02/21/2018 AgreementO D,JMCu'o`F•',� Kevin Madok, CPA
Clerk of the Circuit Court & Comptroller Monroe County, Florida
DATE: March 9, 2018
TO: Tammy Sweeting
Executive Assistant
FROM: Pamela&ancock, D.C.
SUBJECT: February 21" BOCC Meeting
Enclosed are the following items for your handling:
C3 (Ann Mytnik) Contract for $22,000.00 with Stephanie Jaffe Werner, d/b/a ESplanade 7, Inc.,
for public art at Bernstein Park recommended by the Art in Public Places Committee and the Florida Keys
Council of the Arts. This will be funded by the one -cent infrastructure tax.
C4 (Ann Mytnik) Contract for $22,000.00 with J.H. Allen for public art at Bernstein Park
recommended by the Art in Public Places Committee and the Florida Keys Council of the Arts. This will
be funded by the one -cent infrastructure tax.
Should you have any questions, please feel free to contact me at extension 3550.
cc: County Attorney
Finance
File
KEY WEST MARATHON PLANTATION KEY
500 Whitehead Street 3117 Overseas Highway 88820 Overseas Highway
Key West, Florida 33040 Marathon, Florida 33050 Plantation Key, Florida 33070
305-294-4641 305-289-6027 305-852-7145
PK/ROTH BUILDING
50 High Point Road
Plantation Key, Florida 33070
305-852-7145
Monroe County Art in Public Places Award Agreement
This AGREEMENT dated the 21" day of February 2018, is entered into by and
between the BOARD OF COUNTY COMMISSIONERS FOR MONROE COUNTY,
hereinafter "County" or `BOCC", and J.H. ALLEN, a/k/a JACK A. HENRY, hereinafter
"Artist".
WHEREAS, the Monroe County BOCC recognizes the extent of cultural
resources available in the county for development, promotion, and enjoyment of the arts.
It is the intent of the BOCC to enrich culturally and benefit the citizens of this county
through the establishment of Art in Public Places; and
WHEREAS, the Art in Public Places Ordinance #022-2001 (AIPP Ordinance),
codified at MCC §2-233(1), authorizes the allocation of one percent (1%) of the County's
construction costs for new construction exceeding $500,000.00 and renovations
exceeding $100,000.00 to be set aside in a fund and used for acquisition, commission,
installation, and maintenance of works of art to be used in, upon, or around the new or
renovated County buildings; and
WHEREAS, the Ordinance established an Arts in Public Places (AIPP)
Committee to review responses to Requests for Proposals for art to be acquired,
commissioned, installed, and maintained in public construction projects and to advise the
BOCC regarding the art subject to the AIPP allocation; and
WHEREAS, the BOCC desires to acquire public artwork to be installed and
located at the newly developed Bernstein Park to promote understanding and awareness
of the visual arts and to enrich the public environment for residents and visitors; and
WHEREAS, in conformity with the AIPP Ordinance and MCC §2-233, the Artist
was selected by the AIPP Committee to provide public artwork for this location; and
NOW, THEREFORE, in consideration of the mutual covenants and payments
contained herein, the parties have entered into this agreement on the terms and conditions
as set forth below.
1. AGREEMENT PERIOD: This agreement is for a period of ninety (90) days after
issuance of a notice to proceed to execute and complete their work. This
agreement shall remain in effect for the stated period unless one party gives to the
other written notification of termination pursuant to and in compliance with
paragraphs 12 and 13 below. All work for which AIPP funds are to be expended
must be completed by the stated termination date.
2. SCOPE OF AGREEMENT: The Artist shall provide:
500 S.F. of mural painting, in the fresco technique, on the east side of the building and
wrapping around the side walls to end logically at the corners. The artwork will cover
both the first and second floor exterior walls. The design will follow the color palette
and design as proposed
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Art in Public Places — Bernstein Park, J. H. Allen
Artist shall confer with and coordinate activities with Monroe County personnel
and/or Elizabeth Young, Executive Director of the Florida Keys Council of the
Arts, in order to insure that there is as much cooperation and cohesiveness in the
incorporation of the art in or around the building or onto the retaining wall so that
there shall be the least amount of interference by the Artist.
3. AMOUNT OF AGREEMENT AND PAYMENT: The County shall provide an
amount not to exceed Twenty -Two Thousand and 00/100 ($22,000.00) Dollars
for materials and services used to create and install the project. The Board of
County Commissioners assumes no liability to fund this agreement for an amount
in excess of this award. Monroe County's performance and obligation to pay
under this agreement is contingent upon an annual appropriation by the BOCC.
Pursuant to Florida's Prompt Payment Act, upon receipt by County of an Invoice
for each of three (3) phases, and documentation to satisfy the Clerk that the
appropriate phase has been completed, payment shall be made for the following
phases at the referenced rates:
1) Design Phase: 33.3% of total payment;
2) Materials: 33.3% of total when artist submits receipts for materials and
eligible costs equal to or greater than 33.3% of the contract total.
Travel expenses are included in this phase and shall be paid in
accordance with Monroe County Code of Ordinances, Sec. 2-106
et. seq., as described in 2a) below:
2a) Travel: All travel expenses shall be reported on a State of Florida Voucher
for Reimbursement of Travel Expenses as adopted by Monroe
County. If Artist has airfare, the original boarding pass, or
equivalent, must be attached to the Voucher. If Artist travel is in a
vehicle, mileage must be reported on the Voucher. Mileage is
reimbursable at fifty-three ($0.53) cents per mile. Meals are to be
reported as follows: Breakfast — when travel begins before 6 a.m.
and extends beyond 8 a.m. for $10.00; Lunch — when travel begins
before 12 noon and extends beyond 2 p.m. for $15.00; and Dinner
— when travel begins before 6 p.m. and extends beyond 8 p.m. for
$30.00.
A State of Florida Voucher for Reimbursement of Travel Expenses
as adopted by Monroe County is attached and made part of this
contract.
3) Completion: 33.3% final payment due when installation is deemed complete
and contractual agreement specifications are verified by the
Monroe County Project Management Department or its designee.
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Art in Public Places — Bernstein Park, J. H. Allen
Eligible costs and expenditures for the project and the total award include, but are
not limited to:
A. Artist's design fee
B. Labor, materials, and contracted services required for production and
installation
C. Artist's operating expenses related to the project
D. Travel related to this project, pursuant to statutory limitations (see above
paragraph 3, item 2a).
E. Transportation of the work to the site (see above paragraph 3, item 2a).
F. Installation to the site
G. Permits and fees necessary for the installation (applicable for exterior
projects which also require HARC review)
H. Legal costs directly related to the project
I. Liability costs of artist
Payment shall be made upon presentation of an original invoice and
documentation necessary to support the completion of the work. Artist shall also
provide any release of liens, if applicable.
Final payment request must be submitted no later than sixty (60) days after the
completion of the project.
4. OWNERSHIP and RIGHTS: Upon the installation of the artwork and acceptance
by the County, the County shall own the artwork and title to the artwork shall pass
to the County. This Article 4 and the Artist's signature on this Agreement shall
constitute and be construed as the Artist's express waiver of rights as provided in
17 U.S.C. § 106A, et.al., to the extent that the artwork may be removed, adjusted,
replaced, and/or relocated, as deemed necessary by the County without obtaining
a waiver or permission from the Artist, and that modification to the artwork
resulting from conservation or public presentation involving lighting and
placement is not prohibited modification or considered alteration, distortion, or
mutilation of the artwork. Artist agrees that the County as owner of the building
and/or property that includes the artwork may, without the consent or permission
of the Artist, make or authorize the making of alterations and/or destruction of
such building and/or property. Artist agrees that where the artwork may be
created or conceived in any fashion by more than one author, the Artist's
signature and waiver binds the entire group of authors/artists.
5. RECORDS: The Artist shall keep such records as are necessary to document
perfonnance of the agreement and give access to these records at the request of
the County, the State of Florida, or authorized agent and representative of said
government bodies. The Artist understands that it shall be responsible for
repayment of any and all audit exceptions which are identified by the Auditor
General for the State of Florida, the Clerk of Court for Monroe County, the Board
of County Commissioners for Monroe County, or their agents and representatives.
For Public Records requirements see paragraph 22 below.
Art in Public Places — Bernstein Park, J. H. Allen
6. MODIFICATIONS AND AMENDMENTS: Any and all modifications of the
terms of this agreement shall be only amended in writing and approved by the
BOCC. Extensions of time to complete any terms or conditions of this
Agreement must be made in writing and may be approved only by the BOCC.
7. INDEPENDENT CONTRACTOR: At all times and for all purposes hereunder,
the Artist is an independent contractor and not an employee of the Board of
County Commissioners of Monroe County. No statement contained in this
agreement shall be construed as to find the Artist or any of its employees,
contractors, servants or agents to be employees of the Board of County
Commissioners of Monroe County, and they shall be entitled to none of the rights,
privileges, or benefits of employees of Monroe County.
8. COMPLIANCE WITH LAW: In carrying out its obligations under this
agreement, the Artist shall abide by all statutes, ordinances, rules, and regulations
pertaining to or regulating the provisions of this agreement, including those now
in effect and hereafter adopted. Any violation of said statutes, ordinances, rules,
or regulations shall constitute a material breach of this agreement and shall entitle
the County to terminate this agreement immediately upon delivery of written
notice of termination to the Artist.
9. HOLD HARMLESS/INDEMNIFICATION: The Artist hereby agrees to
indemnify and hold harmless the BOCC, Florida Keys Council of the Arts, AIPP
Committee, and Monroe County and any of its officers and employees from and
against any and all claims, liabilities, litigation, causes of action, damages, costs,
expenses (including but not limited to fees and expenses arising from any factual
investigation, discovery or preparation for litigation), and the payment of any and
all of the foregoing or any demands, settlements, or judgments arising directly or
indirectly under this agreement. The Artist shall immediately give notice to the
County of any suit, claim, or action made against the County that is related to the
activity under this agreement, and will cooperate with the County in the
investigation arising as a result of any suit, action, or claim related to this
agreement.
10. NON-DISCRIMINATION: The parties agree that there will be no
discrimination against any person, and it is expressly understood that upon a
determination by a court of competent jurisdiction that discrimination has
occurred, this Agreement automatically terminates without any further action on
the part of any party, effective the date of the court order. The parties agree to
comply with all Federal and Florida statutes, and all local ordinances, as
applicable, relating to nondiscrimination. These include but are not limited to: 1)
Title VII of the Civil Rights Act of 1964 (PL 88-352), which prohibit
discrimination in employment on the basis of race, color, religion, sex, and
national origin; 2) Title IX of the Education Amendment of 1972, as amended (20
USC §§ 1681-1683, and 1685-1686), which prohibits discrimination on the basis
of sex; 3) Section 504 of the Rehabilitation Act of 1973, as amended (20 USC
El
Art in Public Places — Bernstein Park, J. H. Allen
§ 794), which prohibits discrimination on the basis of handicaps; 4) The Age
Discrimination Act of 1975, as amended (42 USC §§ 6101-6107), which prohibits
discrimination on the basis of age; 5) The Drug Abuse Office and Treatment Act
of 1972 (PL 92-255), as amended, relating to nondiscrimination on the basis of
drug abuse; 6) The Comprehensive Alcohol Abuse and Alcoholism Prevention,
Treatment and Rehabilitation Act of 1970 (PL 91-616), as amended, relating to
nondiscrimination on the basis of alcohol abuse or alcoholism; 7) The Public
Health Service Act of 1912, §§ 523 and 527 (42 USC §§ 690dd-3 and 290ee-3),
as amended, relating to confidentiality of alcohol and drug abuse patient records;
8) Title VIII of the Civil Rights Act of 1968 (42 USC §§ 3601 et seq.), as
amended, relating to nondiscrimination in the sale, rental or financing of housing;
9) The Americans with Disabilities Act of 1990 (42 USC §§ 1201), as amended
from time to time, relating to nondiscrimination in employment on the basis of
disability; 10) Monroe County Code Chapter 14, Article II, which prohibits
discrimination on the basis of race, color, sex, religion, national origin, ancestry,
sexual orientation, gender identity or expression, familial status or age; and 11)
any other nondiscrimination provisions in any federal or state statutes which may
apply to the parties to, or the subject matter of, this Agreement.
11. ANTI -KICKBACK: The Artist warrants that no person has been employed or
retained to. solicit or secure this agreement upon an agreement or understanding
for a commission, percentage, brokerage or contingent fee, and that no employee
or officer of the County has any interest, financially or otherwise, in the said
funded project, except for general membership. For breach or violation of this
warranty, the County shall have the right to annul this agreement without liability
or, in its discretion, to deduct from the agreement price or consideration, the full
amount of such commission, percentage, brokerage or contingent fee.
12. TERMINATION: This agreement shall terminate pursuant to Paragraph 1.
Termination prior thereto shall occur whenever funds cannot be obtained or
cannot be continued at a level sufficient to allow for the continuation of this
agreement pursuant to the terms herein. In the event that funds cannot be
continued at a level sufficient to allow the continuation of this agreement pursuant
to the terms specified herein, this agreement may then be terminated immediately
by written notice of termination delivered in person or by mail to Artist. The
County may terminate this agreement without cause upon giving ninety (90) days
written notice of termination to Artist. The County shall not be obligated to pay
for any services or goods provided by Artist after Artist has received written
notice of termination.
13. TERMINATION FOR BREACH: The County may immediately terminate this
agreement for any breach of the terms contained herein. Such termination shall
take place immediately upon receipt of written notice of said termination. Any
waiver of any breach of covenants herein contained to be kept and performed by
Artist shall not be deemed or considered as a continuing waiver and shall not
operate to bar or prevent the County from declaring a forfeiture for any
succeeding breach either of the same conditions or of any other conditions.
Art in Public Places — Bernstein Park, J. H. Allen
14. ENTIRE AGREEMENT: This agreement constitutes the entire agreement of the
parties hereto with respect to the subject matter hereof and supersedes any and all
prior agreements with respect to such subject matter between the County and the
Artist.
15. CONSENT TO JURISDICTION: This agreement, its performance, and all
disputes arising hereunder, shall be governed by the laws of the State of Florida,
and both parties agree that the proper venue for any actions shall be in Monroe
County.
16. ETHICS CLAUSE: Artist warrants that she has not employed, retained or
otherwise had act on her behalf any former County officer or employee in
violation of Section 2 of Ordinance No. 10-1990 or any County officer or
employee in violation of Section 3 of Ordinance No. 10-1990. For breach or
violation of the provision the County may, at its discretion, terminate this
agreement without liability and may also, at its discretion, deduct from the
agreement or purchase price, or otherwise recover, the full amount of any fee,
commission, percentage, gift, or consideration paid to the former or present
County officer or employee.
17. PUBLIC ENTITY CRIME STATEMENT: A person or affiliate who has been
placed on the convicted vendor list following a conviction for public entity crime
may not submit a bid on an agreement to provide any goods or services to a public
entity, may not submit a bid on an agreement with a public entity for the
construction or repair of a public building or public work, may not submit bids on
leases of real property to public entity, may not be awarded or perform work as a
contractor, supplier, sub -contractor, or consultant under an agreement with any
public entity, and may not transact business with any public entity in excess of the
threshold amount provided in Florida Statutes, Section 287.017, for CATEGORY
TWO for a period of thirty-six (36) months from the date of being placed on the
convicted vendor list. Artist represents that Artist is not on the Convicted Vendor
list.
18. AUTHORITY: Artist warrants that it is authorized by law to engage in the
performance of the activities encompassed by the project herein described. Each
of the signatories for the Artist below is authorized to contract Artist's services.
19. LICENSING AND PERMITS: Artist warrants that he or she shall have, prior to
commencement of work under this agreement and at all times during said work,
all required licenses and permits whether Federal, State, County or City.
20. INSURANCE: Artist agrees that it maintains in force at its own expense a
liability insurance policy which will insure and indemnify the Artist and the
County from any suits, claims, or actions brought by any person or persons and
from all costs and expenses occurring during the agreement or thereafter that
results from performance by Artist of the obligations set forth in this agreement.
6
Art in Public Places — Bernstein Park, J. H. Allen
At all times during the term of the agreement and for one (1) year after acceptance
of the project, unless the requirement is waived by the Monroe County Risk
Manager, Artist shall maintain on file with the County a certificate of the
insurance of the carriers showing that the aforesaid insurance policy is in effect.
All insurance policies must specify that they are not subject to cancellation, non -
renewal, material change or reduction in coverage unless a minimum of thirty
(30) days prior notification is given to the County by the insurer.
Acceptance and/or approval of Artist's insurance shall not be construed as
relieving Artist from any liability or obligation assumed under this contract or
imposed by law.
The Monroe County Board of County Commissioners, its employees and officials
will be included as "Additional Insured" on all policies except workers'
compensation.
Any deviations from these General Insurance Requirements must be requested in
writing on the County form titled "Request for Waiver of Insurance
Requirements" and must be approved by Monroe County Risk Management. The
following coverages shall be provided prior to commencement of work governed
by this contract:
1. Workers' Compensation if, and as required by Florida Statutes
2. General Liability Insurance. Coverage shall be maintained throughout the
life of the contract and include, as a minimum:
• Premises Operations
• Products and Completed Operations
• Blanket Contractual Liability
• Personal Injury Liability
• Expanded Definition of Property Damage
The minimum limits acceptable shall be:
$300,000 Combined Single Limit (CSL)
If split limits are provided, the minimum limits acceptable shall be:
$100,000 per Person
$300,000 per Occurrence
$ 50,000 Property Damage
An Occurrence Form policy is preferred. If coverage is provided on a
Claims Made policy, its provisions should include coverage for claims
filed on or after the effective date of this contract. In addition, the period
7
Art in Public Places — Bernstein Park, J. H. Allen
for which claims may be reported should extend for a minimum of twelve
(12) months following the acceptance of work by the County.
21. NOTICE: Any written notice to be given to either party under this agreement or
related hereto shall be in writing and hand delivered or mailed, postage
pre -paid, by certified mail, return receipt requested, and addressed and
delivered as follows:
For Artist:
J. H. Allen
1114 Margaret Street
Key West, FL 33040
For County:
Florida Keys Council of the Arts
1100 Simonton Street
Key West, FL 33040
and
County Attorney
P.O. Box 1026
Key West, FL 33041-1026
22. PUBLIC RECORDS COMPLIANCE: Contractor must comply with Florida
public records laws, including but not limited to Chapter 119, Florida Statutes and
Section 24 of Article I of the Constitution of Florida. The County and Contractor
shall allow and permit reasonable access to, and inspection of, all documents,
records, papers, letters or other "public record" materials in its possession or
under its control subject to the provisions of Chapter 119, Florida Statutes, and
made or received by the County and Contractor in conjunction with this contract
and related to contract performance. The County shall have the right to
unilaterally cancel this contract upon violation of this provision by the Contractor.
Failure of the Contractor to abide by the terms of this provision shall be deemed a
material breach of this contract and the County may enforce the terms of this
provision in the form of a court proceeding and shall, as a prevailing parry, be
entitled to reimbursement of all attorney's fees and costs associated with that
proceeding. This provision shall survive any termination or expiration of the
contract.
The Contractor is encouraged to consult with its advisors about Florida Public
Records Law in order to comply with this provision.
Pursuant to F.S. 119.0701 and the terms and conditions of this contract, the
Contractor is required to:
(1) Keep and maintain public records that would be required by the County to
perform the service.
(2) Upon receipt from the County's custodian of records, provide the County
with a copy of the requested records or allow the records to be inspected or copied
8
Art in Public Places — Bernstein Park, J. H. Allen
within a reasonable time at a cost that does not exceed the cost provided in this
chapter or as otherwise provided by law.
(3) Ensure that public records that are exempt or confidential and exempt from
public records disclosure requirements are not disclosed except as authorized by
law for the duration of the contract term and following completion of the contract
if the contractor does not transfer the records to the County.
(4) Upon completion of the contract, transfer, at no cost, to the County all public
records in possession of the Contractor or keep and maintain public records that
would be required by the County to perform the service. If the Contractor
transfers all public records to the County upon completion of the contract, the
Contractor shall destroy any duplicate public records that are exempt or
confidential and exempt from public records disclosure requirements. If the
Contractor keeps and maintains public records upon completion of the contract,
the Contractor shall meet all applicable requirements for retaining public records.
All records stored electronically must be provided to the County, upon request
from the County's custodian of records, in a format that is compatible with the
information technology systems of the County.
(5) A request to inspect or copy public records relating to a County contract
must be made directly to the County, but if the County does not possess the
requested records, the County shall immediately notify the Contractor of the
request, and the Contractor must provide the records to the County or allow the
records to be inspected or copied within a reasonable time.
If the Contractor does not comply with the County's request for records, the
County shall enforce the public records contract provisions in accordance with the
contract, notwithstanding the County's option and right to unilaterally cancel this
contract upon violation of this provision by the Contractor. A Contractor who
fails to provide the public records to the County or pursuant to a valid public
records request within a reasonable time may be subject to penalties under Section
119.10, Florida Statutes.
The Contractor shall not transfer custody, release, alter, destroy or otherwise
dispose of any public records unless or otherwise provided in this
provision or as otherwise provided by law.
IF THE CONTRACTOR HAS QUESTIONS REGARDING THE
APPLICATION OF CHAPTER 119, FLORIDA STATUTES, TO THE
` CONTRACTOR'S DUTY TO PROVIDE PUBLIC RECORDS RELATING
TO THIS CONTRACT, CONTACT THE CUSTODIAN OF PUBLIC
RECORDS, BRIAN BRADLEY AT PHONE# 305-292-3470 BRADLEY-
BRIAN(a,MONROECOUNTY-FL.GOV, MONROE COUNTY
ATTORNEY'S OFFICE 1111 12TH Street, SUITE 408, KEY WEST, FL
33040.
23. RISK OF LOSS: Risk of loss or damage to the artwork shall be borne by the
Artist until acceptance of the artwork by the County as indicated after the final
9
Art in Public Places — Bernstein Park, J. H. Allen
payment has been made by the County. The Artist shall carry insurance sufficient
to cover the purchase price of the artwork to cover risk of loss or damage to the
artwork until final acceptance by the County.
24. WARRANTIES OF QUALITY AND CONDITION: Artist represents and
warrants that the artwork, as fabricated and installed, will be free from defects in
material and workmanship which cause or accelerate deterioration of the artwork
and that reasonable maintenance of the artwork will not require procedures
substantially in excess of those described in the Artist's maintenance
recommendations or proposal. The warranties described in this Article shall
survive for a period of five (5) years after final acceptance of the artwork, with
periodic required maintenance by the County, according to instructions provided
by the Artist. The County shall give written notice to the Artist of any breach of
this warranty during the five (5) year period. The Artist shall, at no cost to the
County, cure reasonably and promptly the breach of warranty by means of repair,
restoration, refurbishing, re-creation, or replacing the artwork.
25. REPAIRS AND RESTORATION: The County reserves the right to determine
when and if repairs and restorations to the artwork will be made after final
acceptance. Repairs and restorations to the artwork occurring five (5) years after
the County's final acceptance of the artwork will be the responsibility and at the
expense of the County.
IN WITNESS WHEREOF, the parties hereto have caused this agreement to be executed
-by its. duly authorized representative on the day and year first above written.
(SEAL)
BOARD OF COUNTY COMMISSIONERS
ATTESTi KEVIN MADOK, CLERK
OF MONROE COUNTY, FLORIDA
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By: \1 ^^-�"'�
By:
Deputy Clerk
Mayor/Chairman
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Art in Public Places
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WITNESS:
ARTIST:
J. H. ALLEN, a/k/a
JACK A. HENRY
Signature Si ature
Print Name / Print Name
DATE: //a/n DATE:
STATE OF FL
COUNTY OF M 0►)rp.p
On this 1-7-K day of J2hk4 7 , 20j, before me, the undersigned
notary public, personally appeared J. H. Allen, a/k/a Jack A. Henry, known to me to be
the person whose name is subscribed above or who produced FL a L
as identification, and acknowledged that he is the person who executed the above contract
with Monroe County for the artwork at Bernstein Park, for the purposes therein
contained.
Notary Public
Printed Name:
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STATE OF FLORIDA TRAVELER AGENCY
VOUCHER FOR REIMBURSEMENT HEADQUARTERS
OF TRAVEL EXPENSE Check One: OFFICER/EMPLOYEE NON-EMPLOYEE/IND. CONTRACTOR RESIDENCE CITY
Date
2018
Travel Performed
From Point of Origin
To Destination
Purpose or Reason
(Name of Conference)
Hour of
Departure
and Hour
of Return
Meals for
Class
A & B
Travel
Per Diem
or Actual
Lodging
Expenses
Class
C
Meals
Map
Mileage
Claimed
Vicinity
Mileage
Claimed
Other Expenses
Amount Type
M
M
M
M
M
M
M
M
M
M
M
M
M
M
Statement of Benefits to the State: (Conference or Convention)
Column
Total
Column
Total
Column
Total
Miles
Column
Total
SUMM
TOTAL
@ $0.53 per mile
Revolving Fund:
Check No.
Check Date
Agency Voucher No.
Advance:
LESS ADVANCE RECEIVED
$( )
Warrant No.
LESS CLASS C MEALS (Officers/Employees Only)
$( )
Warrant Date
NET AMOUNT DUE
Statewide Doc. No.
Agency Voucher No.
I hereby certify or affirm that the above expenses actually incurred by me as necessary travel expenses in the performance of my official duties; attendance at a
conference or convention was directly related to official duties of the agency; any meals or lodging included in a conference or convention registration fee have been
deducted from this travel claim; and that this claim is true and correct in every material matter and same conforms in every respect with the requirements of Section
112.061, Florida Statutes.
TRAVELER'S SIGNATURE:
DATE PREPARED: TITLE:
Pursuant to Section 112.061 (3)(a), Florida Statutes, I hereby certify or affirm that to the best of my
knowledge the above travel was on official business of the State of Florida and was performed for the
purpose(s) stated above.
SUPERVISOR'S SIGNATURE:
SUPERVISOR'S TITLE:
DATE APPROVED:
FOR AGENCY USE:
Travel Performed by Common Carrier or State Vehicle
This section required to be completed only when common carrier is billed directly to the state a2encv.
Date
Ticket Number or
State Vehicle Number
From To
Amount
Name of Common Carrier or
State Agency Owning Vehicle
GENERAL INSTRUCTIONS
Class A Travel —Continuous travel of 24 hours or more away from official headquarters. Breakfast —when travel begins before 6 A.M. and extends beyond 8 A.M.
Class B travel —Continuous travel of less than 24 hours which involves overnight Lunch —when travel begins before 12 noon and extends beyond 2 P.M.
absence from official headquarters. Dinner —when travel begins before 6 P.M. and extends beyond 8 P.M. or
Class C travel —Travel for short or day trips where the traveler is not away from his when travel occurs during night-time hours due to special assignment.
official headquarters overnight.
NOTE: No allowance shall be made for meals when travel is confined to the city or town of official headquarters or immediate vicinity except assignments of official
business outside the traveler's regular place of employment if travel expenses are approved and such special approval is noted on the travel voucher. Rates of Per Diem
and Meals shall be those prescribed by Section 112.061, Florida Statutes.
Per Diem shall be computed at one-fourth of authorized rate for each quarter of fraction thereof. Travel over a period of 24 hours or more will be calculated on the basis of 6-hour
cycles, beginning at midnight; less than 24-hour travel will be calculated on the basis of 6-hour cycles, beginning at the hour of departure from official headquarters. Hour of departure and
hour of return should be shown for all travel. When claiming per diem, the meal allowance columns should not be used.
Claims for actual lodging at the single occupancy rate plus meal allowances should include the commercial lodging expenses in the "Per Diem or Actual Lodging Expenses"
column and include the appropriate meal allowances in the "Meals for Class A & B Travel" column.
Claims for meal allowances involving travel that did not require the traveler to be away from his headquarters overnight should be included in the "Class C Meals" column.
Vicinity travel must appear in the separate column. When travel is by common carrier and billed directly to the traveler, the amount and description should be included in the
"Other Expenses" column. A copy of the ticket or invoice should be attached to this form. If travel is by common carrier and billed directly to the State agency, then the "Travel Performed
by Common Carrier or State Vehicle" section above should be completed. The name of the common carrier should be inserted in the "Map Mileage Claimed " column in these instances.
Justification must be provided for use of a non -contract airline (or one offering equal or lesser rates than the contract airline) or rental car (or one having lower net rates) when contract
carriers are available. Additionally, justification must be provided for use of a rental car larger than a Class `B" car.
If travel is performed by the use of a State-owned vehicle, the word "State" should be inserted in the "Map Mileage Claimed" column on the reverse side of this form, and the
above section designated as "Travel Performed by Common Carrier or State Vehicle" should be completed.
Incidental travel expenses which may be reimbursed include: (a) reasonable taxi fare, (b) ferry fares and bridge, road, and tunnel tolls, (c) storage and parking fees, (d) telephone
and telegraph expenses, and (e) convention or conference registration fee. If meals are included in the registration fee, per diem should be reduced accordingly. Receipts should be
obtained when possible.
The official Department of Transportation map should be used in computing mileage claimed from point of origin to destination whenever possible.
If travel is complimentary, the abbreviation "Comp." Should be inserted in the "Map Mileage Claimed" column. No mileage is allowed.
When any State employee is stationed in any city or town for a period of over 30 consecutive work days, such city or town shall be deemed to be his official headquarters and he
shall not be allowed per diem or subsistence after the period of 30 consecutive days has elapsed, unless extended by the approval of the agency head.
If travel is to a conference or convention, the "Statement of Benefits to the State" section must be completed or a copy of the Authorization to Incur Travel Expense, Form DBF-
AA-13, must be attached. Additionally, a copy of the agenda and registration receipt must be attached.
Any fraudulent claim for mileage, per diem, or other travel expense is subject to prosecution as a misdemeanor.
GERALD LEWIS
Comptroller
ACC> V CERTIFICATE OF LIABILITY INSURANCE
DATE(MMIO°lYYYY)
0111212018
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(les) must have ADDITIONAL INSURED provisions or 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 canter rights to the certificate holder in Ileu of such endorsement(s).
PRODUCER
NAME: NTACTBrandt Kohlhorsl
SelectSolutions Insurance Services
PHONE. tle (866)5006359 Ne : (925)951.0077
AODRIEss: brandlk@selectsoluflonslns.com
1107 Investment Blvd
INSURERIS) AFFORDING COVERAGE
HAIC /
Suite 100
INSURER A: Ohio Security Insurance Company
24082
El Dorado Hills CA 95762
INSURED
INSURERS:
INSURER C :
JH Allen Art and Design
1114 Margaret Street
INSURER D :
INSURER E :
Key West FL 33040
INSURERF:
COVERAGES CERTIFICATE NUMBER: CL17122723736 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 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
L1R
TYPE OF INSURANCE
N
POLICY NUMBER
POLICY
MMMOIYYxYY
LIMITS
COMMERCIAL GENERAL LIABILITY
EACHOCCURRENCE
s 1.000,000
CLAIMS -MADE ® OCCUR
PREMISES Ea occurrence
S 300,000
MEDEXP(Any one erson)
S 15,000
PERSONAL A ADV INJURY
s 11000,000
A
BLS58480132
12/27/2017
12/27/2018
GENLAGGREGATE LIMIT APPLIES PER:
X POLICY ❑ PRO- LOC
GENERAL AGGREGATE
S 2.000.000
PRODUCTS -COMPIOPAGG
s 2.000,000
s
OTHER
AUTOMOBILE LIABILITY
COMBINEeGLE D SINOMIT
Me ilceld
S
ANY AUTO
BODILY INJURY (Per person)
$
OWNED SCHEDULED
AUTOS ONLY AUTOS
BODILY INJURY (Par accident)
$
HIRED NON-0WNEO
AUTOS ONLY AUTOS ONLY
PROPERTY DAMAGE
Per aeddent
$
s
UMBRELLALIAS
OCCUR
EACHOCCURRENCE
S
HCLAIPAS-MADE
AGGREGATE
$
EXCESSLIAB
DED I I RETENTION S
$
WORKERS COMPENSATION
ANY EMPLOYERS' LIABILITY Y I N
ANY PROPRIETOPJPARTNERIEXECUTIVE r--1
OFFICERIMEMBER EXCLUDED?
NIA
PER PER
EL. EACH ACCIDENT
S
E.L. DISEASE- EA EMPLOYEE
5
(Mandatory In NH)
Irges. describe order
DESCRIPTION OF OPERATIONS below
E.L. DISEASE- POLICY LIMIT
s
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Addidonel Remarks Schedule, may be attached If more space Is required)
Monroe County BOCC Is AddiOonal Insured If required by written contract or written agreement subject to General Liability Blanket
Additional Insured Provision.
P R
W _
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Monroe County BOCC ACCORDANCE WITH THE POLICY PROVISIONS.
1100 Simonton Street Rm 2-216
AUTHORIZED REPRESENTATIVE
Key West FL 33040 -ZaJ
9)1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD
1996 Edition
MONROE COUNTY, FLORIDA
Request For Waiver
of
Insurance Requirements
It is requested that the insurance requirements, as specified in the County's Schedule of Insurance
Requirements, be waived or modified on the following contract:
Contractor: -zzzjt-,, Al. klixi
Contract for:
Address of Contractor:
Phone:
Scope of Work:
i//�I ?
Reason for Waiver: IVIO-Aloa l
Policies Waiver
will apply to:
Signature of Contrl?l .
Risk Management:
Date:
County Administrator appeal:
Approved
Not Approved
Date:
Board of County Commissioners appeal:
Approved Not Approved
Meeting Date:
Administrative Instruction WAN REQ DOC
94709.3 --