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HomeMy WebLinkAboutNon Res Block Party - Murray Miller - Back to School Rally1316 COUNTY-Cri,y BUHMING 227 W. JrTFERSON BOULEVARD Sou'rit BEND. INDIANA 46601-1830 CITY OF SOUTH BEND PETE BuTTIGIEG, MAYOR BOARD OF PUBLIC WORKS July 24, 2018 Murray Miller Greater St. John Missionary Baptist Church 101 N. Adams St. South Bend, IN 46628 RE: Event Name: Back to School Rally Street Closure: Adams St. from Orange St. to Liston St. Date: August 11, 2018 Dear Mr. Miller: PHONt-, 574/235-9251 FAX 574/ 235-9171 The Board of Public Works, at its meeting held on July 24, 2018, approved the closure of Adams Street, as approved in previous years, in place of Orange Street, for your event scheduled for August 11, 2018 from 8:00 a.m. until 2:30 p.m. Please note the Board stated there should be no closure or restrictions on Orange St. The Police, Fire, and Traffic and Lighting Departments requested Orange Street not be closed as it is used as a major emergency vehicle route. For your information, the South Bend Police Department will monitor this event. Enclosed please find a copy of your approved permit. 'rhe 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 curb 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 S,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- 9251. Sincerely, Linda M. Martin, Clerk Enclosure GARY A. Gii,o'r SOZANNA M. FRITZBER(., EuZABET[i A. MARADIK JAMEs A. MUELLIER 71ir,,REM J. DORAU APPLICATION FOR USE OF, AND BLOCKING OF ACCESS _E PUBLIC 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. J El Fee Paid Applicant Name: FITARM 0 z"k 'I I -3� soe'3' Address: 0. 13 City: /3e,4,>/)State: zip: Phone: i i / X 6 i 9) e,,,,, 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 Dweh- 76--7 Sc) 0c, Location 2&,4 leCA-) (Describe Area/Route) Street Closure Name of Street From ealle * e To Aied&'e Date of Event &: �g! t.� g 7 1/ 20 I v , F-1 a.m. Time: Registration/Setup t,,00 E-1 p.m. Start f.Mej Elp.m. End 0,z:jo R—p.m. Approximate Number of Attendees 26-e> 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 R Yes El No 2. Required Information to Accompany Application a. Cettified Check or Money Order in the Amount of $125.00, or: b. For Certified Nonprofit Organizations: Copies of the 5 01 (c)(3) Internal Revenue E3 emption 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, 4"' Floor, County - City Building, 227 W. Jefferson Blvd., South Bend, Indiana, c. Certificate of Insurance d. Maps, drawings and setup plan of the area Yes No e. A copy of a flyer or door hanger that has been distributed to all Yes No affected property owners. 3. a. This event involves City streets Yes F-11 No b. This event involves County roads El Yes R No c. This event involves State highways El Yes No Updated 8/2017 1 d. This event involves the use of the sidewalk e. This event is a local/regional/national event (Please circle the appropriate event type) f. 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). 1� Yes ❑ No Yes ❑ No Yes ❑ No El Yes i�+— No [�— Yes ❑ No IF ALCOHOL IS TO BE SERVED OR SOLD Alcoholic beverages will be served ❑ Alcoholic beverages will be sold ❑ 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 ❑ • 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: ❑ • 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. City of South Bend, Indiana * By of Public Works The Non-residential Block Party will be permitted to take place under the following terms and conditions: 1. Pursuant to Local Ordinance No. 10224-13, there is a $125.00 non-refundable 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 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 c�,�Q 20 APPLICANT Signature i6p� Printed Name BOARD OF PUBLIC WORKS APPROVAL 0�, An UA= — ""A — PresideAC Member embe v 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 7 Date 612612Q18, Gaggle Maps gle Maps ar t""In" Aw h"n"O A10 a Y A- yk IQ 0 A'O (Wd, i, Na, L �nd A- k d,id A-, I nndc'n G1101 Gru(and ("J" k,,flkm 9� �K, G F, ,P 4) SI flmp S� Go; � ,O Adh, 'I w com, Au, Map data (02018 GoogW 100 ft https://www,google.com/mapst@41,6789199,-86.2748166,1 8z ill 'iCesORUi CERTIFICATE OF LIABILITY INSURANCE DATE(MWDDIYYYY) --� 06/19/2018 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 INSURERIS), 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 WANED, 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 CONTACT Dab Childs NAME: Sta—feFarM Deb Childs Agency PHONE IAIC. No. Evil: 574-255-3000 F,uc No): 574-958 1780 16845 Douglas Rd AE ILE 5: deb 4QdebChildS.CQm INSURE S AFFORDING COVERAGE NA1Cp Mishawaka, IN 46545 INSURER A,. State Farm Fire and Casualty Company 25143 INSURED tNSURHR 8 INDIANA BLACK EXPO INSURER C : SOUTH BEND CHAPTER INSURER D PO BOX 335 INSURER E SOUTH BEND IN 46624-0335 INSURERF, COVERAGES CERTIFICATE MIIINRFR- PW%/IQlnu ul 1"Mr-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. INSR L TYPE OF INSURANCE ADDL S SR POLICY EFF POLCYNUMSER MMIDDIYYYY POLICY E0 MMIDDIYY LIMITS COMMERCIAL GENERAL LIABILITY CLACMS-0i1AOE ® OCCUR i 34-GL-2442-1 I 05/2512016 061251201$ (EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTE PREMISES Ea occurrence _ , S 300,000 MED EXP (Any ono person) $ 5,0()0 �OF'LAG GREGATELIMIT APPLIES PER' s POLICY ❑ JJEC El LOG I OTHER: PERSONAL& ADV INJURY $ 1,000,000 GENERAL AGGREGATE s 3,000,000 PRODUCTS -COMPIOPAGG $ 1,000,000 $ AUTOMOBILE LIABILITY ANY AUTO OWNEAUTOS SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY COMBINEO SINGLE LIMIT Ea acciden! s BODILY INJURY (Per ptr=A) s BODILY INJURY Per accident ( ) s PROPERTY DAMAGE I P r accldant $ S UMBRELLA LIAR OCCUR EXCESS LIAR CLAIMS -MADE i EACH OCCURfENCE AGGREGATE j $ $ DED RETENTION $ S WORKERS COMPENSATION AND EMPLOYERS. UABILITY YIN ANY PROPRIETORMARTNERIEXECUTIVE OFFICERIMEMBER EXCLUDED? Li ,(Mandatory in NH) 11 yes, describe Under DESCRIPTION OF OPERATIONS below NIA PER 0714 STATuTE.1 I.ER E.L. EACH ACCIDENT $ E.L, DISEASE -EA EMPLOYE ---•— $ E.L. DISEASE -POLICY LIMIT $ i I I l DESCRIPTION OF OPERATIONS I LOCATIONS / V9HICLE5 (ACORD 191, Additional Remarks Schedule, maybe attached temom apace Is required) not for profit community service organization CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN CITY OF SOUTH BEND ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZE"— EP NTATIVE 4�1 X ©1988-201 CORD CORPORATION. All rights reserved. ACORD 26 (2016103) The ACORD name and logo are registered marks o ORD 100MG6 132849,12 03-16-2016 nr ti YYf IS WIMPV J� gnu t,AJ fD 0 Z plYdh Mal mmmm 0 m m m CL CL 0 4% 0 X m IQpWII 5E I I IS, 00STMI'N 0 in LA 0 90 c Z co m is (D (D r) 0 C. rb 21 0 2L m oj G) 0 0 W� iu W Ep SO rD co (D illl LA (D LA 0 ca sn C) Fortnt ST 105 Indiana Department of Revenue State Fom 49065 11418.05 General Sales 'nx Exetapiion Certificate Indiana registered retail merchants and businesses Iocated outside Indiana may use this certificate, The claimed exemption must be allowed by Indiana code. Exemption Statutes of other states are not valid for purchases from Indiana vendors. This exemption certificate can not be issued for the purchase of Utilities. Pe t, W t teat t, orAli-craft, Purchaser must he registered with (lie Department of Revenue or the appropriate taxing authority of the purchaser's state of residence. Sales tax must be charged unlessall information in each section is fully completed by the purchaser. Purchasers not able to provide all required information trust pay the, tax and may file a claim for refund (.Form OA-1 I0L) directly with the Department of Revenue. Name of Purchaser Greater St. John Missionary Baptist Church Business Address 101 N. Adams St. city South Bend State in Zip 46628 0 r. Purchaser must provide minimum of one ID number below.31 .M 04 Provide your Indiana Registered Retail Merchant's Certificate 0001947850 000 A TfD and LOC Number as shown on your Certificate ..... .......................... ._-__—. _.. T TID11(10 digits) LOC# { 3 digits) if not registered with the Indiana DOR, provide your State Tax Go IDNumber from another State................................................................ ,See instructions on the reverse side if you do not have either number. State JD# State of Issue N o Is this a ® blanket purchase exemption request or a 13single purchase exemption request? (check one) tf#. Description of items to be purchased. Purchaser must indicate the type of exemption being claimed for this purchase. (check one or explain) Sales to it retailer, wholesaler, or manufacturer for resole only. E3 Sale of manufacturing machinery, tools, and equipment to be used directly in direct production. ® Sales to nonprofit organizations claiming exemption pursuant to Sales Tax Information Bulletin 410. (May not be used for personal hotel rooms and meals.) C3 Sales'of tangible personal property predomlnately used (greater then 50 percent) in providing public transportation - provide USDOT#. M A person or corporation who is hauling under someone else's motor carrier authority, or has a contract as a school bus operator, trust provide their SS# or FiD# in lieu of a State ID# in Section M. USDOT# r43 M Sales to persons, occupationally engaged as farmers, to be used directly in production of agricultural products for sale. Notes A fanner not possessing a State Business License# may enter a FID# or a SS# in lieu of a State ID# in Section # 1. 0 Sales to it contractor for exempt projects (such as public schools, government, or nonprofits). ® Sales to Indiana Goverrttilental Units (agencies, cities, towns,, municipalities, public schools, and state universities). ® Sales to tite United States %ederal Governmeut - show agency name. Note: A U.S. Government agency should enter its Federal Identification Number (FID#) in Section # 1 in lieu of a State ID#. 2) other- explain. Use by Non -Profit I hereby certify under the penalties of perjury that the property purchased by the use of this exemption certificate is to be used for an exempt purpose pursuant to the State Gross Retail Sales Tax Act, Indiana Code 6-2.5, and the item purchased is not a utility, vehicle, watercraft, or aircraft. VI confirm my understanding that misuse, (ehherneglibyeul or intentional), and/or fraudulent use of this certificate may subject both me personally and/or the business entity I represent to the 1111position of tax, interest, and civil and/or criminal penalties. cri Signature orPurebaser /.4 -LA Yf<` Date f Printed Name Kertnsth Byrd Sr. Title Treasurer I lie Indiana Department of Revenue may request verification of registration in another state if you are an out-of-state purchaser. Seller luust keep this certificate on file to support exempt safes.