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HomeMy WebLinkAboutNon Res Block Party - DTSB - Tree Lighting Ceremony and First Fridaysm A B APPLICATION ;j;' fF Al FOR USE OF, AND BLOCKING OF ACCESS TO, THE PUBLIC ':w I -FACE RIGHT-OF-WAY FOR NON-RESIDENTIAL BLOCK PARTIES`,'„�_-'z:�,3' iHrs . 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: Downtown South Bend, Inc. Address: 217 S. Michigan St. City. South Bend State: IN Zip: 46601 Phone: 574-968-7293 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 Tree Lighting Ceremony and First Fridays (December 1, 3:30 p.m. to 9.30 p.m.) Location Downtown South Bend (Desedbe Area/Route) Street Closure Name; of Street Washington St. From Michigan St. To Dr, Martin Luther King, Jr. Blvd. Date of Event December 1 20 17 ❑ a.m. a.m. Time: Registration/Setup 3:30 ® p,m. Start 5:00 ® p.m. End 9:30 ® P.M. Approximate Number of Attendees 1500 Answer the following appropriately: 1. This event will have music (live 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, Ott' 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 ® 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 ® Yes ❑ No Updated 4/20t5 1 e. This event is a local regions ational event (Please circle the ® yes ❑ appropriate event type f. Affected property/business owners have been notified of this event. ® Yes ❑ g. 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 ❑ IF ALCOHOL IS TO BE SERVED OR SOLD Alcoholic beverages will be sewed ❑ Alcoholic beverages will be sold ❑ Certified Check or Money Order for $400.00 must be submitted with application. + Application cannot be processed without deposit. s 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. + QuaIifications 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. + Call the Alcohol & Tobacco Commission at (317) 234-4315 for more information. Application cannot be processed without a copy of this license. No No No L ❑N El 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 17 day of October 20 APPLICANT Signature Printed Name K 17 BOARD OF PUBLIC WORKS APPROVAL Member Member Member '1I1VII7 Date RETURN FORM TO: Board of Public Works 1316 County -City Building 227 West Jefferson Boulevard South Bend, IN 46601 Phone: (574) 235-9251 a Fax: (574) 235-9171 e E-Mail: pub]icwks@southbendin.gov Road Closure for December First Fridays and Tree Lighting Ceremony Decem ber 1, 2017 3,30 p.m. to 9.:30 p,m. AC" " CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDIYYYY) 7/25/2017 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 1S 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 CONTACT Stephen Swihart PHONE(800) 814-2122 AfC No; (800)836-2722 Gibson Insurance Agency, Inc. ADDRESS:sswihart@gibsonins.com 130 S Main St, Ste 400 INSURERS AFFORDING COVERAGE NAIC I+ PO Box 11177 INSURERA:Cincinnati. Ins Cc 1.0677 South Bend IN 46601-0177 INSURED INSURER B :Cincinnati Ind Cc 23280 INSURER C : Downtown South Bend, Inc. INSURERD: 217 S Michigan St INSURER E : PO Box 930 [INSURER F: South Bend IN 46624-0930 CCIVPRAnFR CERTIFICATE KII]MRFR17/18 Liab 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, EXCLUSIONSAND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADD S POLICY NUMBER POLICY EFF MMIDDIYYYY POLICY EXP DDIYYYY MMI LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS -MADE � OCCUR AGETO PREM SES (Ea occTurrence) $ 500,000 MED EXP (Anyone person) $ 5,000 EPP0031054 8/2/2017 8/2/2018 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMPIOP AGG $ 2,000,000 PRO JECT ❑ LOG pqPOLICY Employee Benefits $ 1,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident) $ 1,000,000 BODILY INJURY (Per person) $ A ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS X FNON-OWNED HIRED AUTOSAUTOS EPP0031054 8/2/2017 8/2/2018 BODILY INJURY (Per accident) $ PPe�acadentDAMAGE $ X UMBRELLA LIAR OCCUR EACH OCCURRENCE $ 4 OOO 000 AGGREGATE $ 4,000,000 A EXCESS LIAB CLAIMS -MADE ❑ED X I RETENTION 0 $ EEE0031054 8/2/2017 8/2/2018 WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNERIEXECUTIVE Y� X PER ER E.L. EACH ACCIDENT $ 100,000 ER H)EXCLUDED? OFFICERIMEM(Mandatory (Mandatary €n NH) NIA EWCO257774 8/2/2016 8/2/2017 E.L.DISEASE - EA EMPLOYE $ 100 000 E,L, DISEASE - POLICY LIMIT $ 500,000 0 yes, describe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required) City of South Bend is additional insured with respect to General Liability regarding events hosted by Downtown South Bend, Inc. CF'RTIFICATF I-Inl nr-P CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of South Bend THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 227 W . Jefferson ACCORDANCE WITH THE POLICY PROVISIONS. South Bend, IN 46601 AUTHORIZED REPRESENTATIVE G Ins Agency/STSWIH ACORD 25 (2014/01) INS025190i4ntr ©1988-2014 ACORD CORPORATION. All rights reserved, The ACORD name and logo are registered marks of ACORD