HomeMy WebLinkAboutPublic Parking Facility - Beacon Health SystemsINTER -OFFICE MEMORANDUM
BOARD OF PUBLIC WORKS
DATE SENT: 2/15/2018
TO:
,Tom Anderson, Code Enforcement
Federico Rodriguez, Fire Department
AMatt Longfellow, Engineering
xChris Dressel, Community Investment
}Larry Magliozzi, Area Plan
Angela Smith, Area Plan
FROM:
Linda M. Martin, Clerk
License Application for Public Parking Facility- Beacon
SUBJECT:
Health Systemsiftlemorial Hospital Parking Garage -Bartlett
Garage - Renewal
LOCATION:
707 N. Michigan St.
DATE DUE:
February 20, 2018
FAX OR E-MAIL TO:
235-9171 1 Imartin@southbendin.gov
RECOMMENDATIONS AND COMMENTS:
By Date
For all murilcipaj business license ques0ons, contact: tatty of South Bend -Department of Community Investment
227 West Jefferson Blvd - Suate 14005 -South Bend, Indiana 46601 - 574.235.5912 - R 574.235,9021
`
LICENSE APPLICATION FOR - PUBLIC PARKING FACILITY
MUNICIPAL CODE SECTION - 4-39
I. APPLICATION TYPE Check One: New Renewal XXX
I[. BUSINESS DATA
A. Business Name: BEACON HEALTH SYSTEMS I MEMORiAL HOSPITAL PARKING GARAGE ZONED CBD
B. Business Address: 707 N. MICHIGAN ST. I BARTLETT GARAGE
City; SOUTH BEND State: IN Zip: 46601
C. Mailing Address (If different from above):
City, — State: Zip:
D. Business Telephone Number: 574-647-7311
E. Business Fax Number: 574-647-7328
F, E-Mail Address: cv*iA:G, 6A &beaconhe(Ak�-.NK4L li� ,
G. Maximum Number of Vehicles that can be parked at facility at one time: Lau,\
H - Tota 1: Number of Parking Spaces at facility:
L Hours during which vehicles may be stored:
H. Premises are (check one): Leased by Applicant
If Leased:
Owner's Name:
Owner's Busine!
City: T2-(mod State: NJ zip: ftub I
Owner's Residential Address:
Owned by Applicant
City:
State'.
Zip:
J. Insurance Carrier and Amount of Liability Insurance OR Bonding Agent and Amount of Bond:
For Office Use Only
Application Filed FEB 13 2018 Pubiic Works Approval
Application Fee Paid FEB 13 201— License Fee Paid — Sent to Dept, FBA 3 2918 License Number —If
Not Approved
Reason
1
H
2
t
For all municipal business license questions, contact; City of South Bend -Department of Community Investment
777 west Jefferson Blvd - Suite 1400 S -South Bend, Indiana 46601 - 574.235.5912 - F; 574.235.9021
LICENSE APPLICATION FOR - PUBLIC PARKING FACILITY
MUNICIPAL CODE SECTION 4-39
III, PERSONAL DATA
A. Applicant's Legal Name:
B. Residential Address:
City:
C. Residential Telephone Number:
D. Residential Fax Number:
F. Cellphone Number:
F. Position with Business:
State:
IV. OWNERSHIP
A. Type of ownership (check one):
Sole Proprietorship (If sole proprietorship, proceed to 1).
Partnership (If partnership, proceed to 2).
Corporation (If corporation, proceed to 3).
I. Sole Proprietor
Name:
Residential Address:
City: State:
Telephone Number:
2. Partnership (List at least two (2) partners)
Name ttl:
Residential Address:
City:
Telephone Number:
Name#2:
Residential Address:
Citv:
Telephone Number:_
0
State: Zip:
State: ZIP:
3. Corporation s�, l �
Legal name of corporation: , r CxN)CIl
Date and state of incorporation:
01
For all municipal business license questions, contact: City of South Bend • Department of Community Investment
227 West Jefferson Blvd • Suite 1400 S -South Bend, Indiana 46601 •574.235.5912 • F: 574.235.9021
LICENSE APPLICATION FOR - PUBLIC PARKING FACILITY
MUNICIPAL CODE SECTION - 4-39
IV. OWNERSHIP (Continued)
A. Type of ownership (continued):
3. Corporation (continued)
Resident Agent:
NamE
Title:
Business Address:
City:
Officers:
NamE
Title:
Business Address:
City:
Residential Address:
City:
Name #2:
Title:
Business Address:
City:
Residential Address:
City:
Name #3:
Title:
Business Address:
City:
Residential Address:
City:
3
State:
Zip:
State: Zip:
State: Zip:
State: Zip:_
State: Zip:_
State: Zip:_
State: Zip:_
For all municipal business Iicensequestlons, contact: City of South Rend • Department of Community Investment
227 West Jefferson Blvd • Sulte 1400 5 -South Bend, Indiana 46601 • 574.235,5912 • F: 574.235,9071
LICENSE APPLICATION FOR - PUBLIC PARKING FACILITY
MUNICIPAL CODE SECTION - 4-39
V. INCLUDE COMPLETE RATE AND HOUR SCHEDULE WITH APPLICATION
VI. INCLUDE A CURRENT INSURANCE POLICY OR BOND
VI I. INCLUDE $5.00 PROCESSING FEE WITH APPLICATION
I, hereby, certify and affirm that all of the information I have given in this application is true and
accurate to the best of my knowledge. I further certify that I have in no way attempted to
mislead the City in this application by omitting facts known to me. I have read and understand
the regulations of the Public Parking Facility license found in the City of South Bend Municipal
Code, Section 4-39.
Signatu e Date
4
.d►ct�Jrio� CERTIFICATE OF LIABILITY INSURANCE
DATE(MMIDDIYYYY)
11 /22/2017
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 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 endorsements .
PRODUCER
The Horton Group
340 Columbia Place
South Bend IN 46601
NAMEA. Michael Turner
PHONE 574-334-5500 FAX 574-334-5600
-Rn.r+1
I •Matt michael,turner@thehartongroup,com
INSURER(S) AFFORDING COVERAGE
NAIC 8
INSURER A; Medical Protective
11843
INSURED BEACHEA-02
INSURER B:Amerisure Mutual Insurance Co,
23396
Beacon Health System, Inc.
615 N. Michigan Street
South Bend IN 46601
INSURER C
INSURERD:
INSURER E ;
INSURER F :
COVERAGES CERTIFICATE NUMBER: 191173248 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 1S 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
INSD
D
POLICY NUMBER
POLICY EFF
MMIDDIYYYY
POLICY EXP
MMIaDIYYYY
- - LIMITS
A
X
COMMERCIAL GENERAL LIABILITY
CLA€MS•MAbE FX I OCCUR
H002223
12/1/2017
1211/2018
EACH OCCURRENCE
$1,000,000
DAMAGE TO RENTEDPREMISES Ea nccurrance
$50,000
MED EXP (An one person)
$5,000
PERSONAL& ADV INJURY
$1,000,000
GENT AGGREGATE LIMIT APPLIES PER:
X POLICY JECT PRO- ❑ LOG
GENERAL AGGREGATE
$3,000,000
PRODUCTS •COMPIOPAUG
$3,000,000
$
OTHER:
B
AUTOMOBILE
LIABILITY
CA13212592102
8/13/2017
8/13/2018
COMBINEDJEQ SWOUE LIMIT
$1,000,000
XANY
AUTO
BODILY INJURY (Par person)
$
USOSCHEDULED
ATOS
ONLY AOY
AUUTSONL
BODILY INJURY (Per accident)
$
RODAMAGE
c
$TOS
Comp: $250 X Coll; $500
$
A
X
UMBRELLA OAB
OCCUR
E002223
12/112017
1211/2018
EACH OCCURRENCE
$25,000,000
AGGREGATE -
$25,000,000
EXCESS LIAR
X
CLAIMS -MADE
DEO X RETENT€ONs25,000
-
$
WORKERS COMPENSATION
AND EMPLOYERS'LIABILITY YIN
ANY PROPRIETORIPARTNERIEXECUTIVE ❑
OFF€CERIMEMBER EXCLUDED?
NIA
PER OTH-
STATUTE ER
E.E.. EACH ACCIDENT
$
E.L. DISEASE - EA EMPLOYE
$
(Mandatory In NH)
If yes describe under
DESCRIPTION OF OPERATIONS below
E.L. DISEASE -POLICY LIMIT
$
B
Garagekeepers
CA20983310102
11/13/2017
1/13/2011
Physical Damage 500,000
Cori Ded: 26G
Comp Ded: 260/1,000
DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES (ACORD 101, AddlNanal Remarks Schedule, maybe attached If morn space Is required)
Annual Parking Garage license: CMS, Bartlett and Navarre Garages. FAX: 235-9021 Michelle Adams
City of South Bend
227 W. Jefferson Blvd.
Suite 1400 South
South Bend IN 46601
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL. BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
i
f
U 19815-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
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INTER -OFFICE MEMORANDUM
BOARD OF PUBLIC WORKS
DATE SENT: 2/15/2018
TO: Tom Anderson, Code Enforcement
X,Pederico Rodriguez, Fire Department
Matt Longfellow, Engineering
Chris Dressel, Community Investment
Larry Magliozzi, Area Plan
Angela Smith, Area Plan
FROM: Linda M. Martin, Clerk
License Application for Public Parking Facility- Beacon
SUBJECT: Health SystemsMiemorial Hospital Parking Garage -
Navarre Garage - Renewal
LOCATION: 100 Navarre St.
DATE DUE: February 20, 2018
FAX OR E-MAIL TO:
235-9171 1 ]martin@southbendin.gov
RECOMMENDATIONS AND COMMENTS:
By Date
(LI)
N
For all municipal business license questions, contact: city of South bend Department of community Investment
227 West Jefferson Blvd • Suite 1400 5 •5uuth Bend, Indiana 46601 • 574,235,5912 • F:574,235.9021
LICENSE APPLICATION IFOR - PUBLIC PARKING FACILITY
MUNICIPAL CODE SECTION - 4-39
1. APPLICATION TYPE Check One: New
1 �i1lr� 1�1 �'�3.7;t�llsl
Renewal XXX
A. Business Name: BEACON HEALTH SYSTEMS 0 MEMORIAL HOSPITAL PARKING ZONED CBD
B, Business Address: 103 NAVARRE ST. / NAVARRE PARKING GARAGE
City: SOUTH BEND —State: IN Zip: 46601
C. Mailing Address (If different from above): --
City: State: Zip:
D. Business Telephone Number: 574-647-731 `l
E. Business. Fax Number: 574-647-7328
F. -Mail Address:
G. Maximum Number of Vehicles that can be parked at facility at one time:
H. Total Number of Parking Spaces at facility:
I. Hours during which vehicles may be stared: _
H. Premises are (check one): Leased by Applicant Owned by Applicant
If Leased:
Owner's Name: ( n
Owner's Business Address: \� Q 0an
City: State: Zip: -4,kaqv..
Owner's Residential Address:
City:
State:
M
.i, Insurance Carrier and Amount of Liability Insurance OR Bonding Agent and Amount of Bond:
f10D
For Office Use Only
Application Filed FEB 13 2018 Public Works Approvall
Application Fee Pald J— License Fee Paid
Sent to Dept. FEBLicense Number��
,31-aw'd o I f
Not Approved
Reason
I
For all municlpal business license questions, contact: City of South Bend • Department of Community Investment
227 West Jefferson Blvd • Suite 14005 -South Bend, Indiana 46601 •574.235.5912 - F: 574.235.9021
LICENSE APPLICATION FOR - PUBLIC PARKING FACILITY
MUNICIPAL CODE SECTION - 4-39
III, PERSONAL DATA
A. Applicant's Legal Name:
B. Residential Address:
City:
C. Residential Telephone Number:
D. Residential Fax Number:
E. Cellphone Number:_
F. Position with Business:
State:
Zip:
IV. OWNERSHIP
A. Type of ownership (check one):
Sole Proprietorship (If sole proprietorship, proceed to 1),
Partnership (if partnership, proceed to 2).
Corporation (If corporation, proceed to 3),
1. Sole Proprietor
Name:
Residential Address:
City: State: Zip:
Telephone Number:
2. Partnership (List at least two (2) partners)
Name #1:
Residential Address:
City: State: Zip:
Telephone Number:
Name #2:
Residential Address:
City: State: Zip:
Telephone Number:
3. Corporation
Legal name of corporation: C1CAt �1� U��l7tTl1C�
Date and state of incorporation:
2
For all municipal business license questions, contact: City of South Bend • Department of community Investment
227 West Jefferson Blvd • Suite 14005 -South Bend, Indiana 46601 • 574.235.5912 • f: 574.235.9021
LICENSE APPLICATION FOR - PUBLIC LARKING FACILITY
MUNICIPAL CODE SECTION - 4-39
IV. OWNERSHIP (Continued)
A. Type of ownership (continued):
3. Corporation (continued)
Resident Agent:
NamE
Title:
Busi
City:
Officers:
NamE
Title:
Business Address:
City:
Residential Address:
City:
!Name #2:
Title:
Business Address:
City:
Residential Address,
City:
Name ##3:
Title:
Business Address:
City:
Residential Address:
City:
Hess Address:
State: Zip:
V
State: Zip:
State:
State:
State:
State:
State:
Zip:
Zip:
Zip:
Zip:
Zip:
For all municipal business license questions, contact: City of South Bend • Department of Community Investment
227 West Jefferson Blvd • Sulte%400 S -South Bend, Indiana 46601 • 574.235.5912 • F:574.235.9029
LICENSE APPLICATION FOR - PUBLIC PARKING FACILITY
MUNICIPAL CODE SECTION - 4-39
V. INCLUDE COMPLETE RATE AND HOUR SCHEDULE WITH APPLICATION
VI. INCLUDE A CURRENT INSURANCE POLICY OR BOND
VII. INCLUDE $5.00 PROCESSING FEE WITH APPLICATION
VIII. AFFIRMATION
I, hereby, certify and affirm that all of the information I have given in this application is true and
accurate to the hest of my knowledge. I further certify that I have in no way attempted to
mislead the City in this application by omitting facts known to me. I have read and understand
the regulations of the Public Parking Facility license found in the City of South Bend Municipal
Code, Section 4-39.
Ov gnature Date
4
AC[]RL7®
CERTIFICATE OF LIABILITY INSURANCE
DATE (MMIDDIYYYY)
11/22/2017
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 INSUPANCE 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(€es) 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 certiflcate holder in lieu of such endorsements .
PRODUCER
The Horton Group
340 Columbia Place
South Bend IN 46601
CONTACT Michael Turner
PHONE 574 334-550D FAX 574-334 5600
EMAIL . michael.turner@thehortongroup.com
INSURERS AFFORDING COVERAGE
NA€C p
INSURER A: Medical Protective
11843
INSURED BEACHEA-02
INSURER B ;Amer€sure Mutual Insurance Co.
23396
Beacon Health System, Inc.
615 N. Michigan Street
South Bend IN 46601
INSURER c ;
INsuRER D
INSURER E :
INSURER F :
COVERAGES CERTIFICATE NUMBER: 191173248 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,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
LTR
TYPE OF INSURANCE
INSD
WVD
��
POLICY NUMBER
POLICY EFF
MMIDD/YYYY
POLICY EXP
MIDD YY
' LIMITS
A
X
COMMERCIAL GENERAL LIABILITY
H002223
12/1/2017
12/1/2018
EACH OCCURRENCE
$1,000,000
CLAIMS•MADE ❑X OCCUR
PREMISES QEa occu ence
$50,000
MED EXP (Any one person)
$5,000
PERSONAL&AOVINJURY
$1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE
$3,000,000
X POLICY ❑ PRO -
POLICY 1-1LOG
PRODUCTS -COMPIOPAGO-
$3.000,000
..
$
OTHER:
B
AUTOMOBILE
LIABILITY
CA13212592102
811312017
81131201a
Ea aBGde%l INGLIE LIMIT
$1,000,000
BODILY INJURY (Per person)
$
AUTO
OWNED SCHEDULED
AUTOS ONLY AUTOS
BODILYINJURY (Per accident)
$
X
HIRED NON -OWNED
AUTOS ONLY
AUTOS ONLY 1xx
PROPERTY DAMAGE
Per acciden
$
$
XIANY
Comp: $250 Call: $500
A
X
UMBRELLA LIAR
OCCUR
E002223
1211/2017
12/1/2018
EACH OCCURRENCE
$25,000,000
AGGREGATE - -
$25,000,000
EXCESS LIAR
X
CLAIMS -MADE
DED X I RETENTION$25,000.
$
WORKERS COMPENSATION
AND EMPLOYERS'LIABILITY YIN
PER U E ER
STAANY
E.L. EACH ACCIDENT
$
PROPRIPTORIPARTNERIEXI=CUTIVE
OFFICERIMEMBER EXCLUDED? ❑
N 1 A
E.L. DISEASE- EA EMPLOYEE
$
(Mandatary In NH)
Ir yyas, describe under
DESCRIPTION OF OPERATIONS balow
I
I
E.L. DISEASE- POLICY LIMIT
$
B
Garagekeepers
CA20983310102
8/13/2017
8M312018
Physical Damage 500,000
Call Ded; 250
Camp Ded: 250/1,000
DESCRIPTION OF OPERATIONS! LOCATIONS I VEHICLES (ACORD 1101, Additional Remarks Schedule, may be attached if more spaue Is required)
Annual Parking Garage License: CMS, Bartlett and Navarro Garages, FAX: 235-9021 Michelle Adams
CERTIFICATE HOLDER 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 Blvd.
ACCORDANCE WITH THE POLICY PROVISIONS.
Suite 1400 South
South Bend IN 46601
AUTHORIZED REPRESENTATIVE
Oc 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD
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INTER -OFFICE MEMORANDUM
BOARD OF PUBLIC WORKS
M DATE SENT: 2/15/2018
TO: /''Tom Anderson, Code Enforcement
derico Rodriguez, Fire Department
--'Watt Longfellow, Engineering
/'CChris Dressel, Community Investment
Larry Magliozzi, Area Plan
Angela Smith, Area Plan
FROM: Linda M. Martin, Clem'
License Application for Public Parking Facility- Beacon
SUBJECT: Health Systemslt4emor[al Hospital Parking Garage -
Centennial Garage- Renewal
LOCATION: 621 Memorial Dr.
DATE DUE: February 20, 2018
FAX OR E-MAIL TO:
235-9171 1 [martin@southbendin.gov
RECOMMENDATIONS AND COMMENTS:
By Date
For all municipal business license questions, contact: City of south Bend -Department of Community Investment
227 West Jefferson Blvd + Suite 14005 -South Bend, Indiana 46601 • 574.2,35.5912 • R 574,235,9021
LICENSE APPLICATION FOR - PUBLIC PARKING FACILITY
MUNICIPAL CODE SECTION 4-39
I. APPLICATION TYPE Check One: New Renewal XXX
II. BUSINESS DATA
A. Business Name: BEACON I IEALTH SYSTEMS f MEMORIAL HOSPITAL PARKING GARAGE ZONED CBD
B. Business Address: 621 MEMORIAL DR.. // CENTENNIAL GARAGE
City:. SOUTH BEND State: IN
C. Mauling Address (If different from above):
City: State:
D, Business Telephone Number: 574-647-7311
E. Business Fax Number: 574-647-7328'
F. E-Mail Address: OAK %etc\ C :vn
Zip:
G. Maximurn Number of Vehicles that can be parked at facility at one time:
H. Total Number of Parking Spaces at facility: <6U7
I. Hours during which vehicles may be stared: 0pe
H. Premises are (check onie): Leased by Applicant Owned by Applicant
If Leased:
Owner's Namej�mcwla
Owner's Business Address: Mi c hj(2(2gL� f)"
City: 1 V State: )1\1 Zip: �L%c'
Owner's Residential Address:
City: State:: Zip:
J. Insurance Carrier and Amount of Liability Insurance OR Banding Agent and Amount of Bond:
For Office Use Only
Application Piled FEB1 12018 Public Works Approval
Application Fee Paid FEB1 3 2018 License Fee Paid
Sent to Dept. �.]�� LicenseNumber I
of pt;1 IT4
Not Approved
Reason
11
For all municipal business license questions, contact; City of South Bend • Department of Community Investment
277 West Jefferson Blvd - Suite 1400 S -South Send, Indiana 46601 • 574.235.5912 • F: 574,235,9021
LICENSE APPLICATION FOR - PUBLIC PARKING FACILITY
MUNICIPAL CODE SECTION 4-39
Ill. PERSONAL DATA
A. Applicant's Legal Name:
B. Residential Address:
City:
C. Residential Telephone Number:
D. Residential Fax Number:
E. Celephone Number:
F. Position with Business:
State: Zip:
IV. OWNERSHIP
A. Type of ownership (check one):
Sole Proprietorship (If sole proprietorship, proceed to 1).
Partnership (If partnership, proceed to 2).
Corporation (If corporation, proceed to 3).
1. Sole proprietor
Name:
Residential Address:
City:
Telephone Number;
2. Partnership (List at least two (2) partners)
Name #1:
Residential Address:
City:
Telephone Number:
Name #2:
Residential Address:
City:
Telephone Number:,
State: Zip:
State:
Zip:
State: Zip:
3. Corporation 1
Legal name of corporation: I '
Date and state of incorporation:
2
For all municipal business license questions, contact: City of South Bend • department of Community Investment
227 West Jefferson Blvd -Sul te 1400 S -South Bend, Indiana 46601 • 574.235,5912 + F:574.235.9021
LICENSE APPLICATION FOR - PUBLIC PARKING FACILITY
MUNICIPAL CODE SECTION - 4-39
IV. OWNERSHIP (Continued)
A. Type of ownership (continued):
3. Corporation (continued)
Resident Agert-
NamE
Title:
Business Address:
City:
Officers:
N�&�
Title:
Business Address:
City: -
Residential Address:
City:
Name #2:
Title:
Business Address:
Citv:
Residential Address:
City:
Name #3:
Title:
Business Address:
Citv:
Residential Address:
City:
3
State: Zip:
State:
State:
State:
State:
State:
State:
Zip:
Zip:
rz
Zip:
Zip:
Zip:
For all municipal business license gveZons, contact: City of South Bend • Department of Community Investment
227 West Jefferson Blvd • Suite 1400 S •South Bend, Indiana 46601 • 574.235.5912 • F: 574.235.9021
LICENSE APPLICATION FOR - PUBLIC PARKING FACILITY
MUNICIPAL CODE SECTION - 4-39
V. INCLUDE COMPLETE RATE AND HOUR SCHEDULE WITH APPLICATION
VI. INCLUDE A CURRENT INSURANCE POLICY OR BOND
VII. INCLUDE $5.00 PROCESSING FEE WITH APPLICATION
Vill. AFFIRMATION
I, hereby, certify and affirm that all of the information I have given in this application is true and
accurate to the best of my knowledge. I further certify that I have in no way attempted to
mislead the City in this application by omitting facts known to me. I have read and understand
the regulations of the Public Parking Facility license found in the City of South Bend Municipal
Code, Section 4-39.
Si nature Date
4
Accw?& CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDAY"
1111%� 11/22/2017
THIS CERTIFICATE 1S 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 1NSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) 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 endorsements .
PRODUCER
The Horton Group
340 Columbia Place
South Bend IN 46601
ACT
NAOM15:Michael Turner
PHONE 574-334-5500 FAX . 574-334-5600
EMAIL mlchael.turner@thehartongmup.com
INSURERS AFFORDING COVERAGE
NAIC !E
INSURER A: Medical Protective
11843
INSURED BEACHEA-02
INSURERB:Amerisure Mutual Insurance Co.
23396
Beacon Health System, Inc,
615 N. Michigan Street
South Bend IN 46601
INSURER C
INSURER D :
INSURER E :
INSURER F :
C OVFRAGFR rPIPTIPIr'.AT;:IJIIMRFR• 191173248 hilt"011=0.
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.
LTR
TYPE OF INSURANCE
INSO
UUBRINSR
WVD
POLICY NUMBER
POLICY EFF
MMIDDIYYYY
POLICY EXP
MMIDDIYYYY
LIMITS
A
X
COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE ❑X OCCUR
H002223
12/1/2017
12/1/2018
EACH OCCURRENCE
$1,000,000
DAMAGE TO RE
PREMISES Ea occurrence
$50,000
MED EXP_(Any one erson)
$5,000
PERSONAL & ADV INJURY
$1,000,000
GEN'LAGGREGATE
X
LIMIT APPLIES PER:
POLICY ❑ jR 0 LOC
GENERAL AGGREGATE
$3,000,000
PRODUCTS - COMP/OP AGO
$3.000,000
$
OTHER:
B
AUTOMOBILE
LIABILITY
CA13212592102
8/1312017
8/13/2018
COUEa 91NED MRCtE LIMIT
$1,000,000
X
BODILY INJURY (Per person)
$
ANY AUTO
OWNED SCHEDULED
AUTOS ONLY AUTOS
AUTOS ONLY %� AUT08 ONLY
BODILY INJURY Per accldont
( }
$
X
PROPERTY DAMAGE
Per accident
$
X
$
Comp: $250 X Coll: $500
A
X
UMBRELLA LIAB
OCCUR
E002223
12/1/2017
12/1/2018
EACH OCCURRENCE
$25,000,000
AGGREGATE
$25,000.000
EXCESS LIAR X
CLAIMS -MADE
DED X 1. RETENTION$25,000
$
WORKERS COMPENSATION
ANY EMPLOYI=RS' LIABILITY Y 1 N
ANY PROPRIETOWPARTNERIEXECUTIVE ❑
OFF€CERIMEMBER EXCLUOED7
(Mandatary In NH)
If yes, descdbe under
DESCRIPTION OF OPERATIONS below
NIA
PERTUTE ER
STA
—
E,L, EACH ACCIDENT
$
E.L. DISEASE - EA EMPLOYE
$
E.L. DISEASE - POLICY LIMIT
$
B
Garagekeepers
CA20983310102
8/13/2017
r1312018
Physical Damage 500,000
Coll o'd: 250
Comp Ded: 25011,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD iU1, Additional Remarks Scheduta, maybe attached it more space Is required)
Annual Parking Garage License: CMS, Bartlett and Navarre Garages. FAX: 235-9021 Michelle Adams
City of South Bend
227 W. Jefferson Blvd.
Suite 1400 South
South Bend IN 46601
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
01988.2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
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