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AG 13-016RETUKN TO: �xT: � � � CITY OF FEDERAL WAY LAW DEPARTMENT ROUTING FORM 1. ORIGINATING DEPT./DIV: 2. ORIGINATING STAFF PERSON: �AV ic� 5�1n v�„� .L J, _ EXT: (�°I 2 5 3. DATE REQ. BY: 4. TYPE OF DOCUMENT (CHECK ONE): ❑ CONTRACTOR SELECTION DOCUMENT (E.G., RFB, RFP, RFQ) ❑ PUBLIC WORKS CONTRACT ❑ SMALL OR LIMITED PUBLIC WORKS CONTRACT ❑ PROFESSIONAL SERVICE AGREEMENT ❑ MAINTENANCE AGREEMENT ❑ GOODS AND SERVICE AGREEMENT ❑ REAL ESTATE DOCUMENT ❑ ORDINANCE ❑ CONTRACT AMENDMENT (AG#):_ �OTHER M , D. V . 5. PROJECT NAME: ❑ HUMAN SERVICES / CDBG ❑ SECURITY DOCUMENT �E.G. BOND RELATED DOCUMENTS) ❑ RESOLUTION ❑ INTERLOCAL 6. NAMEOFCONTRACTOR: verareCh Seniar G1�1� ADDRESS: �O R I a ��+ �� �y�t R R o D� TELEPHONE 2.53 -°I +i 5- 6 a I o E-MAIL: FAX: SIGNATURE NAME: _�j ��� h���� Y y„„ TITLE � e 5 i d e n� 7. EXHIBITS AND ATTACHMENTS:�i.SCOPE, WORK OR SERV[CES ❑ COMPENSATION ❑[NSURANCE REQUIREMENTS/CERTIF[CATE ❑ ALL OTHER REFERENCED EXHIBITS ❑ PROOF OF AUTHORITY TO SIGN ❑ REQUIRED LICENSES ❑ PR[OR CONTRACT/AMENDMENTS 8. TERM: COMMENCEMENT DATE: �„. (� 2 o I� COMPLETION DATE: nec 3l ,_ 2o I�i 9. TOTAL COMPENSATION $ � o h,� (INCLUDE EXPENSES AND SALES TAX, [F ANY) (IF CALCULATED ON HOURLY LABOR CHARGE - ATTACH SCHEDULES OF EMPLAYEES TITLES AND HOLIDAY RATES) REIMBURSABLE EXPENSE: � YES ❑ NO IF YES, MAX�tUM DOLLAR AMOUNT: $ IS SALES TAX OWED ❑ YES ❑ NO [F YES, $ PAID BY: ❑ CONTRACTOR � CITY ❑ PURCHASING: PLEASE CHARGE TO: �( %� _ 10. DOCUMENT/CONTRACT REVIEW �PROJECT MANAGER Y�DIRECTOR ❑ RISK MANAGEMENT ([F �P[,�C.�[,E) �LAW II�iITIAL / DATE RE IEWED II�TITIAL / DATE APPROVED �S 1 a 1► � z �I.� __ � ���_ '.� . � 11. COUNCIL APPROVAL (IF APPLICABLE) COMMITTEE APPROVAL DATE: COUNCIL APPROVAL DATE: 12. CONTRACT SIGNATURE ROUTING . ❑ SENT TO VENDOR/CONTRACTOR DATE SENT: DATE REC'D: ❑ ATTACH: SIGNATURE AUTHORITY, INSURANCE CERTI�'ICATE, LICENSES, EXHIBITS � LAW DEPARTMENT '� SIGNATORY (1v�AYOR oR nixEC'rOR) B � CITY CLERK �ASSIGNED AG# �SIGNED COPY RETURNED COMMENTS: I1�IITIAL/DAT SIGN D - S� / �.S '� A # � �-CS �,�.(1 DATE SENT: I" I �D-I,,�_ _L. � ��%�% � ����Zi � � u � .� � � � !�� � i �7 L ��' i,.� , � , - . r Memorandum of Understanding Evergreen Senior Club City of Federal Way and Evergreen Senior Club THIS MEMORANDUM OF LTNDERSTANDING ("MOU"), dated effective this 1 St day of January 2013, defines the respective responsibilities of the City of Federal Way ("City") and the Evergreen Senior Club in connection with the Senior meal program at the Federal Way Community Center. Background A. The City and Evergreen Senior Club desire to enter an agreement for use of space at the Federal Way Community Center for a twice weekly meal program from January 1, 2013 through December 31, 2014. B. The City of Seattle has provided funding for a congregate meal program to the Evergreen Senior Club to serve an unmet need in the community. The congregate meal program is donation based and provides warm nutritious meals to low income seniors. C. The City will provide space at the Federal Way Community Center located at 876 S 333� Street, Federal Way WA. 98003 for the purpose of offering a ethnic low income congregate meal program provided by the Evergreen Senior Club. D. The Evergreen Senior Club has permission to use the community rooms and kitchen or other space designated by the Federal Way Community Center on Tuesdays and continued use on Thursdays. Time of use for the Evergreen Senior Club is from 8:00 a.m. until 1:00 p.m. both days. E. The City will provide a separate list of dates outlining the dates that are not available for use by the Evergreen Senior Club or space may be reduced or the meal program moved to another location in the building to accominodate for other uses of the Community Center. F. No party shall be responsible for events that are unforeseeable and beyond its reasonable control, such as acts of God, weather delays or government restrictions. G. This MOU may be terminated by either party with 30 days' notice. NOW, THEREFORE, the parties agree as follows: I. Citv Resaonsibilities. The City agrees to provide the following: • Dining areas and kitchen facilities on the days outlined above. • Tables, chairs and appropriate kitchen equipment. • List of dates that the Evergreen Senior Club will be moved to another location in the building, which may affect the number of people that can be served and a list of dates that the building is not available. Dates/times/locations subject to change. Evergreen Senior Club will be notified two weeks in advance of any schedule change for use of the building not included in the Memorandum of Understanding in writing. II. Evergreen Senior Club Responsibilities • Evergreen Senior Club acknowledges that this agreement is for temporary use of space at the Federal Way Community Center on Tuesdays and will develop an alternative location for continuation of services in 2015. It is understood that a request may be made at the end of this term to continue the meal program at the Federal Way Community Center. • Provide a congregate meal program on Tuesdays and Thursdays at the Federal Way Community Center on the days and times provided above. • Qualified cooks who hold current required permits and training • All food is to be purchased and provided by the Evergreen Senior Club at their sole expense • All paper and plastic products including, but not limited to plates, napkins and utensils are to be purchased and provided by the Evergreen Senior Club at their sole expense • The Evergreen Senior Club is responsible for cleaning the community rooms, kitchen and all equipment after each day of use. • The Evergreen Senior Club is solely responsible for managing it's inventory of food to insure safety and freshness • The Evergreen Senior Club is solely responsible for any fines they incur due to violations of health codes. • The Evergreen Senior Club will provide and maintain a comprehensive general liability insurance policy with limits of Two Million dollars ($2,000,000) per occurrence specifically naming the City of Federal Way additionally insured. This policy shall include personal injury, bodily injury or property claims of the Evergreen Senior Club Services and its agents. • The Evergreen Senior Club will report any damage or malfunctioning equipment to designated Federal Way Community Center staff upon discovery. • The Evergreen Senior Club will agree to repair or replace at their expense any damaged equipment caused by misuse by the Evergreen Senior Club. • The Evergreen Senior Club will only use the designated refrigerator storage space that has been assigned to them. • The Evergreen Senior Club will assist in paying for quarterly kitchen cleanings, limited to no more than the amount of $300.00 per quarter. • This MOU sets forth the intent of the parties herein. [Signature page follows] IN WITNESS, the City and Evergreen Senior Club execute this MOU, effective the last date written below. CITY OF FEDERAL WAY � G�� Cary M. Roe, P. . Director of Parks, Public Works, & Emergency Management DATE: / lS �3 EVERGREEN SENIOR CLUB By: �% � Printed Name: 1 . Title: j DATE: 1a2-- �./ —,,�?D f�, STATE OF WASHINGTON ) ) ss. COUNTY OF � ) ATTEST: ity Clerk, Carol Mc illy, CM APPROVED AS TO FORM: City Att y, Patricia A Richardson On this day personally appeared before me �e��id B. Lkvv►q , to me known to be the _����e,wry / d�rcc�o�r of �.�erqreen SGV�;ar Gl�b that executed the foregoing instrument, and acknowledged the said instrument to be the free and voluntary act and deed of said corporation, for the uses and purposes therein mentioned, and on oath stated that he/she was authorized to execute said instrument and that the seal affixed, if any, is the corporate seal of said corporation. GIVEN my hand and official seal this �/ day of l.� e. , 201�- NOTARY PUBUC STATE OF WASHINGTON JISOO KIM My Appointment Expires JULY 09, 2016 Notary's signature � Notary's printed name rdao �t„�r ' Notary Public in and for the State of Washington. My commission expires �T�j , d 9, �ii � � A�°�'°� CERTIFICATE OF LIABILITY INSURANCE °iv2o��W°o �'� THIS CERTiFICATE iS lSSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFlCATE HOLOER THIS CER'rIFlCA7E DbES N07 AfflRMATNELY OR NEGATNELY AMEND, EXTEND OR ALTER TFfE COVERAGE AFFORDEO BY THE pOLiC1E5 BELOW. THi3 CER7IFICATE OF INSURANCE OOES NOT CONSTITtJ�E A CONTRACT BE7WEEN THE 155UiNG INSURER(S�, AUTHOR1ZEp REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER IMPORTANT: ff tlee certifscate holder is an ADDITIONAL fNSURED, the policy(iea) must be endwsed. If SUBROGATION IS WAIVED, subject !o tha terma and conditions c! the Qolicy, cer�ain policies may require an endorsement A statemerR on this oertificate does not confer rigl� to the certiRcate holder in iieu of such endoiseme�s). �"O� MIKE MANIDICK wn : CHRISMANDICK 10233 BRiDGEPORT WAY SW � : 25358&3633 rb 2 sos Q LAKEWOOD, WA 98499 �'�'�� ; CHRIS MIKEMANDtCK.COM � INSURER 8 AFFONDINO COVERA(�E NAIC A wsul�R A: State fartn Fire and Com n '"�^E° EVERGREEN CLUB n�un�RB: THE KOREAN SENIORS '"g""��� PO BOX 4623 INSURERD: F�DERAL WAY, WA 98063-4623 "'���' COYERAGES CERTIFICATE NUMBER: EtEYfS10N NUMBER: 7HlS IS TO CER11fY THAT Ti1E POLtClES OF INSURANCE U5TEQ BELOW HAVE BEEN tSSUED TO THE II�ISURED NIWIED A�VE FOR THE POUCY PERIOD �IDICAIED. N0T1MfHSTANDING ANY REqUiREMENT, TERM OR CONDfTION OF ANY CONTRACT OR OTIiER DOCUMENT NATH RESPEG7 70 WFIICH THIS CER7IRCATE MAY 8E ISSUED OR MIIY PERTAIN, THE INSURAPICE AFFORDED BY THE POLICIES DE9CRI�D HEREIN !S Sl16JECT TO ALL THE TERMS. D(CLUSION5 AND CONDfiIONS OF SUCH pOf.ICFES. LIMITS SHOWN MAY HAVE 9EEN REDUGED BY PAID CLAtMS- �� rwE oF i�suw►r� B roucr xumaat Pouer �F voucr exa � a��� ��y Y 98-C9-6418� DTHOV2012 07/1012073 EACH OCCIiRRENCE 5 2.00O,U00 X C6MYEl�IAL GENERAL UABILRY PRENISES Ea oac�arenoe t 300,000 CiA1MSMAOE ❑X OCCUR M� ExP Arhr One plrcaf) 9 5�000 PERSONAL i ADV INJURY S 2.000,000 GENERpL AGGREOATE S 4,006,000 GEMLAGGREGATELINRAPPUEBPER: PRODUCTS-C�IPIOPAGG i 4,000,000 X Pot�cv P�O' wc i 11tIT04A0�LE W18MY Q� D SINGLE R s �y ��O BOUILY II�1RY (i�r p�non) s AlLL1TOS�ED �oESULED BODkLY1NAJRY(Perar�denq i HIREDAUf05 Allr�OS1NNED PaeooOert � S f ��u � OCCUR EACH OCCURREMCE i 611Cli5lUi6 CLNMS-MADE ALiQI�OATE S OED RETENTlONf : WORKEIlB CMIPEN50.TION WC STATU- OTH- N�0 FIMPLOriRS tJA�LITY I uMIT, ANY PROPRIETORlPAtt7NERfEXECU714E Ya N 1 A E.l EACH ACCIflEM' t OFfICE1MEMBER EXCWOED? (Yud�me�r in Nlq E.L �ISE/�SE • EA EMPIOYE i nra*, aea� �.�ew E�.as�se-aoucruMK s OESCIOPf10N OF OPERIlT10TIS f IOClI710NS ! VENICLES (Atbch 11CORD 701. AdmtiaW R�emlu SeMdulq N ma� �pacs i� n4u6ef) USE OF FEDERAL WAY COMMUNlTY CENTER CITY OF FEDERAL WAY SMOULD ANY OF 7FIE ABOYE OESGRBED POLIt�ES BE CANCELLED BEF�E THE EXPIRATION DATE THEt2E0F, NO710E YYILL � OELNEftED IN PO BOX 9718 ACGORDANCE iMTFt TFIE POLJGY PROVISIONB. FEDERAL WAY� WA 96063-8T18 �un+o er�ra (4188 2010 ACORD CORPORATION. All �IgMs reselvQd. ACORO 2S (201NO3) The ACORD name and loya are ragiste►ed marks of ACORD 10W486 132849.7 03-01-2012 SK ppllCy NO. 98-C9-6418-4 � 05/11/05 15-2604-F480 ADDITIONAL INSURED ENDORSEMENT Cont�olling Interest POIICy NO.: 98-C9-6418-4 Ndmed Insured: EVERGREEN CLUa THE KOREAN SENIORS ' Name of Person o� Organization: CITY OF FEDERAL t+IAY PO BOK 9718 FEDERAL NiAY WA 98063-9718 WHO 13 AN INSURED, under SECTION il DESIGlVA7101� �F INSURED, is amended to include as an insured the person or orgenization shown above, but only with respect to their liability arising out of: . 1. their financial coritrol of you; or � � � a3 FE-6493 (`��) .,.., .... � �rue�rcL 2, premises they own, maintain or conRrol whEle you lease or occupy those premises. This insurance does not apply to structural alterations, new construction or demolition operations performed by or for that person or organizaiion. FE-6493 � Primed In U S A. (�'et ) . Business Licensing Service:License Query Search • Contact us • Forms • About us • Home • Start vour business • Chanae or update vour business information • How to renewyour license Search Business Licenses License Information: Entity NaMe: EVERGREEN CLUB-THE KOREAN SENIORS Business Name: EVERGREEN CLUB-THE KOREAN SENIORS license Type: Washington SWte Business Enti Tyqe: Nonprofit Corporation UBI: 601389572 Business ID:001 Location ID:0001 StatuS: To check the status of this company, go to Secretarv of State and Denartment of Revenue. Location Address: 31003 14TH AVE S# C-10 FEDERAL WAY, WA, 98003 Reyistered Trade Names: EVERGREEN CLUB-THE KOREAN SENIORS Governing Peonle: CHUNG KWI YOUN DAVID CHUNG MYOUNG OK LEE SOOK YE LEE YUL MO DONG Mailing Address: 31003 14TH AVE S# C-SO FEDERAL WAY, WA, 98003 Status Active Expires N/A Information Current as of O1/02/2013 5:43AM Pacific Time j New Searoh � This site is limited to searching for business licenses issued through the Washington State Business Licensing Service. • Contact us • FortnS • About us • Priv �02011 Washin ton State Department of Revenue and its licensors. All rights reserved. First Issued OS/21/1992 Page 1 of 1 http://bls.dor.wa.gov/LicenseSearch/1qsLicenseDetail.aspx?RefID=2105359 1/2/2013