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HomeMy WebLinkAboutProcession - Center for Hospice CareINTER -OFFICE MEMORANDUM BOARD OF PUBLIC WORKS DATE SENT: 5/17/2017 TO: d Gleckler, Traffic & Lighting edenco Rodriguez, Fire Department att Longfellow, Engineering Kara Wood, Park Department t. Gene Eyster, Police Department Jill Sciccitano, Downtown South Bend iVlarcia Qualls, Streets r Legal Department FROM: Linda M. Martin, Clerk SUBJECT: PROCESSION RECOMMENDATION -Bike Michiana SPONSOR: Center for Hospice Care DATE OF EVENT: September 17 2017 DATE DUE: May 23 2017 FAX OR E-MAIL TO: 235-9171 1 Imartin southbendin. ov RECOMMENDATIONS AND COMMENTS: By Date APPLICATION FOR USE OF PUBLIC RIGHT-OF-WAY FOR PROCESSIONS The Board of Public Works must have FOUR (4) weeks prior notice of the Sponsor: ,,�/ � `oy��Ce Z,.. Submitted By: Address: City: Iyl i6 ��G�Gd. State: % , Zip: �'/� Phone: �S "7�!— 2L/3 *�;// Sponsor may use the public right-of-way described as (describe route and attach map) PLEASE NOTE: THE SOUTH BEND POLICE DEPARTMENT RESERVES THE RIGHT TO CHANGE YOUR ROUTE FOR SAFETY PURPOSES Event name: ZO"/ Q /Grt ❑ The Board of Public Works must have FOUR (4) eeks prior notice before event occurs ❑ All certificates of insurance, pre -paid costs, maps, and any other applicable information requested or required by the Board of Public Works have been provided with this application ❑ The event shall be held on 4 .L0j-:Z- and no other dateP7� 2 ❑ Registration time for the event starts at 9 6./p.m, ❑ Starting time of the procession is 7- �2,/p.m. ❑ Estimated completion time is a.1116 This event involves the use of the following roadways This event involves City streets This event involves County roads ❑ This event involves State highways This event involves use of a park (Must obtain permission fiom Park Board) 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) ❑ This event involves the use of the sidewalk ❑ Participants must stay on the sidewalk and obey all traffic laws. This event is a local/C-eAio4jAationa1 event (Please circle the appropriate event type) This event will be coordinated with the property owner/business where staging will take place Updated 4/06/16 PERMIT/AGREEMENT FOR A PROCESSION 1. Sponsor shall reimburse the Board for the actual cost to the City for the event, if deemed necessary. 2. Sponsor 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. 3. Sponsor shall provide to the Board all additional licenses, permits and documentation required for the event. 4. Sponsor agrees to abide by all terms and conditions of the Board's policy governing walks, runs, parades or other similar event adopted by the Board on March 3, 1985. S. In order to ensure public safety during the event, the Board agrees to furnish traffic planning, materials, equipment and personnel as deemed necessary by the Police Department Traffic Bureau, the Bureau of Traffic and Lighting, and, where applicable, the Board of Park Commissioners. 6. Sponsor acknowledges that the Police Department reserves the right to change this route for safety purposes. 7. In consideration for approval by the Board and the use of the sidewalks for the purposes set out above, the undersigned agrees and undertakes to hold the Civil City of South Bend, Indiana, free and harmless fiom any liability loss, costs, 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 said activity, arising out of the approval of the request to use the sidewalks indicated in the City of South Bend. The undersigned certifies that he/she is authorized to bind the above mentioned sponsor to the terms hereof. 8. Notification of approvalldeuial of this request will be issued by return of this form, upon signed authorization by the Board of Public Works I understand the above riles and regulations and that this application may be denied based on any false or incomplete information. , , / I Sponsor Signature /; /�' I �do (7 Date RETURN FORM TO: 2 Board of Public Works 1316 County -City Building 227 West Jefferson Boulevard South Bend, IN 46601 Phone: (574) 235-9251 • Fax: (574) 235-9171 • E-Mail: publiowks@southbendin,gov CENTFOR-01 KKLINE CERTIFICATE OF LIABILITY INSURANCE F0ATE(MMIDDNYYY)10/29/2016 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 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 endorsement(s). PRODUCER T cT 1st Source Insurance, Inc, PHONE FAX No ; 574 271-5240 6909 Grape Road Arc No, Pad : 674 271-5200 Mishawaka, IN 46545 6 hLAiL__ INSURED Center For Hospice Karl Nolderman $01 Comfort Place Mishawaka, IN 46645 COVERAGIFR f'=10T1=1AAT1T Kit .....".�,�ru�.r.. THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED KtVISIUN NUM13F=R: NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR 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. ILTANSR TYPEOFINSURANCE ADIX SUER PO��CYI FF PO J0 Fa(P D POLICY NUMBER LIMITS MERCIAL GENERAL LIABILITY 1,000,000 LAIMS-MADE DcctfR MFL0043331114 EACH OCCURRENCE $ DAMAGE TO RENTED 11/01/2016 11/0112017 3 �� , rrene S 100,000 TGEItN?'L MED EXP Any one person 6,000 PERSONAL S ADV INJU Y $ 1,000,000 YR GATE LIMpIT APPLIES PER: JECr LOCPRODUCTS-COMPIOPAGGIncluded GENERRLAGGREGATE g3,000,000 R: A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 ANY AUTO MFL0043331114 11/01/2016 11/01/2017 SCHEDULED AUTOS gODILYIN URY Per ers n $ ONLY ER�p UpTNOpSyy� pp AtfTOS ONLY AUTOS ON Y rx BR�ODILYMJURY Peraccldent $ AMAGE Per aecit l $ $ UMSRELLALIAS OCCUR EACH OCCURRENCE S EXCESSUAB CIAIMS-MADE DEO RETENTION$ ATE S WORRIERS COMPENSATION AND EMPLOYERS' LIABILITY OTH- ANYPROPRIErOR1PARINERlEXECUTIVE YIN MFe datorYIM? I EXC UOE09 NIA TU TE ACCII g If yyes des cn'be undo, DE tiR1PTION OF OPERATIONS below - EA EMPLOYE ASE -POLICY LIMIT $ DESCRIPTION OF OPERATIONS! LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, May he attached irmore space is required) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of South Bend, Indiana THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 227 W. Jeferson Blvd ACCORDANCE WITH THE POLICY PROVISIONS. South Send, IN 46601 AUTHORIZED REPRESENTATIVE ACORD 26 (2016103) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD S • Official ride end is 6 pm • Post -ride party end is 7 pm Ste IPGalt5 Elbe ,,:OOam ci m BarBiBid Evil Czech 8:00 am - 4:00 pm Rd 99GUCounty Memoriai Park New Carlisle 9:00 am - 3:00 pm Moser's Cafe Kate O'Connor's EMERGENCY NUMBERS Medical Emergency 911 • Rider Assistance 574-210-7368 I -lz f 'r'