HomeMy WebLinkAboutContract 2012 2441 AGREEMENT FOR SERVICES
PERFORMED BY INDEPENDENT CONTRACTOR
THIS AGREEMENT is made on the y
C; day of Appit, , 2012, between the CITY OF
COLUMBIA HEIGHTS ("City"), whose business address is 590 - 40`x' Ave. NE, Columbia
Heights, MN 55421, and Johnson's Outdoor Service ("Contractor"), whose
business address is P.O. Box 32947,Fridley,MN 55432 .
THE CITY AND CONTRACTOR AGREE AS FOLLOWS:
1. Independent Contractor. The City hereby retains the Contractor as an independent
contractor upon the terms and conditions set forth in this Agreement. The Contractor is not
an employee of the City and is free to contract with other entities as provided herein.
Contractor shall be responsible for selecting the means and methods of performing the work.
Contractor shall furnish any and all supplies, equipment, and incidentals necessary for
Contractor's performance under this Agreement. City and Contractor agree that Contractor
shall not at any time or in any manner represent that Contractor or any of Contractor's agents
or employees are in any manner agents or employees of the City. Contractor shall be
exclusively responsible under this Agreement for Contractor's own FICA payments, workers
compensation payments, unemployment compensation payments, withholding amounts,
and/or self-employment taxes if any such payments, amounts, or taxes are required to be
paid by law or regulation.
2. Contractor's Services. The Contractor agrees to provide services as described in Exhibit
A, attached and made a part of this Agreement. The Contractor shall, in the execution of
services, conform to all applicable federal, state, and local laws, codes, ordinances, and
regulations.
3. Time for Performance of Services. The Contractor shall perform the services according to
Exhibit A.
4. Compensation for Services. The City agrees to pay the Contractor for services as
described in Exhibit A. Compensation shall be in accordance with Exhibit B, attached and
made a part of this Agreement.
5. Method of Payment. The Contractor shall submit to the City, on a monthly basis, itemized
bills for professional services performed under this Agreement. Bills submitted shall be paid
in the same manner as other claims made to the City.
6. Termination. Either party,without cause, may terminate this Agreement by seven (7)days'
written notice delivered to the other party at the address written above. After termination,
the City shall have no further obligation to Contractor except to compensate Contractor for
services performed before Contractor's receipt of notice of termination.
7. Subcontractor. The Contractor shall not enter into subcontracts for services provided under
this Agreement, except as noted in Exhibit A, without the express written consent of the
City.
8. Assignment. Neither party shall assign this Agreement, or any interest arising herein,
without the written consent of the other party.
9. Indemnification. Contractor agrees to defend, indemnify and hold the City, its officers, and
employees harmless from any liability, claims, damages, costs, judgments, or expenses,
including reasonable attorney's fees, resulting directly or indirectly from an act or omission
(including without limitation professional errors or omissions) of the Contractor, its agents,
employees, or subcontractors in the performance of the services provided by this Agreement
and against all losses by reason of the failure of said Contractor fully to perform, in any
respect,all obligations under this Agreement.
10. Workers Compensation Insurance. Worker's compensation coverage shall be furnished
meeting minimum requirements of Minnesota law. The Contractor shall provide proof of
workers' compensation coverage and shall execute the form attached hereto.
11. Records Access. The Contractor shall provide the City access to any books, documents,
papers, and records which are directly pertinent to the Agreement, for the purpose of making
audit, examination, excerpts, and transcriptions, for three years after final payments and all
other pending matters related to this Agreement are closed.
12. General Liability Insurance. The Contractor shall provide the City a Certificate of
Insurance complying with the standard contractor's minimum coverage requirements of
$1,000,000. combined single limit naming the City of Columbia Heights as an additional
insured. Contractor's liability policy shall be so endorsed with a copy delivered to the City.
13. Data Privacy. The Contractor shall comply with Minnesota Statutes Chapter 13, The
Minnesota Government Data Practices Act. The Contractor shall not disclose non-public
information except as authorized by the Act.
14. Ownership of Documents. All plans, diagrams, analyses, reports, and information
generated in connection with performance of the Agreement shall become the property of
the City. The City may use the information as it sees fit. Such use by the City shall not
relieve any liability on the part of the Contractor.
15. Governing Law. The laws of the State of Minnesota shall control this Agreement.
Executes a ,of the day and year first written above.
CITY OF COL 10, :IA HEI I HTS CONTRAC.`OR:
I laygr`-. ; .: it y: A
r
City Administrator
Attest: ril",, l -t
City Clerk
PROOF OF WORKERS' COMPENSATION
INSURANCE COVERAGE
Minnesota Statutes Section 176.182 requires every governmental subdivision entering
into a contract for doing any public work to obtain acceptable evidence of compliance with the
workers' compensation insurance coverage requirement of Section 176.181, subd. 2. The
information required is: the name of the insurance company, the policy number, and dates of
coverage or the permit to self-insure. This information will be collected by the licensing agency
and put in their company file. It will be furnished, upon request, to the Department of Labor and
Industry to check for compliance with Minnesota Statutes Section 176.181, subd. 2.
This information is required by law, and a contract for the doing of any public work may
not be entered into if it is not provided and/or is falsely reported. Furthermore, if this information
is not provided and/or is falsely reported, it may result in a penalty assessed against the applicant
by the Commissioner of the Department of Labor and Industry payable to the Special
Compensation Fund.
Provide the information specified above in the spaces provided, or certify the precise
reason your business is excluded from compliance with the insurance coverage requirement for
workers' compensation.
INSURANCE COMPANY NAME: O _ ' efi>. ,,'eYr■AL(2-,S, tit
(NOT the insurance agent)
POLICY NO. OR SELF-INSURANCE PERMIT NO.: if I, uevw
DATES OF COVERAGE: ' (3 I ,,..- -s 13- 13
- OR—
I am not required to have workers' compensation liability coverage because:
❑ I have no employees covered by the law.
❑ Other(specify):
I HAVE READ AND UNDERSTAND MY RIGHTS AND OBLIGATIONS WITH RE ARD TO
PUBLIC CONTRACTS AND WORKERS' COMPENSATION COVERAGE, AND I CE'',;a= IFY THAT
THE INFORMATION PROVIDED IS TRUE AND CORRECT.
Contr.Pror (Signatur-)/
City of Columbia Heights
Tall Grass and Weed Removal Program
Exhibit A
Description of Work
Contractor will perform the following:
(a) Contractor shall thoroughly familiarize themselves with City ordinances and State
laws dealing with noxious weeds and long grass.
(b) Contractor shall, within two business days, cut or remove weeds and long grass as
instructed by the Fire Department or his representative. Removal of weeds and long
grass includes trimming along all fences, walls and structures, trimming around all
trees and permanent objects, and the mulching or removal of all clippings.
(c) Digital photo's shall be taken on ever., property prior to cutting and after cutting and
shall be sent to the fire department upon completion and also retained by contractor.
City of Columbia Heights
Tall Grass and Weed Removal Program
Exhibit B
Contractor Information
Johnson's Outdoor Service
PO Box 32947
Fridley, MN 55432
(w) 763-757-1797
johnsonsoutdoor.com
Contacts: Chad Johnson
Pricing
$55 minimum for first hour. Time over the initial hour will be paid at $13.75 for quarter
hour increments. Upon arrival if yard is already cut, there will be a one hour trip charge
minimum of$55.
Minnesota Workers' Compensation Assigned Risk Plan
Standard Workers' Compensation and Employers' Liability Policy
Contract Administrator:
RTW Inc.
NCCI Carrier Code: 39579
P.O. Box 390901
Minneapolis, Minnesota 55439-0901
1-888-273-9709
INFORMATION PAGE
WCIP
Renewal of No. MNAR-0000016914-4 Policy Number: MNAR-0000016914-5
Association File Number: 3223068
1.—The Insured
Johnson Outdoor Services LLC Tax ID#: 452550095
PO Box 32947 UIC#: Exempt
Fridley, MN 55432 Date of Mailing: 02/28/2012
Individual Partnership
Other workplaces not shown above: SEE WC990601 Corporation X Other
Limited Liability Company
2.—The policy period is from 12:01 a.m. 03/13/2012 to 12:01 a.m. 03/13/2013 at the insured's mailing address.
3. A. Workers' Compensation Insurance:Part One of the policy applies to Workers' Compensation Law of the state(s) listed here:
MN
B. Employers' Liability Insurance: Part Two of the policy applies to work in each state listed in ITEM 3.A.:
The limits of our liability under Part Two are: Bodily Injury by Accident $500,000 Each Accident
Bodily Injury by Disease $500,000 Each Employee
Bodily Injury by Disease $500,000 Policy Limit
C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here:
E. This policy includes these endorsements and schedules: See POLICY FORM AND ENDORSEMENT SCHEDULE attached.
4. The premium for this policy will be determined by our Manual of Rules, Classifications, Rates and Rating Plans. All information
required below is subject to verification and change by audit.
PREMIUM BASIS RATES CODE ENTRIES IN THIS ITEM, EXCEPT AS SPECIFICALLY ESTIMATED
ESTIMATED PER$100 OR NO. PROVIDED ELSEWHERE IN THIS CONTRACT; DO NOT ANNUAL
TOTAL ANNUAL REMUNERATION MODIFY ANY OF THE OTHER PROVISIONS OF THIS POLICY. PREMIUM
REMUNERATION _
Manual Premium $0
See Schedule Increased Employer Liability Limits 9807 1.00% $50
Standard Premium $50
Merit Rating Credit(.67) 9680 .67 ($17)
Minimum Premium: $514 _ Minimum Premium Adjustment 0990 $301
Adjusted Standard Premium $334
Terrorism 9740 $0.02 $0
Estimated Annual Premium $334
Expense Constant 0900 $180
Agency Name and Address WCRA Assessment 0988 0.60% $3
The Insurance Mart- Fridley Special Compensation Fund Surcharge 0174 3.40% $17
6875 Hwy 65 NE Policy Total Estimated Cost $534
Fridley, MN 55432 Net Deposit Premium Required 100% $534
Premium Paid to Date $534
DATE: 2/28/2012 SIGNATURE: r
Includes copyright material of the National Council on Compensation Insurance used with its permission.
@ 1983 @ 1991 National Council on Compensation Insurance WC 99-00-01
Insured Copy
ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY)
, 2j1 7j2012
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 Sandi Bucheger
INSURANCE MART PHONE (763)574-7447 FAX
(A/C.No.Ex
6875 Highway 65 NE sbuche er fA/C,Nol:(763)574-7544
ADDRESS: g @ insmart.org
..._ _.. .. ._._.. _..INSURER(S)AFFORDING COVERAGE ..... - - NAIC#
Fridley MN 55432 -INSURERA:Owners Insurance 32700
INSURED INSURER El Auto-Owners Insurance 18988
Johnson Outdoor Services LLC INSURER C:
PO Box 3294? INSURERD:
INSURER S:
Fridley MN 55432 INSURER F:
COVERAGES CERTIFICATE NUMBER:REV GL/A/Umb 11/12 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LIS I ED 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 TYPE OF INSURANCE ADM.SUBR POLICY EFF POLICY EXP
(N$A.YRYD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS
GENERAL LIABILITY
EACH OCCURRENCE . $ 1,000,000
DAMAGETO RENTED
X COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) $ 50,000
A CLAIMS-MADE X OCCUR 08460254 12/10/2011 12/10/2012 MED EXP(Anyone person) $ 5,000
PERSONAL&ADV INJURY $ 1,000,000
_ GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 2,000,000
X POLICY E T 1 j LOC $ -
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT accident) $ 1,000,000
A ANY AUTO BODILY INJURY(Per person) $
ALL OWNED —SCHEDULED 4746025901 11/30/2011 11/30/2012 BODILY INJURY(Per $
AUTOS AUTOS ( }
NON-OWNED PROPERTY DAMAGE
. HIRED AUTOS AUTOS (Per accident) $
PIP-Basic $
X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 1,000,000
B EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1,000,000
DEC (RETENTION$ 4746025402 2/10/2012 2/10/2013 $
WORKERS COMPENSATION WC STATU- + OTH-
•AND EMPLOYERS'UABILITY Y I N I TORY LIMITS I ER
ANY PROPRIETOR/PARTNERIEXECUTIVE E.L.EACH ACCIDENT $
OFFICER/MEMBER EXCLUDED? N I A
(Mandatary in NH) E.L DISEASE-EA EMPLOYEE$
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS 1 LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required)
•
,
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
I
Joseph Washleski/SANB - {'' `�"
' '`s' -.ec -
ACORD 25(2010105) 41988-2010 ACORD CORPORATION. All tights reserved.
INS025(201005).01 The ACORD name and logo are registered marks of ACORD
PDF created with pdfFactory trial version wwvv.pdffactory.com
Form w"7 Request for Taxpayer Give Form to the
(Rev.December2011) Identification Number and Certification requester.Do not
Department of the Treasury send to the IRS.
Internal Revenue Service
Name(as shown on your income tax return)
N Business name/disregarded entity name,if different from above
& Johnson's Outdoor Services, LLC
m
Check appropriate box for federal tax classification:
❑ Individual/sole ro rietor C Corporation p p ❑ rpc Q S Corporation ❑ Partnership ❑Trust/estate
O. 0
0
o 0 Limited liability company.Enter the tax classification(C=C corporation,S=S corporation,P=partnership)• [I]Exempt payee
o 2
W
O. ❑ Other(see instructions)•
v
;E Address(number,street,and apt.or suite no.) Requester's name and address(optional)
U
m PO Box 32947 Columbia Height Fire Department
City,state,and ZIP code 825-41st Ave NE.
c Fridley,MN.55432 Columbia Heights, MN.55421
List account number(s)here(optional)
Part I Taxpayer Identification Number(TIN)
Enter your TIN in the appropriate box.The TIN provided must match the name given on the"Name"line I Social security number
to avoid backup withholding.For individuals,this is your social security number(SSN).However,for a
resident alien,sole proprietor,or disregarded entity,see the Part I instructions on page 3.For other - -
entities,it is your employer identification number(EIN).If you do not have a number,see How to get a
TIN on page 3.
Note.If the account is in more than one name,see the chart on page 4 for guidelines on whose Employer identification number
number to enter.
4 5 - 2 5 5 0 0 9 5
Part II Certification
Under penalties of perjury,I certify that:
1. The number shown on this form is my correct taxpayer identification number(or I am waiting for a number to be issued to me),and
2. I am not subject to backup withholding because:(a)I am exempt from backup withholding,or(b)I have not been notified by the Internal Revenue
Service(IRS)that I am subject to backup withholding as a result of a failure to report all interest or dividends,or(c)the IRS has notified me that I am
no longer subject to backup withholding,and
3. I am a U.S.citizen or other U.S.person(defined below).
Certification instructions.You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding
because you have failed to report all interest and dividends on your tax return.For real estate transactions,item 2 does not apply.For mortgage
interest paid,acquisition or abandonment of secured pr perty,cancellation of debt,contributions to an individual retirement arrangement(IRA),and
generally,payments other than interest and 'vidend ou are not required to sign the certification,but you must provide your correct TIN.See the
instructions on page 4.
Sign Signature of f
Here U.S.person• Date• (/J i � /�
General Instructions Note.If a requester gives you a form other than Form W-9 to request
your TIN,you must use the requester's form if it is substantially similar
Section references are to the Internal Revenue Code unless otherwise to this Form W-9.
noted. Definition of a U.S.person.For federal tax purposes,you are
Purpose of Form considered a U.S.person if you are:
A person who is required to file an information return with the IRS must •An individual who is a U.S.citizen or U.S.resident alien,
obtain your correct taxpayer identification number(TIN)to report,for •A partnership,corporation,company,or association created or
example,income paid to you,real estate transactions,mortgage interest organized in the United States or under the laws of the United States,
you paid,acquisition or abandonment of secured property,cancellation •An estate(other than a foreign estate),or
of debt,or contributions you made to an IRA. •A domestic trust(as defined in Regulations section 301.7701-7).
Use Form W-9 only if you are a U.S.person(including a resident
alien),to provide your correct TIN to the person requesting it(the Special rules for partnerships.Partnerships that conduct a trade or
requester)and,when applicable,to: business in the United States are generally required to pay a withholding
tax on any foreign partners'share of income from such business.
1.Certify that the TIN you are giving is correct(or you are waiting for a Further,in certain cases where a Form W-9 has not been received,a
number to be issued), partnership is required to presume that a partner is a foreign person,
2.Certify that you are not subject to backup withholding,or and pay the withholding tax.Therefore,if you are a U.S.person that is a
3.Claim exemption from backup withholding'rf you are a U.S.exempt partner in a partnership conducting a trade or business in the United
payee.If applicable,you are also certifying that as a U.S.person,your States,provide Form W-9 to the partnership to establish your U.S.
allocable share of any partnership income from a U.S.trade or business status and avoid withholding on your share of partnership income.
is not subject to the withholding tax on foreign partners'share of
effectively connected income.
Cat.No.10231X Form W-9(Rev.12-2011)