Loading...
11-019 Agreement, County of Santa Clara, Tobacco Prevention Ordinance Second Amendment to Agreement Between the County of Santa Clara and City of Cupertino for Tobacco Prevention Ordinances This is the second amendment to the Agreement, by and between the County of Santa Clara (COUNTY) and City of Cupertino (CONTRACTOR), effective as of January 10, 2011, as amended as of June 3, 2011 ("Agreement"), to provide tobacco prevention ordinances, P.O. #4300007223. The Agreement is amended as follows effective March 1, 2012: 1. Article 3, Term and Termination, is amended to provide that the Agreement shall begin on January 10, 2011 and expire on March 18, 2012. All other terms and conditions of the Agreement remain in full force and effect. In the event of a conflict between the original Agreement and this Amendment:, this Amendment controls. SIGNATURES COUNTY OF SANTA CLARA: CON = CTOR: By: 2 Z3 / B : S. C. t Z.Y / Y L.147r R ae Wedel, Division Director D to Da • Knapp Date Public Health Director City Manager, City of Cupertino APPROVED AS TO FORM AND LEGALITY: Jen S. L Date Dep ty County Counsel P d ov=`• -S to form: i. APPROVED: Gi y 'ttorney 41 Emily H.:°n Date Deputy ounty Executive Second Amendment to PO#4300007223 Page 1 of 2 For County Use Only—SAP SCC Vendor Number: Account General Cost Amount WBS Internal Order Assignment Ledger Center Line 1 Line 2 H,I or J Expense Code Dept.Code Capital Project Code "PCA"code-Optional ❑ Please give the reason for an increase in price, where there is no change in scope of service or term date: ❑ Amend amount of agreement as follows: A Maximum Financial Obligation: $ (Current Contract Amount) B Requested amount to be amended: $ C Revised maximum contract amount: $ (A+ B will equal C) CONTRACT HISTORY If agreement covers services that occur in more than one fiscal year, enter information below. Total financial obligation from prior fiscal year(s): $ Second Amendment to PO#4300007223 Page 2 of 2 County of Santa Clara x , Public Health Department •� �� i zO Public Health Administration Ai/ 976 Lenzen Avenue, 2nd Floor -, San Jose, CA 95126 r 2856' . `" 408.792.5040 ° '/, February 24, 2012 David Knapp City Manager City of Cupertino 10300 Torre Avenue Cupertino, CA 95014 Re: Second Amendment to the Agreement for Tobacco Prevention Ordinances Dear Mr. Knapp, Enclosed is the partially executed Second Amendment to the Agreement between the County of Santa Clara and the City of Cupertino for Tobacco Prevention Ordinances. The Amendment has been signed by the County of Santa Clara and requires counter- signature by your agency for completion. Once fully executed, please return the original to my attention at the address listed above. Time is critical as we are closing in on the expiration date. We appreciate your flexibility for a quick-turn-around. If you have any questions or need additional information regarding this Amendment, please contact Kathy Yu at 408-793-2772 or by email at Katherine.Yu(c�phd.sccgov.orq. Sincerely, E pe nza Ardourel Management Aide Contracts & Compliance Unit Enclosures OFFICE OF THE CITY CLERK CITY HALL 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 �yc.►94 TELEPHONE: (408) 777-3223• FAX: (408)777-3366 , WEBSITE:www.cupertino.org CUPERTINO March 7, 2012 Esperanza Ardourel County of Santa Clara Public Health Department 976 Lenzen Avenue, 2nd Floor San Jose, CA 95126 Re: Agreement Enclosed is the original executed copy of the Second Amendment to the Agreement between the County of Santa Clara and the City of Cupertino for Tobacco Prevention Ordinances. This office has already made a copy for our files. If you have any additional questions, please contact the City Manager's office at(408) 777-3212. Sincerely, Kirsten Squarcia City Clerk's Office Enclosure County of Santa Clara Public Health Department ' „, Chronic Disease and Injury Prevention /i /* 1400 Parkmoor Avenue, Suite 120B San Jose, CA 95126 U&1O Q, 408.793.2700 January 13, 2011 Cupertino City Hall Attn: David Knapp, City Manager 10300 Torre Avenue Cupertino, CA 95014 -3202 Dear David: I am attaching a contract from the County of Santa Clara for your initials and signature. This contract relates to the Communities Putting Prevention to Work Tobacco grant. I have worked on this contract with Clinton Brownley and Carol Atwood. Please initial page 2 of the Non - Standard Service Agreement Cover Sheet. Your initials indicate that you understand that the County will need to execute a new contract only if the W -9 tax identification number provided by the city changes. Please sign the boilerplate where the second tab is found in the packet. I plan to meet with Clinton on Friday, January 21 at 9:30 AM. Therefore, it would be appreciated if you could initial and sign this packet by the time l meet with Clinton. If you have any questions, please do not hesitate to contact me at Katherine.vu@a,phd.sccgov.org or at 408 - 793 -2772. Thank you for your help. Sincerely, frciaefti.,11A- Katherine Yu Board of Supervisors: Donald F. Gage, George Shirakawa, Dave Cortese, Ken Yeager, Liz Kniss County Executive: Jeffrey V. Smith County of Santa Clara - Non Standard Service Agreement Cover Sheet This form and the Checklist are administrative forms and are not part of the agreement SECTION 1: GENERAL INFORMATION Date: 12/17/10 P.O. Number: (Procurement Department Use Only) Agency /Department Name: Public Health /CDIP Department No.: 0410 Brief Description of Services: Implement anti - smoking policy to prohibit smoking in places of recreation, including parks and trails. Design anti - smoking messages using ideas from youth convention. Implement retail permitting policy that includes enforcement. Maximum Financial Obligation: $ 23,387 Term of Agreement: Start Date January 10, 2011 End Date March 2, 2012 For County Use Only — SAP Account General Cost Center Amount WBS Internal Order Assignment Ledger Line 1 0410 5255100 2942 $ 3,119 CO FY 10 — FY 11 1-04802" Line 2 0410 5255100 2942 $ 20,268 CO FY 11 — FY12 484892' H, I or J Expense Code Dept. Code Capital Project Code "PCA" code - Optional SECTION 11: PARTIES TO AGREEMENT CONTRACTOR COUNTY of SANTA CLARA Legal notices pertaining to this agreement will be sent to the Mail Invoices to County of Santa Clara at: name, address and contact person below: Name: City of Cupertino Agency /Dept: Public Health Department Contact Person: Dave Knapp, City Manager Contract Monitor: Katherine Yu Address: 10300 Torre Avenue Address: 1400 Parkmoor Avenue, Suite 120B City /State /Zip: Cupertino, CA 95014 City /State /Zip: San Jose, CA 95126 Telephone: 408 - 777 -3212 Fax: 408 - 777 -3366 Telephone: Fax: 408 - 793 -2731 408 - 793 -2772 SCC Vendor Number (SAP): Fiscal Contact: Katherine Yu SECTION III: DETERMINATION OF TAX WITHHOLDING AND BENEFIT STATUS For federal tax purposes Dependent/Independent status is an important distinction. It affects how the contractor files tax returns and the contractor's responsibility for various federal and state taxes. The questionnaire also determines the contractor's eligibility for Medicare and Social Security, Public Employees' Retirement System benefits, and other benefits. Is contractor a government entity, corporation, nonprofit organization or school district? X YES - This is an Independent Contractor. Proceed to Section IV CI NO - Complete the Questionnaire (For help with the Questionnaire, visit www.oba) Use form as a cover sheet for agreements approved outside of the Procurement Department's authority. Effective 09 /09.Page 1 County of Santa Clara - Non Standard Service Agreement Cover Sheet This form and the Checklist are administrative forms and are not part of the agreement Questionnaire to be Completed by Contracting Department to Determine Dependent or Independent Status of Contractor YES NO 1 Supervision: Will the County have the right to tell the contractor how to do the work, when to arrive or leave work, or when to take breaks? Do you have other employees performing similar work with a ` , similar degree of supervision? If the answer to any of these questions is YES, mark the box YES. x If NO, please explain. 2 Training: Will the County instruct the contractor on how to do the job or pay for external training? If NO, please explain. 3 Incomplete Work: Will the Contractor be able to resign or terminate the contract without being held either financially or legally liable for unfinished work? If NO, please explain. X 4 Place of Work/Tools: Will the County provide the Contactor with a place to work at a County location and tools to do the job, i.e. computers, telephones, etc? If NO, please explain. 5 Length of Relationship: When the Contractor is hired to complete ongoing departmental duties or functions — answer YES. When the contractor is hired to complete a specific project that was not the regular tasks performed by County employees before - answer NO and explain briefly. 6 Other Customers: Does the County prevent the Contractor from performing similar services for other customers, either due to the amount of work (full- time), or by contractual provision? If NO, please explain. 7 Designation as Business Entity: If the Contractor has a business license or business certificate, mark the box "No ". (This does not pertain to professional licenses or certificates such as a license for a physician or architect.) Enter below the business license number and the city /entity where .— �� — issued. Bus Lic. # Issued by: 8 Payment Schedule: Will payments be made either as an hourly wage or as weekly /monthly salary? If payment is by commission or based on project milestones or deliverables, answer "NO" to this question. If NO, please explain. Be sure this answer matches the contract payment schedule in Section V. 9 Support Services: Will County employees or other independent contractors provide assistance to this Contractor? Assistance is defined as clerical, technical or professional support. If NO, please " � explain. /� If at least 5 of the above questions were answered "NO ", Contractor is an Independent Contractor. ❑ If 5 or more of the above questions were answered "YES ", Contractor is a Dependent Contractor, where the relationship resembles that of employer /employee. Tax withholding is required and benefits are provided. Complete and attach the following forms: Employee's Withholding Allowance Certificate — Federal Form W-4, State Withholding, Form DE-4, Determining PERS Eligibility and PERS Member Action Request. Visit www.oba for more information regarding Dependent Contractors. County insurance requirements do not apply to Dependent Contractors. Contractor understands and agrees that the tax withholding and benefit status checked above is correct. Any changes to the contractor's tax withholding and benefit status require a new contract. Contractor is responsible for any penalties and liabilities assessed by any taxing authority, based on a change of tax withholding and benefit status. Contractor's Initial: �� - ` Reviewed and signed off by Dept. Fiscal Officer Use form as a cover sheet for agreements approved outside of the Procurement Department's authority. Effective 09 /09.Page 2 10300 Torre Avenue Cupertino, CA 95014 -3255 Telephone (408) 777 -3220 Fax (408) 777 -3366 DEPARTMENT OF ADMINISTRATIVE SERVICES MEMORANDUM DATE: January 21, 2011 TO: SCC Public Health Department FROM: Carol Atwood, Director of Administrative Services 0A- CC: Dave Knapp, City Manager SUBJECT: Additional Information for Non Standard Service Agreement Below please find explanations to the answers on the preceding Non Standard Service Agreement cover sheet in regards to the Communities Putting Prevention to Work Tobacco grant. 1. Supervision — The City of Cupertino has exclusive control over how the grant objectives will be achieved and will utilize staff, commissioners and/or contractors without County approval. 2. Training — SCC will not instruct the City on how to execute the grant objectives or pay for external training of our staff 3. Incomplete Work — The City agrees to perform the objectives as listed in Exhibits A, B & C and will not be able to resign or terminate the contract without being held financially or legally liable for unfinished work. 4. Place of Work/Tools — The City will be utilizing their own facilities in executing this grant. - 5. Length of Relationship — City agrees to complete the specific project as outlined in Exhibits A, B & C. 6. Other Customers — The County has no control over the City to prevent similar activities with other agencies. 7. Designation as Business Entity — N /A. The City of Cupertino is a general law city. 8. Payment Schedule — Payments will be made to the City based on project milestones or deliverables only. 9. Support Services — The City intends to utilize their own staff for technical and professional support. Admin Services /grants /SCC Tobacco Grant supplement.doc County of Santa Clara - Non Standard Service Agreement Cover Sheet This form and the Checklist are administrative forms and are not part of the agreement SECTION IV: VENDOR SELECTION PROCESS Contractor was selected by: CHECK ONE ❑ Informal Competitive Process (attach an executive summary in support of your recommendation) ❑ Specified by the Board of Supervisors (attach approved Board transmittal) ® Formal Request for Proposal / Request for Qualifications (see attached) ❑ Sole source (see attached) El Other (see attached) SECTION V: STATEMENT OF ECONOMIC STATEMENT Is Form 700 required? El Yes ® No If Form 700 is required, it must be filed with the Clerk of the Board within 30 days of the contract's effective date of . Contractor must submit Form 700 by to the Department's Contract Monitor. Department's Contract Monitor will submit the completed Form 700 with the Form 700 cover sheet to the Clerk of the Board by SECTION VI: BEVERAGE NUTRITIONAL CRITERIA Contractor shall not use County funds to purchase beverages that do not meet the County's nutritional beverage criteria. The six categories of nutritional beverages that meet these criteria are (1) water with no additives; (2) 100% fruit juices with no added sugars, artificial flavors or colors (limited to a maximum of 10 ounces per container); (3) dairy milk, non -fat, 1% and 2% only, no flavored milks; (4) plant derived (i.e., rice, almond, soy, etc.) milks (no flavored milks); (5) artificially- sweetened, calorie- reduced beverages that do not exceed 50 calories per 12 -ounce container (teas, electrolyte replacements); and (6) other non - caloric beverages, such as coffee, tea, and diet sodas. These criteria may be waived in the event of an emergency or in Tight of medical necessity. Use form as a cover sheet for agreements approved outside of the Procurement Department's authority. Effective 09 /09.Page 3 AGREEMENT BETWEEN THE COUNTY OF SANTA CLARA AND CITY OF CUPERTINO FOR TOBACCO PREVENTION ORDINANCES This is an Agreement between the County of Santa Clara ( "County ") and the City of Cupertino ( "Contractor ") to pursue adoption of Tobacco Prevention Ordinances for City of Cupertino, is made effective January 10, 2011. WHEREAS, the County received grant funds from the Centers for Disease Control and Prevention, for the purpose of implementing population -based approaches to tobacco prevention and control; and, WHEREAS, Contractor submitted a Scope of Work (Exhibit A) to accept funding for and part-take in related research, ordinance development/legal analysis, public outreach and enforcement and compliance activities; and, WHEREAS, Contractor's letter of commirment has been accepted and by virtue of the parties' execution of this Agreement, the Contractor will be awarded funding under the terms of this Agreement; and, NOW, THEREFORE, the parties hereto agree as follows: Article 1. County's Obligations. 1.1. County will provide Contractor funding for tasks and deliverables in Exhibit A based on Line Item Budget and Budget Justification (Exhibit B). 1.2. Subject to the availability of funds, the maximum amount payable by COUNTY to CONTRACTOR under this Agreement shall not exceed $ 23,387 ($ 3,119 for the period January 10, 2011 through March 18, 2011 and $ 20,268 for the period March 19, 2011 through March 2, 2012). COUNTY does not guarantee a minimum payment to CONTRACTOR. Article 2. Contractor's Obligations. 2.1 Contractor shall complete tasks and deliverables as stated in Exhibits A and C. 2.2 Contractor shall maintain records adequate to demonstrate that funding received under this Agreement is used in accordance with this Agreement. These records shall be maintained during the term of this Agreement and for a period of three (3) years from termination of this Agreement or until all claims, if any, have been resolved, whichever period is longer, or longer if otherwise required under other provisions of this Agreement. Agreement w/ City of Cupertino Page 1 of 5 For Tobacco Prevention Ordinance Through March 2, 2012 2.3 Contractor shall permit the County and its authorized representatives to monitor Contractor's performance of this Agreement. To the extent permitted by law, such monitoring may include, but not be limited to, audits and review of records related to this Agreement. Such monitoring shall be permitted at any time during Contractor's normal business hours upon no less than 24 hours advance notice. 2.4 Contractor shall designate a project director /coordinator responsible for overseeing the performance of this Agreement, and serving as County's primary contact for the purpose of monitoring this Agreement. County must be notified in writing of any change of the project director /coordinator. Article 3. Term and Termination. 3.1 Term of this Agreement. This Agreement is effective from January 10, 2011 through March 2, 2012, unless terminated earlier in accordance with this Agreement. 3.2 Termination. a. Termination for Cause. County may terminate this Agreement for cause upon written notice to Contractor. For purposes of this Agreement, cause includes, but is not limited to, any of the following: (a) material breach of this Agreement by Contractor, (b) violation by Contractor of any applicable laws, or (c) assignment by Contractor of this Agreement without the written consent of County. Such notice shall specify the reason for termination and shall indicate the effective date of such termination. b. Termination for Convenience. Either party may terminate this Agreement without cause by giving the other party thirty (30) days written notice. Article 4. Miscellaneous 4.1 Assignment. The parties may not assign this Agreement or the rights and obligations hereunder without the specific written consent of the other. 4.2 Entire Agreement. This document represents the entire Agreement between the parties with respect to the subject matter hereof. All prior negotiations and written and/or oral Agreements between the parties with respect to the subject matter of this Agreement are merged into this Agreement. Agreement w/ City of Cupertino Page 2 of 5 For Tobacco Prevention Ordinance Through March 2, 2012 4.3 Amendments. This Agreement may only be amended by an instrument signed by the parties. 4.4. Waiver. No delay or failure to require performance of any provision of this Agreement shall constitute a waiver of that provision as to that or any other instance. Any waiver granted by a party must be i n writing, and shall apply to the specific instance expressly stated. Article 5. Liability. 5.1 Mutual Indemnification. Each party agrees to indemnify, defend, and hold harmless the other party and its officers, directors, trustees, employees, agents (together "Employees and Agents ") from any claim, liability or loss, including reasonable attorneys' fees arising out of or resulting from the acts or omissions of the indemnifying party or any of its Employees or Agents in connection with this Agreement, excepting only loss, injury or damage caused by the sole negligence of willful misconduct of the non - indemnifying party's Employees and Agents. Each party shall notify the other party immediately in writing of any claim of injury or damage related to activities performed pursuant to this Agreement. The parties shall cooperate with each other in the investigation and disposition of any claim arising out of the activities of this Agreement, provided that nothing shall require either party to disclose any documents, records or communications that are protected under the peer review privilege, the attorney - client privilege or the attorney work - product privilege. The provisions of this section shall survive the termination of this Agreement. 5.2 Limitation of County's Liability. The County is not liable for any damages experienced by the Contractor, or any person or entity arising as a result of: (a) Contractor's use or misuse of the equipment or supplies granted under this Agreement; (b) Contractor's failure to provide services pertaining to the equipment or supplies granted under this Agreement; or (c) any defects in the equipment or supplies granted under this Agreement. Agreement w/ City of Cupertino Page 3 of 5 For Tobacco Prevention Ordinance Through March 2, 2012 Article 6. Contractor Insurance Requirements Without limiting the indemnification of either party to this Agreement, each party shall maintain or cause to be maintained the following insurance coverage: (1) a policy of commercial general liability with limits of liability not less than five hundred thousand dollars ($500,000) per occurrence and five hundred thousand dollars ($500,000) annual aggregate; (ii) a policy of workers' compensation providing statutory coverage; and (iii) such other insurance or self - insurance as shall be necessary to insure it againsl: any claim or claims for damages arising under the Agreement. Each party to this Agreement shall provide a Certificate of Insurance certifying that coverage as required herein has been obtained. The requirements of this section may be satisfied by the provision of similar coverage through a self - insurance program. Signed: PUBLIC HEALTH DEPARTMENT CITY OF CUPERTINO by 4 /l b �� y , Y Dan Peddyco , Director Date pe David Knapp, City Manager ate Public Health Department L/ City of Cupertino P tY p Appr / Approved as to Form: Orr.-. sa " " ' ( Emily ' ; .son Date City Attorney Date Deputy ounty Executive Approved as to Form and Legality: 11 .4 1Z12 Jennifv1V p1 les Date Depu � ounty Counsel Exhibits to this Agreement: Exhibit A: Scope of Work Exhibit B: Line Item Budget and Budget Justification Exhibit C: Program Requirements Agreement w/ City of Cupertino Page 4 of 5 For Tobacco Prevention Ordinance Through March 2, 2012 Article 6. Contractor Insurance Requirements Without limitini; the indemnification of either party to this Agreement, each party shall maintain or cause to be maintained the following insurance coverage: (1) a policy of commercial general liability with limits of liability not less than five hundred thousand dollars ($500,000) per occurrence and five hundred thousand dollars ($500,000) annual aggregate; (ii) a policy of workers' compensation providing statutory coverage; and (iii) such other insurance or self- insurance as stun be necessary to insure it against any claim or claims for damages arising under the Agreement. Each party to this Agreement shalt provide a Certificate of Insurance certifying that coverage a:; required herein has been obtained. The requirements of this section may be satisfied by the provision of similar coverage through a self - insurance program. Signed: PUBLIC HEALTH DEPARTMENT CITY OF CUPERTINO by 7 � by '� Ci Mana A/// Dan Peddycoi��, Director Date 661 David Knapp, ty er g Public Health Department City of Cupertino Appro ' • App as to Form: Prit.■ , 42AA-7 /2,,,V(4P aack6ka Emily ' ; isoii Date City Attorney' Date Deput ount, Executive Approved as ti> Form and Legality: • 111275 Jennif. p1I kles Date DeputP aunty Counsel Exhibits to the s Agreement: Exhibit A: Scope of Work • Exhibit B: Line Item Budget and Budget Justification Exhibit C: Program Requirements Agreement w/ City of Cupertino Page 4 of 5 For Tobacco Pr,vention Ordinance Through March 2, 2012 Zd 1761.0--17t9 -065 c9Z:66 66 6Zuer m�0mC" o7- $ccoo a u a m x n m 3' o o C rt v) 3 _ . va V n A. 0 o 0.�N 0 .fp a0.l 0 O Q ., O y g n o a) . 3 rt° o = .. �, m< a O 7G o u rt -o= N m -, d 0 r-, O � = u 5 CD M n 3 . a 0 0 n? °' v n 7 -, a Z o N 0 rt m 7 a rt �� 40.0 a L n n O cn m .0 f D cu rr rr rt rt 5- . rr (n 3 • , C N d 0 (A 7 (D ri N (D 0 rt 0 0 (D rt C 7 C O m a 3 cu 3 s 0) V) co X n< 0) U) `< -I 5 (0 z n Q co .< o O a 3 C O C O (D O O C p •< 7 0 3 ' _ ffr 3 w' 3 3 n 3 3 G O 3 0 7 r rn ci) a r (n 0 a, Q 3 . (n or m < n O 3 3 O . lD o • 7 cu O) N O) -., N o 3 w m• a 8 �1° g o a� �� ' c� (D rt n °' v, m n n n o, m rt �l n 7 5 =*7nrn` r DO e `D i c a o m o w c IN CU n 0= n I n > = c H a 0 CL �* m n o 0 ex C J. O m m o ( o n o o) r = , c) 13 3 0 d o . o - 5 . 0 ^( 3 a (D rt ( (p A p (D rt * ,- 0 a n �i n o •„ n of s= m la O Ri d a E. 00)) �N = CD C a rt 0 Q r S o O (n 0 7- e O (�(( 0 0 re ( m 0 n rt 0 ((D p 3 N 3 0 (?D o) �v o o (0 S y 3 C (C (D O ) O • C — X' Cr. O m R m. i 2 '0 M 13 m m ? o o'a n `n 0 3" 0 fD p o 0 3 S 0 d 3 3 a /\ "'yf 3 < o• A, -h m C a � 3c� O 3 C Q , r = r p o f a O_ a r � _ r , p lG 3 0 ° �o a 7`�ga o ° In 3 O G 3 rt X - o _ O N 7 (D o a • 3 _< _ x" 0 O O U O O n m O �_ �, 3 0 O co m r- Ort � , N 3 p < ^ r o) O — 01 a ,-1 2 r'F ? a M -0 N m 7 0. (D (D • re IV co - m co hl O cc to co n n 0 �' O S m a N G 0 p 0 o n o, � F+ O -1, a ( 3 _ rt � � re A - �0 � � ' on O r) 0 7 5 5 0- ( d c 3 rt -^ ' ( n =1: m C ( ( 0 ? 0 (( ry0(p n zu 5 n O 0 -I � D 3 7 S a m m m 7 3 N rr a S to 3 C up 0 0 0 o) N • F ,. - 0 = (D S 3 N. '13 d ( O O v -' > > M 0) O "Cl . C Q lc r ( 5 0 (D 3 iv a n z . , !^ 3 = m- d \ N N ( N 0 r 0 A (D (D 0 n a 3 a - 0 CD �, O. = a a) 0 -, CD CD 0 S CD O CD N C 7 O O — fD n 3 fD o r C<D � O, 7 fD N 00 v, Q ° N r ° ta. co o .< ,i. ry C ° ° to A CD (" a 3 ' — x 0 v A CD O n co v �' O r •r a v 7 1 o, t^ a rt 7C I.A. 3 < = n t0 m 0 . o 0 � m = 3 ° — a te _ . _ 7 a F d O O j 0 O rt 0 (I) Ln CD CD j T L , 2. fD �i 3 n' l4...) w 0 v a 3 `°. a y O r , i . < C O •• a 0 3 7 m 5 o 0- 0 • rn � a CU m m c t° m t0 rr. 0 N — 2 rt Cr O fD co n 3 Z U -1 3 Z v) -. n pp '* N v 0 f) cn fp -^ fD V C O o, C 03 : 7 ` -1 N p O A 1:1 Ort, 0 3 3 3 3 0 - 3 < 3 m v) m C s< -h CD ci �' 0 f m 10 f m [ � rt n rt o, ( 3 0, < j N _, , C y, rt 3 O C y, C C;, 0 N 3 3 N a - (1) C 7 tu o O f 7 rt C D r r J F+ X. O o '� y 0 a N 3 c t0 O a O 2] o, :u 0 y 7 T A C rt V 0 i < O c. O '..< 0- rt 0 O M CD 0 C 0 A N O y o � N-1- Cl) CD 7 a) l 0 m O" 0 0- ;--I- ...U1 v, 0 V) .°0 N a. o t0 0 O• O, a p ,--1- y -4, 0 -M) a CD • M Cu rt --1, � 3 -, m 3 M M d •a rn m D A . �� O CD O) a) ,-4. re m: O , n u t O a o) a v, c � �' i v, Fi �'i u, O v) N a 3 2 ,- ' III m 0 o m 0 1° al 3 3 p? r_ O To /-1 rt C) O v, O 7 VI E - E -1 c -r a t0 rt CD 7 0 0 O, 7 . 1 O CD a _� CD O O a [D 7 5 j 0 O , C f (O l0 A s 0 Z r + O, N, u) Q 7 a -- O 0 x 0" p c- y (/) A',4 7.: - ' �a p m10a 3ofD, o� 3 p S o S 0= O CD T7 tD 3 to 0 ° v , • R o, V °, 2 o A Ca O cu 0 rt 7 71 to O, p �j O d c c c t0 < VI r+ O t0 to tD Q Ol D CD O, T CU R fp p v) v 0 O o C Ti o, t 3 0 G U o . N o pc. n • o 0 CD on v ° t o °' f D z A. o, O , < 0. a to m m In . r4.,• - E. a Ft- 0 Q) 7 t 0 -1 fD O m rt N 0 7 O rt C N O 0 .< Li r m 3 m £ n* = 3 0 � _ 0 >_ CD 0- ,nmR O vi p to O 0 w °, a C( U /f f n O d N 7.1. A a S • r-F y rt fD c 5 7 G r 0 r C p.,. r � c f) n n n ,. n y p - a d d A.: p 7 fD al v, '='r - E. d' to O )3 4. ( n to a C O a n al O 0 7 a to N VI j Ln = 0 to •� ,� ,.. p CD a rt CD C of ( O 3 0 C i n a 3 g in F . m a 0c O c 0 0. 3 c 3 0 3 .• m c 0 )i m N O T N T NJ a 0 3 O ,•-, (D r 0 CD ,-1, E i ro/ c 0 e = � = - = �_ a° E 6 . a g K o 3 � �f 0 -- ® � g E202®� C 2 ] E E 4 n— I � . 4. 5 7 m CD = s § A a Q FD CI " a • E@ o -1, 2 : co = 7 \ / 2 to \ °. 0_ a , Em fp Jm 7 o E °n ( EEE RRR m o 5 ) k) 1 < = q -o o m c E = E§ & ■ a � E gA - o n E ✓ «u' gi&= O &27 .<2 ^0 c A k ° 0 c In m a » o $ in rt _ > c 7 m E . rn »QED X m 77/ 2 X - PD 0 E o c & — 7 7 g 3 3, ° E il 2 o 0 O. I n E E o § -' "0 e o 2 * ° 0 \ - 0. E 0 S g I q k E e §SA " CU F M¢ / 7"a) $ CU ] n 0 2 g e K J )� n �\ © & _� co , & a = = 0 � n k uz w RR52o n E • = § 7 Z % 0m 7, . 5' E a o k 3 d \ } I-. k 3 M I-. 1-.. vn oo > c 0 • Z c X m M g 3 Z m = O 5 f H H � ..1 Z m Z O 3 C 1 • i' RI y 3 Z i 3 z Z rt c ' � c a 3 o bi' g a m d y Pe: rp o . N C y 1 1."13. } LI a rt R m 3 ` rt° 1 O n d g 3 1 c cr c 0 g o m C c 3 w a 3 0 m ? =R 3 a q rr a f c o C a tpe 0 r o v to W3 070 { - H g � C 3 d ° _rt ' C CO 0 ID el 0 a L c 3 9 9 (D C - o m v o u 3 -I G v I c y , c n ,. 3 4... m rt c F+ A 0 CO co 9 3 CO ICI 01 A =, = °' °' = ai ' CP v► La r2 (C1 N 3 CI C v * c Q ` ml F-• CT cn V) Q o w e c c 31 ~ o z o S c c rt �+ rt •p el O (D o F• - - o o p S — ' rti m rt =1: N 1-1 3 g U a m 3 O rP 3 ' C c co Ci M-+ O W a _ co = =. CD 3 d et m y FiF y C 3 (D L .i N ,, ...v.. ,, ( 3 rt S I- ...... z 0. c d 4 F+ r+ ci. �� ° rP - V N 0 3 O(D in rt 3 M (D 9 O 7 0 3 o rt v 1 1 1 1 re — — — _- — m 0 IAD ilr if) FA iR { A rt 3 co 3 O 3 3 O w 3 1+ N F+ s fD 7 in o) . o 0 [D a O 7 r N N r N O r+ 0 ? 0 n CI a o a 0 7 O 8 TI p T . 'TI O N 0 N. C n • "n C (/t M n N _ „' go Lr go Q' go C n = f�° C S 4. = 0 rD O• N g = g, = c a $ 8 m W g 3 4I 0 0, o or - a 3 0 3 0 3 0 d .94 0 a to st 0. m m m eu m 3 N y ? y 0 a DD a 2 o to � a r n O l 7 -, T �. _. a rA) Q Q n a C j y ' to n m m = m m 0 Ex, rt et CD v a (0•1 j O c CA a =� C ft, W a a �� C v � ° y CD z .0 en � o ° T n ( 7 Pr- ) y V D c P � � 4 O1 co n g n o a A 7a ° Q p n cu cu z� o r o �' M tzt �� n m y •-- 6" a J- y � -'� w s me ► v o g CU o 4 c y p Cr 0. 4 a m 3 ° t o W a > O y m 3 g o o v, . ..1 Q l3 a � co ° o o ° v 0 co 3 0. o iD o o 1 0 rt 5 -p � 0 3 3 ar m rn St ..-• � w a c -I a O D o 0 0 CD m 7 CD > > �� N OD o , a m n 6 y 3 �a a 1 al � CD � `" N " U u) PP 0 0 CD O "~ rt A q 3 to c Q rr y a 0. [D S -1/V -EA. -EA. 41- fq iA iA a r 7 TT 7 y� y r H to N V 01 C F... N H f+ m vi o N K R 0 - - - o ... CI rii Ia. n 2 iil k n rn rn o s y r m 0 0 0 * D. c C D C - O c n 01 Z .. H N = Q d r o 3. tp N J -� m ' 0 0 0 7 O . n 5 r ,= cu j k' T m o1 N1 A p 0 O a y . ' � m r 0 3 or t, '13 e 1 ° o _e. co c cf�� co c o rr (n rn (n to s) 7 O N " 0 D. C L �; , C d n'r Z P n rb O; o r d r p • of to rD a G . o + m < o A) y 1 i c al c -0 y O . �0 p a �„ 7 . cn g p co cu " a a A . � Cu � o of Q �l R 7 CD O 0 fD 7 sR (.1 00 7 a 3 O o 77 1 O g, M O m- mg 2 c 01 cp CU o "" a _� o 4 m F v 7 to N � � d9 r• 2. o W r O 7 R 4 N _ n fi? 94 4 rp 0 0 c k` a v � tn cb j y `', a to .-t. % r c a O ry - 6 d a N n m p' S ga.. o '` m d 3 o 3 5 g m m O n' o 0 r p u co C r O j co a 0 0 t y 71 N O n a rt O a C O Cb C r�r CL O P a O B � � = r C - I - rt CD So 4/1. +n OF 0 iK s` ,A -v o.. 0 s p re c6 CL 0 U i .... y J' NJ CD 0 G/ 711 m P 0 vi , a Z Z o 0 0 o A ��� a c n �' � q Z m > a c ,° 0 w -. _ m m X X d �' c3 � m ° m r Ti m frn En 2 0 a g 3 r ° "' l m = — (A ° x o 2' m v m 3 ag a m 0 g Z 3 .. Q , Q ni 0 0 m m o y > > 3 o 1n v, @ X < m (D - n m of m A ai 5i n n A E 0 . < a a m m n a N m a o o Q rD (n > > m x c n (D 1--. F'` (n n n II y�y 0 V OJ Er cu cu N c cu 11) 0 O CD CD o n A ooi a n to o 0 ` (D D ` M m (D X o 0. 0. S n W c� > = -, Q • �+ cu cu r P m ° (D CO n m (D n a c c a (D 0 > > m n 0. x lo o 0 - cu * * A = 1 5' > > e x o ° or d H 3 a a of co o. "; 3 c r � a > > m v 0 6T tn ti, - 0 N H o A o o Q g 0 f * c c o N - 0 ( (DD 0 0 g 5 19. a _ g CD 0. 4 ili 4 0 IV N r N Nj N CO CA O CO CO ■ 1 1 I . i i 1 N 0 l cI 7 v n co a * o O 0 /O, rr Z / 1 M 12 M 4 o O d 2 = 2 s 3 O rn F+ [� - co rn H 0 A N zu 2 C c �O a o ~ rn 3 tr m q A A 3: H rn q C 3 c 2 as g a m rt o 0 Z A 0 0- d ' 3, 5= t G A: m m a 1 t- - C O rt - q .. o Oi O O 3 X. o g m C rt co m a` y q N d Ft y O . 0 - a' 3 c o m 3 rt. O 1 C TP CO CT c to 3 . U1 Q c o 3 e g o c a d 3 t G 0 0. (72 rn C 0 a '*, .� q C fl x O Ito �►' � 0. 3 H m 0 9 U 11H '1 r v C IR Y! _ �l! 3 O V 0. .r o rt. N* o do A. 0 rr A 1 3 C O v O 3 'r 2 v rt 2 01 pp 2 Or S F QC. o N3 Fr £ y o 3 u 1 - a re ; m -, ro 7 3 c < v L 3 c. rt 3 O v 0 cr. F es ' O d+ rn N N 01 N 7 co 03 O , N N M aa. 1 N O r 0 n 7 r °, z n C g 0 Oi $ -n 'O 21 'O ? '9 3 O C7 ?� to > > a c a a ¢ ° c ¢° c ¢° Cr. c p, a n' ¢° a S Z o m ` m y tr 8 g 3 S, 3 g, 3 a Si 6 3 W y, z Z o _ Di ,, v ° Z z z � "' 3 . • Z MI 3 R �~ L * 2 L* G Z m C J j Q 3 m m m a „m m ' J 3 3 2n IA in 0 0- 0 , tD 8 3 CD z n D a d 2 - 3 Col 0 z- -j o m 3< o o C 3 o g 5 y\ r� n o � o � tz m v a I- 1 o.F a n gp 30 a A 0 • 0 y0 3'°' -< A �g� [ �a o m n =t m . o @ .-� _ 0 al '7 H X I ,Z N o a o 0 0 0 0 "� 1 Q .A a g ' ° o oo ° o = 3 C 71: = R n o0 1111 A 1-1. m ° � � I = a o ∎\ `� of oa a , g S. g 4 Q N I' N co re 5i �! O O -{R i!+ AF► iPr V) iA VI to • o �'r oQ a W .+ . � r M. x N F+ F' O O r Ll iv F•+ CO N O F.• 0 ( a F o 53 .1 m I I I I I 0 0 0 o ° o c 11 H H B.3m <? 0 0 ,,-n o Z' or m 01 of .1:. m. n - ' O m • m 1 a @ 1 a o o n 2 0 a: a g j h m t G v o = b Co INN % o @i m 0 cu cu a n = O So C' rt O< N eo to O O d d o, - 3 n 0 rr a a o a g 0 a o a to j 3 {gi p 1 a O cu E (p Q O ,2( "4 = N tO cOD a co o N a� mx g • a. rt [D o m iz3" o a a • to • �O °' - c) � to co to 7 n R O o a t�A X N O to to 1 1! o, g 1; 4 k cu 2 = m Q o 3 tr3 3 m co CI u0 or CD d to a m a to Y m 6 CV Q � u, 3 ET in oo, g at c 2 a tp O = p �� = , 1 2 — -ce, -EA 44 tO O ■ ►• $ CIJ r o O p� 01 al \ o o tp , p r 1-• 03 N 0 r 0 0 q �,. n D . o n c y O. c C 5 0 40 y % - ; � . 2 c� coo m in 7 in m m O 3 N f H . ,. - n -� cn CD R =49 c _ o 0 o O � � n1 -0 ;n g��g co c i t t ! 3 Z c m 0 CD a n n n n !� m cu g m o m m to o y < c o n a �n o m co 0 0 . g fnf rt cu �L*. 01 O Q o 0 0 m - n r N 3 U 'f-Dr 5 m or = m C r m o rt 01 C1 n � O d { p > > n > o om � n 0 a n c+ n - 0 0 'n C n ° co m w cc ( 0 o - co o C A. A > > 01 t 0 a a O1 0. o W 0 0 0 cr n 3 0) ° -. CD < n 0 c co 07 a 0 d o 0 0 m N 3 d d s a c. 3 - ' m g g f° o n m ' � 0 ' r - : c g ' d N t 0 h ^ _ c. Q ' O, O, § 0 r' t a z 0 rr 7 . t--# g. � x •' zs � y Y . o. 00 N o o Co 1 ... r co NJ 0 r• 0 0 n 'v QI 14 CD m Z Z o ° m .an g • a m Z 3 a • m X CD rt Cii o a °o 0 30 a y CD cn o X W C O II g m Of v a CO m d CD d V CV M V c. g a a _ C cr g g obi r V N � O o ✓ CO N O r O Exhibit C Program Requirements Item Deadline ❑ Quarterly Reports April 1 (service period 12/1 — 3/31) Invoice July 1 (service period 4/1 — 6/30) Narrative of accomplishments October 1 (service period 7/1 — 9/30) Report 1512 Information January 1 (service period 10 /1 — 12/31) (for CDC) ❑ Quarterly Meetings /Trainings* TBD * Must make arrangements to attend the following training: California Regional Tobacco Prevention Forum San Jose Regional Forum: Wednesday, February 23, 2011 8am to Noon: Secondhand Smoke in the Workplace Noon to 4pm: Tobacco Price Manipulation Sainte Claire Hotel 302 South Market Street San Jose, CA 95113 Information and Registration: http: / /www.cdph.ca.gov/ programs / tobacco /Pages/RegionalForums.aspx Agreement w/ City of Cupertino Page 5 of 5 For Tobacco Prevention Ordinance Through March 2, 2012 COUNTY OF SANTA CLARA POLITICAL REFORM ACT (PRA) CONSULTANT APPLICABILITY ANALYSIS FORM (CAA FORM) For every service provider (individual or business entity) contracting with a Code Agency, the Code Agency needs to analyze, based on the provision of services under the contract, if the individual, or any individuals working for the business entity, meets the definition of a "PRA Consultant." This includes, but is not limited to, individuals hired through a service agreement, a contract or agreement, direct pay, or any other arrangement. See last page of this document for reference information. The Code Agency should fill out this CAA Form indicating, based on the scope of work and duties of the service provider, the Code Agency's conclusion as to whether any individual(s) providing service under the contract will meet the definition of a "PRA Consultant." The Code Agency should retain this CAA Form with its contract paperwork. Further, for all service contracts and amendments (contract document) submitted to the Office of the County Counsel for review, the Code Agency shall provide a copy of this completed CAA Form to the Office of the County Counsel with the contract document for review. See Last Page of This Document for Reference Information. 1. Code Agency (County Department, Board, Commission) Name: Public Health Department 2. Name of Individual (if single named individual not working through a business) or Business Entity Providing Service: City of Cupertino 3. Project Title /Contract Subject: Adoption of a smoke -free policy protecting town residents from exposure to second -hand smoke in parks and pathways. 4. "Political Reform Act Consultant" Applicability Analysis Indicate if Any Individual(s) Providing Service Under this Contract Meets the Definition of a PRA Consultant: (See Last Page for Reference Information) • No. Individual (includes any individual(s) working for the business entity) will not be "making a government decision" or "serving in a staff capacity." No disclosure is required. ❑ Yes. Individual (includes any individual(s) working for the business entity) will be "making a governmental decision" or "serving in a staff capacity and in that capacity participating in making governmental decisions or performing duties that would be performed by an individual in a designated position." The Code Agency must also fill out and submit a "Disclosure Determination for PRA Consultant" (DDC) Form. If a prior DDC Form is already on file for this PRA Consultant for this same contract, please attach a copy of that prior DDC Form instead of filling out a new DDC Form, unless the PRA Consultant's duties have changed. 5. Prepared By (Printed Name and Title): 6. Phone Number: Roya Rousta, 408.792.5108 Management Analyst 7. Agency Head or Designee Name & Title: Authorized Signature: Date: Dan Peddycord, ,� f Director of Public Health Department VP) Upon completion: - The Code Agency should retain this CAA Form with its contract paperwork. - For all service contract documents to be reviewed by the Office of the County Counsel, the Code Agency shall provide a copy of completed CAA Form to the Office of the County Counsel with the contract document for review. County of Santa Clara Page 1 of 3 rev 06/30/10 "PRA Consultant" Applicability Analysis