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HomeMy WebLinkAboutRIVERA, RODRIGO SALOMON (2)INSURANCE ON FILE WORK MAY PROCEED UNTIL INSURANCE EXPIRES N-2021-200 CLERK OOF"C UNC DATE: RECREATION SERVICES AGREEMENT 0 Psi (fr��kN¢r�Utncf�i=)(I) T.T. THIS AGREEMENT is made and entered into on this '50 day of September, 2021 by and between Rodrigo Salomon Rivera, an individual, ("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"). City and Provider are also referred to as "the Parties." RECITALS r� A. The City desires to retain a recreation service provider having special skills, resources and 0 knowledge to provide Beginner & Advanced Latin Dance classes in its recreation class program. B. Provider represents that he is able and willing to provide such services to the City. C. In undertaking the performance of this Agreement, Provider represents that he is knowledgeable in his field and that any services performed by Provider under this Agreement will be performed in compliance with such standards as may reasonably be expected. D. The Parties acknowledge that the City intends to provide recreational activities to the public but must balance the need to comply with all COVID-19 guidance and restrictions. 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: 1. SCOPE OF SERVICES A. Provider shall perform those services as set forth in Exhibit A to this Agreement. B. All classes operated pursuant to this Agreement for conducting recreation classes at City facilities, including parks, will comply with all applicable guidance and public health orders, including those from the Centers for Disease Control ("CDC"), California Department of Public Health ("CDPH"), the Orange County Health Care Agency ("OCHCA") and the City itself for as long as those orders and guidance remain in place. Provider will remind participants of these guidelines. To the extent that Provider needs assistance with enforcing any rules or requirements, Provider will contact a City Parks' employee or City security for assistance. C. Provider shall not attend a class or teach any class if Provider is sick or has any symptom(s) associated with COVID-19 including but not limited to, fever above 100.4, chills, cough, shortness of breath loss of taste or smell, nausea, muscle or body aches, vomiting, headache, sore throat or diarrhea. D. Provider will not attend class or teach a class if Provider or any member of Provider's household has been asked to quarantine or self -isolate due to symptoms of COVID-19 or a positive test result for COVID-19. E. Provider acknowledges that, to the extent that City is able to and chooses to conduct classes indoors, this Agreement will also cover classes conducted at one of City's recreational centers during the term of this Agreement. F. City reserves the right to change the location(s) at which the services contemplated by this Agreement are provided. G. Provider shall comply with the City's recreation classes policy manual and any other City rules and regulations regarding the operation of recreation classes. 2. COMPENSATION a. In consideration for the provision of the programs set forth in Exhibit A, City agrees to pay, and Provider agrees to accept as total payment for their services for the City, seventy percent (70%) of all gross revenue received from program participants. Total revenue to Provider shall not exceed twenty-five thousand dollars and zero cents ($25,000). b. 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 the date first written above and end on September 30, 2022 unless terminated earlier in accordance with Section 14 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. Insurance Services Office Form CG 00 01 covering CGL on an "occurrence" basis, including products and completed operations, property damage, bodily injury and personal & advertising injury with limits no less than $1,000,000 per occurrence. If a general aggregate limit applies, either the general aggregate limit shall apply separately to this projecttlocation (ISO CG 25 03 or 25 04) or the general aggregate limit shall be twice the required occurrence limit. 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. Consultant shall maintain all insurance required above in full force and effect for the entire period covered by this Agreement. ii. Certificates of insurance shall be furnished to the City upon execution of this Agreement and shall be approved by the City. iii. 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. iv. Where the amounts or coverage provided by the certificates of insurance provides coverage greater than those listed by this Agreement, the amounts provided by the certificates of insurance shall be incorporated by reference into the Agreement. V. Consultant shall supply City with a fully executed additional insured endorsement. 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. e. The Executive Director of Human Resources and the Risk Manager, reserve the right to reduce, waive, or modify insurance requirements under this Agreement. 6. INDEMNIFICATION Provider agrees to defend, and shall indemnify and hold harmless the City, its officers, agents, employees, Providers, 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 harness 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. CONFIDENTIALITY If Provider receives from the City information which due to the nature of such information is reasonably understood to be confidential and/or proprietary, Provider agrees that it shall not use or disclose such information except in the performance of this Agreement, and further agrees to exercise the same degree of care it uses to protect its own information of like importance, but in no event less than reasonable care. "Confidential Information' shall include all nonpublic information, including but not limited to student records. Confidential information includes not only written information, but also information transferred orally, visually, electronically, or by other means. Confidential information disclosed to either party by any subsidiary and/or agent of the other party is covered by this Agreement. The foregoing obligations of non-use and nondisclosure shall not apply to any information that (a) has been disclosed in publicly available sources; (b) is, through no fault of the Provider disclosed in a publicly available source; (c) is in rightful possession of the Provider without an obligation of confidentiality; (d) is required to be disclosed by operation of law; or (e) is independently developed by the Provider without reference to information disclosed by the City. 8. COVID-19 ASSUMPTION OF RISK AND WAIVER Provider acknowledges that Provider could be exposed to persons that may have COVID- 19 providing services pursuant to this Agreement. Provider understands that interacting with any person currently comes with the inherent risk of exposure to COVID-19 and that COVID-19 is highly contagious. Provider assumes the risks associated with providing services pursuant to this Agreement, namely potential exposure to COVID-19. Provider acknowledges that while some people have no symptoms or mild symptoms from COVID-19, some people have become seriously ill requiring hospitalization and that some people have died from COVID-19. Provider acknowledges that persons over the age of 65 and persons with underlying health conditions are at greater risk of contracting COVID-19 and are potentially risking serious injury or death. Provider is agreeing to provide classes pursuant to this Agreement and does so of Provider's own free will. Provider intends to be legally bound by this assumption of risk, release and waiver and to bind Provider's heirs, personal representatives, next of kin and anyone who may make a claim on Provider's behalf. Provider knowingly releases and waives any and all claims that Provider may have or could have in the future and includes any claims resulting from potential exposure or actual exposure to COVID-19, this includes claims for personal injury, transmittal of COVID-19 to others, and/or wrongful death. Provider agrees to hold harmless, defend and indemnify the City, its public officials, officers, employees, volunteers, and agents from any and all claims for liability or damages, including those for exposure to or diagnosis with COVID-19 as a result of providing services pursuant to this Agreement. 9. 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. 10. BACKGROUND CHECK Provider shall ensure that all employees, and any volunteers are fingerprinted and background checked prior to conducting any work pursuant to this Agreement. Provider shall not assign any employee, agent, subcontractor, volunteer or the Provider personally to provide services pursuant to this Agreement, if that employee, agent, subcontractor, volunteer, or the Provider personally are required to register as a sex offender under California Penal Code Section 290 et seq, have a conviction for any crime of moral turpitude, have a conviction for a sexual based crime, have a conviction for a violent felony as defined in California Penal Code Section 667.5(c), or has a conviction for a serious felony as defined in California Penal Code Section 1192.7(c). Disqualifying convictions include but are not limited to, violations of California Penal Code Sections 37,128,136.1 with Section 186.22, 187,190-190.4 and 192(a), 205, 206, 207-209.5, 211, 212, 212.5, 213, 214, 215, 218-219, 220, 236.1(b) or 236.1(c), 243.4, 261, 261.5, 273.5, 262, 264.1, 266, 266c, 266h, 266i, 266j, 267, 269, 272, 273a, 273ab, 273d, 285, 286, 288, 288a, 288.2, 288.3, 288.4, 288.5, 288.7, 289, 290, 311.1, 311.2, 311.3, 311.4, 311.10, 311.11, 314, 347(a), 368, 417(b), 451(a),518 with 186.22, 647.6, 65311(c), 664 and 187, 667.5(c), 18745, 18750, or 18755, 12022.53, 11418(b)(1) or (b)(2); Business and Professions Code Section 729. 11. 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 fast 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 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 To Provider: Mr. Rodrigo Salomon Rivera 709 S. Parton Street Santa Ana, CA 92701 Phone: (714) 713 -8204 or(714) 541-3506 Email: mrhipsnn,latinhips.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. 12. 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. 13. 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. 14. 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 1 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. 15. WAIVER No waiver of breach, failure of any condition, or any right or remedy contained in or granted by the provisions of this Agreement shall be effective unless it is in writing and signed by the party waiving the breach, failure, right or remedy. No waiver of any breach, failure or right, or remedy shall be deemed a waiver of any other breach, failure, right or remedy, whether or not similar, nor shall any waiver constitute a continuing waiver unless the writing so specifies. 16. 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. 17. NON-DISCRIMINATION Provider shall not discriminate because of race, color, creed, religion, sex, marital status, sexual orientation, gender identity, gender expression, gender, medical conditions, genetic information, or military and veteran status, 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. 18. 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. 19. 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. Provider shall notify the City immediately and in writing of their inability to obtain or maintain such permits, licenses, approvals, waivers, and exemptions. Said inability shall be cause for termination of this Agreement. 20. 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. 21. EXHIBITS All Exhibits referenced herein and attached hereto shall be incorporated as if fully set forth in the body of this Agreement. 22. 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. N-2021-200 IN WITNESS WHEREOF, the parties hereto have executed this Agreement the date and year first above written. ATTEST: APPROVED AS TO FORM: SONIA R. CARVALHO City Attorney Deputy City Attorney RECOMMENDED C IN Executive Director of Parks, Recreation and Community Services Agency CITY OF SANTA ANA KrWe Ridge - City Manager Jim -""tom Rodrigo Salomon Rivera Exhibit A SCOPE OF SERVICES A. Provider shall conduct Introduction to Latin Dance -Beginner & Advance class for ages 18 years old to Adults 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. Latin Dance Beginners Partners not required for this class. Salomon will be introducing the most important skills to understand and learn to dance Salsa, Bachata, Cha cha cha and Cumbia. At the end of this session, you will have enough knowledge to enjoy yourself at any Latin party. INSTRUCTOR: Salomon Rivera LOCATION: EI Salvador Center, 1825 W. Center St., Santa Ana, (714) 647-6559 Latin dance (Beg) class that will consist of monthly sessions, held 1 day per week, 1 hour per day Latin Dance Advance Class is designed for those who love to dance even without a partner. In this class, Salomon will teach solo footwork and routines with many Latin rhythms, including Salsa, Bachata, Cha-cha-cha and Cumbia. INSTRUCTOR: Salomon Rivera LOCATION: El Salvador Center, 1825 W. Center St., Santa Ana, (714) 647-6559 Latin dance (Adv) class that will consist of monthly sessions, held 1 day per week, I hour per day. 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 1) Each class must have a minimum of 3 paid students and no more than 10 students. 2) No registration accepted after the second meeting of classes. 3) If the minimum registration not 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 remaining classes that were cancelled in that session. CLASSFEES 1) Each participant shall pay class registration fees as established by City. 2) Provider may not waive class participation/registration fees. 3) Only registered participants may participate in class. 4) Any refunds to participants will be made in accordance with City policy. 5) Any materials fee shall be established by mutual agreement of City and Provider and shall be payable directly to Provider. A. Instructor and participants shall wear a mask at all times to participate. B. Temperature will be taken at the beginning of the class for instructor and participants. C. Social Distancing should be adhered to at all times. D. State of California COVID-19 regulations shall apply FrancineR, Digitally signed by Francine R. R. Villareal Villareal Date: 2021.07.1915:58.04 .Arun' "`� CERTIFICATE OF LIABILITY INSURANCE DAM MM0DNYYYJ 0512612021 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 po icy(jes) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVEDsubject to the terms and conditions of the policy, certain policies may require an endorsement A statement on this certificate does not confer i rhts to the certificate holder in lieu of such endorsements . PRODUCER CONTACT NAME: Mass Merchandising UndeWyfRing K&K Insurance Group, Inc. 1712 Magnavox Way Fort Wayne IN 46804 PN NE NoNo at): 1-800-506-4656 p/C Ne; 1-260-459-5590 ADDRESS: info@rdnessinsurance-kk.com MUuUQLH CUSTOMER ID: INSURER(S) AFFORDING COVERAGE NAIC# INSURED INSURER A: Nationwide Mutual Insurance Company 23787 Salomon Rivera INSURER B: 709 S. Parton St Santa Ana, CA 92701 INSURERC: INSURER D: A Member of the Sports, Leisure & Entertainment RPG INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: W01955619 RFVI.CInm NIIMIRFR- 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 TYPE OF INSURANCE ADDL INSO UBR WVO pODCY NUMBER P F MMIO POLICY MMIDD/YYYY UNITS A X COMMERCIAL GENERAL LIABILITY MADE OCCUR X 6BRPG000OD07446200 06/01/2021 12:01 AM EDT 06/01/2022 12:01 AM EACH OCCURRENCE $1,000,000 DAMA PREMISES Ea Ocwnence $ 1,000,000 GEN'L MED UP(Any one person) $5,000 PERSONAL &ADV INJURY $1.000.000 GENERAL AGGREGATE $5,000,000 AGGREGATE LIMIT APPLIES PER POLICY PRO- JECT LOC OTHER: PRODUCTS—COMP/OP AGG $1,000,000 PROFESSIONAL LIABILITY $1,000,000 LEGAL LIAR TO PARTICIPANTS $1,000,000 AUTOMOBILE LIABILITY ANY AUTO OWNED AUTOS SCHEDULED ONLY LJ AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY NOT PROVIDED WHILE IN HAWAII COMBINED SINGLE L M Ea accident BODILY INJURY (Per persen) BODILY INJURY(Peraccident) Per accident UMBRELLA DAB OCCUR EXCESS LIAR CLAIMS -MADE DELI RETENTION EACH OCCURRENCE AGGREGATE WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANYPROPRIETOR/PARTNEW Y/N EXECUTIVE OFFICERIMEMBER ❑ EXCLUDED? (Mandatory in NH) Ryes, desodba under DESCRIPTION OF OPERATIONS below NIA PER STATUTE OTHER E.L EACH ACCIDENT E.L DISEASE —EA EMPLOYEE E.L DISEASE—POUCV LIMIT MEDICAL PAYMENTS FOR PARTICIPANTS PRIMARY MEDICAL EXCESS MEDICAL DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be atFachad if more space is required) Non -certified Instructor of. Salsa The certificate holder is added as an additional insured, but only for liability caused, in whole or in part, by the acts or omissions of the named insured. CERTIFICATE HOLDER CANCELLATION City of Santa Ana Risk Management Division SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 20 Civic Center Plaza, 4th Floor THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Santa Ana, CA 92702 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE (Owner/Lessor of Premises) Coverage is only extended to U.S. events and activities. lrMto "NOTICE TO TEXAS INSUREDS: The Insurer for the purchasing group may not be subject to all the insurance laws and regulations of a Risk l+q REV isle marlagenlerdDtliatlm ® APPRCNB1n p4m r nee P, vd� ACORD 2E (2016103) ©1988-2016 A The ACORD name and logo are registered marks of ACORD l Risk Management Analyst POLICY NUMBER: 6BRPG0000007446200 COMMERCIAL GENERAL LIABILITY CG 20 26 0413 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 Persons Or Organization(s) City of Santa Ana Risk Management Division 20 Civic Center Plaza, 4th Floor Santa Ana, CA 92702 Named Insured: Salomon Rivera 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 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 omissions or the acts or omissions of those acting on your behalf: 1. In the performance of your ongoing operations; or 2. In connection with your premises owned by or rented to you. However: 1. The insurance afforded to such additional insured 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 insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide 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 contractor agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. CG 20 26 04 13 © Insurance Services Office, Inc., 2012 Of RldrMnsagrnuntlxvlelon , �����j�\ (RenavreD&ArPaovaoft rM�htM.l �. ViUNbc� ® Ruk Management Analyst POLICY NUMBER: 6BRPG0000007"6200 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY INSURANCE -ADDITIONAL INSURED This endorsement modifies insurance under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM SECTION IV —COMMERCIAL GENERAL LIABILITY CONDITICNS, 4. OtKer Insurance, a. the fc4lowing is added: Coverage afforded under this Policy is primary insurance and OTHER INSURANCE shalt not apply as respects to the additional insured named below, however this insurance does not apply to the sole negligence of such additional insured. Further, we will have no duty to defend such additional insured against any suit to which this insurance does not apply. Additional Insured: City of Santa Ana, officers, agents, employees, and volunteers Risk Management Division 20 Civic Center Plaza Santa Ana, CA 92702 Effective: 06101/2021 —0610112022 Named Insured: Salomon Rivera CP# 37 SRPG8018 E. RlekMnwganadDMsLn Rentwm n Appwv®BY: lL V:t!LvreL ® Risk Manzgemenl Anzlyrt POLICY NUMBER: 6BRPG0000007446200 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CANCELLATION This endorsement modifies insurance under the following: COMMON POLICY CONDITIONS, A_ Cancellation, 2_b_ is deleted and replaced by: 30 days before the effective date of cancellation if we cancel for any other reason. This endorsement applies only to the insureds designated below: Named Insured: Salomon Rivera Additional Insured: City of Santa Ana, officers, agents, employees, and volunteers Risk Management Division 20 Civic Center Plaza Santa Ana, CA 92702 Effective: 06/0112021 — 06/0112022 Named insured: Salomon Rivera CP# 37 SRP68018 Rick Mougen dMisiot REMEWM&APRaMRr WO Risk Management Anyst 0Tv o aA Y7,A A lbvA RtS;,q IAANACZAtW 4 4.&i-., # HkAAAN If ; III lip a* +""We Omw WORKERS' COMPENSATIQN DECLARA711ON Salomon Rivera hereby affirm under penalty cif perjury, the following declaration: I certify on 'behalf cif Salomon Rivera that during the term of any contract for -)once services with the City of Santa Aria, 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 the provisions and provide proof of workers' compensation coverage immediately. rrllt ; June 10, 2021 Print Name: Salomon Rivera Print Title: lance 'Instructor Telephone: (714) 713-8204 WARNING, FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNi.I VVF"Ji AND St'HAI I :5UBJE TAN EMPLOYER To CRIMINAL PENALTIES AND CIVIL FINES UP IO ONL HUNDRED THOUSAND D0(I..ARJ5 i,5JC0,QW), IN ADDITION TO THE COST OF COMPLNSAIlC, N. OAM.AG( SAS PROVIDED FOR IN SECTION .S706 OF THE LASOR CODF, IN7rFRFST, AND ATTORNFY'S YFES. 1,4 k tr?gmi9lnw+orse Rr +t rn,tsi.;c u�4nGrrt p C9iS2rAi.' R Rl8kMVW9VAadDMs1on REMEWM&A-MMED9Y: ��—�' Rlsk Management Analyst Woman 1U, wra 709 9 pmw.,&L Sots Aft VA. W114 713421134 10010 jUno 1,0� 0021 RE Aft rAouw"R"UftWn1 Dear My or SaWih Arta RU Manage mient Olviolon. "Omni AW&I hu tit to oda into an agmewd iployft, Chy algufta Am Throupowil; Um! 6ourso ofThfo agirwrnim, Pmpo , 9 WkWoo,' MUD, a, Salomon, IFOVOra Nub J, wll�e 0690M auan ta d tram �T 71r, Mfi[72. an og%ftmoW vAlh the offy of Soft An ifts well ithe I"W kft.h; 1Y to Rugg 90'MO gatam emsom It 40. QN1' 60% A is kwd that lWaWM noA"j 191W odhe"UIMW swomeft InAms dMinounill, arld'hoo AOt POVJdOd 90. MK IMUM AUD 1190111Y 111W&ftCO w** 0! si villrion -W owrom ow comm WAI be 0owderad im am yak and the cdMpWW will be bdd IW]y IWO for SM and ON 04OU". Rkk DiMslm RW APPRaJm BY: Pz, vj&w� Risk Management Analwt 8014101*4 at"m lospumst Sop III Ask CA. [ftAVpQvHc.wm iN 11134M V I iv k 021 Oy' '011omAw niomw"t"I"I Ixosi" 20. cav*10mbli-PIU4, Ufa AmN CA IWO Rc Pffift4oW UkUkohni AUM Idlurmt Reqkmcm mad Mumt cf IA*dlly,, MftrO(Y of, Silmls A -ma RiA MamWmv4- lHiftsm flltOM IN Cif OMMAUUSAWty. I tm 0 1 t Z" I *Swlo: MV M, Zft Dum Ch M M a um W Oe Pot'. 1"82 5 w "Itemwojivc. SFU Avjt� C& abmw% ��:;=DBY. F4,0� R j&IIAI R¢k Manage'ment Analyst FrancineR, Digitally signed by Francine R. R. Villareal Date: 2021.07.1915:58:04 Villareal CERTIFICATE OF LIABILITY INSURANCE DATE(MMI)o/YYYY) 05/26/2021 TH S CERT F CATE IS SSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO R GHTS 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. MPORTANT: 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 this certificate does not confer rights to the certificate holder In lieu of such endorsements . PRODUCER K&K Insurance Group, Inc. 1712 Magnavox WayINC,No Fort Wayne IN 46804 CONT TNAME: Mass Merchandising Underwrtbng PN NE 1-800-506-4856 Eat: Nc No: 1-260-459-5590 ADDRESS: info@fitnessinsumnce-kk.com PRODUCER CUSTOMERID: INSURER(S) AFFORDING COVERAGE NNC4 INSURED INSURER A: Nationwide Mutual Insurance Company 23787 Salomon Rivera 709 S. Parton St Santa Ana, CA 92701 INSURERS: INSURER C: INSURER D: A Member of the Sports, Leisure & Entertainment RPG !SURER E: !SURER F: COVERAGES CERTIFICATE NUMBER- WM9RRR19 DCTACrnu unaa000. 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 LTR TYPE OF INSURANCE INSD R MD POLICY NUMBER EFF MMa1 EXP MMIDD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS. X OCCUR MADE X BBRPG0000007446200 06/01/2021 12:01 AM EDT 06/012022 12:01 AM EACH OCCURRENCE $1,000,000 AMA E T D PREMISES Ea Occurrence $1,000,000 MED EXP (Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GENERALAGGREGATE $5,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POUCY OJEa ❑LOC PRODUCTS—COMP/OPAGG $1,000,000 PROFESSIONAL LIABILITY $1,000,000OTHER' LEGAL LIAR TO PARTICIPANTS $1,000,000 AUTOMOBILE LIABILITY ANY AUTO OWNED AUTOS SCHEDULED ONLY AUTOS NON -OWNED AUTOS ONLY AUTOS ONLY NOT PROVIDED WHILE IN HAWAII N LIMIT Eaccident a BODILY INJURY (Per parson) BODILY INJURY (Per accident)HIRED Per accident UMBRELLAIJAB OCCUR EXCESS LIAB CLAIMS -MADE DEO P RETENTION EACH OCCURRENCE AGGREGATE D WORKERS COMPENSATION ANPER EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNER/ YIN EXECUTIVE OFFICER40u1EMBER EXCLUDED?(Mandatory in NH) El Ryes, describe under DESCRIPTION OF OPERATIONS bebw N/A STATUffELJ OTHER E.L EACH ACCIDENT E.L DISEASE —EA EMPLOYEE E.L DISEASE —POLICY LIMIT MEDICAL PAYMENTS FOR PARTICIPANTS PRIMARY MEDICAL EXCESS MEDICAL DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached! R more space Is required) Non -certified Instructor of: Salsa The certificate holder is added as an additional insured, but only for liability caused, in whole or in part, by the acts or omissions of the named insured. LCR I IrMA 1 C MULUCK CANCELLATION City of Santa Ana Risk Management Division SHOULD ANY OF THE ABOVE DESCRIBED P L CIES BE CANCELLED BEFORE 20 Civic Center Plaza, 4th Floor Santa Ana, CA 92702 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE (Owner/Lessor of Premises) Coverage is only extended to U.S. events and activi8es. "NOTICE TO TEXAS INSUREDS: The Insurer for the purchasing group may not be subject to all the insurance laws and regulations of 1r` �MmWwd�sc` [CREVIEW/®& APPROVEO BY: ACORD 25 ( ) ©1988-2015 Al2016103 r�Y..n.e P. t The ACORD name and logo are registered marks of ACORD Risk Management Anaryst POLICY NUMBER: 6BRPG0000007446200 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 Persons Or Organization(s) City of Santa Ana Risk Management Division 20 Civic Center Plaza, 4th Floor Santa Ana, CA 92702 Named Insured: Salomon Rivera 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 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 omissions or the acts or omissions of those acting on your behalf: 1. In the performance of your ongoing operations; or 2. In connection with your premises owned by or rented to you. However: 1. The insurance afforded to such additional insured 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 insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide 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 contractor agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. CG 20 26 04 13 C Insurance Services Office, Inc., 2012 _ ... "Mm gatDMdvn n ltsmEw 6 Avntuvm Sr: �V;tGs,,.,�[ ®' Risk Management Ana[pt POLICY NUMBER: 6BRPG0000007446200 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY INSURANCE - ADDITIONAL INSURED This endorsement modifies insurance under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS, 4. Other Insurance, a the following is added: Coverage afforded under this Policy is primary insurance and OTHER INSURANCE shall not apply as respects to the additional insured named below, however this insurance does not apply to the sole negligence of such additional insured_ Further, we will have no duty to defend such additional insured against any suit to which this insurance does not apply. Additional Insured: City of Santa Ana, officers, agents, employees, and volunteers Risk Management Division 20 Civic Center Plaza Santa Ana, CA 92702 Effective: 06/0 U2021 — 06101 /2022 Named insured: Salomon Rivera SRPGO018 Risk MuNgenenEDhialm REVEwm& Sr. �' Risk Management Analyst POLICY NUMBER: 6BRPG0000007446200 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CANCELLATION This endorsement modifies insurance under the following: COMMON POLICY CONDITIONS, A. Cancellation, 21- is deleted and replaced by: 30 days before the effective date of cancellation if we cancel for any other reason. This endorsement applies only to the insureds designated below: Named Insured: Salomon Rivera Additional Insured: City of Santa Ana, officers, agents, employees, and volunteers Risk Management Division 20 Civic Center Plaza Santa Ana, CA 92702 Effective: 06/01/2021—0610112022 Named Insured: Salomon Rivera CP# 37 SRPG8018 5 y RleleM1tiDugemmLDMdon RwEwm&Ar. Rov®Br. 8l K'� F4,� I\. V�(Ltn.ucC �4XWF Risk Management Analyst RW MANACEMENTa 4ow4w aj'Hk*m I Flisc�zac s IMi1A� � ays�p�lr�IMlll Ci1�11�b WORKERS' COMPENSATION DECLARATION I Salomon River hereby -affirm under penalty of perjury, the f.gavr .1rlrrfi,l following declaration: I certify on behalf,of Sallornon Rivera fCurar,u«tu!tt�,FCtx�ti�r:y twr�r�,I that during the terra of my contract for Dame . _ services withthe City of Santa Ana, frFw of I will not employ any person in any manner SO as to become subject to the workers' compensation taws of California, and agree that if I should become subject to the workers` compensation provisions of Section 3700 of the Labor Cade, I shall forthwith cornPly with the provisions and provide proof of workers' compensation coverage immediately, June 10, 021 Print Salomon Rivera Print Title: Rance Instructor Signature: Te?ephone �1 471 3$204 WARNING, FAILURE TO SEcu,?E WORKERS' COMPENSATION COVEFtAGE IS UNLAWFUL_ AND SHAI I SURJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES Ufa r� 0, E HUN'DRED THOUSAND DO11.AkS (,� CO OCO}, IN ADDIT IONTO THE COST OF COMPEi'+`SAIION, 0AM,ACt,5 AS PRCIVIOEO FOR IN SIeC' I ON 5706 0-- THE LASC)R =)F., INTERFST, AND A7TCIRNCY-S FFFS. t��.s rr'gm<9.�nwuorcr P.ca,�.*e�:.;n,r,}7 ff �pn`crn •�+ 1a�iSc't�i4 C R twEoBr. Risk Management Analyst ft;"mian Rimpra 709 9 PWW SL Samia AmN tA. 714 134204 Rec AOmourwvm,ROVjIeSMOMt r Cky of SmaAla Fftk (ManogementDGvt a WW; M'S hgg ilawt b edw. Into an sgre nl +a he iho Chy olgma Ana t :. a - Y.- a.,. is a- •.0 n. ',,...; e _ i!,: 1 .1n ly,�l:.. i,!( M•A d :: P, �rt�a• NIN 'iGY.g .� N �i �� 1!N'� Y ,1 kw%'011i -ICUTNIP�`y ipY01?.I IC:d Ali q.-it; i;�o y.,I. 1 k1;;� i 'hF� Psi �9 t.'I y I..j,�i I�qi �-4'i Yi ;� r•i'..:t,. 'tl ,Ip P:a.tl- A d� A N 1 i?PIB i4'2 9-- •11 .}'N-` Y:,i:a it ; •the o Hamm a as welf �� the 1 ®il I�uill�rl�r to e�tast ti�l the memsab ii '1D%A iel►g WNRIB#( � CIS fil W'8086M10OWN' lit• goo.uocuMoo and boo not pAWOO Vw Min IMUM AUM, IlaWliry 10OWWOO Boole otili Million r '. Vm'wdW w M be corodbrod,rr4F#1 sW wW, eW the cdffipwW will be hdd My I bte for wW and all Owa I . seItietClWCbO� t(['16m t rw-1114 1"13 iamdfm; n IPS I)TWiLosa+4 y RIekM mgnnetttrnvWwt <9 yt REmeNmSAPPRw®BY: . J ' f�aw,:� f% VtlLcnrd �' Risk Management Analyst rs soulam awft lospawfit. afIllo Auk CA. Niv k 2-fib 00Y.10"ALIN Am RIA Moot I W 6" i6 aiv piffA, USIA Ank tAW42 M PIvft'dMW UIKIir3vMd AUM imaltsm Rcqubmm ind Railtm of IAWJIIV, NarCMY of, SamilAtia Righ Mop Mpa-W Miftkw FAVOM, Oil RivtM MAM iMMAMMM, bfttW IVIWM The 04! d. AWMARtUdifily, I do Ra lk"ffiwaynblett kbDmm Mid loft, fig"Not "Wh 6kchy, AM60"ILY4 [dftW*IimWPwW0d ditsirS *60" iftflay. &maa !X* The Rom 14" 1, no] *Wsh N%fn ZOML Dir" ctm*% m ulwAtor PA. IIINS w comw Djivc. S" AmaP CA, Rkk MwwgnnwL DMalon REMEWED &APPROVED 13Y. p '. Risk Management Malpt 01