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HomeMy WebLinkAboutSMALL, PETER M.City of Santa Ana Clerk of the Council AGREEMENT TERMINATION FORM Please complete this form when the attached agreement and all amendments (if any) are no longer in effect. Note: If your agreement is grant related, please ensure that all grant retention requirements have been satisfied prior to signing the termination form. Return form to the Clerk of the Council Office (Nl-30) . Call 647-1520 if you have any questions. The agreement with No. N-2016-084 (List all amendments. Revised: 0 1-07-1 6 was completed on Use space ,below if needed.j COTC office Use Only G 20 � (Q PN-ERK' -OF THE COUKIL - 3 Ply --:29 and final payment has been made. Department: P � L (2) A Phone/Ext.: Signature: Date: qA�'�IQA i q INSURANCE ON FILE WORK MAY PROCEED UNTIL. INSURANCE EXPIRES CLERK OF COUNCILOY f DATE: AN 2 2 2016 & pRcso1 5,1 MaCue\0,3 June 9, 2016 Peter M. Small ("Speaker/Performer") P.O. Box 3452 Fullerton, California 92834 Re: Speaker/Performer Engagement Agreement N-2016-084 This letter represents your agreement with the City of Santa Ana ("City") as entered into on the above date for the engagement described below: 1. Event Description: Historical Re-enactment Services, character: George Washington 2. Date(s): Monday, July 4, 2016 3. Event Time(s): 6:00 pm to 9:30 p.m. 4. Location: Show will be presented at �I+Raarp;z'tiCrw si ftnt­�, Santa Ana CA 942-T*("Property„) 5. Compensation: $225 (payable by check on the day of the event) provided agreement is fully executed; SpeakerlPerformer must provide IRS form W-9 before payment can be made 6. Equipment provided by City: none 7. Equipment provided by Speaker/Performer: all supplies, costumes, and equipment, required for the show 8. City Contact Person (for coordinating purposes only): Sonia Buttes Independent Contractor: Speaker/Performer 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 professional manner in which Speaker/Performer performs the services that are the subject matter of this Agreement; however, the services to be provided by Speaker/Performer shall be provided in a manner consistent with all applicable standards and regulations. Speaker/Performer 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, 10, Indemnification: Speaker/Performer, his or her agents, or employees (if applicable) agrees to and shall indemnify, defend, and hold harmless the City, its officers, agents, employees, consultants, special counsel, and representatives from and against all loss, expenses, or liability (including costs and attorney's fees) arising from the negligence or willful misconduct of Speaker/Performer, his or her agents, or employees. IL Release: Speaker/Perfortner accepts the Property and any City -provided equipment used in connection with the performance in their "as -is" condition, with all faults. Speaker/Performer fully releases, waives and discharges forever any and all claims, demands, rights, and causes of action of any kind or nature against, and covenants not to sue, City, its elected officials, officers, employees, agents and volunteers, and all persons acting on behalf of, by, through or under each of them, under any present or future laws, statutes, or regulations for any claim or event relating to the condition of the Property or City -provided equipment or Speaker/Perfortmer's use thereof. Letter Agreement — Peter M. Small Page 2 12. Commercial General Liability Insurance. SpeakerlPerformer shall maintain commercial general liability insurance naming the City, its officers, employees, agents, volunteers and representatives as additional insured(s) and 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 Speaker/Performer'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, with $2,000,000 in the aggregate. Such insurance shalt: (1) name the City, its officers, employees, agents, volunteers, and representatives as additional insureds; (2) be primary and not contributory with respect to insurance or self-insurance programs maintained by the City; and (3) contain standard separation of insured provisions. 13. Worker's Compensation Insurance. In accordance with the California Labor Code, Speaker/Performer, if Speaker/Performer has any employees, is required to be insured against liability for worker's compensation or to undertake self-insurance. 14. The City shall have the right and royalty -free license to simulcast or produce and show a tape -delayed broadcast of Speaker/Performer's presentation to the City community or general public, through webcast or any other means. This license shall be non-exclusive and the copyright shall remain with the Speaker/Performer. Copies of Speaker/Performer's presentation may be maintained by the City, and Speaker/Performer consents to use of such recordings. 15. Speaker/Performer shall not discriminate because of race, color, creed, religion, sex, marital status, sexual orientation, age, national origin, ancestry, disability, or any other basis protected by applicable law in connection with any activities related to this Agreement. 16, This Agreement shall in all respects shall be interpreted, enforced, and governed exclusively by and under the laws of the state of California. Both parties 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. 17. This Agreement represents the complete and exclusive statement between the City and Speaker/Performer regarding the subject matter herein and supersedes any and all other agreements, oral or written, between the parties. This Agreement may not be modified except by written instrument signed by the City and by an authorized representative of Speaker/Performer. Please execute this letter to reflect your agreement to the terms and conditions set forth herein. Cl O� SA TANA S& A. RIVI� d� DAVID C VAZOS y: City Manager PETER M. SMALL ATTEST: APPROVED AS TO FORM: M &4d t eel • ' By; ' . atr1ARIA D. IIUIZAR ,i0 r . FUNK Clerk of the Council Assistant City Attorney RECOMMENDED FOR PPROVAL �s )lay GERARDO MOUET, Executive Director, Parks, Recreation, and Community Services Agency 5CQPE QF SERVICES PETER M. SMALL IMPRESSIONIST P.O. BOX 3452, FULLERTON, CA 92834 TELEPHONE: 949-631-2703, cell: 760-717-9666E-MAIL; historyaliveS@hotmail.com, WESSITE: www.history-alive.com INVOICE Submitted to City of Santa Ana for services performed on and at: Date: Monday, July 4, 2015 Time: 6:00-9:00 P.M. Place: Independence Day Event Program: George Washington Performer: Peter M. Small Paid to the order of: Peter M. Small Social Security Number: Amount to be paid: $225.00 Address: P.O. Box 3452, Fullerton, CA 92834 (Residence: 2117 Elden Avenue, #9, Costa Mesa, CA 92627) 'Vlles ;t'lully ubmit ed, � i Peter M. Small April 5, 2015 AC40R o CERTIFICATE OF LIABILITY INSURANCE DATE 618/2016 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(les) must 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 PRODUCER Paczolt Insurance Alliance One Westbrook Corp Center Suite 330 Westchester IL 60154 INSURED Peter M. Small, Historical Impressionist PIAI LLC al (708) 579-3126 _'AIC Nal: (988)333-1239 holly@paczolt.com INSURER(S) AFFORDING COVERAGE _ _ NAIC p 3URERAMesa Underwriters Specialty ins Co 136838 Peter M. Small INSURERD: PO Box 3452 INSURER E: Fullerton CA 92839 INSURER F: COVERAGES OFRTIFIr:ATF NIIMRFR.15-16 Peter M Small RFVIS Ir1N NI IMRFR- 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. INSIR LTR TYPE OFINSURANCE IADOLiSUBR'. POLICY NUMBER T POLICY EFF MMIDCIVYYY POLICY EXP DI N IDVYVV LIMITS X COMMERCIAL GENERAL LIABILITY I- A I 17 CLAIMS -MADE X OCCUR X i,. MEP0012009000283 10/6/2015 10 /6/2016I EACH OCCURRENCE II$ 1,000,000 DAMAGE TRENTED PREMISES Be occurrence $_ 100,000 _ MED EXP(Any one person) 5,000 _;_$ PERSONAL INJURY $ 1,000,000 GEN'L AGGREGrATE LIMIT APPLIES PER X'. POLICY AGGREGATE jET_ 71 LOC II ' i --- _ ,GENERAL AGGREGATE $ 2,000, 000 PRODUCTS - COMP/OP AGO $ 1,000,000 $ .. ., OTHER',,. ' AUTOMOBILE LIABILITY ANY AUTO ALL OWNED I,N SCHEDULED AUTOS F__. AUTOS _ HIRED AUTOS Ir I NON -OWNED AUTOS - COMBINED SINGLE LIMIT $ Eaecclden9__ _ - BODILY INJURY (Per person) II$ _ BODILY INJURY (Per accident) $ \n'R,I• ! PROPERTY DAMAGE - $ vYE 4< ereccdfmp $ UMBRELLA LIAB OCCUR N I EACH OCCURRENCE _ $ EXCESS LIA�ET ',. AGGREGATE $ DEpENTION$ GJ y WORKERS NSATION Y AND EMPLO ERSELIA ILIITV 'NIA ANY PROPRIETOR/ OFFICERIMEMBER EXCLUDIUEXECUTIVE (Mandan In NH �.� if yes, describe under DESCRIPTION OF OPERATIONS below '�° I PER STATUT BLEACH ACCIDENT ERH ... � EL DISEASE-POLICYLMIE $ $ _--- DESCRIPTION OF OPERATIONS ILOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) The Certificate Holder is listed as an additional insured with regard to liability and defense of suits arising from the operations and uses performed by or on behalf of the named insured. This insurance shall be primary and non-contributory to insurance or self-insurance carried by the City of Santa Ana The City of Santa Ana 20 Civic Center Plaza Santa Ana, CA 92701 P 11912"as!L1111i 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 Scheive/HOLLY ©1988-2014 ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD INS025 iPnlnnl i POLICY NUMBER: MP0012009000283 COMMERCIAL GENERAL LIABILITY CG 20 37 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Additional Insured Person(s) Or Organization(s): I Location And Description Of Completed Ooerations e City of Santa Ana, its officers, agents, employees and volunteers 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 insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury" or "property damage" caused, in whole or in part, by "your work" at the location designated and described in the schedule of this endorsement performed for that additional insured and included in the "products -completed operations hazard". <, sANSOR \r ;�G CG 20 37 07 04 © ISO Properties, Inc., 2004 Page 1 of 1 Insurance Company ADDITIONAL INSURED D ENDORSEMENT Mesa Underwriting Specialty Ins, Co. This endorsement modifies such insurance as is afforded by the provisions of Policy # MP0012009000283 relating to the following: 1. The City of Santa Ana, 20 Civic Center Plaza, Santa Ana, California 92701; its officers, employees, agents and volunteers 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 to the additional insureds, this insurance shall not be canceled, 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 06/09/2016 Policy # MP0012009000283 this endorsement form as a part of Issued to The Puppeteers of America I Peter M Small Named Insured. t �� -1i Countersigned by u rorl ere enta Ive CITY of SANrA ANA ) RISK MANAGEMENT 126 CIVIC CENTER PLAZA, SANTA ANA, CA 927011 Tr:L (714) 571-4200 WORKERS'COMPENSATION DECLARATION [ ete�M � hereby affirm under penalty of perjury, the (Naine/ri[le) following declaration: I certify on behalf of ({adz rrr d(r ��that during the tern of my (ConsulwantlCompoi Name) contract for /Q veA _ 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: �J-vn� �t, 2-01& M. 1 f/ Name: Title: h0i Tlr_-y V Telephone: 6s1_2-`70 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 ($I00,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. dvi 01\. ?a Cj$; ` p