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HomeMy WebLinkAboutNon Res Block Party - Kite Realty - Family Fun DayINTER -OFFICE MEMORANDUM BOARD OF PUBLIC WORKS DATE SENT 5/8/2017 TO: Ed Gleckler, Traffic & Lighting Gene Eyster, Police Department att Longfellow, Engineering ris Dressel, Community Investment ederico Rodriguez, Fire Department arcia Qualls, Engineering Kara Wood, Park Department [II Sciccitano, Downtow S uth Bend FROM: Linda M. Martin, Clerk SUBJECT: Non- Residential Block Party -Family Fun Day LOCATION: _Eddy Street from Angela Blvd toNapoleon St DATE AND TIME: June 1P, 2017 8:00am to 2:00pm SPONSOR: KRG Eddy Street Commons -Family Fun Da DATE DUE: May 16, 2017 FAX OR E-MAIL TO: 235-9171 1 Im hbendin.gov artm soot,,,,,. RECOMMENDATIONS AND COMMENTS: By Date .m-_.�v v tit . � �� .--- M .. - - . APPLICATION FOR USE OF AND BLOCKING OF ACCESS TO THE PUBLIC RIGHT-OF-WAY FOR NON-RESIDENTIAL 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 Applicant Fee Paid INCLUDED WITH APPLICATION. _ `�/ t�, � � Name: Carissa Mencil 30 S Meridian St {� Address: Ste 1100 City: Indianapolis State: IN Zip: 46204 Phone: This application is made to the City of South Bend, Indiana, Board of Public Works, for the use of the specified public right-of-way by Applicant for the holding of the hereinafter described event: Event Name Family Fun Da Location Edd Street Commons 1234 Eddy Street (Describe Area1Ro te) Street Closure Name of Street EddyStreet From An-ela To Napoleon Date of Event 6/I0 20 17 Time: Registration/Setup 8 !� a m. Start 11 a.m L! p ❑ p.m. ❑ a.m. End 2 Approximate Number of Attendees Answer the following appropriately: 1. This event will have music (live or other). Yes ❑ a. I understand the Noise Ordinance described in the Agreement/Permit 2. Required No Yes ❑ No 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 14 yes ❑ No additionally filed with the Office of the City Clerk, 4"' Floor, County- City Building, 227 W. Jefferson Blvd., South Bend, Indiana. c. Certificate of Insurance d. Maps, drawings of the area and setup plan yes ❑ No 3. a. This event involves City streets b. This event involves County roads Yes ❑ No ❑ Yes No c. This event involves State highways ❑ Yes No Updated 4/2015 1 3 d- This event involves the use of the sidewalk e. This event is a local/regional/national event (please circle the appropriate event type) f Affected property/business owners have been notified of this event. 9. I understand that I must arrange a meeting with all affected governmental agencies to organize the above event (Call Marcia Qualls, Customer Service Manager, 235-5939 to organize meeting). Yes Yes Yes ❑ No ❑ No ❑ No Yes ❑ No IF ALCOHOL IS TO BE SERVED OR SOLD Alcoholic beverages will be served ❑ Alcoholic beverages will be sold ❑ Certified Check or Money Order for $400.00 mast be submitted with application. Application cannot be processed without deposit. ❑ Deposit will be returned upon inspection of event area by the Board Names and phone numbers of THREE security of Public Works. guards ® To monitor underage drinking. ❑ Qualifications must be listed (e.g. Off -duty ty police officer, professional security guard, or event A dxawing must be submitted showing: ® Fencing around serving area D ® Trash receptacles. o Ample trash receptacles must be provided to ensure proper disposal of refuse. Temporary liquor license. * Call the Alcohol & Tobacco Commission at (317) 234-4D 15 for more information. e 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 of the public right-of-way for the event described above. I have read the Application and Permit and the Agreement for the "Use ofRight-of Way for Special Events" and I understand and agree to the above rules and regulations. I also understand that this application .may be denied based on anyr,false of incomplete information. Dated this �� day of i V 20 APPLICANT Signature Printed Name BOARD OF PUBLIC WORKS APPROVAL President J Me ex Member Member Me ber Date RETURN FORM TO: Board of Public Works 1316 County -City Building 227 West Jefferson Boulevard South Bend, Phone: (574) 235-9251 • Fax: (574) 235-917 ®E Mail: end' publicwks southb @ un.gov City of South Bend, Indiana ® Board of Public Works 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: I. Pursuant to Local Ordinance No. 10224-13, there is a $125.00 non-refundable 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, 4th 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 by return of this form, upon signed authorization by the Board of Public Works, 6. The APPLICANT shall provide to the Board a Certificate of Insurance showing a liability policy in full force and effect with limits of $300,000.00 per occurrence and $5,000,000.00 aggregate and the City of South Bend listed as an additional named insured for this event. 7. The APPLICANT assumes full responsibility for providing ample disposal containers for refuse/recycling and assures the area will be cleaned up upon the conclusion of the event. $. 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 in 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, 1 I . 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 of the 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 submitted with 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 information. Application cannot be processed without a copy of this license. 3 ........... 0 Pure barre IS 't1 103E.4.551.SF 310178 Ate.-.^ " L(�(-"J'R CERTIFICATE OF LIABILITY INSURANCE IQ[]IYYYY) =51912017 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 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 confer rights to the certificate holder in lieu of such endorsemeni(s). PRODUCER - Commercial Lines - (404) 923-3700 Wells Fargo Insurance Services USA, Inc. CONTACT Kimberlee Koili NAME: HAX !aAICAC o404 923 3532 877 362-9069 AE-MAtL kimberlee.m.kofli wellsfar O.COm DDRESS' @ g INSURER S AFFORDING COVERAGE NAIC p 3475 Piedmont Road NE, Suite 800 INSURERA: LM Insurance Corporation 33600 Atlanta, GA 30305-2886 INSURED INSURER a ; Allied World National Assurance CO. 10690 Kite Realty Group Trust W INSURER C INSURER D. 30 S. Meridian St., Ste. 1100 INSURER E INSURERF: Indianapolis IN 46204 COVERAGES CERTIFICATE NUMBER: 11760500 REVISION NUMBER: See below 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 ADOL SUBR D __ POLICY NUMBER POLICY EFF� MMIDDIYYYY POLICY EXP MMlDOIYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE X OCCUR TB6Z91453740077 No Deductible/Retention 03/01/2017 03/01/2018 EACH OCCURRENCE S 1,000,000 DAIA11 TO RENTED PREMISES Ea occurrence S 800.000 MED EXP (Any one person) $ Excluded Applies to GL PERSONAL & AOV INJURY S 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY E] JE� I LOC PRODUCTS-COMPlOPAGG $ 2,000,000 S OTHER: A AUTOMOBILE LIABILITY AS5Z91453740067 03/01/2017 03/01/2018 COMBINED SINGLE LIMIT Ea accident $ 1.000,000 BODILY INJURY (Per person) $ X ANY AUTO No deductible OWNED SCHEDULED AUTOS ONLY AUTOS on Auto Liability y BODILY INJURY (Per accident) S PROPERTYDAMAGE fper accident $ X HIRED X NON -OWNED AUTOS ONLY AUTOS ONLY B X UMBRELLALIAB X OCCUR 3088008 03/0112017 03/01/2018 EACH OCCURRENCE $ 26,000,000 AGGREGATF $ 25,00g000 EXCESS UAa CLAIMS -MADE D£D I X RETENTIONS 5,000 $ A WORKERS COMPENSATION AND EMPLOYERS` LIABILITY YIN ANYPROPRIETORIPARTNERlEXECUTiVE OFFICERIMEMBEREXCLUDED? E (Mandatory in NH) NIA WC5Z914537400a7 03101I2017 0310112D18 X STATUTE ORH E.L. EACH ACCIDENT 1,000,000 $ E.L. DISEASE -EA EMPLOYEE $ 1,000'am E.L. DISEASE - POLICY LIMIT $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES fACORD 101, Additional Remarks Schedule, may be attached if more space is required) Re: KRG Eddy Street Commons, LLC , Eddy Street Commons 1044-1234 Eddy Street, South Bend, IN 46601 CERTIFICATE HOLDER CANCELLATION City of South Bend Department of Public Works, Engineering Division SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 227 W Jefferson Blvd., Suite 1316 AUTHORIZED REPRESENTATIVE South Bend, IN 46601 ((� yC +o lr, The ACORD name and logo are registered marks of ACORD @ 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) {rhig ,gNrWlB ,epleres raN(Iralek 117fi64351ssuetl an 51Bl2017)