DESCRIPTION OF OPERATIONS be. I'rA A/,EL. DISEASE -POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS/ VEHICLES (ACORD 101, Additional Remarks SahaEule, may be attaohed it morelspace is req.ir.d) Karate School Additional Location:2320 N Grand Ave Santa Ana CA 92705 Certificate holder, its officers, agents, and employees are named as Additional Insured in regard to General Liability Att:PRCSA 20 CIVIC CENTER PLAZA M-23 PO BOX 1988 SANTA ANA CA 92702 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 I 1 1 ©1988-2015 ACORD CORPORATION. All riahts reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD Produced usina Farms Bass Plus software. wvvW.FormsBoss.comImoressive Publishina 800-208-1977 POLICY NO. AH-GA2692-004 COMMERCIAL GENERAL LIABILITY NAME INSURED:Toyama Karate Do 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 Person or Organization: City of Santa Ana , its officers, agents and employees 20 Civic Center Plaza Santa Ana, CA 92701 (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) WHO IS AN INSURED (Section II) is amended to include as an Insured the person or organization shown in the schedule, as an insured but only with respected to liability arising out of your operations or premises owned by or rented to you. CG 20261185 Copyright, ISO Properties, Inc., 2004 Page 1 of 1 ADDITIONAL INSURED ENDORSEMENT Insurance Company United States Fire Insurance Company This endorsement modifies such insurance as is afforded by the provisions of Policy # AH-GA2692-004 relating to the following: 1. The City of Santa Ana, 20 Civic Center Plaza, Santa Ana, California 92701; it officers, employees, agents and representative are named as additional insureds ("additional insureds") with regard to liability and defense of suits arising from the operations and uses performed by or on behalf of the named insured. 2. With respect to claims arising out of the operations and uses performed by or on behalf of the named insured, such insurance as is afforded by this policy is primary and is not additional to or contributing with any other insurance carried by or for the benefit of the additional insureds. 3. This insurance applies separately to each insured against whom claim is made or suit is brought except with respect to the company's limits of liability. The inclusion of any person or organization as an insured shall not affect any right which such person or organization would have as a claimant if not so included. 4. With respect the additional insureds, this insurance shall not be cancelled, or materially reduced in coverage or limits except after thirty (30) days written notice has been given to the City of Santa Ana, 20 Civic Center Plaza, Santa Ana, California 92701. (Completion of the following, including countersignature, is required to make this endorsement effective.) Effective 01/01/2018 this endorsement form as part of Policy # AH-GA2692-004 Issued to Toyama Karate Do Name Insured Countersigned by nvurm, .-\gem Synam:a /� , WORKERS' COMPENSATION DECLARATION I, Rodolfo Cazales dba Toyama Karate -Do, hereby affirm under penalty of perjury, the following declaration : I certify on behalf of Toyama Karate -Do that during the term of my (Consultant/Company Name) contract for Karate 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: Title: 66w, -met -Telephone: 2j Y 1 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, 4"!i'1TORNEY'S FEES.