AG 20-775 - Patricia Kho DDSEXT: 2412
CITY OF FEDERAL WAY LAW DEPARTMENT ROUTING FORM
*RIGINATING DEPT./DIV:
*RIGINATING STAFF PERSON: TIM JOHNSON, — EXT: 2412 3. DATE REQ. BY. ASAP
4. TYPE OF DOCUMENT (CHECK ONE):
El CONTRACTOR SELECTION DOCUMENT (E.G., RFB, RFP, RFQ)
El PUBLIC WORKS CONTRACT El SMALL OR LIMITED PUBLIC WORKS CONTRACT
El PROFESSIONAL SERVICE AGREEMENT 0 MAINTENANCE AGREEMENT
• GOODS AND SERVICE AGREEMENT El HUMAN SERVICES/ CBG
• REAL ESTATE DOCUMENT El SECURITY DOCUMENT (E.G. BOND RELATED DOCUMENTS)
FSKeyagEff-IM14111
FEW1=1910111910
* CONTRACTA NT (AG#): El INTERLOCAL
* OTHER CARES ACT FUNDS BUSINESS SUPP014GRANT AGREEMENT
5. PROJECT NAME: CARESACT GRANT ROUND2
6. NAME OF CONTRACTOR: PATRICIA KHO DDS PLLC
ADDRESS: 33915 1 ST VVY S # 201, FEDERAL WAY WA 98003-6396 T ELEPHONE: (253) 927-6411
E-MAIL: PATRICIAKHO@YAHOO.COM
SIGNATURE NAME: PATRICIA KHO TITLE: SEE ATTACHED
7. EXHIBITS AND ATTACHMENTS: Ej SCOPE, WORK OR SERVICES El COMPENSATION 0 INSURANCE PEQUIREMENTS/CERTIFICATE El ALL
OTHER REFERENCED EXHIBITS El PROOF OF AUTHORITY TO SIGN 13 REQUIRED LICENSES El PRIOR CONTRACT/AMENDMENTS
8. TERM: COMMENCEMENT DATE: SEE ATTACHED AGREEMENT COMPLETIONDATE:
9. TOTAL COMPENSATION $ (INCLUDE EXPENSES AND SALES TAX, IF ANY) TWO THOUSAND AND NO/ 100 (S2,000AO)
(IF CALCULATED ON HOURLY LABOR CHARGE - ATTACH SCHEDULES OF EMPLOYEES TITLES AND HOLMM�
REIMBURSABLE EXPENSE: El YES X NO IF YES, MAXE\4UM DOLLAR AMOUNT: $__ --
IS SALES TAX OWED El YES X NO IF YES,
RETA1NAGE: RETAINAGE AMOUNT:
PAID BY: 0 CONTRACTOR 0 CITY
RETAINAGE AGREEMENT (SEE CONTRACT) OR 0 RETAINAGE BOND
0 PURCHASING: PLEASE CHARGE TO: .001-1800-990-518-10-490 Project (Lqde #267662-25060
10. DOCUMENT/CONTRACT REVIEW INITIAL DATE REVIEWED INITIAL / DATE APPROVED
=F-1 PR JECT MANAGER
RE, CTOR
0 RISKMANAGEMENT (IF APPLICABLE)
El LAW
11. COUNCIL APPROVAL (IF APPLICABLE) SCHEDULED COMMITTEE DATE: COMMITTEE APPROVAL DATE:
SCHEDULED COUNCIL DATE: COUNCIL APPROVAL DATE:
Moto—IMIJOULOXTAN 00191 Lill
El ATTACH: SIGNATURE AUTHORITY, INSURANCE CERTIFICATE, LICENSES, EXHIBITS
0 CREATE ELECTRONIC REMINDER/NOTIFICATION FOR I MONTH PRIOR TO EXPIRATION DATE
(Include dept. support staff if necessary and feel free to set notification more than a month in advance if council approval is needed.)
INITIAL / DATE SIGNED
El LAW DEPARTMENT
ATORY (MAYOR OR DIRECTOR)
0 CITY CLERK I
11 ASSIGNED AG# AG#
COMMENTS:
1/2020
This Grant Agreement ("Agreement") is made between the City of Federal Way, a Washington municipal
corporation ("City"), and Patricia Kho DDS PLLC, a professional limited liability company ("Grantee"). The
WiVI& &r -
any notice required under this Agreement.
PATRICIA Kit
HO
33915 1 st Way S # 201
FEDERAL WAY, WA 98003
Ade Ariwoola
33325 8th Ave. S.
Federal Way, WA 98003-6325
(253) 835-2414 (telephone)
(253) 835-2509 (facsimile)
1. TERM. This agreement contemplates a one-time grant of funds to the Grantee under the conditions
described herein.
Mnnpp�, �#mLt "Im
11 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) fill -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;
Grantee does not operate as a tax-exempt business as defined by the Internal Revenue
Service;
g) Due to COVID- 19, Grantee business (Slh�eck all �that ably):
% Was required by state or local order to close
Was forced to lay off employees due to reduced patronage
incurred over $ 1,000 in COVID- 19 related expenses
Experienced 10-50% lost revenue
Experienced over 50% lost revenue
AML OF CITY V.NLL
--E 33325 Sth Avenue South
1�606ml Vft Federal Way. WA 98003-6325
V;A�(253),835-1000
www�4�4*com
2.2 JL§eoLFunds- Grantee affirms that grant fimds 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 fLmds and will provide them to the City or its
designee upon request.
3. TEMNATICIN., Should any of the conditions described in section 2.1 above, not be mc4 the City
may recover all disbursed grant funds and terminate this agreement.
4. GRANTAMOUNT.
4.1 Amount. In order to promote healthy economic activity in the City and in response to the losses
x-mt
not to exceed Two Tbousand and NO/l 00 Dollars ($2,000.00).
4.2 i * ipMpdation of Funds. If sufficient funds are not appropriated or allocated for payment
under this Agreement for any fiscal period, the City will not be obligated to make payments under this
agreement.
event of liabty for damages ansing out of bodily injury to persons or damages to property caused by or
RA-02AA14-N-WA I K'A I WALIM
unas EO av01
—rapartyund
i n acts� disaNilfty benefit act or any other benefits acts or programs. The Parties fin-ther
acknowledge that they have mutually negotiated this waiver.
ITT F COCITY HALL
4% 33325 8th Avenue South
Federal Way, WA 98003-6325
Federal Way (253) 835-7000
ar com
6.3 , Execution. Each individual executing this Agreement on behalf of the City and Grantee
represents and warrants that such individual is duly authorized to execute and deliver this Agreement. This
AW-MR701ar-TWe executed "anp 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 compnised 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.
v 12i I . i
111FIRI'lir mr1111111:111111 III
By:
Printed Name: K
Title:
DATE:
"-ARES ACT BUSINESS GRANT AGREEMENT -4-
10/512020 Washington State Department of Revenue
z cj,no Side Depai.-ieill- of r Pe,
< Business Lookup
Entity name:
PATRICIA KHO, DDS, PLLC
Business name:
PATRICIA KHO DDS PLLC
Entity type-
Professional Limited Liability Company
UBI #.
602-808-551
Business ID:
001
Location ID:
0002
Location:
Active
Location address: 33915 1ST WAY S STE 201
FEDERAL WAY WA 93003-6396
Mailing address: 33915 1ST WAY S
STE 201
FEDERAL WAY WA 98003-6396
Excise tax and reseller permit status* Click here
Secretary of State status., Click here
Endorsements
Ucqnw,�, count Detaiiis
Dentat X-R-a,,,=/CT/ PanXeph 4
Federal Way GenerA Business 08--10132S-00-BL
X -Ray
Dentia l/Pod wnc/Vetennarte
Governing People
Govvrnnig peqjh, Title
KHO, PATRICIA
Registered Trade Names
Rsgistt,red trade names Status -
FEDERAL WAY ENDODONTICS' Active
PATRICIA KHO DDS PLLC Active
https://secure.dor.wa.gov/gteunauth/,/#1 3
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