HomeMy WebLinkAboutAG 20-546 - A+ DentalRETURN TO. TIM JOHNSON EXT, 2412
CITY OF FEDERAL WAY LAW DEPARTMENT ROUTING FORM
1. ORIGINATrNG DEPT/DIV.- A_ECONQNK�P�P
2. ORIGINATING STAFF PERSON: _11M joHNSoLq EXT. --2412 3. DATE Q. BY: ASAP
4. TYPE OF DOCUMENT (CHECK ONE):
u CONTRACTOR SELECTION DOCUMENT (E.G., R.FB, RFP, RFQ)
C3 PUBLIC WORKS CONTRACT 0 SMALL OR LIMITED PUBLIC WORKS CONTRACT
• PROFESSIONAL SERVICE AGREEMENT 11 MAINTENANCE AGREEMENT
• GOODS AND SERVICE AGREEMENT 0 HUMAN SERVICES / C
• REAL ESTATE DOCUMENT 0 SECURITY DOCUMENT (E.G. BOND RELATED DOCUMENTS)
• ORDINANCE 11 RESOLUTION
• CONTRACT AMENDMENT (AG#)-._ OINTERLOCAL
• OTHER —CARES ACT FjNDS BUS SSS RTGRANTAGREE ENT
5. PROJECT NAME: —CARES ACT GRANT — ROUND I
6. NAME OF CONTRACTOR: A4-DENTA1:CO9_
ADDRESS: 33516 r AVE S #9, FEDERAL WAY, WA 98003 TELEPHONE: (425) 301-8391
E-MAIL: HsHAHRASBI @YAHOO.COM
SIGNATURE NAME: HOSSEIN SHAHRASBI, D.D.S. TITLE: SEE ATTACHED
7. EXHIBITS AND ATTACHMENTS: 0 SCOPE, WORK OR SERVICES D COMPENSATION 0 INSURANCE REQUIREMENTS/CERTLFICATE 0 ALL
OTHER REFERENCED EXHB31TS UPROOF OFAUTTIORITYTO SIGN 0 REQUIRED LICENSES OPRIOR CONTRACT/AMENDMENTS
8. TERM: COMMENCEMENT DATE: EE ATTACHED AGREEMENT COMPLETION DATE:
9. TOTAL COMPENSATION$ (INCLUDE EXPENSES AND SALES TAX, IF AN�SAND AND NO/100 ($VOO.00)
(IF CALCULATED ON HOURLY LABOR CHARGE - ATTACH SCHEDULES OF EMPLOYEES TITLES AND HOLIDAY RATES)
REIMBURSABLE EXPENSE: 0 YES X NO IF YES, MAXIMUM DOLLAR AMOUNT: S
IS SALES TAX OWED CIYES X NO IFYES,S_ -PAID BY: 0 CONTRACTOR 0 CITY
RETAINAGE: RETAiNAGEAmouNT: 0 RETAINAGE AGREEMENT (SEE CONTRACT) OR 0 RETAINAGE BOND
PROVIDED
13 PURCHASING: PLEASE CHARGE TO:
10. DOCUMENT/CONTRACT REVIEW
INITIAL / DATE REVIEWED INITIAL/ DATE APPROVED
0 PROJECT MANAGER
C&f)IRECTOR
�'3
El RISK MANAGEMENT (IF APPLICABLE)
0 LAW
11. COUNCIL APPROVAL (IF APPLIC ABLE)
SCHEDULED Co EE DATE: CONMTTEE APPRovAL DATE:
SCHEDULED CouNc[L DATE: CouNcil, APPRovAL DATE:
12, CONTRACT SIGNATURE ROUTING
• SENT TO VENDOR/CTOR
SE T: DATE RECD,
• ATTACH: SIGNATURE AUTHORITY, INSURANCE CERTIFICATE, LICENSES, EXHIBITS
11 CREATE ELECTRONIC REMINDER/NOTIFICATION FOR I MONTH PRIOR TO EXPIRATION DATE
(Include depL supports if ncoessray and feel free to set notification more than a month in advance if council approval is needed.)
INITIAL DATE SIGNED
0 L�A I DEPARTMENT
GNATORY (v[1AYOR OR DIRECTOR)
40
0 CITY CLERK
El ASSIGNED AG#
AG # A—
COMMENTS:
1/2020
Vill ill IFFIR
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Q*roiutee "P are located and do business at.. the'bees wt�ich al be Valid v y
notic e-teligyxitYd.
r:ffiis�e
a
WIN WUNUM "I
335: o 6 S# 9
FED Y
NVA:9800
(425) 301-8391 0,10hoW,
OF
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Im
1. jj�gg Thisagreement pp#COMIateS a one-time: gmtit of IWS tO the: biar6e undevthe�. cob"ons
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OR!
for.. the ipuoos'
eg:
�OES� ACT BUSMBS MANTAOMMENT , I
M=
Grantee: agrees to retain receipts documenting use of: grant tmds and will provide: them: to the City-ol.rjts,
designee upon request,
® JEMW_ATTON. Should any of thezonditions described inseetion 2.1, above, not bemet,, the: City:
m a y r
rcover all disbursed grant funds and terminate thi&:agreernent.
4. GRANT AMOUNT.
�1111111111 !I 111 11 11 111 111 11 .
not to exceed T" and N01100 D611aft ($2,000,00).
4.2: Non-Appropna—tion, of, FLjd If sufficientbanar. 0
ds _e ta iated -orall
ppropri ally ted` for -payment,
ement Ci will t to
under this Agte for:.any fiscat period, the tot be obligated make payments under this
agreemevL
5. jkMg�MU_CA_T1ON.
r7t
these c6vtbAnf§ of d6m&fication.
Milli '11
O"E SS GRANTAGREENENT
Title., 6p
DATO, 2 '?1 W 2
CARES ACT BUSINESS GRANT AGREENIENT -4-
8/12/2020 eServices
M.101SUPAIWIT1111,13- TIN
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t Services Business Lookup A+ DENTAL COSMETIC & IMPLANTS
... ...... .......... .. ..
License Information:
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Entity name:
HOSSEIN SHAHRASBI, D.D.S., P.S.
Business name:
A+ DENTAL COSMETIC & IMPLANTS
Entity type:
Professional Service Corporation
UBI #:
603-179-479
Business ID:
001
Location ID:
0003
Location:
Active
Location address:
33516 9TH AVE S STE 9
FEDERAL WAY WA 98003-6322
Mailing address:
33516 9TH AVE S STE 9
FEDERAL WAY WA 98003-6322
Excise tax and reseller permit status: Click here
Secretary of State status:
Click here
Endorsements
Endorsements held at this location License # Count Details
Status
Expiration date
First issuance
Dental X-ray/CTI Pan/Ceph 5
Active
Feb -28-2021
Nov -08-2013
Federal Way General Business
Active
Jul -31-2021
Jul -30-2020
X -Ray: Dental/Podiatric/Veterinary
Active
Feb -28-2021
Nov -08-2013
Governing People May Include governing people not registered with Secretary or State
Governing people Title
SHAHRASBI, ABDOLHOSSEIN
Registered Trade Names
Registered trade names Status
First issued
A+ FAMILY DENTISTRY Active
Nov -25-2019
The Business Lookup information is updated nightly. Search date and time: 8/12/2020 4:16:28 PM
https://secure.dor.wa.gov/gteunauth/—,/#92 1/1
