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Home My WebLink AboutSALGADO, SILVIA 1ACity of Santa Ana Clerk of the Council AGREEMENT TERMINATION FORM Please complete this form in its entirety when the attached agreement and all amendments (if any) are no longer in effect. 2 Note: If your agreement is grant related, please ensure that all grant retention requirements Cij have been satisfied prior to signing the termination form. _, Is the agreement(s) a permanent record? Yes No Return form to the Clerk of the Council Office (M-30). Call 647-1520 if you have any questions. The agreement with No. N-2016-014-001 was completed on (List all amendments. Use space below if needed.) core uttice use unry ?I Pet * 9 K OF COUNCIL p t3l 120ijand final payment has been made. Department: Mc S A Phone/Ext.: 'ARM Signature:l,�i�n/ Date: Revised: 10-1 a-16 ;o,o fANCE ON FILE U h MAY PROCEED IL INSURANCE EXPIRES OL---/n-; 117 MAYOR Miguel A. PuildoCL MAYOR PRO TEMDA VloantaSarmiento COUNCILMEMBERS Angelica Amezcua P. David Benavides Michele Martinez a Roman Reyna Sal Tinajero CITY Silvia Salgado 610 S. Clara St, Santa Ana, CA 92703 OF SANTA ANA PARKS, RECREATION, AND COMMUNITY SERVICES AGENCY 20 Civic Center Plaza M-23 • P.O. Box 1988 M-23 Santa Ana, California 92702 zm,§9akI-ana.orq November 23, 2016 Re: Extension of Recreation Services Agreement Agreement No. N-2016-014 Dear Ms. Salgado: CITY MANAGER David Cavazos CITY ATTORNEY Sonia R. Carvalho CLERK OF THE COUNCIL Marta D. Hulzar Pursuant to Section 3 of the above -referenced agreement between you and the City of Santa Ana, the term of such Agreement is hereby extended for an additional one (1) year period, from January 1, 2017 through December 31, 2017. All insurance certificates are required to be extended and/or renewed to cover this extension, All other terms and conditions of the Agreement remain unchanged and in full force and effect. Sincerely, Gerardo Mouet, Executive Director Parks, Recreation, and Community Services Agency CITY+, 7 S bavid Cavazos City Manager APPROVED AS TO FORM J# M. Funk Assistant City Attorney ATTEST AMaria D. Huizar Clerk of Council SANTA ANA CITY COUNCIL hNque! A. Pulido Nncente. Sarmlanto Mchele hMninez Angaitca Amezcua P. David aenaWtles Roman Rayna Sa! Tinetero Mayor Mayor Pro Tarn. Ward t 1 Ward i WVd3 1 Ward4 Ward5 ! Ward6 MF,d'tlofi)asMa-arw.am VSem!eeMfa�,santa-arta am � �LAgQ igSd$santa.ana am l AAmezcueAwtaans w0 reNdesR'Dsanie-ana om RRematol p(�- I ^jFy � MOM EVANSTON INSURANCE COMPANY CERTIFICATE NO.: 635U3362887259633 CERTIFICATE OF INSURANCE SPECIAL EVENT LIABILITY PROGRAM PRODUCER PUBLIC ENTITY (ADDITIONAL INSURED) Alliant Insurance Services, Inc. in conjunction with City of Santa Ana Apex Insurance Services P. 0. Box 6450 Newport Beach, CA 92658 License No: OC 36861 NAMED INSURED (EVENT HOLDER): EVENT INFORMATION: Silvia Salgado TYPE: Aeroblcs 610 S Clara St DATE(S): 02/01/2016 - 02/01/2017 Santa Ana, CA 92703 LOCATION: Jerome 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. The insurance described herein is subject to all the terms, exclusions and conditions of such policy(ics) unless amended as described in Special Conditions. INSURANCE CARRIER: Evanston Insurance Company MASTER POLICY NUMBER: SEP41020 MASTER POLICY DATES: EFFECTIVE: January 01, 2016 EXPIRATION: January 01, 2017 COMMERCIAL GENERAL LIABILITY General OCCURRENCEPORM DEDUCTIBLE. NONE Aggregate Limit $ 2,000,000 Products & Completed Operations 1,000,000 SPECIAL CONDITION& Personal & Advertising Injury 1,000,000 The following endorsements attached to Each Occurrence Limit 1,000,000 the Master Policy do not applyto this Damage To Premises Rented'1'o You (Any Ono Premises) 100,000 Ceetlftcate Of Iasarunce: Medical Payments (Any One Person) 5,000 Liquor Liability (If purchased) 1,000,000 Optional Limits Purchased ❑ $1,000,000/$3,000,000 El$2,000,000/$2,000,000 �041111 �'d ,Gt Property Damage (If purchased),/ No Property Damage Coverage 1-0110 Gu.0° VA The limits of insurance apply separately to each event insured by this policy as if separate policy ofAVONins e has b t even[ OTHER ADDITIONAL INSUREDS CANCELLATION: Should the above described policy be cancelled before the expiration date thereof, notice will be delivered in accordance with the policy provisions. AUTHORIZED REPRESENTATIVE: DATE ISSUED: WORKERS' COMPENSATION DECLARATION I Silvia Salgado hereby affirm under penalty of petjury, the (Nmnefritle) following declaration : I certify on behalf of Silvia Salgado that during the term of my (Consultam/Company Name) contract for Rpnrpatinn (aaccpc 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, 1 shall forthwith comply with those provisions and provide proof of workers' compensation coverage. DATE: I Z" /" 16 44 „� Name: Silvia Salgado Title: Recreation Class Instructor Telephone: 714 488-9919 WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE 1S 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 1N SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. EVANSTON INSURANCE COMPANY CERTIFICATE NO.: 2017-08 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: Silvia Salgado TYPE: Zumba 610 S Clara St. DATE(S): 01/01/17-12/31/17 Santa Ana, CA 92703 LOCATION: Jerome Center *Liquor Liability YesEl No C I . Lip C) I i cy"�� I "Liquor Liability after 12 am ends before 2 a E] 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: SEP41023 MASTER POLICY DATES: EFFECTIVE: JANUARY 1, 2017 EXPIRATION: JANUARY 1, 2018 COMMERCIAL GE"NFRAL LIABILITY OCCURRENCE FORM DEDUCTIBLE: NONE General Aggregate Limit $2,000,000 Products & Completed Operafions 1,000,000 SPECIAL CONDITIONS: Personal & Advertising Injury 1,000,000 The following endorsements attached to Each Occurrence Limit 1,000,000 the Master Policy do not apply to this Damage To Premises Rented To You (Any One Premises) 100,000 Cerr t )of. InSffance: Medical Payments (Any One Person) 5,000 Liquor Liability (if purchased) I'mo,000 Optional Limits Purchased k $1,000,0001$3,000,000 $2,000,000/$2,000,000 Coe 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 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: December 20, 2016...by Stella Faiard WORKERS' COMPENSATION DECLARATION I Silvia Salgado hereby affirm under penalty of perjury, the (Nance,, tle) following declaration I certify on behalf of Silvia Salgado that during the term of my (ConsulLint/Company Name) contract for Recreation 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: By:; , Name: SiMa Salgado Telephone: 714 488-9919 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„ INTEREST, AND ATTORNEY'S FEES.