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AG 15-129 II RETURN TO: EXT: CITY OF FEDERAL WAY LAW DEPARTMENT ROUTING FORM 1. ORIGINATING DEPT./DIV:PARKS 2. ORIGINATING STAFF PERSON:ROBE EXT: 2002 3. DATE REQ.BY:ASAP 4. TYPE OF DOCUMENT(CHECK ONE): I ❑ 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 ❑ HUMAN SERVICES/CDBG ❑ REAL ESTATE DOCUMENT ❑ SECURITY DOCUMENT(E.G.BOND RELATED DOCUMENTS) ❑ ORDINANCE ❑ RESOLUTION ❑ CONTRACT AMENDMENT(AG#): ❑ INTERLOCAL x OTHER CONCESSIONS AGREEMENT FOR RWBF 5. PROJECT NAME:GENERAL STORE CONCESSIONS 6. NAME OF CONTRACTOR:KIwANIS CLUB OF FEDERAL WAY ADDRESS:P.O.BOX 3232,FEDERAL WAY,WA 98003 TELEPHONE 206-793-8547 E-MAIL:DLARSON72 @COMCAST.NET FAX: SIGNATURE NAME:DAVE LARSON TITLE PRESIDENT 7. EXHIBITS AND ATTACHMENTS:❑ SCOPE,WORK OR SERVICES ❑ COMPENSATION ❑ INSURANCE REQUIREMENTS/CERTIFICATE ❑ALL OTHER REFERENCED EXHIBITS ❑ PROOF OF AUTHORITY TO SIGN ❑ REQUIRED LICENSES ❑ PRIOR CONTRACT/AMENDMENTS 8. TERM: COMMENCEMENT DATE:JULY 4,2015 COMPLETION DATE:JULY 4,2015 9. TOTAL COMPENSATION$N/A THEY PAY US (INCLUDE EXPENSES AND SALES TAX,IF ANY) (IF CALCULATED ON HOURLY LABOR CHARGE-ATTACH SCHEDULES OF EMPLOYEES TITLES AND HOLIDAY RATES) REIMBURSABLE EXPENSE:❑YES ❑NO IF YES,MAXIMUM DOLLAR AMOUNT: $ IS SALES TAX OWED ❑YES ❑NO IF YES,$ PAID BY:❑CONTRACTOR❑ CITY ❑ PURCHASING: PLEASE CHARGE TO: 10. DQCUMENT/CONTRACT REVIEW IN /DATE REVIEWED INITIAL/DATE APPROVED C7 PROJECT MANAGER 4,---- ❑ DIRECTOR 5 f t./!-r 7.15/ 4' /�, ' ❑ RISK MANAGEMENT (IF APPLICABLE) �,,, ❑ LAW Y ,GC, 0( f 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 CERTIFICATE,LICENSES,EXHIBITS INITIAL/D TE�}IGNED ❑ LAW DEPARTMENT Tat- co 15-11c ❑ CHIEF OF STAFF ❑ SIGNATORY(MAYOR OR DIRECTOR) / rp frS!/,r "A.CITY CLERK f 0--IS--(� ASSIGNED AG# AG Is"- 121 SIGNED COPY RETURNED DATE SENT: tJ 2Q itc ictA;COMMENTS: - .- . a.)_ .a. _11,.....4- 11/9 • _ ` CITY OF CITY HALL '�....., 33325 8th ue South Fe d e ra I Way FWay,Wayy,,WA 98003-6325 (253)835-7000 www cityoffederalway corn CONCESSIONAIRE AGREEMENT FOR RED,WHITE AND BLUES FESTIVAL This Concessionaire Agreement("Agreement")is made between the City of Federal Way,a Washington municipal corporation ("City"), and Kiwanis Club of Federal Way, a non-profit corporation ("Contractor"). The City and Contractor(together"Parties")are located and do business at the below addresses which shall be valid for any notice required under this Agreement: KIWANIS CLUB OF FEDERAL WAY: CITY OF FEDERAL WAY: Dennis Hulse, President Rob Ettinger P.O. Box 3232 33325 8th Ave. S. Federal Way, WA 98003 Federal Way, WA 98003-6325 (253) 835-2002 (telephone) (206) 793-8547(telephone) (253) 835-2010 (facsimile) Dlarson72@comcast.net Robe(acityoffederalway.com The Parties agree as follows: 1. TERM.The term of this Agreement shall commence upon the effective date of this Agreement,which shall be the date of mutual execution, and shall continue through the clean-up of the City's 4th of July Red, White and Blues Festival (the "Event") located at Celebration Park, 1095 S. 324th St.,Federal Way,WA on July 4,2015 ("Term"). 2. WORK. 2.1 Work. The Contractor shall provide goods, materials or services and otherwise perform the work more specifically described in Exhibit"A", attached hereto and incorporated by this reference ("Work"), performed to the City's satisfaction,within the time period prescribed by the City and pursuant to the direction of the Mayor or his or her designee. 2.2 Warranties.The Contractor warrants that it has the requisite training,skill,and experience necessary to provide the Work and is appropriately accredited and licensed by all applicable agencies and governmental entities,including but not limited to obtaining a City of Federal Way business registration. The Contractor warrants it will provide services in a manner consistent with the accepted practices for other similar services within the Puget Sound region in effect at the time those services are performed. 2.3 Clean Up.At any time ordered by the City and no later than 11:59 pm on July 4,2015,the Contractor shall,at its own expense, clean up and remove from Celebration Park all refuse and unused materials of any kind resulting from the Work. In the event the Contractor fails to perform the necessary clean up, the City may, but in no event is it obligated to, perform the necessary clean up and the costs thereof shall be immediately paid by the Contractor to the City and/or the City may deduct its costs from any remaining payments due to the Contractor. 3. / O TERMINATION.Either party may terminate this Agreement,with or without cause,upon providing the other party thirty days written notice at its address set forth on the signature block of this Agreement. The City may terminate this Agreement immediately if the Contractor fails to maintain required insurance policies,breaches confidentiality,or materially violates Section 9 and such may result in ineligibility for further City agreements. CONCESSIONAIRE AGREEMENT - 1 - RWBF— 1/2015 411‘, CITY OF CITY HALL "�•... h 33325 Federa Way Feder 8th Avenue South Federal Way,WA 98003-6325 �►..•/ (253) 835-7000 www cityoffederaiway.corn 4. COMPENSATION. 4.1 Amount. 4.1.1 Flat Rate Payment.The Contractor agrees to pay the City a one time flat rate of$125.00 for one 10x10 booth space. 4.1.2 Deposit Payment.The Contactor agrees to pay the City a one time refundable deposit of$125 to ensure the Contractor meets the conditions outlined in this Agreement. To receive a full refund, Contractor must meet all of the following:(1)meet all permit requirements,(2)pass health inspection at the Event,(3)be set-up on time as outlined in Exhibit A,and(4)be in compliance with the City-approved menu as outlined in Exhibit A.If the Contractor is not in compliance with any of the above requirements, a 25%fee for each unmet requirement will not be returned from the deposit payment. 4.2 Method of Payment.The Flat Rate and Deposit Payment to the City are due from the Contractor at the time this Agreement is executed. 4.3 Contractor Responsible for Taxes. The Contractor shall be solely responsible for the payment of any taxes imposed by any lawful jurisdiction as a result of the performance and payment of this Agreement. 5. INDEMNIFICATION. 5.1 Contractor Indemnification.The Contractor agrees to release indemnify,defend,and hold the City,its elected officials, officers, employees, agents, representatives, insurers, attorneys, and volunteers harmless from any and all claims, demands,actions,suits,causes of action,arbitrations,mediations,proceedings,judgments,awards,injuries,damages,liabilities, taxes, losses, fines, fees, penalties expenses, attorney's fees, costs, and/or litigation expenses to or by any and all persons or entities, including,without limitation,their respective agents,licensees,or representatives,arising from,resulting from,or in connection with this Agreement or the performance of this Agreement,except for that portion of the claims caused by the City's sole negligence. Should a court of competent jurisdiction determine that this Agreement is subject to RCW 4.24.115,then,in the event of liability for damages arising out of bodily injury to persons or damages to property caused by or resulting from the concurrent negligence of the Contractor and the City, the Contractor's liability hereunder shall be only to the extent of the Contractor's negligence. Contractor shall ensure that each sub-contractor shall agree to defend and indemnify the City, its elected officials,officers,employees,agents,representatives, insurers,attorneys,and volunteers to the extent and on the same terms and conditions as the Contractor pursuant to this paragraph. The City's inspection or acceptance of any of Contractor's work when completed shall not be grounds to avoid any of these covenants of indemnification. 5.2 Industrial Insurance Act Waiver. It is specifically and expressly understood that the Contractor waives any immunity that may be granted to it under the Washington State industrial insurance act,Title 51 RCW,solely for the purposes of this indemnification. Contractor's indemnification shall not be limited in any way by any limitation on the amount of damages,compensation or benefits payable to or by any third party under workers' compensation acts,disability benefit acts or any other benefits acts or programs. The Parties further acknowledge that they have mutually negotiated this waiver. 5.3 City Indemnification. The City agrees to release, indemnify, defend and hold the Contractor, its officers, directors, shareholders, partners, employees, agents, representatives, and sub- contractors harmless from any and all claims, demands,actions,suits,causes of action,arbitrations,mediations,proceedings,judgments,awards,injuries,damages,liabilities, losses,fines,fees,penalties expenses,attorney's fees,costs,and/or litigation expenses to or by any and all persons or entities, including without limitation,their respective agents,licensees,or representatives,arising from,resulting from or connected with this Agreement to the extent solely caused by the negligent acts,errors, or omissions of the City. 5.4 Survival. The provisions of this Section shall survive the expiration or termination of this Agreement with respect to any event occurring prior to such expiration or termination. CONCESSIONAIRE AGREEMENT - 2 - RWBF— 1/2015 CITY OF CITY HALL �.... Federal Way Avenue South � Feder Federal Way,WA 98003-6325 �../ ,rI (253) 835-7000 www cityoffederalway corn 6. INSURANCE.The Contractor agrees to carry insurance for liability which may arise from or in connection with the performance of the services or work by the Contractor, their agents, representatives, employees or subcontractors for the duration of the Agreement and thereafter with respect to any event occurring prior to such expiration or termination as follows: 6.1. Minimum Limits. The Contractor agrees to carry as a minimum,the following insurance, in such forms and with such carriers who have a rating that is satisfactory to the City: a. Commercial general liability insurance covering liability arising from premises,operations,independent contractors,products-completed operations,stop gap liability,personal injury,bodily injury,death,property damage,products liability, advertising injury, and liability assumed under an insured contract with limits no less than $1,000,000 for each occurrence and$2,000,000 general aggregate. b. Workers'compensation and employer's liability insurance in amounts sufficient pursuant to the laws of the State of Washington; c. Automobile liability insurance covering all owned, non-owned, hired and leased vehicles with a minimum combined single limits in the minimum amounts required to drive under Washington State law per accident for bodily injury, including personal injury or death, and property damage. 6.2. No Limit of Liability. Contractor's maintenance of insurance as required by the agreement shall not be construed to limit the liability of the Contractor to the coverage provided by such insurance,or otherwise limit the City's recourse to any remedy available at law or in equity. The Contractor's insurance coverage shall be primary insurance as respect the City. Any insurance, self-insurance, or insurance pool coverage maintained by the City shall be excess of the Contractor's insurance and shall not contribute with it. 6.3. Additional Insured,Verification. The City shall be named as additional insured on all commercial general liability insurance policies. Concurrent with the execution of this Agreement,Contractor shall provide certificates of insurance for all commercial general liability policies attached hereto as Exhibit`B"and incorporated by this reference. At City's request,Contractor shall furnish the City with copies of all insurance policies and with evidence of payment of premiums or fees of such policies. If Contractor's insurance policies are"claims made,"Contractor shall be required to maintain tail coverage for a minimum period of three(3)years from the date this Agreement is actually terminated. 6.4 Survival. The provisions of this Section shall survive the expiration or termination of this Agreement. 7. CONFIDENTIALITY.All information regarding the City obtained by Contractor in performance of this Agreement shall be considered confidential subject to applicable laws. Breach of confidentiality by the Contractor may be grounds for immediate termination. All records submitted by the City to the Contractor will be safeguarded by the Contractor. The Contractor will fully cooperate with the City in identifying, assembling, and providing records in case of any public records disclosure request. 8. INDEPENDENT CONTRACTOR/EMPLOYEE CONDITIONS. 8.1 Independence.The Parties intend that the Contractor shall be an independent contractor and that the Contractor has the ability to control and direct the performance and details of its work,the City being interested only in the results obtained under this Agreement. The City shall be neither liable nor obligated to pay Contractor sick leave, vacation pay or any other benefit of employment, nor to pay any social security, income, or other tax which may arise as an incident of employment, except as specifically provided in Section 4. Industrial or any other insurance that is purchased for the benefit of the City, regardless of whether such may provide a secondary or incidental benefit to the Contractor,shall not be deemed to convert this Agreement to an employment contract. If the Contractor is a sole proprietorship or if this Agreement is with an individual,the Contractor agrees to notify the City and complete any required form if the Contractor retired under a State of Washington retirement system and agrees to indemnify any losses the City may sustain through the Contractor's failure to do so. 8.2 Safety.Contractor shall take all necessary precautions and shall be responsible for the safety of its employees, agents,and subcontractors at the work site and in the performance of the contract work and shall utilize all protection necessary for that purpose. Contractor shall comply with all applicable provisions of federal, state and municipal safety and health laws and codes,including without limitation,all OSHA/WISHA requirements,Safety and Health Standards for Construction Work CONCESSIONAIRE AGREEMENT - 3 - RWBF— 1/2015 ` CITY OF CITY HALL , Federal Way 33325 8th Avenue South Federal Way,WA 98003-6325 (253) 835-7000 www cityoffederalway corn (Chapter 296-155 WAC), General Safety and Health Standards (Chapter 296-24 WAC), and General Occupational Health Standards(Chapter 296-62 WAC).Contractor shall erect and properly maintain,at all times,all necessary guards,barricades, signals and other safeguards at all unsafe places at or near the site for the protection of its employees and the public, safe passageways at all road crossings,crosswalks,street intersections,post danger signs warning against known or unusual hazards and do all other things necessary to prevent accident or loss of any kind.Contractor shall protect from damage all water,sewer, gas,steam or other pipes or conduits,and all hydrants and all other property that is likely to become displaced or damaged by the performance of the Work.The Contractor shall,at its own expense,secure and maintain a safe storage place for its materials and equipment and is solely responsible for the same 8.3 Risk of Work. All work shall be done at Contractor's own risk,and Contractor shall be responsible for any loss of or damage to materials,tools,or other articles used or held for use in connection with the work.Industrial or any other insurance that is purchased for the benefit of the City,regardless of whether such may provide a secondary or incidental benefit to the Contractor, shall not be deemed to convert this Agreement to an employment contract. Even though Contractor is an independent contractor,the work must meet the approval of the City and shall be subject to the City's general right of inspection to secure satisfactory completion 9. EQUAL OPPORTUNITY EMPLOYER.In all services,programs,activities,hiring,and employment made possible by or resulting from this Agreement or any subcontract,there shall be no discrimination by Contractor or its subcontractors of any level,or any of those entities'employees,agents,subcontractors,or representatives against any person because of sex,age (except minimum age and retirement provisions),race,color,religion,creed,national origin,marital status,or the presence of any disability, including sensory, mental or physical handicaps, unless based upon a bona fide occupational qualification in relationship to hiring and employment. This requirement shall apply to, but not be limited to, the following: employment, advertising, layoff or termination, rates of pay or other forms of compensation, and selection for training, including apprenticeship.Contractor shall comply with and shall not violate any of the terms of Chapter 49.60 RCW,Title VI of the Civil Rights Act of 1964,the Americans With Disabilities Act,Section 504 of the Rehabilitation Act of 1973,49 CFR Part 21,21.5 and 26, or any other applicable federal, state,or local law or regulation regarding non-discrimination. 10. GENERAL PROVISIONS. 10.1 Interpretation and Modification. This Agreement, together with any attached Exhibits, contains all of the agreements of the Parties with respect to any matter covered or mentioned in this Agreement and no prior statements or agreements,whether oral or written,shall be effective for any purpose. Should any language in any Exhibits to this Agreement conflict with any language in this Agreement,the terms of this Agreement shall prevail.The respective captions of the Sections of this Agreement are inserted for convenience of reference only and shall not be deemed to modify or otherwise affect any of the provisions of this Agreement.Any provision of this Agreement that is declared invalid,inoperative,null and void,or illegal shall in no way affect or invalidate any other provision hereof and such other provisions shall remain in full force and effect. Any act done by either Party prior to the effective date of the Agreement that is consistent with the authority of the Agreement and compliant with the terms of the Agreement,is hereby ratified as having been performed under the Agreement.No provision of this Agreement,including this provision,may be amended,waived,or modified except by written agreement signed by duly authorized representatives of the Parties. 10.2 Non-Exclusive Right. This Agreement does not grant the Contractor an exclusive right to distribute its products. The City reserves the right to grant to other persons or entities any of the rights contained herein or otherwise. 10.3 Assignment and Beneficiaries.Neither the Contractor nor the City shall have the right to transfer or assign,in whole or in part,any or all of its obligations and rights hereunder without the prior written consent of the other Party.Ifthe non- assigning party gives its consent to any assignment,the terms of this Agreement shall continue in full force and effect and no further assignment shall be made without additional written consent. Subject to the foregoing,the rights and obligations of the Parties shall inure to the benefit of and be binding upon their respective successors in interest, heirs and assigns. This Agreement is made and entered into for the sole protection and benefit of the Parties hereto.No other person or entity shall have any right of action or interest in this Agreement based on any provision set forth herein. CONCESSIONAIRE AGREEMENT - 4 - RWBF— 1/2015 Nib, CITY OF CITY HALL e3e5 8th Avenue South Federal Way Federal Way,WA 98003-6325 (253) 835-7000 www atyoifederalway com 10.4 Compliance with Laws. The Contractor shall comply with and perform the Services in accordance with all applicable federal,state,local,and city laws including,without limitation,all City codes,ordinances,resolutions,regulations, rules,standards and policies,as now existing or hereafter amended,adopted,or made effective.If a violation of the City's Ethics Resolution No.91-54,as amended,occurs as a result of the formation or performance of this Agreement,this Agreement may be rendered null and void,at the City's option. 10.5 Execution. Each individual executing this Agreement on behalf of the City and Contractor represents and warrants that such individual is duly authorized to execute and deliver this Agreement.This Agreement may be executed in any number of counterparts,each of which shall be deemed an original and with the same effect as if all Parties hereto had signed the same document.All such counterparts shall be construed together and shall constitute one instrument,but in making proof hereof it shall only be necessary to produce one such counterpart. The signature and acknowledgment pages from such counterparts may be assembled together to form a single instrument comprised of all pages of this Agreement and a complete set of all signature and acknowledgment pages.The date upon which the last of all of the Parties have executed a counterpart of this Agreement shall be the"date of mutual execution"hereof. [Signature page follows] CONCESSIONAIRE AGREEMENT - 5 - RWBF— 1/2015 Ahh, CITY OF CITY HALL , Federal Way Federal 8W Way,WA South Federal Way,WA 98003-6325 (253) 835-7000 www cityoffederalway corn IN WITNESS,the Parties execute this Agreement below, effective the last date written below. CITY OF FEDERAL WAY ATTEST: J / 11 g/ L l A _■ John tton, P irector (VC erk, Stephanie Court- CMC DATE: G/S/ APPROVED AS TO FORM: O)2C'i City Attorney, Amy Jo Pearsall KIW IS CLUB OF FEDERAL WAY By: / 4 , 4 Pi + • Printed NameIQviuct S . I1JQ Title: I r e5 ( 4e,v\- DATE: C ' a 0 / c STATE OF WASHINGTON ) ) ss. COUNTY OF Min ) On this day personally appeared before me /j j if. _4 , to me known to be the Pr €1d0 of ,1`_ /_i '. «�, ; ,d, ,i, / • that executed the foregoing instrument,and acknowledged the said instrument to be ' e free and volunt. I 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 9 day of i . I/ , 20 G-- "-a�A M' ,4 4'`' Notary's signature L,/!'! /</A? ! / O 0 y.II Notary's printed name ALOrI'nG� f)f OJ?)Of7 y ��1'wJ�I' 3�� I Notary Public in and for the State of Washington. ' `' a-5- aoi9 � ��'/� .a; My commission expires ‘‘‘wASHIV CONCESSIONAIRE AGREEMENT - 6 - RWBF— 1/2015 CITY OF CITY HALL Federal Way F Way, 33325 8th South Federal Wayy,,WA 98003-6325 (253) 835-7000 www crtyoflederalway corn EXHIBIT "A" CONCESSIONAIRE SERVICES 1. Contractor shall provide concession services at a concession stand("Concession Stand")during the City's 4th of July Red, White and Blues Festival (the "Event") located at Celebration Park in a manner consistent with the accepted practices for other similar services,performed to the City's satisfaction,within the time period prescribed by the City and pursuant to the direction of the Mayor or his or her designee. 2. Hours of Operation.The Contractor must be prepared for the health inspection and electrical troubleshooting by 4:00 pm on July 4th. Concession Stands will be open to the public from 6:00 pm until 10:00 pm. 3. Products and Pricing. All food,beverage or other products offered for sale by Contractor to the public shall be approved in writing by the City prior to distribution or sale of any such products. All items submitted must be translated in English to ensure accurate menu item description.Items not on the approved menu are not to be served. If items served are not on the approved menu,the City will request removal of such item or require the closure of the booth immediately.If closure occurs the vendor will forfeit both the booth fee and deposit.If a shutdown occurs the vendor will be unable to sell items for the remainder of the event,however the vendor will be unable to breakdown and depart until after 10:15 pm.Contractor shall comply with any reasonable requests made by the City to either add or eliminate certain types of food,beverage or other products.All pricing of any food,beverage or other product as set forth below must be competitive and must be approved in writing by the City. Contractor may not change any pricing without the City's prior written consent, which consent may be withheld for any reason. Approved Menu Items Pricing Electrical See attached 4. Customer Service. Contractor and all of its employees,agents, or representatives shall provide the highest quality of customer service and shall treat all customers with courtesy and respect. Contractor shall honor all reasonable requests for refunds including requests from customers that are dissatisfied with any food,beverage or other product sold by Contractor or from customers who have lost money in any vending machine owned by Contractor. 5. Employee Appearance.All of Contractor's employees,agents,representatives or licensees shall have a neat, clean and sanitary personal appearance and those who come in direct contact with the public shall wear clothing or identification, which distinguishes them as employees of Contractor. 6. Employee Training.Contractor shall provide a training program for its employees,agents,or representatives for the development of the skills and techniques necessary to perform its obligations under this Agreement including but not limited to promoting customer service,produce and service presentation,cleanliness,positive attitude and promoting the City Parks and Recreation Department's philosophy and policy. CONCESSIONAIRE AGREEMENT - 7 - RWBF— 1/2015 CITY OF CITY HALL ,,1,∎411kibb, . , Federal Way 33325 8th Avenue South Federal Way,WA 98003-6325 (253) 835-7000 www crtyoffederahvay corn 7. Staffing. The Concession Stands shall be properly staffed in order to prevent undue delay to the public. Contractor shall plan its staffing in advance and anticipate to the best of its ability any events, such as holidays or special events, which may require additional staffing. In the event the City determines in its sole discretion that Contractor is not adequately staffing the Concession Stands, it may notify Contractor of that fact and Contractor shall immediately increase its staffing to meet the City's recommendation. CONCESSIONAIRE AGREEMENT - 8 - RWBF— 1/2015 1 1 cm o, Federal Way Red, White & Blues Festival July 4th, 2015 Celebration Park, Federal Way,WA Food/Drink Vendor Application Business Name: Kiwanis Club of Federal Way Address: P.O. Box 3232 City/St: Federal Way ZIP: 98003 Main Contact: Dave Larson Title: President Phone: 206-793-8547 Cell: 206-793-8547 Email:dlarson72@comcast.net Fax: N/A Type of Person or Entity: Individual Sole Proprietor X Non-profit Corporation Tax ID#/ SS# Menu Information: (We reserve the right to alter your menu based on other approved food vendors. We do not allow any type of frying or hot oil preparation methods) ITEM NAME PORTION SIZE PRICE Candy and chips 1 Package $1.25 Water 1 20 oz. Bottle $1.00 Kettle Korn 1 Bag $6.00 V cP cc _5'14411 In 60,\ Mix fity.00 Various Trinkets Varies / 1/41 $1.00-10.00 Soda 12 Oz Cans or 20 $1.00 or$2.00 1 Oz bottle Does your booth need electricity?(please circle) No If yes, please list all electrical items and their specificati• Electrical Item Amps Volts Type of Electrical Prong (SEE ATTACHED DIAGRAM) Cash register ? 120 #C MAIL APPLICATION TO: City of Federal Way(ATTN: Rob Ettinger) 3200 SW Dash Point Road, Federal Way, WA 98023 FAX: 253-835-2010 Phone: 253-835-2002 cit robe @ Y offederalwa Y.com _._ • CITY OF Federal Way RED, WHITE & BLUES FESTIVAL JULY 4T11, 2013 Electrical Diagrams *Venue can only accommodate following electrical plugs. (drawings not to scale) U r \ # A # B 50 AMP 50 AMP/240 VOLT 0 U # C 110 VOLT/20 AMP "' ® DATE(MM/DD/YYYY) A ° CERTIFICATE OF LIABILITY INSURANCE 5/8/2015 _ 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(ies)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 certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Lisa Christenson Hylant Group Inc-Indianapolis -817-5172 No.E>nr317 817 5172 ((AA/C,No): 317-817-5151 301 Pennsylvania Parkway,#201 E-MAIL Indianapolis IN 46280 ADDRESSkiwaniscert@hylant.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Lexington Insurance Company 9437 INSURED KIWANO3 INSURER B Evanston Insurance Co. 5378 Kiwanis International,All Clubs and Their Members INSURER C: 3636 Woodview Trace INSURER D: Indianapolis IN 46268 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:293586304 REVISION NUMBER: 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. INSR •.. SUBR- POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER (MM/DD/YYYY) (MM/DDIYYYY) A GENERAL LIABILITY Y 013136005 11/1/2014 11/1/2015 EACH OCCURRENCE $2,000,000 DAMAGE TO RENTED X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence) $500,000 CLAIMS-MADE X OCCUR MED EXP(Any one person) $5,000 X Agg Per District PERSONAL&ADV INJURY $2,000,000 X Liquor Liability GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: _PRODUCTS-COMP/OP AGG $2,000,000 _ POLICY PRO LOC Liquor Liability $1,000,000 .IECT COMBINED SINGLE LIMIT A AUTOMOBILE LIABILITY 013136005 11/1/2014 11/1/2015 (Ea accident) $1,000,000 ANY AUTO BODILY INJURY(Per person) $ — ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS X HIRED AUTOS X NON PROPERTY DAMAGE $ -OWNED (Per accident) AUTOS iAggregate $3,000,000 B UMBRELLA LIAB X OCCUR XONJ486614 11/1/2014 11/1/2015 EACH OCCURRENCE $9,000,000 X EXCESS LIAB CLAIMS-MADE AGGREGATE $9,000,000 DED RETENTION$ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE N I A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? - (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ A Self-Insured Retention 013136005 11/1/2014 11/1/2015 All Claims $75,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Certificate Holder is named as Additional Insured as respects to General Liability only regarding the following Kiwanis event(setup,take down&rain date(s)are included): 07/24/2015 or any future date(s)in the policy term-Kiwanis Club of Federal Way Annual Salmon Bake/Wine and Beer festival held at Steel Lake Park, Federal Way,WA CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Federal Way,WA ACCORDANCE WITH THE POLICY PROVISIONS. 33325 8th Ave S Federal Way WA 98003 AUTHORIZED REPRESENTATIVE C").LN-641: V- l'-^0.-ILI-40),Cr' ..n ©1988-2010 ACORD CORPORATION. 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