The URL can be used to link to this page

Home My WebLink AboutZAPATA, MICHAEL 1A-2013City of Santa Ana Clerk of the Council AGREEMENT TERMINATION FORM Please complete this form when the attached agreement and all C amendments (if any) are no longer in effect. i Return form to the Clerk of the Council Office (M-30). Call 647-1520 if you have any questions. The agreement with No. 14-2013A22-001 was completed on (List all amendments. Use space below if needed.) COTC Office Use Only MUG 21 F11 4: 57 F SANTA ANA OF COUNCIL ,0/@ol and final payment has been made. Department:PRCSA Phone/Ext.: (42 k� Signature: Date: !Iq,(RoC 01 Revised 10-31-12 iMURANCE ON FILE N-2013-122-001 MAYOR `� PROCEED CITY MANAGER -Miguel A. PulidoRK UNTIL INSURANCE EXPIM David Cavazos MAYOR PRO TOM ode %- { CITY ATTORNEY Sal Tinajer° CLERK OF COUNCIL, "p Sonia R. Carvalho COUNCIL MEMBERS 0ATE5 JUN t 0 201� .�..E CLERK OF THE COUNCIL Angelica Amezcua ! ®, p� ( 1) Maria D, Huizar P. David Benavactin Michele Martinezz CITY OF SANTA ANA Roman A. Reyna Vincent F. Sarmienzo PARKS, RECREATION AND COMMUNITY SERVICES AGENCY 20 Civic Center Plaza P.O. Box 1988 e Santa Ana, California 92702 June 2, 2014 Michael Zapata 2130 S. Lewis Street, Apt. 103 Anaheim, CA 92802 Re: Agreement N-2013-122, Karate Instruction Program Dear Mr, Zapata, Pursuant to Section 3 Term, of Agreement N-2013-122, which you entered with the City of Santa Ana, dated August 19, 2013, the time period of said Agreement, which is set to expire June 30, 2014, is hereby extended for an additional two (2) years, through June 30, 2016. The insurance certificates are required to be extended and/or renewed to cover this extension. All other terms and conditions of said Agreement remain unchanged and in full force and effect. If you have any questions regarding this matter, please contact Silvia Cuevas in the Parks, Recreation and Community Services Agency at 714-647-525 Sincerely, ---; —21 � GERARDO MOLIET Executive Director Parks, Recreation and Community Services Approved as to Form: David Cavaz city Manager city of Santa Ana ATTESM PROVIDER MICHAEL ZQPATA c: Clerk of the Council Exhibit A SCOPE OF SERVICES - Michael Zapata/Karate Do Kiai A. Provider shall conduct Martial Arts techniques for children 3%2-16 year olds B. Karate Do Kiai for ages 3 Y2-8 year olds, held Monday & Wednesday, 2 days per week, 50 minutes per day- first class is $20/per month, and second is $25/per month C. Karate Do Kiai for ages 9-16 year olds, held Monday & Wednesday- 2 days per week, 50 minutes per day- $25/per month. Family Discount $5.00 off for families 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 Providers' insurance. Provider shall provide City with documentation to verify instructor and insurance requirements. Black -belt rated students may warm up beginning students, however, Provider must be present at all times. CLASS SIZE REGISTRATION A. The minimum number or participants is 5 per class, the maximum is 50. B. No registration will be accepted after the second week of classes. 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 Provider compensation. FEES A. Each participant shall pay a $20.00/$25.00 monthly. Anticipated class revenue not to exceed $25,000.00 annually. B. No refunds will be made to participants after the commencement of a session unless the class is cancelled by the City. C. The City shall collect registration fees from each participant during the registration period. Provider shall not collect fees, but shall refer all interested participants to City for registration. D. Provider shall receive seventy percent (70%) of the total fees collected each month. City and Provider agree that City shall retain thirty percent (30%) of the fees collected as an administration fee. E. Provider agrees that City is entitled to audit Provider's records and classes to insure compliance EVANSTON INSURANCE COMPANY CERTIFICATE NO.: 2014-22 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 Newport Beach, CA 92658 License No: OC 36861 NAMED INSURED (EVENT HOLDER): EVENT INFORMATION: Michael Zapata TYPE: Martial Arts 2130 S. Lewis Street DATE(S): 01/31/14—12/31/14 Anaheim, CA 92802 LOCATION: Santa Anita 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. 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 policy listed and it does not constitute a contract between the insurance carrier, authorized representative, producer and certificate holder. The insurance described herein is subject to all the terms, exclusions and conditions of such policy(ies). INSURANCE CARRIER: Evanston Insurance Company MASTER POLICY NUMBER: SEP41014 MASTER POLICY DATES: EFFECTIVE: JANUARY 1, 2014 EXPIRATION: JANUARY 1, 2015 COMMERCIAL GENERAL LIABILITY OCCURRENCE FORM DEDUCTIBLE: NONE General Aggregate Limit $ 2,000,000 Products & Completed Operations 1,000,000 Personal & Advertising Injury 1,000,000 y V A TO FORM Each Occurrence Limit 1,000,000 Fire Damage (Any One Fire) 100,000 Medical Payments (Any One Person) 5,000 Liquor Liability (If purchased) 1,000,000 Optional Limits Purchased '? I a1 ❑ $1,000,000/$3,000,000 IODGE ❑ $2,000,000/$2,000,000 rant it y Attorney Property Damage (If purchased) ❑ Limit $50,000 Deductible $500 ❑ Limit $100,000 Deductible $1,000 The limits of insurance apply separately to each event insured by this policy as if a separate policy of insurance has been issued for that event. "Who is insured" is amended to include, as an insured, the person or organization shown in this schedule, but only with respect to liability arising out of the ownership, maintenance or use of the premises used by the named insured (event holder). This insurance does not apply to: Any `occurrence" which takes place after the event holder ceases to be a tenant in that premises. OTHER ADDITIONAL INSUREDS Geraldine Valencia 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 3, 2014 by Briza Morales EVANSTON INSURANCE COMPANY CERTIFICATE NO.: 2015-13 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 Newport Beach, CA 92658 License No: OC 36861 NAMED INSURED (EVENTHOLDER): EVENT INFORMATION: Michael Zapata TYPE: Martial Arts 208 W. Wilken Way DATE(S): 1/16/15 — 12/31/15 Anaheim, CA 92802 LOCATION: Santa Anita and Garfield Centers P N _,``�,.f '"-�� *Liquor Liability Yes [I 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: SEP41017 MASTER POLICY DATES: EFFECTIVE: JANUARY I, 2015 EXPIRATION: JANUARY 1, 2016 COMMERCIAL GENERAL LIABILITY OCCURRENCE FORM DGDUC"1113LL: NONE General Aggregate Limit S 10W0(lo Products & Completed Operations I,000MR) SPECIAL CONDITIONS: Personal & Advertising Injury I,0o(1,o0o The following endorsements attached to Each Occurrence Limit 1.000.000 the Master Policy do not apply to this Damage To Premises Rented 'I'o You (Any One Premises) 100,000 Certifeate Of Insurance- Medical Payments (Any One Person) 5,000 Liquor Liability (If purchased) 1,000,000 Optional Limits Purchased ❑ $1,000,000/$3,000,000 ❑ S2,000,00052,000,000 Damage To Property (If purchased) The limits of insurance apply separately to each event insured by this policy as if a separate policy of insurance has been issued for that event. OTHER ADDITIONAL INSUREDS Geraldine Valencia Flor Hernandez CANCELLATION: Should the above described policy be cancelled before the expiration date thereof, notice will be delivered in accordance with the policy —visions, pro AUTHORIZED REPRESENTATIVE: DATE ISSUED: January 16 2015 by Briza Morales