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INTF5264P01223127055 CITY OF SOMERVILLE — File 23-1127

File 23-1127·7 pages·📄 Original PDF (city portal)·sha256 b10f69cadf18…
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x STANDARD CONTRACT FORM 7KLVIRUPPXVWEHVLJQHGZLWKDQDXWKRUL]HG signatureGDWHGDQGUHWXUQHGYLDHPDLOVFDQ'RQRWXVH FRUUHFWLRQIOXLGDQ\ZKHUHRQWKHIRUPV $OODWWDFKPHQWVPXVWEHFRPSOHWHGIRU\RXUFRQWUDFWSDFNDJHWREHSURFHVVHG x CONTRACTOR AUTHORIZED SIGNATORY LISTING (CASL) $&RQWUDFWRU$XWKRUL]HG6LJQDWRU\/LVWLQJ&$6/IRUPPXVWEHVLJQHGZLWKDQDXWKRUL]HG signature GDWHGDQGUHWXUQHGYLDHPDLOVFDQIRUHDFKQHZFRQWUDFWRUDPHQGPHQWFRQWUDFWSDFNDJH (QFORVHGSOHDVHILQGD6WDQGDUG&RQWUDFWSDFNDJHIRU\RXWRUHYLHZVLJQDQGUHWXUQYLDHPDLOVFDQ3OHDVHWDNH QRWHRIWKHIROORZLQJ ,I\RXKDYHDQ\TXHVWLRQVDERXW\RXUcontract package,SOHDVHFRQWDFW 3OHDVHVLJQZLWKDQDXWKRUL]HG signatureDQGUHWXUQWKHFRQWUDFWSDFNDJHYLDHPDLOVFDQWR WWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWQRODWHUWKDQFORVHRIEXVLQHVV 6LQFHUHO\ %XUHDX'LUHFWRU $FFHSWDEOHIRUPVRI$XWKRUL]HGVLJQDWXUHV 7UDGLWLRQDOKDQGGUDZQ³ZHWVLJQDWXUH´LQNRQSDSHU 6FDQ&RS\RIKDQGGUDZQVLJQDWXUH (OHFWURQLFVLJQDWXUHWKDWLVHLWKHU D +DQGGUDZQXVLQJDPRXVHRUILQJHULIZRUNLQJIURPDWRXFKVFUHHQGHYLFH E $QXSORDGHGSLFWXUHRIWKHVLJQDWRU\¶VKDQGGUDZQVLJQDWXUH (OHFWURQLFVLJQDWXUHVDIIL[HGXVLQJDGLJLWDOWRROVXFKDV$GREH6LJQRU'RFX6LJQ 3OHDVH1RWH 7KHW\SHGWH[WRIDVLJQDWXUHHYHQLQFRPSXWHUJHQHUDWHGFXUVLYHVFULSWRUDQHOHFWURQLFV\PERODUHQRW DFFHSWDEOHIRUPVRIHOHFWURQLFVLJQDWXUH Derek Westhaver at Derek.A.Westhaver@mass.gov. Kevin Cranston Bureau of Infectious Disease & Laboratory Sciences Derek Westhaver at Derek.A.Westhaver@mass.gov, 06/27/2023.
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PROMPT PAYMENT DISCOUNTS (PPD): Commonwealth payments are issued through EFT 45 days from invoice receipt. Contractors requesting accelerated payments must identify a PPD as follows: Payment issued within 10 days _@@_% PPD; Payment issued within 15 days @@@@% PPD; Payment issued within 20 days @@@@% PPD; Payment issued within 30 days @@@@% PPD. If PPD percentages are left blank, identify reason: __agree to standard 45 day cycle __ statutory/legal or Ready Payments (G.L. c. 29, § 23A); __ only initial payment (subsequent payments scheduled to support standard EFT 45 day payment cycle. See Prompt Pay Discounts Policy.) BRIEF DESCRIPTION OF CONTRACT PERFORMANCE or REASON FOR AMENDMENT: (Enter the Contract title, purpose, fiscal year(s) and a detailed description of the scope of performance or what is being amended for a Contract Amendment. Attach all supporting documentation and justifications.) 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Date: . (Signature and Date Must Be Handwritten At Time of Signature) Print Name: . Print Title: . AUTHORIZING SIGNATURE FOR THE COMMONWEALTH: X: . Date: . (Signature and Date Must Be Handwritten At Time of Signature) Print Name: . Print Title: . BUUBDIFEBOEJODPSQPSBUFEJOUPUIJT$POUSBDU"DDFQUBODFPGQBZNFOUTGPSFWFSSFMFBTFTUIF$PNNPOXFBMUIGSPNGVSUIFSDMBJNTSFMBUFEUPUIFTFPCMJHBUJPOT E-Mail: Contract Manager: CITY OF SOMERVILLE Department of Public Health 93 HIGHLAND AVE SOMERVILLE, MA 02143 250 Washington Street, Boston MA 02108 Kelley Hiland khiland@somervillema.gov Derek Westhaver [phone removed] Derek.A.Westhaver@mass.gov VC6000192138 [phone removed] INTF5264P01223127055 223127 06/30 300,000.00 900,000.00 Renewal with Maximum Obligation Change 07/01 06/30 23 001 DPH ✔ 24 ✔ ✔ 23 ✔ ✔
Commonwealth of Massachusetts CONTRACTOR AUTHORIZED SIGNATORY LISTING This form is jointly issued and published by the Office of the Comptroller (CTR) and the Operational Services Division (OSD) as the default form for all Commonwealth Departments when another form is not prescribed by regulation or policy. Page 1 of 1 Signature for Corporation (C or S), Partnership, Trust/Estate, Limited Liability Company (must match Form W-9 tax classification) Contractor Legal Name Contractor Vendor/Customer Code LIDYDLODEOHQRWWKH7D[SD\HU,GHQWLILFDWLRQ1XPEHURU6RFLDO6HFXULW\1XPEHU INSTRUCTIONS: Any Contractor (other than a sole-proprietor or an individual contractor) must provide a listing of individuals who are authorized as legal representatives of the Contractor who can sign contracts and other legally binding documents related to the contract on the Contractor’s behalf. In addition to this listing, any state department may require additional proof of authority to sign contracts on behalf of the Contractor, or proof of authenticity of signature (a notarized signature that the Department can use to verify that the signature and date that appear on the Contract or other legal document was actually made by the Contractor’s authorized signatory, and not by a representative, designee or other individual.) For privacy purposes DO NOT ATTACH any documentation containing personal information, such as bank account numbers, social security numbers, driver’s licenses, home addresses, social security cards or any other personally identifiable information that you do not want released as part of a public record. The Commonwealth reserves the right to publish the names and titles of authorized signatories of contractors. There are three types of electronic signatures that will be accepted on this form: 1) Traditional “wet signature” (ink on paper); 2) Electronic signature that is either: a. hand drawn using a mouse or finger if working from a touch screen device; or b. An upload picture of the signatory’s hand drawn signature; 3) Electronic signature affixed using a digital tool such as Adobe Sign or DocuSign. Typed text of a name not generated by a digital tool, computer generated cursive, or an electronic symbol are not acceptable forms of electronic signature. Authorized Signatory Name Signature (Signature as it will appear on contract or other documents) Title Phone Number Email Address Acceptance of any payment under a Contract or Grant shall operate as a waiver of any defense by the Contractor challenging the existence of a valid Contract due to an alleged lack of actual authority to execute the document by the signatory. I certify that I am a responsible authorized officer of the Contractor and as an authorized officer of the Contractor I certify that the names of the individuals identified on this listing are current as of the date of execution and that these individuals are authorized to sign contracts and other legally binding documents related to contracts with the Commonwealth of Massachusetts on behalf of the Contractor. I understand and agree that the Contractor has a duty to ensure that this listing is immediately updated and communicated to any state department with which the Contractor does business whenever the authorized signatories above retire, are otherwise terminated from the Contractor’s employ, have their responsibilities changed resulting in their no longer being authorized to sign contracts with the Commonwealth or whenever new signatories are designated. Please note you cannot self-certify your own signature as a single signer listed above. Signature Date Print Name Phone Number Title Email Address A copy of this listing must be attached to the “record copy” of a contract filed with the department. &$6/' &$6/6 &$6/7 &$6/$61 &$6/($ &$6/3U1 &$6/3K1 &$6/($ &$6/7 &$6/7 &$6/7 &$6/7 &$6/6 &$6/6 &$6/6 &$6/$61 &$6/$61 &$6/$61 &$6/($ &$6/($ &$6/($ &$6/6 &$6/3K1 &$6/3K1 &$6/3K1 &$6/3K1 CITY OF SOMERVILLE VC6000192138
6FRSHRI6HUYLFHV " " "$+ !$+$++ + INTF5264P01223127055 Renewal for FY 2024 with no change to the scope or delivery of service. Contract Amendment - Increase
PAYMENT VOUCHER INPUT FORM THE COMMONWEALTH OF MASSACHUSETTS DEPARTMENT / ORGANIZATION NAME Department of Public Health DOCUMENT ID TRANS DEPT ORG PRC DPH BIDLS ACTION: (E) Sch Pay Date FISCAL YEAR 202 CITY OF SOMERVILLE Denise Holland 93 HIGHLAND AVE SOMERVILLE, MA 02143 DOCUMENT TOTAL: /RFDO6XSSRUW)2127055 VC6000192138 CONTRACT NUMBER QUANTITY DESCRIPTION UNIT PRICE INTF5264P01223127055 1 300,000 300,000.00 RFR 223127 - /RFDO6XSSRUWIRU&29,'DQGRWKHU LQIHFWLRXVGLVHDVHLQYHVWLJDWLRQDQGUHVSRQVH TOTAL: 300,000.00 $ REFERENCE ORDER LN Trans Dept Org Number PRC DPH BIDLS INVOICE NUMBER F2127055 MA # MA LN# DATES OF SERVICE Line Amount P/F 7/1/202 P Instructions to vendor: I hereby certify under the penalties of perjury that all laws of the Commonwealth governing disbursements of public funds and the regulations thereof have been complied with and observed. o Fill in shaded areas PREPARED BY: TITLE: DATE: o Direct inquiries to ENTERED BY: TITLE: DATE: state organization The undersigned authorized signatory approving this document certifies that this document and any attachments are accurate and complete and comply with all applicable general and special laws and regulations APPROVED BY: TITLE: DATE: PHONE: Number APPROPRIATION ACTIVITY (Please Sign Here) VENDOR CODE: VENDOR PAYMENT REF NUMBER: Vendor Name and Address I certify that the goods were shipped or the services rendered as set forth below TO THE COMPTROLLER OF THE COMMONWEALTH OF MASSACHUSETTS: SERVICE DESCRIPTION AMOUNT VENDOR'S CERTIFICATION VENDOR'S CERTIFICATION
Department of Public Health Vendor Name DPH Bureau/Program Name CITY OF SOMERVILLE Bureau of Infectious Disease & Laboratory Sciences Vendor Code Fiscal Year Contract Number RFR# Today's Date VC6000192138 2024 6/20/2023 CURRENT Proposed Proposed Program Component FTE BUDGET Changes +/- New Budget Justification (A) (B) (C) (D) 1. Direct Care/Prog. Support Staff - $ - $ - $ - $ - $ - $ SUB TOTAL 0.00 - $ - $ - $ Fringe Benefits #DIV/0! - $ 1. TOTAL DIRECT CARE/PROGRAM STAFF - $ - $ - $ CURRENT Proposed Proposed Program Component BUDGET Changes +/- New Budget Justification (A) (B) (C) (D) 2. Other Direct Care/Program - $ - $ - $ - $ - $ - $ 2. TOTAL OTHER DIRECT/PROGRAM - $ - $ - $ Occupancy Program Facility - $ Facility Operations, Maint. and Furn. - $ - $ 3. TOTAL OCCUPANCY - $ - $ - $ $ SUB TOTAL: 1 + 2 + 3 - $ - $ - $ Administrative Support Max Cap Amount: #DIV/0! 4. AGENCY ADMIN. SUPPORT - $ TOTAL 1+ 2 + 3 + 4 - $ 300,000.00 $ INTF5264P01223127055