AG 20-802 - Sidney G Gallego Inc DDS PSRETURN TO: Tim Johnson EXT: 2412
CITY OF FEDERAL WAY LAW DEPARTMENT ROUTING FORM
ORIGINATING DEPT./DIV: ---ECONOMIC DEVELOPMENT
ORIGINATING STAFF PERSON: TIM JOHNSON EXT: 2412 3. DATEREQ.BY' ASAP
I . 00
0 ' G
0043011 VwAxk" LI.W59I
11 a a an I Me's 1141vial alkos
1:1 PUBLIC WORKS CONTRACT El SMALL OR LIMITED PUBLIC WORKS CONTRACT
C3 PROFESSIONAL SERVICE AGREEMENT 1-1 MAINTENANCE AGREEMENT
El GOODS AND SERVICE AGREEMENT 1:1 HUMAN SERVICES/ CDG
• REAL ESTATE DOCUMENT 1:1 SECURITY DOCUMENT (E.G. BOND RELATED DOCUMENTS)
• ORDINANCE C1 RESOLUTION
• CON -1RACTA MENDMENT(AG#): El INTERLOCAL
• OTHER CARES ACT FUNDS BUSINESS SUPPORT GRANT AGREEMENT
5. PROJECT NAME: CARES ACT GRANT — ROUND 2
6. NAME OF CONTRACTOR: SIDNEY R. GALLEGOS INC, DDS, PS,, W 6
ADDRESS: 926 S 348TH ST, FEDERAL WAY WA 98003 T ELEPHONE: (253) 924-0717
E-MAIL: DOC@SIDNEYRGALLEGOSDDS.COM
SIGNATURE NAME: SIDNEY LEGOS TITLE: SEEATTACHED
7., EXHIBITS AND ATTACHMENTS: El SCOPE, WORK OR SERVICES 11 COMPENSATION D INSURANCE REQUIREMENTS/CERTIFICATE El ALL
OTHER REFERENCED EXHIBITS 11 PROOF OF AUTHORITY TO SIGN El REQUIRED LICENSES 0 PRIOR CONTRACT/AMENDMENTS
9. TOTAL COMPENSATION$ (INCLUDE EXPENSES AND SALES TAX, IF ANY) TWO THOUSAND AND NO/100 ($2,000.00)
(IF CALCULATED ON HOURLY LABOR CHARGE - ATTACH SCHEDULES OF EMPLOYEES TITLES AND HOLIDAY RATES)
REIMBURSABLE EXPENSE:0 YES XNO IF YES, MAXIMUM DOLLAR AMOUNT: $
IS SALES TAX OWED DYES X NO IF YES,$ PAID BY: [I CONTRACTOR D CITY
RETAWAGE: RETAINAGE AMOUNT: El RETAINAGE AGREEMENT (SEE CONTRACT) OR El RETAINAGE BOND
PROVIDED
11 PURCHASING: PLEASE CHARGE TO: 00 1 - 1800-990-518-10-490 Pro iect Code #267662-25060
10. DOC INT/CONTRACT REVIEW INITIAL DATE REVIEWED INITIAL / DATE APPROVED
0 P JECT MANAGER
fRQCT OR
El SM GEE (IFAPPLICABLE)
0 LAW
11. COUNCIL APPROVAL (IF APPLICABLE) SCHEDULED COMMITTEE DATE: COMMITTEE APPROVAL DATE:
SCHEDULED COUNCIL DATE: COUNCIL APPROVAL DATE:
12. CONTRACT SIGNATURE ROUTING
11 SENT TO VENDOR/CONTRACTOR DATE SENT: DATE C'D:
El ATTACH: SIGNATURE AUTHORITY, INSURANCE CERTIFICATE, LICENSES, EXHIBITS
El CREATE ELECTRONIC REMINDER/NOTIFICATION FOR I MONTH PRIOR TO EXPIRATION DATE
(Include dept. support staff if necessary and feet free to set notification more than a month in advance if council approval is needed.)
INITIAL / DATE SIGNED
D LAW DEPARTMENT
1+69ATORY (MAYOR OR DIRECTOR)
11 CITY CLERK ff
El ASSIGNED AG # AG4::&D
COMMENTS:
I ;11A=1ZAnM= I
QrY OF CITY HALL
33325 8th Avenue South
Fe d e ra I Wa y Federal Way Y/A 98003-6325
(253) 835-7000
�,lt,v�vcflyoffe(IerEjt&vcivcf,)fri
CARES ACT FUNDS BUSINESS SUPPORT GRANT AGREEMENT
WITH
SIDNEY R. GALLEGOS INC, DDS, PS, INC
This Grant Agreement ("Agreement") is made between the City of Federal Way, a Washington municipal
corporation (""City')„ and Sidney R. Gallegos file, ITS, PS, a Washington corporation ("Grantee"). The City
mid Grantee (together "Parties") are located and do business at the below addresses which shall be valid for any
notice required under this AgTeement:
SIDNEY GALLEGOS
926 S 348th St
FEDERAL WAY, WA 98003
Ade Ariwoola
33325 8th Ave. S.
Federal Way, WA 98003-6325
(253) 835-2414 (telephone)
(253) 935-2509 (facsimile)
1. TERNI, This agreement contemplates a one-time grant of funds to the Grantee under the conditions
described herein.
2.1 Warranties: The Grantee warrants the following, which are pre -requisites for grant eligibility:
a) Grantee operates a business physically located within. the political boundaries of the City
of Federal Way-,
b) Grantee maintains a current City of Federal Way business license;
c) Grantee has paid all taxes and government fees due up to the date of execution of this
grant agreement;
d) Grantee's business employees no more than the equivalent of ten (10) full-time
employees (20,800 man-hours total for all employees per year);
e) Grantee's net revenues do not exceed more than $1.5 million per year;
f) Grantee does not operate as a tax-exempt business as defined by the Internal Revenue
Service;
g) Due to COVID-19, Grantee business (oficck all �that qf�l
Was required by state or local order to close
Was forced to lay off employees due to reduced patronage
Incurred over S 1,000 in COVID- 19 related expenses
Experienced 10-50% lost revenue
Experienced over 50% lost revenue
0TV OF
IzOdemj !Akiy
CITY HALL
33325 Sth Avenue South
(253) 835-7000
0AV,V01YOffe(jeT,j[tV'jyCojyj
2.2 Use of Funds: Grantee affirms that grant funds will be used for the following purposes-,
a) Mortgage or Rent
b) Personal Protection Equipment
c) Insurance
d) Utilities
e) Marketing
f) Payroll
Grantee agrees to retain receipts documenting use of grant funds and will provide them to the City or its
designee upon request.
3. I:ER241 ATION. Should any of the conditions described in section 2, 1 above, not be met, the City
may recover all disbursed grant funds and ten-ninate this agreement.
4.1 Amount. In order to promote healthy economic activity in the City and in response to the lossi
Grantee has incii;ied due to the COVID- 19 pandemic, the City shall provide a grant to the Grantee in an amou
not to exceed Two Thousand and N01100 Dollars ($2,000.00).
4�2 Ngn��rigfioa of P�qnds. if sufficient fUnds are not appropriated or allocati:d for payment
under tW Agreement for any fiscal -period, -tjV city will not be obligated to make payments under this
.. .........
�i Jill iiii
9 11MV14 toil
CARES ACT BUSINESS GRANT AGREEMENT -211
%�k' cttv OF
Offl 7a '-�
P�6deral My
CITY HALL
33325 Sth Avenue South
(253) 835-7000
minv cityoffederoltvay cul;;
5.3 Cit� j6d6mitfication. The City agrees to release, Indemnify, defend and hold the Grantee, i
officers, directors, shareholders, partners, employees, agents, representatives, and subcontractors harmless fro
any and all claims, demands, actions, suits, causes of action, arbitrations, mediations, proceedings, judgment
awards, injuries, damages, liabilities, losses, fines, fees� penalties expenses, attorney's fees, costs, and/
litigation expenses to or by any and all persons or entities, including without limitation, their respective agenit
licensees, or representatives, arising from, resulting from or connected with this Agreement to the extent sole i
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.
6. GENERAL PROVISIONS.
IM
CN NIFAI 1IOL ne construe(I to be a wwver
or relinquishment of those covenants, agreements or options, and the same shall be and remain in full force and
effect. Failure or dela of the Cit to 0
. . . . . . . . . . .
m&E i 3-H rf i inrh-�
Parties' rights to indemnification under Section 5 of this Agreement.
CARES ACT BUSINESS GRANT AGREEMENT -31
CITY OF
Fi�deml My
CITY HALL
33325 Sth Avenue South
13 -942 5
(253) 835-7000
mviv c0offederalwaY com
6.3 Execution. Each individual executing this Agreement on behalf of the City and Grant
represents and warrants that such individual is duly authorized to execute and deliver this Agreement. T
A2r.mement mag be executed in any, number ofcountei3arts each of which shll)irwi
the same effect as if all Parties hereto had signed the same document. All such counterparts shall be constru t
together and shall constitute one instrument, but in making proof hereof it shall only be necessary to produl-
one such counterpart. The signature and acknowledgment pages from such counterparts may be assembIf #
together to form a single instrument comprised of all pages of this Agreement and a complete set of
signature and acknowledgment pages. The date upon which the last of all of the Parties have executed
counterpart of this Agreement shall be the it of mutual execution" hereof.
-U)s
By:
vu
Printed Name:
ty
Title:
DATE: IZ> Iu I -ZD-zc)
1016/2020 Washington State Department of Revenue
< Business Lookup
License Information:
New search Back to results
Entity name: SIDNEY R. GALLEGOS, INC.,D.D.S., P.S.
Business name: SIDNEY R. GALLEGOS, INC., DDS, PS
Entity type, Professional Service Corporation
UI #: 601-257-487
Business ID: 001
Location 1113- 0001
Location: Active
Location address: 926 S 348TH ST
FEDERAL WAY WA 98003
Mailing address- 926 S 348TH ST
FEDERAL WAY WA 98003
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 clai
Dental X-Ray/CT/ Pan/Ceph 04893 4
Active
Jun -30-2021
Aug -11-2007
Federal Way General Business 00 -101579 -00 -BL
Active
Jun -30-2021
Jun -15-2000
X -Ray: 04893
Active
Jun -30-2021
Aug -11-2007
Dental/Podiatric/Veterinary
Governing People M., 1-1.deg—(�g people ..t regW—d with S-rnaqr.fStt.
Governing people Title
GALLEGOS, SIDNEY
Registered Trade Names
Registered trade names Status First issued
DENTISTRY FOR CHILDREN Active Nov -19-2019
SIDNEY R. GALLEGOS, INC., D.D.S., P.S. Active Jun -07-2016
The Business Lookup information is updated nightly. Search date and time: 10/6/2020 9:47:46 AM
https://secure.dor.wa.gov/gteunauth/—/#23 1/2