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Home My WebLink AboutNon Res Block Party - Sunnyside Presbyterian Church1316 COUNTY-0"j"y BUILDING 227 W. JEFFERSON BOULEVARD SOUTH BEND. NDIANA 46601-1830 CITY Or SOUW BEND PETE BUFTIGIEG, MAYOR BOARD OF PUBLIC WORKS June 12, 2018 Pastor Taylor Hall Surmyside Presbyterian Church 115 S. Frances Street South Bend, IN 46617 RE: Event Name: All Church Picnic Street Closure: S. Frances St. from Washington St. to Jefferson Blvd. Date: June 17, 2018 Dear Pastor Hall: PHONE 574/235-9251 FAX 574/ 235-9171 The Board of Public Works, at its meeting held on June 12, 2018, approved your request to close the above referenced street for your event scheduled for June 17, 2018 from 8:00 a.m. to 2:00 p.m. For your information, the South Bend Police Department will monitor this event. Enclosed please find a copy of your approved permit. The Bureau of Traffic and Lighting will deliver barricades necessary to close the street to the applicant's address. You will be responsible for their placement and removal at the conclusion of the closing of various streets. Please note that a ten foot (10') clear and unobstructed lane must be maintained at either curl) or down the center of the street for emergency purposes and that no fires are allowed in the street. The Applicant will be liable for the replacement cost of $50.00 per cone as a result of any missing or damaged cones. If you have any further questions regarding this matter, please call this office at (574) 235-925 1, Sincerely, Linda M. Martin, Clerk Enclosure c: Gene Eyster, Police Department Ed Gleckler, Traffic & Lighting GARY A. Gii,o,r SUZANNA M. FRrrZBER(, EuZABETH A. MARADIK JAMES A. MUELLER THERESE J. DORAU 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 INCLUDED WITH APPLICATION. //�� ee Paid .. Applicant Name: Sunnw-Jf �re5 �-� 64t,, J Address: 1 S t o �� City: �t41..... State; r�jj% Zip: eK Phone: (7N 1 7.87-1 SZ4 Email: 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 411 C.,tn �. Location 1 �� r' s .-c.k i Street Closure Name of Street S G I&YN(ks S� From To Date of Event —Ta,Rp 17 20 Pg-'a.m, Time: Registration/Setup c ❑ p,m, Approximate Number of Attendees Ma.m. Start q ❑ p.m. End Answer the following appropriately: 1. This event will have music (live or other). a. I understand the Noise Ordinance described in the Agreement/Permit 2. Required Information to Accompany Application a. Certified Check or Money Order in the Amount of $125.00, or: fiv 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 additionally filed with the Office of the City Clerk, 4`i' Floor, County - City Building, 227 W. Jefferson Blvd., South Bend, Indiana. Certificate of Insurance -- 6-v S `n.o,,*(d "% 11Q- �-► �• l � d. Maps, drawings and setup plan of the area e. A copy of a flyer or door hanger that has been distributed to all affected property owners. a, �u.�� ,'s �� ohl� b,; IA- 3 a. This event involves City streets b. This event involves County roads c. This event involves State highways o.• too B�oGI; er "� on Z ❑ a.m. �' p.m. Yes No Yes ❑ No [� Yes ❑ ❑ �, Yes ❑ Yes ❑ Yes ❑ Yes []� Yes No No No No No Updated 8/2017 d. This event involves the use of the sidewalk e. This event is lot /regional/national event (Please circle the appropriate event type) £ Affected property/business owners have been notified of this event. g. There is/are resident(s) affected by the event that may need ADA transportation assistance to their residence. h. 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 No Z Yes ❑ No [a Yes ❑ No ❑ Yes 2"� No Ef Yes ❑ No IF ALCOHOL IS TO BE SERVED OR SOLD/ V o ! Alcoholic beverages will be served ❑ Alcoholic beverages will be sold ❑ Certified Che or Money Order for $400.00 must be submitted with application. • Application not be processed without deposit. • Deposit will be re . ed upon inspection of event area by the Board of Public S. Names and phone numbers o REE security guards • To monitor underage drinking. • Qualifications must be listed (e.g. -duty police o r, professional security guard, or event APPLICANT), A drawing must be submitted showing: • Fencing around serving area • Trash receptacles. o Ample receptacles must be provided to ensure pr er disposal of refuse. Temporary liquo , 'tense. • Call the Alcohol & Tobacco Commission at (317) 234-4315 for more information. • Application cannot be processed without a copy of this license. CVIUf (' ` 1 � ti c-e— S �11 0 ��Cl � s�nrl Sae C`reS�j��,,I�GN 7 a X application only. Event end times are pursuant to the recommendations of the South Bend Police Department. 13. 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. 14. 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 day of 20 APPLICANT Signaturef Printed Name a� BOARD OF PUBLIC WORIK-S APPROVAL 4��A� ^ "e Presidenr Member Member Member Member RETURN FORM TO: Board of Public Works 1316 County -City Building 227 West Jefferson Boulevard South Bend, IN 46601 Phone: (574) 235-9251 Date 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 tape place under the following terms and conditions: 1. Pursuant to Local Ordinance No. 10224-13, there is a $125.00 non-refiindable 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. All residents and businesses within the affected area must be notified of this event. The APPLICANT must obtain signatures from and/or has made an attempt to notify all residents that reside on the block. A copy of a brochure or door hanger distributed to all affected residents/businesses describing the event purpose, date, and time must be included with the application. 4. The applicant is responsible, prior to the event, for determining if there are any residents or business owners affected that could potentially need assistance in accessing their property. The applicant is responsible for providing said resident/business owner transportation to their property. 5. The APPLICANT shall reimburse the Board for the actual cost to the City for the event, if deemed necessary. 6. APPLICANT shall include a flyer or letter describing the details of the event. 7. Notification of approval/denial of this request will be issued by return of this form, upon signed authorization by the Board of Public Works. 8. 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 $5,000,000.00 aggregate and the City of South Bend listed as an additional named insured for this event. 9. The APPLICANT assumes full responsibility for providing ample disposal containers for refuse/recycling and assures the area will be cleaned up upon the conclusion of the event. 10. Barricades will be delivered and picked up at the event location. The APPLICANT is responsible for seeing that all cones are maintained and returned undamaged. 11. The APPLICANT will follow the City of South Bend Noise Ordinance, which is in effect at all hours. Between the hours of 11:00 p.m. and 7:00 a.m. certain noises are particularly prohibited. These include operating radio receiving sets, musical instruments, phonographs and other sound reproduction devices if audible fifty (50) feet away, as well as shouting, yelling, hooting, whistling, or singing in the streets in a manner to disturb the peace (Municipal Code 13-57). 12. The APPLICANT assures the City that the area will be closed during the times indicated on the 3 Form' NP�l S W& Foie 5 1065 W'6`3) . ludiang D . cpartinent of Revenue Iudian'q GpVuhihotif Center IN-orih in&napolii, Indiana 46204 IndWha Nojiroflt Saks Tax Exemption C.6i-Meate (ill's vdrtffiqato may not . be used to collect sales tax) DateIssued Txpayer IdentHication A 061 09/2003 0001951 .6,83 OQO 0 030001910426 1111.11. 110.111.1.1 Hill M IN 111, 10.11111 1111111111HIM an Ifulmil 1111111 SUNNYSIDE PR.E$BYTERLAN CHURCH CORPORATION 1.15 9 FRAN-CIS ST , SOU MBEND 17, iN 4660-3195 Organization is only exempt f . r6m 0ymqqt of gales -tax on purchases for which thd'org-quization is granted exemption. . ........... 7" Fo.riri N?—1 State Form 510,65 (4-013) Indiana Departaienf of Rovqi'pe Indiana Govemment Cente#LN-brth indianapoLis, Indiana 46264 Indiana Nmptofit Sales Tax t1eniption Certfflcgits ('.his cerO.qato 14aynot, be used to collect sales tax) DatejsOed Taxpayer Itieui3fication 0610912003 000195.16.83 0.00 0 03006191 i 742rl 111111 11H Mi Hill EM 111 lull 111 111111111111 Bull I Dt PPh,9 Bti E-Rilm- CHURCH CORPORATION 115.S FUNCI.S.ST SQ=.BAND 1.7; 19 46617-3195 Organization is only exbinptfrom payment o?sales . tax onpurchases for whidh Vie orgaruzatio-n is gtantedoxoaOOon. A4CR" CERTIFICATE OF LIABILITY INSURANCE DATE(MMfDDlYYYY) 0511712018 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 CONTACT Susan Thompson NAME: Laven Insurance Agency Inc. A1�NNo Ext : {574) 291 5510 arc No : {574) 291-8505 EMAIL suet@laveninsurance.com ADDRESS: P. O. Box 2379 INSURERS) AFFORDING COVERAGE NAIC N INSURERA: Liberty Mutual SOUTH BEND IN 46680 INSURED INSURER B : INSURER C : Sunnyside Presbyterian Church Corp. INSURER D : 115 N. Frances Street INSURER E : INSURER F : South Bend IN 46617 COVERAGES CERTIFICATE NUMBER: 18-19 Master REVISION NUMBER: THIS IS TO CERTIFYTHATTHE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEDABOVE 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. IOLICY TIR TYPE OF INSURANCE INSD WVD POLICY NUMBER MMIDDNYYY EXP € €MIDDIYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE x OCCUR BKS58277002 01/01/2018 01/01/2019 EACH OCCURRENCE $ 1,000,000 DA T R o PR MISES Ea occurrence $ 1,000,000 MED EXP (Any one person) $ 10,000 PERSONAL& ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMITAPPOES PFR: JECT %� POLICY ❑ PRO LOC OTHER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS -COMPIOPAGG $ 2,000,000 $ A AUTOMOBILE LIABILITY ANYAUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED HNON-OWNED AUTOS ONLY AUTOS ONLY BAS58277002 01/01/2018 01/01/2019 COMBINEDSINGLE LIMIT Ea accident $ 1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ $ A X UMBRELLA LIAB EXCESS LIAR ITILAIMS CCUR -MADE US058277002 01/01/2018 01101l2019 EACH OCCURRENCE $ 2,000,000 AGGREGATE $ 2,000,000 DED I X1 RETENTION $ 0 $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNERIEXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA XWS58277002 01/01/2018 01l01l2019 SPER X1 TATUTE 6RH E.L. EACH ACCIDENT 500,000 $ E.L. DISEASE - EA EMPLOYEE $ 500,000 E.L. DISEASE - POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached If more space Is required) r:FRTIFlr`ATF I-InI r11-P CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of South BendlPubIic Works ACCORDANCE WITH THE POLICY PROVISIONS. 227 W. Jefferson Blvd. AUTHORIZED REPRESENTATIVE South Bend IN 46601{ @ 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD o June 17tl ■