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Home My WebLink AboutNon Res Block Party - Our Lady of Hungary Parish Festival��,x z t .�' �> .�s �:= �•� � '; M b. This event involves County roads ❑ Yes ❑ No El Yes No c. This event involves State highways X d. This event involves the use of the sidewalk X Yes ❑ No El e. This event is a local/regional/national event (Please circle the ❑ Yes ❑ No appropriate event type) f. Affected property/business owners have been notified of this event. X ❑ Yes ❑ No g. I understand that I must arrange a meeting with all affected governmental agencies to organize the above event (Call Marcia El Yes ❑ No Qualls, Customer Service Manager, 235-5939 to organize meeting). IF ALCOHOL IS TO BE SERVED OR SOLD Alcoholic beverages will be served X❑ Alcoholic beverages will be sold X❑ 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 X • 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; X • Fencing around serving area ❑ • Trash receptacles. o Ample trash receptacles must be provided to ensure proper disposal of refuse. Temporary liquor license. X • Call the Alcohol & Tobacco Commission at (317) 234-4315 for more information. ❑ • Application cannot be processed without a copy of this license. Lip": 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 of the public right-of-way for the event described above. I have read the Application and Permit and the Agreement for the "Use of Right -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 any false or incomplete information. Dated this 14th day of June 20 2017 APPLICANT Signature Denise M. Domonkos 255-1906 ddomonkos@sbcsc.kl2.in.us Printed Name Denise M. Domonkos We will have 4-5 security guards through A-1 Security. BOARD OF PUBLIC WORKS APPROVAL k,1(XA k, -a Presi ent Member Member it� 7. Member Member Date RETURN FORM TO: 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: publicwlcs@southbendin.gov Ditte: 6114/2017 Certificatte of Coverage -g This Certificate is issued as -a matter of information om[iy and The Diocese of Fort Waync-South Bend, Inc. Chancery Office confers no rights upon the holder of this certificate- Tlkiq certificate does not amend, extend or alter the coverage afforded below. P.O_ Box 390 Fort. Wayne, IN 46801 Conipany Affording Coverage 71113 CATHOLIC MUTUAL RELIEF SOCIETY OF AMERICA 10943 OLD MILL RD Covered Location Otw Lady ofHungaryParish OMAHA, N-E- 68154 829 W Calvert Street South Bend, IN 46613 :Covers geg . 4. 4t: This is to certify that the coverages listed below have been issued to the certificate holder named Above for the certificate 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 coverage afforded described herein is subject to all the terms, exclusions and conditions ofstich coverage. Limits show-n may have been reduced by paid claims. Type of Coverage 1: Certificate !Numbertale Coverage Effective Coverage Fspiration Date Limits; property Real & Personal Property D. Cach Occurrence 1,000,000 General Aggregate Occurrence 0 Claims Made 8679 10/1/2016 10/1/2017 Froducts-CotopfOl! Agg personal & Adv Injury Fire Damage (Any one fire) Med Ezp (Any one person) Excess Liability Each Occurrence Annual Aggregrate Other Each Occurrence Claims Made Annual AggMrate Limillcovemge 1Deseriptlnn of Operations!Locations/VehicleslSpecial Items (the following hinguage supersedes any other languagein this endorsement O]r the Certificate in conflict with this language) Coverage is verified for claims arising out of Our Lady of Hungary Parish during their.festival on July 15, 2017, Holder of CertlfJcate'--':-1 Should Any of the above described coverages be cancelled co issuing company will before the expiration date thereof, the MP t, endeavor to Mail 30 days written notice to the holder of City of South Bend, IN certificate named to the left, but failure to wail'%uch notice shall impose no obligation or liability of any kind upoh the company, its agents or representatives. 10067003080 Authorized itepresentativc CA t0L9-69Z-VL9 8'Jud AAubunH 10 APIal ino n09:L0 Z>, % unr BEER/ WINE AUTHORITY / TYPE 118 State Form 35494 (R8 111-15) 1� Approved by State Board of Accounts, 2016 INSTRUCTIONS, 1, Applicant must complete all requested infonnaf(on. 2. Please type or print clearly. 3. Submit appllceflon and payment to the focal excise distrlat office. Send, deliver, or mail to: DISTRICT 1 52422 County Road 17 Bristol, IN 46507 Telephone: (574) 264-9480 DISTRICT 2 1353 South Governors Drive Columbia City, IN 46725 Telephone: (260) 244-4286 DISTRICT 3 279 West 300 North Crawfordsville, IN 47933 Telephone: (765) 362-6816 DISTRICT 4 651 S, Commerce Dr. Seymour, IN 47274 Telephone: (812) 523 8314 DISTRICT 6 3650 South US Hwy 41 Vincennes, IN 47501 Telephone: (012) 882-1292 DISTRICT 6 6400 East 30th Street Indianapolis, IN 46219 Telephone: (317)541-4100 STEP 1. GENERAL INFORMATION Name of applicant applying for permit (organization. club, corporation, Individual) Our Lady of Hungary Parish TM Permit number (issued byATC) Address of applicant (numberand street city, state, and ZIP code) 735 W Calvert South Bend, IN 46613 E-mall address ddomonkos@sbcsc.kl2.i Name. of person making application Denise M. Dornonkos Fax number ( ) Emergency contact telephone number (574) 2551906 Printed name of contact person of event Denise M. Domonkos mergeney con(W telephone number (574) 8493478 STEP 2. EVENT INFORMATION SaVupjay ry)Toy��el�onth, day, year) Ezialurday Tame of event Start time 4 ❑ AM ® PM i End time O ❑ AM ®PM Type or description of event Parish Festival 71M.816afentRulgibronMIrffendalM04 e) G STEP 3. FLOOR PLAN See Ste 4, Number 2 aJ . a se -cur'- y l_ + - n� c7- .s vw y ��nS vo men 5 �.t},,�om bq+h roam Ga per+ n fro nc Page 1 of 2 Ee h-+rct rz e BEER I WINE AUTHORITY I TYPE 118 Stale Form 35494 (R8111-16) ,. Approved by Slate Board of Aanunts, 2015 ems' INSTRUCTIONS: i. Applicant must complete all requested information. 2. Please type or print clearly. 3. Submit application and payment to the local excise district office. Send, deliver, or mail to: DISTRICT 1 52422 County Road 17 Bristol, IN 46507 Telephone: (574) 264-9480 DISTRICT 2 1353 South Governors Drive Columbia City, IN 4672S Telephone: (260) 244-4285 DISTRICT 3 279 West 300 North Crawfordsville, IN 47933 Telephone: (755) 362-8815 DISTRICT 4 651 S. Commerce Dr, Seymour, IN 47274 Telephone: (812) 523-8314 DISTRICT 5 3650 South US Hwy 41 Vincennes, IN 47591 Telephone:1812) 082-1292 DISTRICT 6 6400 East 301h Street tndianapolis, IN 46219 Telephone: (317) 541 ■4100 STEP 1. GENERAL INFORMATION Name orapplicant applying for permit (organization, club, corporation, Individual) TM Permit number pssuedbyAX) Our Lady of Hungary Catholic Church Address of applicant (numberand street city, state, and ZIPWo) E-mail address 731 West Calvert Street South Send, IN 46613 rect"ouriadyothungary@gmall,com Name of person making appllcaiion Father Kevin Bauman Fax number i 574 ) 289-6704 Emergency contact telephone number ( 574 ) 339.3124 Printed name of contact person of event Karen Carizzosa Emergency contact WepliQno number ( 574 ) 202-4040 .STEP 2. EVENT WFORMATION Beginning day Saturday 8eginning date (month, day, year) Ending day Juiy 15, 2017 Saturday Ending date (month, day, year) July 15, 2017 Time of event Start time 1:30 ' El AM ❑v PM J End time 10:0D ❑ AM [0 PM Type or description of event Parish Festival Exact address of avant (nurnberandstreet, clty, stale, and ZIPcode) 731 West Calvert Street, South Bend, IN 46613 STEP 3.. FLOOR PLAN See Stop +4, Number 2 1. 3 L I I I C+q 1 e i, l m , 1 _i.��b r _ t I ( G ( I a 1 1 Fj- 10 ...I ... +1 h ... TT '1 �ID.a�O.-Ti t44v�M j. • ,n j-#) 4'OM0 Page 1 of 2 STEP 4. ACKNOWLEDGEMENT In order to qualify for this authority to serve beer and wine, the following guldetlnes must be met: 1. There must be a well defined premises, i.e. building, tent, enclosure, or fenced -in or designated area. 2. You must have a defined floor plan or diagram. This is to be drawn on Page 1, Step 3 of this application, If minors are to be present, you must have a defined separation between the bar area and family area. (Must be on floor plan.) 3. There shall be NO carry -out privileges, NO carry -In privileges and NO spirituous beverages allowed. 4. Each applicant must designate an individual to be responsible for the event and such person shall sign the authority. S. ANY and ALL persons dispensing or accepting payment for alcoholic beverages MUST POSSESS a valid ATC employee permit. 6. The event must meet applicable Indiana State Board of Health requirements, particularly with regard to rastroom facilities. 7. If the event is held in a town park, you must have approval from the town board. 8. Legal Hours of dispensing alcoholic beverages: (Prevailing time) Monday through Saturday — 7 AM to 3 AM the following day Sunday -- 7 AM to 3 AM the following day 9. Applicant must file with the district office at which the event will be held at least five (S) days prior to the event. 10. The authority must be posted in the most conspicuous place at the location of the event. An excise officer or commissioner, for good cause, has the authority to revoke the authority during the event. :STEP 6. COMMUNITY CLEARANCE t. Signature of Shoriff of county, or Chief of Police, or7own Marshall of Jurisdiction where the avant will be hold Bate signed (month, day, year) 2. Signature of the mayor (if the event Is held In Fort Wayne) Rate signed (month, del+, year) Note: Please post your approved request In a conspicuous place where the alcoholic beverages are being dispensed at the location. If for any reason this request is denied, you may be notified either in person or by telephone. I swear or.affirm under penalties of perjury that the information is true an accurate. Slgnjg ra iof parmilloq fray nl gvur sfpna uro a nowle gas flint you have read and V91 obfdo by the lulus and guldaflgas.) Data signed (month, day, year) 13 FOR DISTRICT USE ONLY - District number Rate Issued (month, day, year) Reviewed by Excise Police District Representative ❑ Approved ❑Denied 1. ALL ANTS ARE $50.00 PER DAY. BUSINESS CHECKS OR MONEY ORDERS ARE ACCEPTED MADE OUT TO THE INDIANA ALCOHOL AND TOBACCO COMMISSION. 2. SERVING PAST MIDNIGHT, NO LATER THAN 3 AM, IS ONE DAY, 3. NO RAIN CHECKS ON ANY OF THE ABOVE EVENTS. Page 2 of 2 STEP 4. ACKNOWLEDGEMENT In order to qualify for this authority to serve beer and wine, the following guidelines must be met: 1. There must be a well defined premises, i.e. building, tent, enclosure, or fenced -In or designated area. 2. You must have a defined floor plan or diagram. This is to be drawn on Page 1, Step 3 of this application. If minors are to be present, you must have a defined separation between the bar area and family area. (Must be on floor plan.) 3. There shall be NO carry -out privileges, NO carry -in privileges and NO spirituous beverages allowed, 4. Each applicant must designate an individual to be responsible for the event and such person shall sign the authority. 5. ANY and ALL persons dispensing or accepting payment for alcoholic beverages MUST POSSESS a valid ATC employee permit. S. The event must meet applicable Indiana State Board of health requirements, particularly with regard to restroom facilities. 7. If the event is held in a town park, you must have approval from the town board. S. Legal Hours of dispensing alcoholic beverages., (Prevailing time) Monday through Saturday -- 7 AM to 3 AM the following day Sunday -- 7 AM to 3 AM the following day 9. Applicant must file with the district office at which the event will be held at least five (5) days prior to the event. 10, The authority must be posted in the most conspicuous place at the location of the event. An excise officer or commissioner, for good cause, has the authority to revoke the authority during the event. STEP 5. COMMUNITY CLEARANCE 1. Signature of Sheriff of county, or Chief of Police, or Town Marshall of jurisdiction where the event will be held Date signed (month, day, year) 2. Signature of the mayor (if the event is herd in Fort Wayne) Date signed (month, day, year) Note: Please post your approved request In a conspicuous place where the alcoholic beverages are being dispensed at the location. If for any reason this request is denied, you may be notified either In person or by telephone. I swear or affirm under penalties of perjury that the information is true and accurate. Signature of permittee r agent (Your acknowledges that you have read and will abide by the rules and guidelines.) Date signed (month, day, year) rss�ig�nature FOR DISTRICT USE ONLY District number Rate Issued (month, day, year) Reviewed by Excise Police District Representative Approved [] Denied 1, ALL EVENTS ARE $50.00 PER DAY. BUSINESS CHECKS OR MONEY ORDERS ARE ACCEPTED MADE OUT TO THE INDIANAALCOHOL AND TOBACCO COMMISSION. 2. SERVING PAST MIDNIGHT, NO LATER THAN 3 AM, IS ONE f1) DAY. 3. NO RAIN CHECKS ON ANY OF THE ABOVE EVENTS. Page 2 of 2 afkcd(�(f� r:i„��rFil e' f �s s 1�a 3k i 0 JULY 159 2017 4:00 PM. 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