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Home My WebLink AboutNon Res Block Party - La Casa de AmistadI n INTER -OFFICE MEMORANDUM BOARD OF PUBLIC WORKS DATE SENT 4/25/2017 TO: Ed Gleckler, Traffic & Lighting Gene Eyster, Police Department M ongfellow, Engineering �sG,hs Dressel, Community Investment i/Federico Rodriguez, Fire Department 1+�Marcia Qualls, Engineering Kara Wood, Park Department Jill Sciccitano, Downtow South Bend FROM: Linda M. Martin, Clerk SUBJECT: Non- Residential Bloc Party LOCATION: 2900 Block W. Western Ave DATE AND TIME: May 31, 2017 SPONSOR: La Casa De Amistad DATE DUE: May 2, 2017 FAX OR E-MAIL TO: 235-9171 1 Imartinatsouthbendin.gov RECOMMENDATIONS AND COMMENTS: By Date APPLICATION R USE OF AND BLACKING OF ACfCESS ZQ, THE PUBLIC SIGHT-QF--WAY FOR NON-RE,SIDENU) AL BLOCK PARTIES The Board of Public Works must have FOUR (4) weeks prior notice of the event. A NON-REFUNDABLE APPLICATION FEE OF $125.00, IN THE FORM OF A CERTIFIED CHECK OR MONEY ORDER, PAYABLE TO THE CITY OF SOUTH BEND, MUST BE INCLUDED WITH APPLICATION. ❑ Fee Paid Applicant Name: l.a Casa de Amisiad Address: 3� � S . H4--1*T City: State: 1 rd Zip: t; (o/ 9 Phone: 5"+4_03-z_l_zo [ocF�c�� 6t�.0b.0042 This application is made to the City of South Bend, Indiana, Board of Public Works, for the rasc of the specified public right-of-way by Applicant for the holding of the hereinafter described event: Event Name —'I�sT-' V\/�"DNC5-rom . t-ve fZ Location 2-1 4 0 -Soc c V4. W-5T f2" /-Jta . (Describe: Atea/Route) Street Closure Name of Street From T4 Date of 1{ vent M A-d '3 I 20 117 Time. Registration/Setup ❑ pan. Approximate Number of Attendees 11000 4 Answer the following appropriately: ❑ a.tn. ❑ R.M. Start ap.m. End _ _ WPM. L This event will have music (five or other). Yes ❑ No a. I understand the Noise Ordinance described in the Agreement/Permit Yes ❑ No 2. Required Information to Accompany Application a. Certified Check or Money Order in the Amount of $125.00, or: b. For Certified Nonprofit Organizations: Copies of the 501(c)(3) Internal Revenue Exemption Status Document and a current copy of Form 990 of Form 990-EZ are included with this application, and Yes ❑ No additionally filed with the Office of the City Clerk, a Floor, County - City Building, 227 W. Jefferson Blvd., South Bend, Indiana. c. Certificate of Insurance 3. d. Maps, drawings of the area and setup plan 0 Yes Q No a. This event involves City streets 0 Yes ❑ No b. This event involves County roads ❑ Yes ❑ No c. This event involves State highways ❑ Yes ❑ No d. This event involves the use of the sidewalk 0 Yes ❑ No Updated 4/2015 1 e. This event is a loeaU gio aYnational event (Please circle the yes Q No appropriate event type f. Affected propeAy/business owners have been notified of this event. Yes ❑ No g. I understand that I mast arrange a meeting with all affected governmental agencies to organize the alcove event (Call Marcia � Yes El No Qualls, Customer Service Manager, 235-5939 to organize meeting). N ,ALCOHOL IS TO BE SERVED OR SOLD Alcoholic beverages will be served N Alcoholic beverages will be sold n Certified Check or Money Order for $400.00 must be submitted with application. ®' • Application cannot be processed without deposit. • Deposit will be returned upon inspection of event area by the Board of Public Works. Names and phone numbers of THREE security guards + To monitor underage drinking, + Qualifications must be listed (e.g. Off -duty police officer, professional security guard, or event . APPLICANT). A drawing must be submitted showing; +► Fencing around serving area + Trash receptacles. o Ample trash receptacles must be provided to ensure proper disposal of refuse. Temporary liquor license.. Z • Call the Alcohol & Tobacco Commission at (317) 234-4315 for more infonnation. S1 4,MA • Application cannot bo processed without a copy of this license. —Pp—N p hr� 2tG S City of South Bend, Indiana + Board of PublieWorks PERMIT AND AGREEMENT FOR THE USE OF THE RIGHT-OF-WAY FOR NON-RESIDENTIAL BLOCK PARTIES The Non-residential Block party will be permitted to take place under -the following terms and . conditions, 1. Pursuant to Local Ordinance No. 10224-13, there is a $125.00 non-refmdable fee for non - .residential Block Parties. Non-profit organizations meeting Section 501(c)(3) of the Internal Revenue Code are exempt from the fee provided copies of the 501(c)(3) Internal Revenue Exemption Status Document and a current copy of Form 990 of Form 990-EZ are filed with this application and with the Office of the City Clerk, 41h Floor, County -City Building, 227 W. Jefferson Blvd., South Bend , Indiana. 2. The APPLICANT must comply with all terms and conditions of this Permit and Agreement. 3. The APPLICANT shall reimburse the Board for the actual cost to the City for the event, if deemed necessary. 4. APPLICANT shall include a flyer or letter describing the details of the event. 5. Notification of approval/denial of this request will be issued byretum of this form, upon signed authorization by the Board of Public Works. G. The APPLICANT shall provide to the Board a Certificate of Insurance showing aliabilitypolicy in full force and effect with Im' Wts of $300,000.00 per occurrence and $5,000,000.00 aggregate and the City of South, Bead listed as an additional named insured for this event. 7. The APPLICANT assumes full responsibility for providing ample disposal containers for refuselrecycling and assures the area will be cleaned up upon the conclusion of the event. 8. Barricades will be delivered and picked up at the event location, The APPLICANT is responsible for seeing that all cones are maintained and returned undamaged, 9. The APPLICANT will follow the City of South Bend Noise Ordinance, which is in effect: at all hours. Between the hours of 11:00 p.m. and 7;00 a.m. certain noises are particularly prohibited, These include operating radio receiving sets, musical instruments, phonographs and other sound reproduction devices if audible fifty (50) feet away, as well as shouting, yelling, hooting, whistling, or singing 3n the streets in. a manner to disturb the peace'(Municipal Code 13-57). 10. The APPLICANT assures the City that the area will be closed during the times indicated on the application only. Event end times are pursuant to the recommendations of the South Bend Police Department. 11, IF ALCOHOL IS TO BE SERVED OR SOLD a Certified Check or Money Order for $400.00 must be submitted with application. The application cannot be processed without a deposit. The deposit will be returned by the Board of Public Works upon inspection ofthe event area after the event, and provided there is no damage to the area. Names, phone numbers, and qualifications (e.g. Off -duty police officer, professional security guard, or event APPLICANT) of THREE security guards to monitor underage drinking, must be submittedwith the application. A drawing must be submitted showing fencing around serving area, and trash receptacles. For a temporary liquor license call the Alcohol and Tobacco Commission at (317) 234-4315 for more 3 information. Application cannot be processed without a copy of this license. 12. APPLICANT agrees to indemnify, defend and hold harmless the Civil City of South Bend, Indiana, from any liability, loss, costs, damages or expenses, including attorney fees, which. the Civil City of South Bend, may suffer or incur as a result of any claims or actions which may be made by any person, including a participant in the activity, arising out of the approval of this request by the Board of Public Works to close a portion ofthe public fight -of -way for the event described above. I have read the Application and Permit and theAgreement for the "U'se of Right of -Way far Special Events" and I understand and agree to the above rules and regulations. I also understand that this application may be denied based on any false or incomplete information. Dated this Z-11 _ day of 20 1 APPLICANT Signature BOARD OF PUBLIC WORKS APPROVAL President- Me bet em Member, Member 770,'I r3 0_ t l Date RETURN FORM TO: Board of Public Works 1316 County -City Building 227 West Jefferson Boulevard South, Bend, IN 46601 Phone: (574) 235-9251 0 Fax. (574) 235-9171 0 E-Mail: publicwks@southbendin.gov �cca�n® CERTIFICATE OF LIABILITY INSURANCE �..,.-� DATE(MMIODIYYYY) 1/31/2017 THIS CERTIFICATE 18 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEDATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURGR(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER, IMPORTANT: If the certlllcate holder Is an ADDITIONAL INSURED, the policy(ies) must W endorsed, If SUSROGATION'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 endorsements , RODUCER Michelle Waaaaki libgon Insurance Agency, Inc. .30 S Main St, Ste 400 PH NS , {B00) BI4-2122 C 1, i0001e36-2122 EMAI6DiwagoekiQgibaanins,cam PO Box 11177 louth Bend IN 46601-0177 _ INSURER S AFFORDINQ COVERAGE NAIC# INSu ERA:Cinainnati Ins Ca _ 10677 ISURED wouRaae:Acoident Fund Ins Cc Amer 10166 INSURERC: ,a Cana do Amistad, Inc. 46 S Meade Street INSURERD: _ INsuRER e : ' :ouch Bend IN 46619 INSURERF OVERAGES CERTIFICATE NUM8ER!2/15/17-18 Y,iab Cart RFVISIAN NIIMRRR• 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 1S SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. 8R TYpI10PIN5URRNCEWVD POUPYNUMBFR PGBpYRF VI POLIO 8XP LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE Q OCCUR EACH OCCURRENCE $ 1,000,000 Ono$ 1,000,000- MEDFxp Anyone arson 4 10,000 ETD 0234322 2/15/2017 2/15/2018 PERSONAL& ADV INJURY $ 1.,000,000 GEN'LAGGREGATE LIMIT APPLIESPER: R POLICY❑JECTT LOC, GENERALAGGREGAT& 3 3,000,000 PROnuCTS•COMPIOPAGO 5 1,000,000 S OTHER: AUTOMOBILE LIABILITY COMBINED SINGIE LIMit Eaaocldent) 3 1,000,000 A ANY AUTO ALL SOS AUTOS AUTOS HIRED AUTOS NON -OWNED _ AUTOB E2'0 0234322 2/15/2017 2/15/2018 BODILY INJURY (Per parson) 3 BODILY INJURY (Per accldanp $ PROPERTYDAMAGE ; $ UMBRELLA UAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAR CLAIMSUADE DEO RETENTION $ B WORKERS COMPENSATION AND EMPLOYER$' LIABILITY YIN ANY PROPRIETORIPARTNERIEXECUT€VE OFFICERIMEMeER WLUDED7 (Msndelory 1n NN) tie describe under 0SUtR€PTION OF OPERATIONS balwv N to WCV6099304 2/15/2017 2/15/2018 R E,L EACH ACCIDENT $ 500,000 E.L. DISEASE • EA EMPLOYE $ 500,000 111, DISEASE -POLICY LIMIT I $ 500,000 MSCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLE8 tACORD 101, Addilienel Rornarka Schedule, may be etlached i1 more space Is required) )0 NOT RENEW :ertifioate holder is additional insured with respect to general liability coverages an required by Britten contract. Board of Public Works 1316 County -City Building 227 West Jefferson 131vd South Bend, 2N 46601 SHOULD ANY OF THE ABOVE DESCRIBED POLICIt S BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL HE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, AUTHORIZED REPRIBtINTATIVE Iris Agency/MWASOS ACORD 25 (2014101) INS025 (2014011 (01968.2014 ACC The ACORD name and logo are registered marks of ACORD All rights reserved. BEST. WEDNESDAY. EVER May 31st, 2017 2900 Block Western Ave. Taco/Food Truck Parking Activity Area Headquarters / VPA Lounge !seln[s lChoh Wood In Chi -lei � gee�r/Music .,Kids Area t� � Parking � 1'00 Ideas�� Us[C� � - #. •. 29t3g . ` Western Ale r .� C.8 J spl + �,• r ;+.:,r M! S •-• sue. •r +r+ ROCk will rouse) .... - Western Ave W.West.ern Ave �' ' _ •'� ` "'*N Westen-i Ave JW `l.act�eria'. .. l Market'J�°'� ing x 3 t, Pop.' p R IiunelesSuper lvlarkpl Park - - " r ; Pero McAl . i C� U��:.trolleW orthe Tled.rn,p 3t�'7fj l S tn�rrnnt tirvrnue service P.C. Box 2508 In reply refer tos 0752255928 Cincinnati. OH 45201 Jan. 25, 2017 LTR 4168C 0 35-1350013 000000 00 00015294 BODC: TE LA CASA DE AMISTAD INC 746 S MEADE ST L-2 SOUTH BEND IN 46619-3235 025922 Employer ID Number: 35-1350013 Form 990 requiredt YES Dear Taxpayert This is in response to your request dated Jan. 13, 2017, regarding Your tax-exempt status. We issued you a determination letter in JANUARY 1982, recognizing you as tax-exempt under Internal Revenue Code (IRC) Section 501(c) (3), Our records also indicate you're not a private foundation as defined under IRC Section 509(a) because you're described in XRC Sections 509[a)(1) and 1700)(l)(A)(vi). Donors can deduct contributions they make to you as provided in IRC Section 170. You're also qualified to receive tax deductible bequests, legacies, devises, transfers, or gifts under IRC Sections 2055, 2106, and 2522. In the heading of this letter, we indicated whether you must file an annual information return. If a return is required, you must file Form 990, 990-EZ, 990-N, or 990-PF by the 15th day of the fifth month after the end of your annual accounting period. IRC-Section 6033(J) provides that, if you don't file a required annual information return or notice for three consecutive years, your exempt status will be automatically revoked on the filing due date of the third required return or notice, For tax forms, instructions, and publications, visit www.irs.gov or call 1-800-TAX-DORM (1-600-829-3676). If you have questions, call. 1-877-829-5500 between 8 a.m. and 5 p.m.► local, time, Monday through Friday (Alaska and Hawaii follow Pacific Time). LA CASA DE AMISTAD INC 746 S MEADE ST SDUTH BEND IN 46619-3235 0752255926 Jan. 25, 2017 LTR 4168C 0 35-1350013 000000 00 00015295 Sincerely ,yours, Teri M. Johnson Operations Manager, AM Ops. 3