Loading...
HomeMy WebLinkAboutDeliciosa Tuba de Colima - Concession Agree Rd 36 Soccer FieldsCONCESSION/LEASE AGREEMENT 2021 Road 36th Soccer Fields Concession Area 1. PARTIES. This Lease Agreement (Agreement) is made and entered into as of the Z l day of 3anf, _, 2021, by and between the City of Pasco, a municipal corporation (City) and Deliciosa Tuba De Colima (Juan Moreno) (Concessionaire). Official mail correspondence should be sent to the following addresses: CITY OF PASCO DELICIOSA TUBA DE COLIMA Attn: Brent Kubalek Attn: Juan Moreno PO Box 293 1520 W. Clark St. Apt H Pasco, WA 99301 Pasco, WA 99301 509-543-5790 509-302-8547 2. TERM. This Agreement shall commence upon execution, and unless terminated for a breach or as provided herein, shall continue in full force and effect through October 31, 2021. 3. PREMISES. City hereby leases to Concessionaire and Concessionaire hereby leases and takes from City that certain real property at the Road 361h Soccer Complex in the City of Pasco, County of Franklin, State of Washington. The leased premises consists of approximately a 25 x 15 foot area of open space, more or less (referred to as the Premises), together with all improvements thereon and appurtenances thereto, as shown in the attached Exhibit A. 4. FEE. Monthly Fee shall be payable to the City by the Concessionaire in the amount of and on specified dates included in Appendix B. Fee shall be payable to City at the address shown below, or to such other address as City may designate by written notice as provided herein, without demand and without deduction, setoff or counterclaim. 5. CONCESSION RIGHT. Concessionaire shall have the exclusive right during scheduled rentals (dates and times in appendix B) only, subject to payment of the concession compensation and the provisions set forth herein, to sell food and non-alcoholic beverages in the premises based on the agreed upon menu in the attached Exhibit C. 5.1 Concession Equipment. Concessionaire shall supply, at its own expense, all equipment, fixtures, power, supplies and staff and other items required or necessary to provide concessions to patrons of the Premises. 5.2 Concessionaire is required to supply and use adequate electrical equipment. 6. CONCESSION RIGHT COMPENSATION. Concessionaire shall pay City for the exclusive food and beverage service concession at the Rd 36th Soccer Fields during the dates and times specified in Appendix B, with monthly Fee payments. 6.1 Reports. Concessionaire shall provide to City with each monthly concession payment, an itemization of its gross receipts for the month, listing separately food, beverage, and any other general product sales category conducted on the premises, and year to date totals in each category and total gross sales. 7. DEFINITION OF GROSS RECEIPTS. For the purposes of this agreement, the term "gross receipts" shall mean the total sum of all sales made at or from the designated premises, whether for cash or on credit, less the amount of any sales tax or other direct consumer tax which may specifically be paid by the purchaser or customer at the time of purchase or payment, and including but not limited to orders taken at the premises but filled elsewhere and orders taken elsewhere but filled at the premises. 8. USE OF LEASED PREMISES. Concessionaire agrees that the leased premises shall be used by the Concessionaire exclusively for food and non-alcoholic beverage service and associated office use. Such use shall conform with applicable city ordinances and state and federal laws. No other usage of the area shall be allowed unless prior written consent is obtained from the Administrator & Community Services Director which shall be granted or not granted at the absolute discretion of the city. Concessionaire may not sublet any or all of the premises without prior written approval from the Administrator & Community Services Director. 9. DAYS AND TIME OF OPERATION. Concessionaire shall provide food and beverage services from the designated premises during the dates and times listed on Appendix B. 10. OTHER CONCESSIONAIRE RESPONSIBILITIES. In addition to providing the concession services described above, Concessionaire shall provide for the following: 10.1 To provide for all litter pick-up in the designated premises and to assist the league directors in litter pick-up throughout the soccer complex at the close of service each day. 10.2 To negotiate with the City's selected soft drink vendor for the beverages it shall offer for sale. For 2021 this is Coca-Cola and the contact is Matt Sanders 509-547-6712. 10.3 To present its employees as neat, clean and professional with clothing or identification which distinguishes them as employees of the Concessionaire. 10.4 To provide for City's review and secure the City's approval of the products and prices that it proposes to offer to patrons of the Premises. City's approval shall not be unreasonably withheld. 11. CONCESSIONAIRE PROVIDED EQUIPMENT. Cash registers shall be sealed and so designed as to show the customer the amount of the sale and to record accurately all the daily and monthly total gross receipts. Such cash registers shall be available to City at any reasonable time for inspection. 12. CITY'S REPRESENTATIONS, WARRANTIES AND COVENANTS. City hereby represents and warrants to Concessionaire that it has the full right, power and authority to lease the Premises to Concessionaire. Except as specifically set forth herein, neither City nor its agents have made any representations with respect to the Premises. No rights, easements, or licenses are acquired by Concessionaire by implication or otherwise except as expressly set forth in the provisions of this Agreement. The taking of possession of the leased property by the Concessionaire shall be conclusive evidence that the Premises were in good condition at the time possession was taken. CONCESSIONAIRE ACCEPTS THE PREMISES AS -IS. 2 13. EARLY TERMINATION. Either party may terminate this agreement by giving written notice of its intent to terminate 30 days in advance. 14. QUIET ENJOYMENT. City agrees that so long as Concessionaire observes and performs all of the agreements and performs all of the agreements and covenants required of it hereunder, Concessionaire shall peaceably and quietly have, hold and enjoy the Premises for the Term without any encumbrance, interference or hindrance by City, its agents or employees. 15. TAXES. Concessionaire shall pay all taxes assessed against and levied upon Concessionaire's trade fixtures, and all other personal property of Concessionaire contained in or around the Premises. 16. INDEMNIFICATION / HOLD HARMLESS. Concessionaire shall defend, indemnify, and hold harmless the City, its officers, officials, employees and volunteers from and against any and all claims, suits, actions, or liabilities for injury or death of any person, or for loss or damage to property, which arises out of Concessionaire's use of Premises, or from the conduct of Concessionaire's business, or from any activity, work or thing done, permitted, or suffered by Concessionaire in or about the Premises, except only such injury or damage as shall have been occasioned by the sole negligence of the City. 17. INSURANCE. The Concessionaire shall procure and maintain for the duration of the Agreement, insurance against claims for injuries to persons or damage to property which may arise from or in connection with the Concessionaire's operation and use of the leased Premises. 17.1 Minimum Scope of Insurance. Concessionaire shall obtain insurance of the types described below: (a) Commercial General Liability insurance shall be written on Insurance Services Office (ISO) occurrence form GC 00 01 and shall cover premises and contractual liability. The City shall be named as insured on Concessionaire's Commercial General Liability insurance policy using ISO Additional Insured Managers or Lessors of Premises Form CG 20 11 or a substitute endorsement providing equivalent coverage. (b) Property insurance shall be written on an all risk basis. 17.2 Minimum Amounts of Insurance. Lessee shall maintain the following insurance limits: (a) Commercial General Liability insurance shall be written with limits no less than $1,000,000 each occurrence, $2,000,000 general aggregate. (b) Property insurance shall be written covering the full value of Concessionaire's property and improvements with no coinsurance provisions. 17.3 Other Insurance Provisions. The insurance policies are to contain, or be endorsed to contain, the following provisions for Commercial General Liability insurance: (a) The Concessionaire's insurance coverage shall be primary insurance with respect to the City. Any Insurance, self-insurance, or insurance pool coverage maintained by the City shall be excess of the Concessionaire's insurance and shall not contribute with it. 3 (b) The Concessionaire's insurance shall be endorsed to state that coverage shall not be cancelled by either party, except after thirty (30) days prior written notice by certified mail, return receipt requested, has been given to the City. 17.4 Acceptability of Insurers. Insurance is to be placed with insurers with a current A.M. Best rating of not less than A:VII. 17.5 Verification of Coverage. Concessionaire shall furnish the City with original certificates and a copy of the mandatory endorsements, including but not necessarily limited to the additional insured endorsement, evidencing the insurance requirements of the Concessionaire. 17.6 Waiver of Subrogation. Concessionaire and City hereby release and discharge each other from all claims, losses and liabilities arising from or caused by any hazard covered by property insurance on or in connection with the Premises. This release shall apply only to the extent that such claim, loss or liability is covered by insurance. 17.7 City's Property Insurance. City shall purchase and maintain during the term of the Agreement, all-risk property insurance covering the Premises for their full replacement value without any coinsurance provisions. 18. DAMAGE OR DESTRUCTION; CONDEMNATION. If the Premises are damaged or destroyed in whole or in part; or if the Premises or a substantial portion thereof were taken by condemnation or under the power of eminent domain, City may, at its option, elect to terminate this tenancy. 19. SURRENDER AT EXPIRATION. Upon expiration of the Agreement term or earlier termination on account of default, Concessionaire shall surrender the Premises in the same condition as at the commencement of the Agreement, reasonable wear and tear expected. 20. DEFAULT. Concessionaire shall be in default of this Agreement if it fails to comply with any term or condition or fulfill any obligation of the Agreement. In the event of a default, this Agreement may be terminated at the option of City by written notice to Concessionaire. Whether or not the Agreement is terminated by the election of Concessionaire or otherwise, City shall be entitled to recover damages from Concessionaire and City may retake possession of the Premises, and reserves any other remedy available to the City under the applicable law. 21. MISCELLANEOUS. 21.1 Environmental Compliance By Concessionaire. Concessionaire shall not cause or permit any Hazardous Material to be brought upon, kept or used in or about the Premises. 21.2 Signs. Concessionaire shall not erect signage without City's prior written consent. 21.3 Non -waiver. Waiver by either party of strict performance of any provision of this Agreement shall not be a waiver or of prejudice to the parry's right to require strict performance of the same provision or any other provision in the future. 21.4 Notices. Any notice required or permitted under this Agreement shall be deemed to have been given when actually delivered or 72 hours after deposited in the United States mail as 0 certified mail addressed to the address first given in this Agreement or to such other address as may be specified from time to time by either of the parties in writing. 21.5 Time of Essence. Time is of the essence of the performance of each of the obligations under this Agreement. 21.6 Recording of Agreement. This Agreement shall not be recorded. 21.7 Concessionaire shall observe reasonable Rules and Regulations established and amended by City for the Premises from time to time upon 30 days advance, written notice from City to Concessionaire. Concessionaire shall have a reasonable opportunity to comment on proposed rules and regulations. 21.8 Assignment. Concessionaire shall not assign, transfer or grant to any third party the right to occupy the Premises or to sell food or beverages as granted under this Agreement. 21.9 Alterations, Improvements And Additions. Concessionaire shall make no alterations, improvements or additions to the Premises without prior written approval of the City. Concessionaire shall not add furniture or other items to the Premises, except for furnishings, which are reasonably necessary for Concessionaire to conduct its permitted activities. 2 1. 10 Compliance with Laws, Ordinances and Regulations. Concessionaire shall comply with all laws, ordinances and regulations of any governmental agency or public authority having jurisdiction over the Premises or Concessionaire's use thereof. 21.11 Responsible Party. Following is the name and phone number of the party which may be contacted in an emergency (24 hours per day; 7 days per week availability): Name: Deliciosa Tuba De Colima Juan Moreno Phone Number 509-302-8547 IN WITNESS WHEREOF, the parties hereto have executed or caused this instrument to be executed as of the day and year first above written. CITY OF PASCO CONCESSIONAIRE Date: Z / 77 2021 5 Appendix A The following map indicates, in orange, the locations that the concessionaire will be allowed to set up his/her concession stand(s) on the dates and times specified in Appendix B. The south location will the main stand and the location on the north by the parking lot will be a smaller satellite concession stand. 3 Appendix B Fee amount payable to the City of Pasco, to provide concessions at the Road 36�h Soccer Complex on Saturdays and Sundays from April 25 to October 31, shall be according to the schedule that follows and will grant the Concessionaire permission to sell concessions during scheduled use times on the indicated days. First Payment = $300.00 due on 6-29-2021 (Concessionaire has credit on his account from 2020 cancelled season. Balance due shall be $300 less the credit) This allows sales from 6-26-2021 through 7-25-2021 on Saturday's and Sunday's only. Second Payment = $300.00 due on 7-28-2021 This allows sales from 7-31-2021 through 8-29-2021 on Saturday's and Sunday's only. Third Payment = $300.00 due on 9-1-2021 This allows sales from 9-4-2021 through 10-2-2021 on Saturday's and Sunday's only. Optional (If games extend beyond October 2 and Concessionaire exercises the right to sell): Fourth Payment = $150.00 due on 9-29-2021 This allows sales from 10-9-2021 to 10-31-2021 on Saturday's and Sunday's only. 7 Appendix C The following menu and prices have been agreed to by both parties for the 2021 season and anything not listed on this menu that is offered for sale will constitute a contract default as described in section 20 of the contract. Item Price Tuba - 12/16/20/24/32 oz. 3.50/4.50/7.00/8.00/9.00 Tuba — Gallon 25.00 Fanta, Coca Cola, Sprite — glass/plastic/cans 2.50/2.00/1.50 PowerAde 3.00 Energy Drink 3.00 Red Bull Fruit Mix Drink (Strawbeny or Mango) 6.00 Fresh Flavored Water Sm/Md/Lr 2.25/3.50/4.50 Sunny D 1.50 Bottled Water 1.25 Ice Cream Bars 2.00/2.50 Chicharones with Skins 9.00 Tostilocos 9.00 Bag of Chicharron 2.50 Takis 2.50 Japanese Peanuts 1.00 Cup of Mixed Fruit & Vegetables 7.50 Sabritas Chips 1.50 Corn (On Stick) 4.00 Corn (In Cu) 6.00 A Variety of Candies 0.25 - 2.00 Gum 2.50 IV MORENO, JUAN (DELICIOSA TUBA DE Event: SOCCER FIELD CONCESSION COLIMA) Permit Issued: 06121/202'1 56.81: TEMP. 1ST DAY - MED. PRIORITY ROAD 36 PASCO Permit Valid: JUNE 30.1 JULY 3149 2021 56.83: TEMP - ADDITIONAL DAYS (NO MAX) This operator has met the necessary requirements and agreed to comply with the regulations for preparing, serving, andlor vending food to the public at o temporary community event. This permit is subject to revocation at any time this establishment is not operated in a sanitary manner in accordance with Washington Administrative Code 246-215 and other applicable codes enforced by the Renton -Franklin Health District. This permit is issued to the.above named establishment, event location, for the above dates and is NON -1-RAN5AFRABLE. if this businessis sold to a new owner or Qdterwise altered. permit holder must not fy-the qer n- mnktin ffgalth District to avoid future liability under this agreement. m Dr. Amy Person District Health Officer This permit must be posted for public view. www.bfhd.wa.gov PUBLIC *EMT" Prevent • Prnnmte • Protect Environmental Health Specialist MORENO, JUAN (DELICIOSA TUBA DE Event: SOCCER FIELD CONCESSION COLIMA) ROAD 36 PASCO Permit Issued:06/21/2021 Permit Valid: JUNE 2: , 261 27,2021 56.81: TEMP. 1ST DAY - MED. PRIORITY 56.83: TEMP - ADDITIONAL DAYS (NO MAX) This operator has met the necessary requirements and agreed to comply with the regulaians for preparing, serving, andlor venc(ing Toad to the public at a temporary community event. This permitis subject to revocation at any time this establishment is not operated in a sanitary manner in accordance with Washington Administrative Cade 24&215 and other applicable codes enforced by the Benton -Franklin Health District. This permit is issued to the above named establishment eventlaCation, for the above dates and is NON TRANSFERABLE. if this business is sold to a new owner or othenvise.altered, perti?itholder must notify the $ ton-Franktiq Health District to avoid future tiojir7ity under this agreement. Dr. Amy Person District Health Officer This permit must be posted for public view. www.bfhd.wa.gov .f PUBLIC TM Prevent • Promote # Protect EnvironmeeMi4-Wealth Specialist Benton -Franklin Health District Environmental Health Division PUBLIC 7102 W. Okanogan Place . Kennewick, WA 99336 For flffce Use On] (509) 4604205 or (800) 814-4323 APP A= ted B is z www.bfhd.wa.gov A piicacion de Comisario Un comisario es un establecimiento aprobado para que la comida sea guardada, preparada, dividida, o empacada para servicio en otro lugar. Tambi6n es usado para servir, limpiar, disinfectar, proveer, y mantener el equipo y unidades m6viles. Fecha de Aplicaci6n G j fi'/ 21 Nombre del Establecimiento ,-- J coca., YL It,(, OYC 1A6 Direcci6n de Correspondencia - F Nombre del Direcci6n del Comisario d1 '6) La aplicaci6n debe ser aprobada antes de empezar el servicio de Telefono ----- Fwjmero de Fax Ciudad - I Estado y el C6digo Postal 1- 4Va a guardar el m6vil en el comisario (necesita guardar el m6vil en el comisario o en el Lugar 2. 4Va a guardar ❑ papeles, ❑ comida congelada, y ❑ comida refrigerada en el comisario? 3. 6Va a usar ❑ agua potable o ❑ hielo del comisario? 4. LVa a desechar ❑ agua sucia y ❑ basura en el comisario? 5. LVa a lavar, enjugar, y disinfectar los platos en el comisario? Si si, c6mo? fregadero con tres com artimientos o lava latos? 6. LVa a lavar frutas y verduras (en un fregadero aprobado solo para lavar verduras) en el comisario? 7. ZVa a ❑ cocinar o ❑ enfriar comida en el comisario? 8. ZPuede usar el bano en el comisario? 9. LVa a limpiar el m6vil en el comisario? El horario de comisario disponible par el solicitante: Dom: a Lun: a^ Mar: - a Mie: Para ser comprendido y firmado por el propietarlo del comisario: Yo, el propietario o designado del comisario nombrado anteriormente, doy permiso a este solicitante a utilizar mi establecimiento como un comisario para cada uno de los artfculos marcados como "Si" en la section 3 de esta aplicaci6n. -- Firma de Propietario de comisario Telefono Er& ❑ No Si ❑ No ❑ oN ❑Sl [tr No ❑ Si allo FSi ❑ No ❑Si ❑ No Rtf ❑ No ❑ No Jue:._ a ._.. Vie: a Sab: Para ser comprendido y formado por el solicitante: Yo, el solicitante, concuerdo en utilizar el comisario anteriormente escrito comp "Si" en la section 3 de esta aplicaci6n. Si cualquier infomtaci6n en esta aplicaci6n cambia por el dueno del comisario o de mi mismo, yo notificare al Distrito de Salud de Benton -Franklin para la aprobacion. Firma de Solicitante Nombre/Fecha Impresa Los comentarios del Propietario de Comisario: A. Nombre/Fecha Impresa AC40 o® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 06/24/2021 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLYAND 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 terns 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: NE Mid Valley General Agency LLC JAI.. N : (503) 365-7001 A/C No): (503) 365-7354 888 Madison St NE, Ste 100 ADDARESS: certs@midvalleyga.com INSURE S AFFORDING COVERAGE NAIC N Salem OR 97301 INSURERA: Rainier Insurance Company 43915 INSURED INSURER B : Juan Moreno INSURER C : DBA Deliciosa Tuba De Colima INSURER D : 1520 W Clark St Apt H INSURER E : Pasco WA 99301 INSURER F : rn►reoer_ec rCOTICIreTC dlrlluClFQ• RFVI4kIn1J NI IMRFR• 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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. LTR TYPE OF INSURANCE INSO VYVD POLICY NUMBER IMMIDDIYYYYI (MMIDD=LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE0AII� OCCUR P AGEZ'S TrF $ 100,000 $ 5,000 MED EXP (Any one personj PERSONAL& ADV INJURY $ 1,000,000 A SCL-705152 06/23/2021 06/23/2022 GEN'LAGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $ 2,000,000 x POLICY ❑ JET LOC PRODUCTS - COMP/OP AGG Inc in Gen Agg $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT accde"" $ BODILY INJURY (Per person) $ ANY AUTO BODILY INJURY (Per accident) $ ALLOWNED SCHEDULED AUTOS AUTOS PROPERTY DAMAGE .'accident $ NON -OWNED HIREDAUTOS AUTOS $ UMBRELLALIAB OCCUR EACH OCCURRENCE i AGGREGATE i EXCESS LLAB CLAIMS -MADE DED I I RETENTION $ S WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N PER OTH- TATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? ❑N N/A E.L. EACH ACCIDENT S (Mandatory In NH) E.L. DISEASE - EA EMPLOYE $ E.L. DISEASE - POLICY LIMIT It Ryes, describe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached If more space Is required) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Pasco ACCORDANCE WITH THE POLICY PROVISIONS. 525 N 3rd Ave AUTHORIZED REPRESENTATIVE Pasco WA 99301 I O< ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD Aco V AGENCY Pasco -Good Oman Insurance 1103 N 20th Ave Pasco COMMERCIAL INSURANCE APPLICATION APPLICANT INFORMATION SECTION CARRIER COMPANY POLICY OR PROGRAM NAME WA 99301 POLICY NUMBER W'E�" ` Darin Oman UNDERWRITER AIC No Ext : (509) 545-8783 (AIC,_Haj: ADDRESS: Darin@GoodOmanlnsumnce.com CODE: SUBCODE: AGENCY CUSTOMER ID: 1 INFQ AF RI IQIIJCQQ STATUS OF TRANSACTION DATE (MMIDDIYYYY) 0&1712021 UNDERWRITER OFFICE QUOTE ISSUE POLICY BOUND (Give Date andlor Attach Copyk CHANGE DATE TIME CANCEL I NAIC CODE 1 PROGRAM CODE RENEW AM � PM INDICATE LINES OF BUSINESS PREMIUM PREMIUM PREMIUM BOILER d, MACHINERY i CYBER AND PRIVACY i YACHT i BUSINESSAUTO 4 FIDUCIARY LIABILITY i i BUSINESS OWNERS $ GARAGE AND DEALERS i i COMMERCIAL GENERAL LIABILITY $ LIQUOR LIABILITY S i COMMERCIAL INLAND MARINE i MOTOR CARRIER i i COMMERCIAL PROPERTY i I TRUCKERS $ i CRIME i UMBRELLA i i ATTAr`I•INIFNTQ ACCOUNTS RECEIVABLE I VALUABLE PAPERS GLASS AND SIGN SECTION STATEMENT I SCHEDULE OF VALUES ADDITIONAL INTEREST SCHEDULE HOTEL I MOTEL SUPPLEMENT STATE SUPPLEMENT (I applicable) ADDITIONAL PREMISES INFORMATION SCHEDULE INSTALLATION! BUILDERS RISK SECTION VACANT BUILDING SUPPLEMENT APARTMENT BUILDING SUPPLEMENT INTERNATIONAL LIABILITY EXPOSURE SUPPLEMENT VEHICLE SCHEDULE CONDO ASSN BYLAWS (for D&O Coverage onty) INTERNATIONAL PROPERTY EXPOSURE SUPPLEMENT CONTRACTORS SUPPLEMENT LOSS SUMMARY COVERAGES SCHEDULE OPEN CARGO SECTION DEALERS SECTION PREMIUM PAYMENT SUPPLEMENT DRIVER INFORMATION SCHEDULE PROFESSIONAL LIABILITY SUPPLEMENT ELECTRONIC DATA PROCESSING SECTION RESTAURANT I TAVERN SUPPLEMENT POLICY INFORMATION %PROPOSED /TF DATE PROPOSED EXP DATE BILLING PLAN PAYMENT PUW 1 METHOD OF PAYMENT AUDIT DEPOSIT i PREMIUM i POLICY PREMIUM i DIRECT n AGENCY + PPUCANT INFORMATION NAME (First Named Insured) AND MAILING ADDRESS (including ZIP+4) GL CODE SIC NAICS FEIN OR SOC SEC M Juan Moreno DBA Deliciosa Tuba De Colima 1520 W Clark St Apt H BUSINESS PHONE #-. 509-302-8547 j WEBSREADDRESS Pasco WA 99301 CORPORATION JOINT VENTURE NOT FOR PROFITORG SUBCHAPTER'S' CORPORATION INDIVIDUAL LLC AN M MEMBERS AND MANAGERS: PARTNERSHIP 'TRUST NAME (Other Named Insured) AND MAILING ADDRESS (including ZIP+/) GL CODE • SIC NAILS FEIN OR SOC SEC 0 BUSINESS PHONE I: •--- —•� — - WEBSITEADDRESS -- --- CORPORATION _71JOINT VENTURE NOT FOR PROFIT OR G SUBCHAPTER'S' CORPORATION ANAGERS: MEMBERS INDIVIDUAL LLC AND MANAGERS: AN PARTNERSHIP TRUST NAME (Other Named Insured) AND MAILING ADDRESS (including 7JP+4) GL CODE SIC NAK:S FEIN OR SOC SEC 0 BUSINESS PHONE M: WEBSITE ADDRESS -- CORPORATION JOINT VENTURE NOT FOR PROFIT ORG SUBCHAPTER'S' CORPORATION INDIVIDUAL LLC AN OF MEMBED MANAGERS:RS AN PARTNERSHIP TRUST %ownw 140 kAulumJ) rage 1 or,* W 1ifi13-AU10 AVVKU wKrUKAI IUN. An rlgnts reserve( y� The ACORD name and logo are reglstered marks of ACORD CONTACT IMCnauATlnM AGENCY CUSTOMER ID: CONTACT TYPE: Owner CONTACT TYPE: CONTACT NAME: Juan Moreno CONTACT NAME: PHONE S HOME © BUS Cj CELL 509-302-8547 PHONESAmy HOME BUS A CELL S- _���-3la PHONES [:]HOME BUS CELL PHONE S ❑ HOME []BUS CELL PRIMARY EMAIL ADDRESS: PRIMARY E-MAIL ADDRESS: SECONDARY E-MAIL ADDRESS: 13ECONDARY EMAIL ADDRESS: LOCI 1 STREET Road 36, Soccer Fields CRY LMIITS INSIDE OUTSIDE INTEREST OWNER TENANT S FULL TIME EMPL ) ANNUAL REVENUES: f ii 500 OCCUPIED AREA: SO FT OLDS CITY: Pasco STATE: WA S PART TIME EMPL OPEN TO PUBLIC AREA: SO FT COUNTY: ZIP: 99301 TOTAL BUILDING AREA: SO FT DESCRIPTION OF OPERATIONS: ANY AREA LEASED TO OTHERS? Y 1 N LOC S STREET CRY LIMrrB INSIDE OUTSIDE INTEREST S FULL TIME EMPL ANNUAL REVENUES: $ OWNER OCCUPIED AREA: SO Fr TENANT S PART TIME EMPL OPEN TO PUBLIC AREA: SO FT TOTAL BUILDING AREA: SO FT OLD S CRY: STATE: COUNTY: ZIP: DESCRIPTION OF OPERATIONS: ANY AREA LEASED TO OTHERS? Y I N LOC S STREET CITY LSARS INSIDE OUTSIDE INTEREST S FULL TIME EMPL j ANNUAL REVENUES: $ OWNER OCCUPIED AREA: SO FT TENANT S PART TIME EMPLOPEN TO PUBLIC AREA: SO FT TOTAL BUILDING AREA: SO FT ANY AREA LEASED TO OTHERS? Y I N BLDS CRY: STATE: COUNTY: ZIP: DESCRIPTION OF OPERATIONS: LOC S STREET CITY LIMITS INSIDE OUTSIDE INTEREST OWNER TENANT S FULL TIME EMPL ANNUAL REVENUES: S OCCUPIED AREA: SOFT OLD S CITY: STATE: S PART TIME EIIPL .OPEN TO PUBLIC AREA: SO FT TOTAL BUILDING AREA: SO FT COUNTY: ZIP: DESCRIPTION OF OPERATIONS: ANY AREA LEASED TO OTHERS? Y I N nn � un� yr eru�me� APARTMENTS CONTRACTOR MANUFACTURING RESTAURANT _ SERVICE `r STARTED � CONDOMINIUMS HINSTITUTIONAL OFFICE _ RETAIL ; WHOLESALE 01/01/2010 DESCRIPTION OF PRIMARY OPERATIONS - Concessions - candy, bottled water, cookies, chips, licorice, etc. Buy packaged for regale. No cooking, no microwave INSTALLATION, SERVICE OR REPAIR WORK RETAIL STORES OR SERVICE OPERATIONS % OF TOTAL SALES: % DESCRIPTION OF OPERATIONS OF OTHER NAMED INSUREDS OFF PREMISES INSTALLATION, SERVICE OR REPAIR WORK AUU11 IUNAL IN TENEST not aN nems apply to an scenarios • Rrovicle only the necessa data Attach ACORD 45 for more Additional Interests INTEREST NAME AND ADDRESS RANK: EVIDENCE: CERTIFICATE POLICY SEND BILL INTEREST IN REM NUMBER ONAL �C ADDITIINSURED uENHOLDER LOCATION: BUILDING: BREACH WARRANTY LOSS PAYEE City of Pasco VEHICLE: BOAT: CO-OWNER MORTGAGEE AIRPORT: AIRCRAFT: EMPLOYEE 525 N 3rd Ave, LEASEBACK Pasco WA 99301 CLASS: ITEM DESCRIPTION OWNER REGISTRANT LEN06R'S LOU PAYABLE TRUSTEE REFERENCE I LOAN S: INTEREST END DATE: LIEN AMOUNT: PHONE (AIC, No, Ed): FAX (AM, No): REASON FOR INTEREST: EMNL ADDRESS: ACURU TZ5 (ZUIWW) Page 2 of 4 GENERAL INFORMATION AGENCY CUSTOMER ID: EXPLAIN ALL 'YES* RESPONSES Y / N 19. IS THE APPLICANT A SUBSIDIARY OF ANOTHER ENTITY 7 7- PARENT COMPANY NAME RELATIONSHIP DESCRIPTION %OWNED 1b. DOES THE APPLICANT HAVE ANY SUBSIDIARIES? N SUBSIDIARY COMPANY NAME RELATIONSHIP DESCRIPTION %OWNED 2. IS A FORMAL SAFETY PROGRAM IN OPERATION? SAFETY MANUAL SAFETY POSITION 71 MONTHLY MEETINGS r7 OSHA N 3. ANY EXPOSURE TO FLAMMABLES, EXPLOSIVES, CHEMICALS? N 4. ANY OTHER INSURANCE WITH THIS COMPANY? (List policy numbers) LINE OF BUSINESS POLICY NUMBER LINE OF BUSINESS POLICY NUMBER N 5. ANY POLICY OR OVERAGE DECLINED, CANCELLED OR NON -RENEWED DU ING THE PRIOR THREE 3 R ANY PREMI ES OR OPERATIONS? (Missoutl pllcants - Do not answer this question) NONPAYMENT AGENT NO LONGER REPRESENTS CARRIER F NONAENEWAL UNDERWRITING ^ 1 CONDITION CORRECTED (Desert): 6. ANY PAST LOSSES OR CLAIMS RELATING TO SEXUAL ABUSE OR MOLESTATION ALLEGATIONS, DISCRIMINATION OR NEGLIGENT HIRING? 7. DURING THE LAST FIVE YEARS (TEN IN RI), HAS ANY APPLICANT BEEN INDICTED FOR OR CONVICTED OF ANY DEGREE OF THE CRIME OF FRAUD, BRIBERY, ARSON OR ANY OTHER ARSON -RELATED CRIME IN CONNECTION WITH THIS OR ANY OTHER PROPERTY? (In RI, this question must be answered by any applicant for property insurance. Failure to disclose the existence of an arson conviction is a misdemeanor punishable by a sentence of up to one year of imprisonment). 8. ANY UNCORRECTED FIRE AND/OR SAFETY CODE VIOLATIONS? OCCUR DATE EXPLANATION RESOLUTION RESOLVE DATE N N N N 9. HAS APPLICANT HAD A FORECLOSURE, REPOSSESSION, BANKRUPTCY OR FILED FOR BANKRUPTCY DURING THE LAST FIVE (5) YEARS? N OCCUR DATE EXPLANATION RESOLUTION RESOLVE DATE i 10. HAS APPLICANT HAD A JUDGEMENT OR LIEN DURING THE LAST FIVE (5) YEARS? N OCCUR DATE EXPLANATION RESOLUTION RESOLVE DATE 11. HAS BUSINESS BEEN PLACED IN A TRUST? NAME OF TRUST: N 12. ANY FOREIGN OPERATIONS, FOREIGN PRODUCTS DISTRIBUTED IN USA, OR US PRODUCTS SOLD / DISTRIBUTED IN FOREIGN COUNTRIES? (If "YES', attach ACORD 815 for Liability Exposure and/or ACORD 816 for Property Exposure) N 13. DOES APPLICANT HAVE OTHER BUSINESS VENTURES FOR WHICH COVERAGE IS NOT REQUESTED? N 14. DOES APPLICANT OWN / LEASE / OPERATE ANY DRONES? (If "YES", describe use) N 15. DOES APPLICANT HIRE OTHERS TO OPERATE DRONES? (If "YES", describe use) N REMARKS / PROCESSING INSTRUCTIONS (ACORD 101, Additional Remarks ScheduleF may be attached if mores ace Isrequired) PRIOR CARRIER INFORMATION YEAR CATEGORY GENERAL LIABILITY AUTOMOBILE PROPERTY OTHER: CARRIER Rainier Ins Cc 2019 POUCYNUMBER SCL704572 : PREMIUM t 696 $ i EFFECTIVE DATE 4/18/2019 EXPIRATION DATE 4/1812020 AGVRU TZO (ZUIWU3) Page 3 Of 4 PRIOR CARRIER INFORMATION Ir_nnfinuarin AGENCY CUSTOMER ID: YEAR CATEGORY GENERAL L1/161LIY AUTOMOBILE PROPERTY OTHER: CARRIER Mesa Underwriters POLICY NUMBER MP0036002001106 2017 PREMIUM s 766 s s ; EFFECTIVE DATE 4/18/2017 EXPIRATION DATE 4/18/2018 CARRIER Mesa Underwriters POLICY NUMBER MM36002002185 2016 PREMIUM S 960.76 ; EFFECTIVE DATE 4/18/2016 EXPIRATION DATE 4/18/2016 LOSS HISTORY 1 7C I Gheck tf none [Attach Loss Summary for Addltlenal Less Infermatlenl ENTER ALL CLAIMS OR LOSSES (REGARDLESS OF FAULT AND WHETHER OR NOT INSURED) OR OCCURRENCES THAT MAY GIVE RISE TO CLAIMS FOR THE LAST 0 YEARS TOTAL LOSSES: i DATE OF OCCURRENCE LINE TYPE/DESCRIPTION OF OCCURRENCE OR CLAIM DATE OF CLAM AMOUNT PAID AMOUNT RESERVED SUBRO- GAIN YIN CLAIM OPEN YIN J Copy of the Notice of Information Practices (Privacy) has been given to the applicant. (Not required in all states, contact your agent or broker for your state's requirements.) PERSONAL INFORMATION ABOUT YOU, INCLUDING INFORMATION FROM A CREDIT OR OTHER INVESTIGATIVE REPORT, MAY BE COLLECTED FROM PERSONS OTHER THAN YOU IN CONNECTION WITH THIS APPLICATION FOR INSURANCE AND SUBSEQUENT AMENDMENTS AND RENEWALS. SUCH INFORMATION AS WELL AS OTHER PERSONAL AND PRIVILEGED INFORMATION COLLECTED BY US OR OUR AGENTS MAY IN CERTAIN CIRCUMSTANCES BE DISCLOSED TO THIRD PARTIES WITHOUT YOUR AUTHORIZATION. CREDIT SCORING INFORMATION MAY BE USED TO HELP DETERMINE EITHER YOUR ELIGIBILITY FOR INSURANCE OR THE PREMIUM YOU WILL BE CHARGED. WE MAY USE A THIRD PARTY IN CONNECTION WITH THE DEVELOPMENT OF YOUR SCORE. YOU MAY HAVE THE RIGHT TO REVIEW YOUR PERSONAL INFORMATION IN OUR FILES AND REQUEST CORRECTION OF ANY INACCURACIES. YOU MAY ALSO HAVE THE RIGHT TO REQUEST IN WRITING THAT WE CONSIDER EXTRAORDINARY LIFE CIRCUMSTANCES IN CONNECTION WITH THE DEVELOPMENT OF YOUR CREDIT SCORE. THESE RIGHTS MAY BE LIMITED IN SOME STATES. PLEASE CONTACT YOUR AGENT OR BROKER TO LEARN HOW THESE RIGHTS MAY APPLY IN YOUR STATE OR FOR INSTRUCTIONS ON HOW TO SUBMIT A REQUEST TO US FOR A MORE DETAILED DESCRIPTION OF YOUR RIGHTS AND OUR PRACTICES REGARDING PERSONAL INFORMATION. (Not applicable in AZ, CA, DE, KS, MA, MN, ND, NY, OR, VA, or WV. Specific ACORD 38s are available for applicants in these states.) (Applicanes Initlals): Applicable In AL, AR, DC, LA, MD, NM, RI and WV: Any person who knowingly (or willfully)* presents a false or fraudulent claim for payment of a loss or benefit or knowingly (or willfully)• presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. *Applies in MD Only. Applicable in CO: It is unlawful to knowingly provide false, Incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. Applicable In FL and OK: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, Incomplete, or misleading information is guilty of a felony (of the third degree)'. 'Applies in FL Only. Applicable In KS: Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written statement as part of, or In Support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial Insurance, or a claim for payment or other benefit pursuant to an Insurance policy for commercial or personal Insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act. Applicable in KY, NY, OH and PA: Any person who knowingly and with intent to defraud any Insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fad material thereto commits a fraudulent Insurance ad, which is a crime and subjects such person to criminal and civil penalties (not to exceed five thousand dollars and the stated value of the claim for each such violation)'. `Applies in NY Only. Applicable in ME, TN, VA and WA: it is a crime to knowingly provide false, incomplete or misleading information to an Insurance company for the purpose of defrauding the company. Penalties (may)* include imprisonment, fines and denial of insurance benefits. *Applies in ME Only. Applicable In NJ: Any person who includes any false or misleading Information on an application for an insurance policy Is subject to criminal and civil penalties. Applicable in OR: Any person who knowingly and with intent to defraud or solicit another to defraud the Insurer by submitting an application containing a false statement as to any material fact may be violating state law. Applicable In PR: Any person who knowingly and with the intention of defrauding presents false information in an insurance application, or presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents more than one claim for the same damage or loss, shall incur a felony and, upon conviction, shall be sanctioned for each violation by a fine of not less than five thousand dollars ($5,000) and not more than ten thousand dollars ($10,000), or a fixed tern of imprisonment for three (3) years, or both penalties. Should aggravating circumstances [be] present, the penalty thus established may be increased to a maximum of five (5) years, if extenuating circumstances are present, it may be reduced to a minimum of two (2) years. THE UNDERSIGNED IS AN AUTHORIZED REPRESENTATIVE OF THE APPLICANT AND REPRESENTS THAT REASONABLE INQUIRY HAS BEEN MADE TO OBTAIN THE ANSWERS TO QUESTIONS ON THIS APPLICATION. HEISHE REPRESENTS THAT THE ANSWERS ARE TRUE, CORRECT AND COMPLETE TO THE BEST OF HIS/HER KNOWLEDGE. PRODUCER'S NAME (Please Priori Darin Oman AL;UKU 125 t2U1 WU3) Page 4 Or 4 AGENCY CUSTOMER ID: '4�i O� COMMERCIAL GENERAL LIABILITY SECTION DATE 117/20JY1 owl �no21 AGENCY CARRIER NAIC CODE Pasco -Good Oman Insurance _ 42846 POLICY NUMBER IEFFICTTYIEDATE APPLICANT / FIRST NAMED INSURED 4 a { J— Moreno DBA Deliciosa Tuba De Colima IMPORTANT - If CLAIMS MADE is checked in the COVERAGE I LIMITS section below, this is an application for a claims -made policy. Read all provisions of the policy Carefully. COMMERCIAL GENERAL LIABILITY I GENERAL AGGREGATE_ i 2000000 PREMIUMS CLAIMS MADE ©OCCURRENCE LIMITAPPLIESPER: a POLICY LOCATION PREMISESIOPERATIO, OWNER'E i CONTRACTOR'S PROTECTIVE PROJECT I JOTHER: PRODUCTS i COMPLETED OPERATIONS AGGREGATE $ 1000000 PRODUCTS DEDUCTIBLES PERSONAL i ADVERTISING INJURY $ 1000000 PROPERTY DAMAGE $ EACH OCCURRENCE : 1000000 OTHER BODILY INJURY $ R CLAIMren M DAMAGE TO RENTED PREMISES (each occurce) S 100000 PER $ OCCURRENCE MEDICAL EXPENSE (Arty our person) 1 5000 TOTAL EMPLOYEE BENEFITS $ OTHER COVERAGES, RESTRICTIONS ANWOR ENDORSEMENTS (For hkedMon ;; d auto coverapu attach tM apPSeable stab Businea Auto SeeWn, ACORD 137) APPLICABLE ONLY IN WISCONSIN: IF NON -OWNED ONLY AUTO COVERAGE IS TO BE PROVIDED UNDER THE POLICY: 1. UM I UIM COVERAGE IS F-1 IS NOT AVAILABLE. 2. MEDICAL PAYMENTS COVERAGE 14 IS NOT AVAILABLE. sGMtUULC Uh HALARUS AGOKD ZT7 Schedule Of Hazards, may be attached If mores ace Is reoUlredw LDC• HAZi CLASS CODE PREMIU BASISM EXPOSURE TERR RATE PREMIUM PMM/OPS PRODUCTS PREMIOPS PRODUCTS ] j Unit 1.00 CLASSIFICATION DESCRIPTION LOCI HA2i CLASS PREMIUM CODE BASIS EXPOSURE TERRPREMIOPS RATE PREMIUM PRODUCTS PREMIOPS PRODUCTS 1 IUnit 1.00 CLASSIFICATION DESCRIPTION LOC! CLASS PREMIUM HAZ>< CODE BASIS EXPOSURE RATE TERR PREM/OPS PRODUCTS PREMIUM PREMlOPS PRODUCTS 1 11168 G Sales 8,500 CLASSIFICATION DESCRIPTION RATING AND PREMIUM BASIS (P) PAYROLL - PER $1,000/PAY (C) TOTAL COST - PER $1,000/COST (U) UNIT - PER UNIT IS) GROSS SALES - PER $1,000/SALES (A) AREA- PER 1,000/SO FT (M) ADMISSIONS - PER 1,000/ADM (() OTHER u an raa +ca uaaa EXPLAIN ALL -YES- RESPONSES Y / N 1. PROPOSED RETROACTIVE DATE: 2. ENTRY DATE INTO UNINTERRUPTED CLAIMS MADE COVERAGE: 3. HAS ANY PRODUCT, WORK, ACCIDENT, OR LOCATION BEEN EXCLUDED, UNINSURED OR SELF -INSURED FROM ANY PREVIOUS COVERAGE? N WAS TAIL COVERAGE PURCHASED UNDER ANY PREVIOUS POLICY? EMVLUYEE BENEFITS LIABILITY 1. DEDUCTIBLE PER CLAIM: $ 13. NUMBER OF EMPLOYEES COVERED BY EMPLOYEE BENEFITS PLANS: 2. NUMBER OF EMPLOYEES: 14. RETROACTIVE DATE: ACORD 126 (2016109) Attach to ACORD 125 ®1993-2016 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD CONTRACTORS AGENCY CUSTOMER ID: EXPLAIN ALL 'YES" RESPONSES (For all past or present operations) Y I N 1. DOES APPLICANT DRAW PLANS, DESIGNS, OR SPECIFICATIONS FOR OTHERS? N 2. DO ANY OPERATIONS INCLUDE BLASTING OR UTILIZE OR STORE EXPLOSIVE MATERIAL? 3. DO ANY OPERATIONS INCLUDE EXCAVATION, TUNNELING, UNDERGROUND WORK OR EARTH MOVING? N N N 4. DO YOUR SUBCONTRACTORS CARRY COVERAGES OR LIMITS LESS THAN YOURS? 5. ARE SUBCONTRACTORS ALLOWED TO WORK WITHOUT PROVIDING YOU WITH A CERTIFICATE OF INSURANCE? N 6. DOES APPLICANT LEASE EQUIPMENT TO OTHERS WITH OR WITHOUT OPERATORS? N DESCRIBE THE TYPE OF WORK SUBCONTRACTED OAID to 3UB. OF WORK FULL. PART. NTRACTORS: SUBCONTRACTED: I TIME STAFF: TIME STAFF: PRODUCTS ! COMPLETED OPERATIONS PRODUCTS ANNUAL GROSS SALES i OF UNITS TIME IN MARKET EXPECTED LIFE INTENDED USE PRINCIPAL COMPONENTS EXPLAIN ALL "YES' RESPONSES (For all pastor present Products or operations) PLEASE ATTACH LITERATURE, BROCHURES, LABELS, WARNINGS, ETC. Y / N 1. DOES APPLICANT INSTALL, SERVICE OR DEMONSTRATE PRODUCTS? N 2. FOREIGN PRODUCTS SOLD, DISTRIBUTED, USED AS COMPONENTS? (If'YES", attach ACORD 815) N 3. RESEARCH AND DEVELOPMENT CONDUCTED OR NEW PRODUCTS PLANNED? N 4. GUARANTEES, WARRANTIES, HOLD HARMLESS AGREEMENTS? N 5. PRODUCTS RELATED TO AIRCRAFT/SPACE INDUSTRY? N N 6. PRODUCTS RECALLED, DISCONTINUED, CHANGED? ?. PRODUCTS OF OTHERS SOLD OR RE -PACKAGED UNDER APPLICANT LABEL? N 8. PRODUCTS UNDER LABEL OF OTHERS? N S. VENDORS COVERAGE REQUIRED? 10. DOES ANY NAMED INSURED SELL TO OTHER NAMED INSUREDS? N N ACORD 126 (2016109) Page 2 of 4 AGENCY CUSTOMER ID: ADDITIONAL INTEREST 1 CERTIFICATE RECIPIENT I IACCIRD45attachw INTEREST NAME AND ADDRESS RANK: EVIDENCE: I KI CERTIFICATE ADDITIONAL INSURED EMPLOYEE AS LESSOR City of Pasco LENDER'S LOSS PAYABLE 525 N 3rd Ave LII►HOLDER Pasco, WA 99301 LOSS PAYEE MORTGAGEE REFERENCE I LOAN is GFNFRAL INFARMATInN INTEREST IN REM NUMBER LOCATION: BUILDING: iIEw- ` } REM: CLASS: REM DESCRIPTION EXPLAIN ALL "YES" RESPONSES (For s3 past or present operations) Y I N 1. ANY MEDICAL FACILITIES PROVIDED OR MEDICAL PROFESSIONALS EMPLOYED OR CONTRACTED? N N 2. ANY EXPOSURE TO RADIOACTIVEINUCLEAR MATERIALS? 3. DOIHAVE PAST, PRESENT OR DISCONTINUED OPERATIONS INVOLVE(D) STORING, TREATING, DISCHARGING, APPLYING, DISPOSING, OR TRANSPORTING OF HAZARDOUS MATERIAL? (e.g. landfills, wastes, fuel tanks, etc) N 4. ANY OPERATIONS SOLD, ACQUIRED, OR DISCONTINUED IN LAST FIVE (5) YEARS? N 5. DO YOU RENT OR LOAN EQUIPMENT TO OTHERS? N EQUIPMENT TYPE OF EQUIPMENT INSTRUCTION GIVEN (YIN) SMALL TOOLS LARGE EQUIPMENT SMALLTOOLS L_jLARGE EQUIPMENT 6. ANY WATERCRAFT, DOCKS, FLOATS OWNED, HIRED OR LEASED? N 7. ANY PARKING FACILITIES OWNED/RENTED? N 8. IS A FEE CHARGED FOR PARKING? N 9. RECREATION FACILITIES PROVIDED? N 10. ARE THERE ANY LODGING OPERATIONS INCLUDING APARTMENTS? (if -YES', answer the following): N ■ APTS I TOTAL APT AREA Sq. Ft I DESCRIBE OTHER LODGING OPERATIONS 11. IS THERE A SWIMMING POOL ON PREMISES? (Check all that apply) APPROVED FENCE LIMITED ACCESS DIVING BOARD SLIDE ABOVE GROUND IN GROUND LIFE GUARD N 12. ARE SOCIAL EVENTS SPONSORED? N 13. ARE ATHLETIC TEAMS SPONSORED? TYPE OF SPORT CONTACT AGE GROUP TYPE OF SPORT CONTACT AGE GROUP SPORT (YIN) 13 - 18 SPORT (YIN) 13 -18 12 8 UNDERHOVER 18 12 3 UNDER OVER 18 EXTENT OF SPONSORSHIP: EXTENT OF SPONSORSHIP: N 14. ANY STRUCTURAL ALTERATIONS CONTEMPLATED? N N 15. ANY DEMOLITION EXPOSURE CONTEMPLATED? AGUKII WO (ZUIWU8) PaQ@ 3 OT 4 GENERAL INFORMATION lrnnnflnuadl AGENCY CUSTOMER ID: EXPLAIN ALL 'YES' RESPONSES (For as pant or present operations) YIN 16. HAS APPLICANT BEEN ACTIVE IN OR IS CURRENTLY ACTIVE IN JOINT VENTURES? N 17. DO YOU LEASE EMPLOYEES TO OR FROM OTHER EMPLOYERS? N LEASE TO WORKERS COMPENSATION COVERAGE CARRIED (YIN) LEASE FROM WORKERS COMPENSATION COVERAGE CARRIED (YIN) 1S. IS THERE A LABOR INTERCHANGE WITH ANY OTHER BUSINESS OR SUBSIDIARIES? N 19. ARE DAY CARE FACILITIES OPERATED OR CONTROLLED? N 20. HAVE ANY CRIMES OCCURRED OR BEEN ATTEMPTED ON YOUR PREMISES WITHIN THE LAST THREE (3) YEARS? N 21. IS THERE A FORMAL, WRITTEN SAFETY AND SECURITY POLICY IN EFFECT? N 22. DOES THE BUSINESSES' PROMOTIONAL LITERATURE MAKE ANY REPRESENTATIONS ABOUT THE SAFETY OR SECURITY OF THE PREMISES? N REMARKS 1ACORD 101. Additional SIGNATURE Applicable in AL, AR, DC, LA, MD, NM, RI and WV: Any person who knowingly (or willfully)' presents a false or fraudulent claim for payment of a loss or benefit or knowingly (or willfully)' presents false information in an application for insurance Is guilty of a crime and may be subject to fines and confinement in prison. *Applies in MD Only. Applicable In CO: It Is unlawful to knowingly provide false, incomplete, or misleading fads or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may Include imprisonment, fines, denial of insurance and civil damages. Any Insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. Applicable In FL and OK: Any person who knowingly and with intent to injure, defraud, or deceive any Insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony (of the third degree)'. 'Applies in FL Only. Applicable In KS: Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written, electronic, electronic impulse, facsimile, magnetic, oral, or telephonic communication or statement as part of, or in support of, an application for the issuance of, or the rating of an Insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false Information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act. Applicable In KY, NY, OH and PA: Any person who knowingly and with Intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance ad, which is a crime and subjects such person to criminal and Civil penalties (not to exceed five thousand dollars and the stated value of the claim for each such violation)'. 'Applies in NY Only. Applicable In ME, TN, VA and WA: It Is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties (may)' include Imprisonment, fines and denial of insurance benefits. 'Applies in ME Only. Applicable in NJ: Any person who Includes any false or misleading Information on an application for an insurance policy is subject to criminal and civil penalties. Applicable in OR: Any person who knowingly and with intent to defraud or solicit another to defraud the insurer by submitting an application containing a false statement as to any material fad may be violating state law. Applicable In PR: Any person who knowingly and with the Intention of defrauding presents false information in an insurance application, or presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents more than one claim for the same damage or loss, shall incur a felony and, upon conviction, shall be sanctioned for each violation by a fine of not less than five thousand dollars ($5,000) and not more than ten thousand dollars ($10,000), or a fixed term of imprisonment for three (3) years, or both penalties. Should aggravating circumstances [be] present, the penalty thus established may be increased to a maximum of five (5) years, if extenuating circumstances are present, it may be reduced to a minimum of two (2) ears. THE UNDERSIGNED IS AN AUTHORIZED REPRESENTATIVE OF THE APPLICANT AND REPRESENTS THAT REASONABLE INQUIRY HAS BEEN MADE TO OBTAIN THE ANSWERS TO QUESTIONS ON THIS APPLICATION. HE/SHE REPRESENTS THAT THE ANSWERS ARE TRUE, CORRECT AND COMPLETE TO THE BEST OF HIS/HER KNOWLEDGE. PRODUCER'S SIGNATURE _ _ _ PRODUCER'S NAME (Please Print) (RsqulrW in Florida) Darin Oman APPLICANT'S SIGNATURE DATE NATIONAL PRODUCER NUMBER 268039 ACORD 126 (20161091 Paea A of A