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Home My WebLink AboutTransient Merchant License Renewal - St. Joseph County FairgroundsFor all municipal business license questions, contact: City of South Bend • Department of Community Investment 227 West Jefferson Blvd • Suite 14005 -South Bend, Indiana 46601 •574.235.5912 • F: 57.4.235.9021 9045i7aa $5.01) LICENSE APPLICATION FOR -TRANSIENT MERCHANT MUNICIPAL CODE SECTION -4-60 I. APPLICATION TYPE Check One: New Renewal II. BUSINESS DATA A. Name of Event: St. Joseph County 4-H Fair B. Business Name: St. Joseph County 4-H Fair, Inc. C. Business Address: 5117 South Ironwood Drive City: South Bend D. Mailing Address (if differs):_ City: E. Business Telephone Number: F. Business Fax Number: State: IN Zip: State:. 574-291-4870 574-291-7302 G. E-Mail Address: info@4hfair.com H. Indiana State Retailer License number: 00031352840000 Zip: I. Proposed location where business will be conducted: total grounds J. Description of building or premises to be used: total grounds K. Proposed Dates of Operation: L. Proposed Hours of Operation: June 30, 2017 - July 8, 2017 8:00 a.m. - 11:00 p.m., daily X 46614 M. Types of goods to be sold: fair food, crafts, carnival rides N. Scales will be used in business transactions: Yes No X If yes, please attach certificate from the Sealer of Weights and Measures, O. Food will be served in ready -to -eat condition: Yes X No P. Description of nature of proposed advertising: Radio, TV, Newspaper Application Filed Application Fee I Sent to Dept. _ Not Approved Reason For Office Use Only JAN 19 2017 Public Works Approval License Num her (1' 56 VPWVED Board of PCfdic Works FEB 14, Z1,17 /I --I 1 For all municipal business license questions, contact: City of South Bend • Department of Community Investment 227 West Jefferson Blvd • Suite 1400 S -South Bend, Indiana 46601 • 574.235,5912 • F: 574.235.9021 LICENSE APPLICATION FOR -TRANSIENT MERCHANT MUNICIPAL CODE SECTION - 4-60 V. PERSONAL DATA (Additional Owner, if applicable) A. Owner's Legal Name: B. Residential Address: City: State: C. Residential Telephone Number: D. Cellphone Number: E. Position with business: F. Social Security Number: G. Gender: H. Date of birth: I. Race: VI. INCLUDE $5.00 PROCESSING FEE WITH APPLICATION WE VII. INCLUDE NAMES, ADDRESSES, AND TELEPHONE NUMBERS OF ALL GROUP EVENT PARTICIPANTS. VIII. INCLUDE A CURRENT CERTIFICATE OF LIABILITY INSURANCE WITH THE CITY OF SOUTH BEND LISTED AS THE CERTIFICATE HOLDER. IX. AFFIRMATION I, hereby, certify and affirm that all of the information I have given in this application is true and accurate to the best of my knowledge. I further certify that I have in no way attempted to mislead the City in this application by omitting facts known to me. I understand that the completed application must be filed no later than thirty days before the planned event is to begin. I have read and understand the regulations of the Transient Merchant license found in the City of South Bend Municipal Code, Section 4-60. Si tur Date ACI Rh® CERTIFICATE OF LIABILITY INSURANCE TE DDIYYYY DA4/(7/2016 ) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER McCarthy Insurance Group P.O. Box 1377 802 Lincolnway West Mishawaka IN 46544 CONTACT Chris Young pHoN o E (579) 259-5622 FAX No: (674)256-7822 E-MAIL Chris@mccarthyins.com ADDRESS: INSURERS AFFORDING COVERAGE NAIC9 INSURER A:Philadel hia Insurance Com an INSURED St Joseph County 4-H Fairgrounds, inc. 5117 South Ironwood Road South Bend IN 46614 INSURER B Accident Fund INSURERC: INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:2016-2017 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 CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADOLSUBft POLICY NUMBER MMIDDYIYWY MMIDOY/YEYXI'pY LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE X OCCUR PHPK1300734 3/19/2016 3/19/2017 EACH OCCURRENCE $ 1,000,000 DAMAGE TO -RENTED PREMISES Ea occurrence $ 100,000 MED EXP(Anyone person) $ 0 PERSONAL B ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO- JECT ❑ LOC OTHER: GENERAL AGGREGATE $ 3,000,000 X PRODUCTS-COMP/OP AGG $ 3,000,000 $ AUTOMOBILE LIABILITY ANY AUTO ALLOWNED SCHEDULED HIRED TSAUTOS AUTOS NON -OWNED AUTOS COMBINED SINGLE LIMIT -LEa accident $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) 5 PROPERTY DAMAGE Peracddma $ $ A X UMBRELLALIAB EXCESS LIAB x OCCUR CLAIMS -MADE 3?010491369 3/19/2016 3/19/2017 EACH OCCURRENCE $ 5,000,000 AGGREGATE $ DED I X I RETENTION$ 10,000 $ B WORKERS COMPENSATION ANDEMPLOYERS LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE [NIA OFFICERIMEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below wCV6125194 3/19/2016 3/19/2017 x PER OTH- STATUTE ER E. L. EACHACCIDENT $ Soo 000 E.L. DISEASE - EA EMPLOYE $ 500 000 E.L. DISEASE -POLICY LIMIT 1 $ 500,000 DESCRIPTION OF OPERATIONS/ LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) City of South Bend is additional insured as respects general liability, according to the terms and conditions of the policy. City of South Bend 227 West Jefferson Blvd South Bend, IN 46601 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Vervynckt/CHRIS ACORD 25 (2014/01) INS025OT14011 U 19BB-ZU14AGORD CORPORA LION. All rights reserved. The ACORD name and logo are registered marks of ACORD AIM Water Treatment Terry Miller 1123 Division St Mishawaka IN 46545 574-255-4246 Aqua Systems Tom Adamson 2121 McKinley Ave South Bend IN 46617 574-855-4422 Doors & Drawers Brad Botts 2302 Dierdorff Road Goshen IN 46526 574-533-3509 C C Concessions, Inc. Jason Colglazier P.O. Box309 New Carlisle IN 46552 574-654-8751 AJ Construction and Roofing Josh Hill P.O. Box 618 Osceola IN 46561 574-674-4226 Cherie Rogers Tastefully Simple 62550 Ash Road Wakarusa IN 46544 Phone: 574-354-0711 Lafayette Bee Windows LLC - Erin Beckman 115 Shadowlawn Drive Fishers IN 46038 (317)-283-8522 C & E Concessions EarlScheler P. O. Box 367 Fairdale KY 40118 502-415-5501/502-553-8994 Coalbush United Methodist Church Creative Memories/Legacy Republic Michelle Ritschard Kay Crum 15977 Jackson Rd 613 Misty Harbor Court Mishawaka IN 46544 574-259-4136 Mishawaka IN 46544 Phone: 574-259-7356 Cell: 574-514-4344 Forte Enterprises (Tupperware) Henna Art Designs Jenny McCormick Jayshree Patel 51317 CR 25 52076 Myrtle Ave Bristol IN 46507 574-265-5205 South Bend IN 46637 574-273-8708 Hodson's Concessions Gideons International dba Bruce's Concessions Jeffrey McWhirt Jeffrey W. Bruce PO Box 1643 802 South Church Street Mishawaka IN 46546 574-259-5891 Hastings MI 49058 269-838-5731 Fire N The Hole Wood Fired Pizzas Hoosier Racing Tire Stacy Reed Marge Newton Skaggs 5389 E 1000 S 65465 SR 931 Claypool IN 46510 574-268-8306 Lakeville IN 46536 574-784-3152 Homeworks Investments No Assumptions, Inc. Zachary Lewis Robert Holbrook 309 South Logan Road 661 North Park Road South Bend IN 46615 574-315-5777 Benton harbor MI 48022 Phone: 269-369-0380 Katherine Krzenski Kate's Diner 3730 Sailmaker Lane Katie Greene Holiday FL 34691 (202)-230-6997 9506 284`h Street East Myakka City FL 34251 813-528-1803 Lakeville Lions Rose Russell P.O. Box 506 Lakeville IN 46536 Millennium Home Designs Attention: Leslie 3300 Lower Huntington Road Fort Wayne IN 46809 Janice Verace Pampered Chef 20411 Meridian Court Goshen IN 46528 Papa John's Pizza Alison Patton 4504 Epinay Court Louisville KY 40272 Partylite Patti Sowers 1844 Saint Michaels Ct South Bend IN 46614 Phone: 574-784-8666 Phone: 877-356-6556 Phone: 574-875-9377 McKinney Food Service Shawn McKinney 3290 FM 161 N Hughes Springs TX 75656 Parnell Foods Brett Rubert 1101 North Ave Belvidere IL 61008 Penn Township 4-H Booth Joyce Schultz 2809 Northwood Mishawaka IN 46545 903-237-9863 815-222-1142 574-876-6721 502-935-6329 Planned Parenthood of Indiana Julie Wells 3005 Grape Road, Suite B Mishawaka IN 46545 574-287-3808 574-246-0803 old Tyme Taffy Brian Myers 111 Washington Street Sturgis MI 49091 269-254-2099 Bathfitter Attn: Chad 1258 West Lincolnway Valparaiso IN 46385 Phone: 219-464-7373 Sattler's Hats & Leather Tommy Sattler 9125 San Carlos Blvd. Fort Meyers FL 33967 239-707-0187 Sinnamon Show Supply Scott Sinnamon 1586 N 880 W Kokomo IN 46901 765-438-1092 Softub,Inc. Attn: Jon 150 Kendall Point Drive, Suite F Oswego IL 60543 317-308-0630 St. Joseph County Dairy Association Becky Freeman 13800 New Road Mishawaka IN 46544 574-514-7069 Snowba Steven Towers 12482 Shearwater Run Fort Wayne IN 46845 574-274-4416 St. Joseph County Democratic Party Mary Jo Sullivan 135 South Lafayette Boulevard South Bend IN 46601 574-229-6426 Star Martial Arts Melanie Birky 123 N. Elkhart Ave Elkhart IN 46516 574-522-5425 The Donut Family Todd Hawkins 445 Lake Ave St Paul MN 55110 651-398-5527 The Pretzel Wagon Sue Miller 11797 Harder Three Rivers MI 49093 269-625-0966 Bianco Foods The Salvation Army Ray Bianco Kroc Center 1503 Middleton Rd Meg Sauer Anderson SC 29624 864-245-8264 900 West Western Avenue Trade Midway South Bend IN 46601 Phone: 574-233-9471 Link Interactive Megz Gemz Dan Grover Kellie Marsing 3293 Harrison Boulevard 9221 E. Baseline Rd, Ste 109282 Ogden, Utah 84403 Phone: 801-885-5408 Mesa AZ 85209 480-204-2479 801-826-5443 GreenMark Equipment, Inc. McGrotha Foods Attention: Dave Brad McGrotha 60001 Elm Road 305 Charnie Drive Mishawaka IN 46544 Phone: 574-255-3337 Thomasville GA 31792 229-221-5399 Tracie Gaedtke Oaklawn Foster Care Program Scentsy Attn: Karl Tarman 1218 Walnut Street 330 Lakeview Drive Niles MI 49720 Phone: 269-240-4492 Goshen IN 46528 Phone: 574-533-1234 Fiske Concessions Mary Kay Jerry Price c/o Rina Young P.O. Box 1177 820 East 10th Street Brooksville FL 34605 352-796-5865 Mishawaka IN 46544 Phone: 574-210-3057 Thirty -One Gifts Indiana National Guard Kim Johnson SSG Price 7752 N Mohawk Trail 2540 Miracle Lane PO Box 265 Mishawaka, IN 46544 Rolling Prairie IN 46371 219-778-4623 Shipshewana Hardwoods United States Army Kendra Kidder Recruiting Office 5345 W 200 N Attn: Sgt V Class Stith Shipshewana IN 46565 260-768-4021, ext 235 413 West McKinley Mishawaka IN 46545 574-252-5193 Laser Bob's Custom Crafts Forte Waterproofing Robert Fritz Mark Forte 16320 East Road Post Office Box 921 Hudson FL 34667 727-505-6543 Mishawaka IN 46546 MJSS Enterprise Indiana Health Centers Chaudhry Sattar Miranda Buena 19634 Rolling Acres Drive 1901 Western Avenue, Suite B South Bend IN 46614 574-329-1855 South Bend, Indiana 46619 Phone: 574-259-4040 Phone: 574-234-9033 PJ Stewart Enterprises Jamie Stewart 45 Maple Street Dunlap TN 37327-3330 817-659-0134 Pam Harper ViVi Jewelry & Guardian Village Handicrafts 5082 South State Road 13 Pierceton IN 46562 Phone: 419-203-3469 10' Booth $420.00 Commercial Building Deposit: $0 Mr Edward Bradford Miami Trails Congregation of Jehovah's Witnesses c/o 11245 Fairfax Drive South Bend IN 46614 Phone: 574-315-3460 McLellan's Concessions Inc. Fran McLellan 942 Pup Circle Hudson WI 54016 Phone: 651-983-5820 Tessa Campbell Marketing Assistant TWO DAY VENDOR Visit Fort Wayne 927 S. Harrison Street Fort Wayne, IN 46802 iessa@visitfortwayne.com JAK Concessions dba Porky's Seafood Jean -Ann Miller 5401 South 900 East Lafayette IN 47905 Phone: 765-476-1211 Heather Hudson Pink Zebra PO Box 97 North Liberty IN 46554 Phone: 574-298-6339 JAK Concessions dba Porky's BBQ Jean -Ann Miller 5401 South 900 East Lafayette IN 47905 Phone: 765-476-1211 KldsPeace Tam! Maier 401 Eat Colfax, Suite 108 South Bend, Indiana 46617 Heather Horrall 58710 Magnolia Road South Bend IN 46614 Career Academy Attention: Kristen Carney 3801 Crescent Drive South Bend IN 46618 Sam's Club Attn: Kendra Ricker/Shea Dick 120 Indian Ridge Mishawaka IN 46545 Gourdacious Creations of Indiana Sid Meyers 9494 County Line Road Phone: 574-237-1046 New Carlisle IN 46552 (574) 229-0107 Next TV Justin Baker Phone: 738 North Olive Street South Bend, Indiana 46628 Traeger Pellet Grills Kelly Hymas 1215 E Wilmington Ave., Suite 200 Salt Lake City LIT 84106-4282 Phone: 574-299-9800 Phone: 574-243-8203 Phone: 801-701-7180 Aunt Martha's c/o Charles Michael Belcher 1305 Fairdale Road Fairdale KY 40118 Phone: 574-233-7000 Phone: 502-919-0552 Renewal by Andersen Windows & Patio Doors Attn: Ricky Kirk 12262 Hancock Street Carmel IN 46032 Phone: 800-471-8950 Cell: 860-319-4139 Healthmate International LLC Attn: Ann Bennett 8901 Washington Street Kansas City MO 64114 Phone: 816-359-3478 Cream Sugar Love Lisa Clark 516A Begonia Street SE DeMotte IN 46310 Chubby Buddies BBQ Keith Steiley 15840 Muckshaw Road Phone: 219-869-2834 Argos IN 46501 Phone: 574-540-1591 (chubbvbuddiesbarbecue@amail.com) Alfred E. Shirtman P.O. Box 152 Thornton IL 60476 Phone: 847-507-0735 Smoke Free St. Joe Attn: Latorya Greene 215 West 4tb Street, LL 201 Mishawaka IN 46544 Phone: 574-335-3896