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APPLICATION FOR USE OF v
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The following special events have been approved by the Special Events Committee. 1865
Submitted by: Denise Miller
Event name: Bacon Around the Bend 5K
Event Date: 6/19/21
Street Closure: South on Niles to Madison, West on Madison to the East Race Bank Trail,
North on the East Race Bank crossing Howard onto the foot bridge to
Pokagon Street, West on Pokagon to Hillcrest, South on Hillcrest to
Parkovash, West on Parkovash to Lafayette, South on Lafayette to Tonti,
East on Tonti to Hillcrest, North on Hillcrest to Pokagon and back down
the foot bridge to the East Race Bank Trail, East on East Race Bank Trail
South of Niles Ave, Dog Park to Niles Ave, South on Niles to Corby's Irish
Pub.
Closure Times: 8:00 am to 11:00 am
Sidewalk Closure: ❑ Yes ❑ No
Comments: Annual event to benefit the Family Justice Center. Fun walk/run that starts
at the FJC and ends at Corby's Irish Pub.
CITY OF SOUTH BEND, INDIANA
BOARD OF PUBLIC WORKS
Elizabeth A. Maradik, President
Gary A. Gilot, Member
Joseph R. Molnar, Member
Jordan V. Gathers, Member
Murray L. Miller, Member
Attest: Anne Fuchs, Clerk
45-rra City of South Bend Special Event Application
City and Regional Event
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$50 application fee if filed 60 days or greater (up to 360 days) in advance of event
$100 expedited application fee if filed 30-59 days in advance of event
Review the Instructions on the Special Events page before completing the application. City and Regional Special
Event applications must be submitted more than 30 days in advance of the event date or the application will not
be accepted.
Date of Application: 4/13/21
Section A - Applicant Information
Organization Name. -Family -Justice Justice Center
Applicant (Contact) Name:Amy Stewart-Brown
317-690-8840 astewartbrown fcs c.or
Applicant (Contact) Phone: _________ Contact Email: @ � 1 g__
Address: 533 N Niles - Ave _ city/State/zIP: South Bend, IN 46617
List any professional event organizer, event service provider or commercial fundraiser that is authorized to work
on your behalf to plan, produce and/or manage your event.
Organization Name: _---------- Contact Name:
Contact Phone: Contact Email: _
Address: --------- City/State/ZIP: __--_______
Section B - Event Information
Bacon Around the Bend 5K Race
Event Name :—----------------------- ____ Event Type: (Festival, Race, Parade, Other):________
Event Classification: 0 Non -Profit' ❑ For -Profit
❑ City (Civic) Sponsored ❑ Other (If Other, please describe): --------------------- ...__-__-____ .
'The Special Events Committee may request proof of non-profit status.
Provide a brief description and timeline of event (Note: A detailed map plan is required in Section H of this
application. The description should be a summary overview.)
This will be the 4th annual Bacon Around the Bend 5K to benefit the Family Justice Center.
This is a fun run/walk that starts at the FJC and ends at Corby's Irish Pub.
Date of Event Setup [mm/dd/yy]: 06/19/21
Begin Date of Event [mm/dd/yy]: 06/19/21
End Date of Event [mm/dd/yy]: 06/19/21
Event Cleanup Completion [mm/dd/yy]: 06/19/21
Total anticipated attendance: 250
Time: 6AM
Time: 8AM
Time: 11 AM
Time: 12PM
The proposed event will require the closing of: ❑ Streets ❑ Sidewalks
Is the event ticketed or include fees? ® Yes ❑ No If yes, list fees and fee groups below:
Adult $35
Under 21 $25
Kids $10
Does the event have any partnered sponsorships? n■ Yes ❑ No
If yes, list the number of sponsors at each level of partnered sponsorship:
:f
Is this a returning special event or part of a series of special events? ❑ Yes ® No
If yes, provide the date, location, and attendance of past special events and/or future planned events in the
series:
If your event is a parade, race, or other processional -type event, please complete Section C. Otherwise,
continue to Section D.
Section C - Parades Races and other Processional Events
What is the estimated number of parade/race spectators on the proposed route? 25 volunteers for race support
Describe any sound equipment that will be used in the parade/race:
Music will be played at the finish line near Corby's Irish Pub.
Does the event have participant categories? For example, a run that has different race divisions or a parade with
separate walking/marching groups.
❑ Yes H No
If yes, list categories and anticipated participants per category.
If your event is a parade, what is the approximate number and type(s) of animals, vehicles, and floats participating
in the parade? (Note: If using animals in a parade, event organizers are responsible for cleaning up animal waste
left on the parade route.) Describe parade participants below:
Section D - Equipment, Set-up, and Lv istics
Are you hiring a company to provide entertainment, games or inflatables? ❑ Yes ® No
o If yes, you must submit proof of insurance for all stage and entertainment companies three (3) weeks
before the event.
Describe any hired entertainment:
Will you be staking any tents, inflatables, portable restrooms or any other anchorings? ❑ Yes ® No
o If yes, you must provide proof of locates (locate number) two (2) weeks prior to your event. Locates can
be found by calling 811.
Does your event include the use of fireworks, rockets, lasers, or other pyrotechnics? ❑ Yes 007 No
o Depending on the potential fire risk, applicants may need to receive approval of the South Bend Fire
Department (process facilitated by event coordinator).
o Describe the event's proposed fire -related entertainment:
Will there be any musical entertainment features at the event? ❑ Yes ® No
o If yes, describe the type of music, schedule of sound check/performances, and the names of any artists
performing:
Section E - Food
Are you having food at your event (food vendors, caterers, food trucks, etc.)? ® Yes ❑ No
o If yes, the event coordinator must apply for and receive a St Joseph County Health Department
Temporary Event Permit.
o Vendor(s) must also apply for and receive a St. Joseph County Health permit. Health Permits must be
filed with the county 30 days prior to the proposed event. Each vendor must obtain necessary permits to
serve on-site and display these permits at the event.
o All applications and guidelines can be found at the St. Joseph County Health Department Food Service
website: sLchd.org/food-service.
Please select food sales types: ❑ Food Vendor ❑ Caterer ❑ Food Truck ❑ Other:
If a Food Truck, please list company name:
Describe how food will be cooked and served:
Section F - Alcohol
Will alcohol be served or sold? ® Yes ❑ No
If no, please continue to Section G - Contingency and Strategic Planning
If yes:
o The applicant must apply for and receive a temporary liquor license from the Alcohol & Tobacco
Commission. Indiana ATC forms are located at ingov/2tc/2409.htm. (Temporary Permits are near the
bottom of the form list.) Forms must be filed with the district ATC office five (5) days prior to the
requested event date.
o Application cannot be processed without a copy of this license.
o A refundable $400.00 deposit paid by card or check (made to City of South Bend) must be submitted
with application.
o Application cannot be processed without deposit. Deposit will be returned upon inspection of
event area by the Board of Public Works.
Events with have alcohol sales must provide security. If your event will be hiring a security company,
please provide its contact information in sub -section (a) below. Otherwise, please list the names, phone
numbers, and qualifications (e.g. off-duty police officer, professional security guard, or event applicant) of
three (3) security guards in the fields provided in sub -section (b).
(a)
Company Name:______ ________ Contact Name:
Contact Phone: Email:
Address: ------ _----------- City/State/ZIP:
(b)
Name: _ Contact Phone:
Qualifications:__..
Name:
Qualifications:
Name:
Qualifications:
Contact Phonc:
Contact Phone -
Section G - Contingency and Strategic Plannin
For each of the following, please provide detailed descriptions. If you run out of space, attach a response to this
application submission.
• Emergency Safety Plan - This plan should include, but is not limited to:
o The number of Indiana Law Enforcement Academy certified officers, fire, and emergency
medical personnel, and the need to use any of the City's public safety or emergency response
services,
o If hiring a security service, provide contact information and the number of hired event personnel.
o Proposed internal communications systems and public address systems.
We will hire security based on the number of participants registered.
Proposed Cleanup Plan - This plan should include, but is not limited to:
o Measures in place to collect and remove trash, litter and recyclables.
Event will be cancelled if there is extreme inclement weather and we have the ability to
communicate with participants via text and email.
• Inclement Weather Plan - This plan should include, but is not limited to:
o Safety measures that will be taken in the event of a tornado warning, tornado watch,
thunderstorm, and extreme temperatures.
Event will be cancelled if there is extreme inclement weather and we have the ability to
communicate with participants via text and email.
Proposed Lost and Found Plan - This plan should include, but is not limited to:
o A description of the use of signage, announcements on public address systems or pre -event
handouts.
Section H - Site Plan 1 Route Map
For parades, races and other processional events:
Are you selecting one of South Bend Police Department's (SBPD) pre -approved race routes? ❑ Yes ® No
You must select from SBPD's pre -approved race routes (see links on application site) or provide sufficient
evidence of event participation if the applicant is proposing a different route through South Bend.
If your event will not be using a pre -approved race route, the proposed event map should include a route plan
clearly identifying the timing and locations of proposed street closures, and the direction of parade
movement.
If your event will not be using a pre -approved race route, please explain:
Map attached (same route as previous years)
Site Plan / Route Map - For All Events:
Provide an attached map with the geographic locations of all event items listed below,
• Outline of entire event venue including the names of all affected streets and areas.
• Clear markings for street closures and a schedule for each.
• Location of fencing, barriers, and/or barricades. Indicate any removable fencing and exit locations for
emergency purposes.
• Location of all stages, platforms, bleachers, grandstands, tents, booths, cooking areas, vehicles, trailers,
and other temporary structures. Applicants should also clearly mark locations of food and alcohol
serving or sales, if applicable.
• The location(s) and number of all portable toilets and wash stations.
■ The location(s) and number of all trash and recycling containers, including dumpsters.
• The location of generators or any source of electricity.
• Traffic plan and map, including proposed loading/drop off areas, barricades, secured areas, vehicle and
bicycle parking areas, and considerations for TRANSPO bus route changes.
Section I - Miti ag tion. of Impact
If you are using and/or closing public sidewalks or streets, you are required to notify area business owners and
residents. You must:
o Present your event concept to the surrounding stakeholders (residents, businesses, and neighborhood
groups) that represent the venue area.
Attach a copy of the brochure or door hanger distributed to all affected residents/businesses/neighborhood
groups describing the event purpose, date and time.
Section J - Insurance
A Certificate of Insurance (copy) confirming the existence of a liability policy (General Liability and Automobile
Liability) of not less than $700,000 per occurrence and $1,000,000 aggregate, which specifically names the City
of South Bend, IN as an additionally insured for the event must be submitted. Copy of Certificate of Insurance
must be submitted two (2) weeks prior to the date of the event.
Section K - Indemnity & Hold Harmless Agreement
City of South Bend Special Events Committee
Indemnity & Hold Harmless Agreement
Date: 4/13/2021 ______-_____ Event Date: 6_/19/2021
Event Name: Bacon Around the Bend 5K
Organization: Family Justice Center of -St. JosephCounty
Applicant (Contact) Name: Amy Stewart -Brown
Applicant (Contact) Phone: 317-690-8840 (cell)
Email: astewartbrown@fjcsjc.org
Address: 533 N Niles Ave
Event Location (Please describe):
533 N Niles Ave
Length of Event (Dates/Times): 3 hours
Alt. Phone:
City/State/ZIP: South Bend, IN 46617
Insurance Amount: This event is insured for no less than $700,000 per occurrence and $1,000,000 in aggregate,
and the certificate of insurance includes a rider naming City of South Bend, Special Events Committee, and Board
of Public Works as additionally insured for the event.
Family Justice Center of St. Joseph County
Organization Name: Y 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, Indiana, may suffer or incur as a result of any claims
or actions which may be made against the City, its agents, employees, or subdivisions by any person, including a
participant in the activity, arising out of the approval of this request by the Civil City of South Bend, Indiana,
through the Board of Public Works, to close a portion of the public right-of-way for the event described above,
or for any harm or damage alleged to have occurred because of the holding of the special event. The
undersigned certifies that he/she is authorized to bind the APPLICANT to these terms.
April 13, 2021 r
Signed on this Date: A _ p �
rized Organizer Signature
Amy Stewart -Brown, Executive Director
Printed Name and Title
Section L - Permit & Agreement
Pursuant to Local Ordinance No. 10628-18, there is a $50.00 non-refundable fee for Tier II and III event
applications filed 60 or greater days in advance of the event, or a $100 non-refundable expedited fee for
applications filed between 30 and 59 days in advance of the event.
2. The APPLICANT must comply with all terms and conditions of this Permit and Agreement.
3. The APPLICANT must obtain signatures from and/or make 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, time and contact information must be included with the
attachments to this application. The applicant is responsible for providing affected residents and
business owners with transportation to their property.
4. The APPLICANT shall reimburse the Board for the actual cost to the City for the event, if deemed
necessary.
5. Notification of approval/denial of this request will be issued by return of this form, upon signed
authorization by the Special Events Committee.
6. The APPLICANT shall provide to the Board a Certificate of Insurance showing a liability policy in full
force and effect with limits of $700,000.00 per occurrence and $1,000,000.00 aggregate and the City of
South Bend, Special Events Committee, and Board of Public Works listed as an additional named insured
for this event.
7. 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.
8. 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.
9. 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).
10. 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.
I have read the Application and the Permit and Agreement for this Special Event and I affirm the truth of
the information provided by me to the best of my knowledge. I understand and agree to the above rules
and regulations, and any applicable state and federal laws. I also understand that this application may be
denied based on any false or incomplete information.
Date: April 13, 2021
Applicant Signature:
Printed Name: A y t 4a -Brown
SPECIAL EVENTS COMMITTEE APPROVAL
-------- o4AV
President Me ber Mern
Member Member Date
NEW
Renewal of Number
POLICY DECLARATIONS
No. SE 2004000
Mount Vernon Fire Insurance Company
1190 Devon Park Drive, Wayne, Pennsylvania 19087
A Member Company of United States Liability Insurance Group
NAMED INSURED AND ADDRESS:
FAMILY JUSTICE CENTER OF ST. JOSEPH COUNTY
533 N NILES AVE
SOUTH BEND, IN 46617
POLICY PERIOD: (MO. DAY YR.) From: 06/19/2021 To: 06/21/2021 12:01 A.M. STANDARD TIME AT YOUR
MAILING ADDRESS SHOWN ABOVE
FORM OF BUSINESS: Limited Liability Company
BUSINESS DESCRIPTION: Special Event
IN RETURN •- THE PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL THE TERMS OF THIS POLICY, WE AGREE
WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY.
THIS POLICY CONSISTS OF THE FOLLOWING COVERAGE PARTS FOR WHICH A PREMIUM IS INDICATED.
THIS PREMIUM MAY BE SUBJECT TO ADJUSTMENT.
PREMIUM
Commercial Liability Coverage Part $253.00
TOTAL: $253.00
Coverage Form(s) and Endorsement(s) made a part of this policy at time of issue
See Endorsement EOD (1/95)
Agent: GIBSON INSURANCE AGENCY, INC. (SOUTH BEND, IN) (4579) Issued: 04/06/2021 1:13 PM
202 S Michigan Street, Suite 1400
South Bend, IN 46601
By: Authorized Represe ati e
THESE DECLARATIONS TOGETHER WITH THE COMMON POLICY CONDITIONS, COVERAGE PART DECLARATIONS,
UPD (08-07) COVERAGE PART COVERAGE FORM(S) AND FORMS AND ENDORSEMENTS, IF ANY, ISSUED TO FORM A PART THEREOF,
COMPLETE THE ABOVE NUMBERED POLICY.
EXTENSION OF DECLARATIONS
Policy No. SE 2004000
Effective Date: 06/19/2021
12:01 AM STANDARD TIME AT YOUR MAILING ADDRESS
FORMS AND ENDORSEMENTS
The following forms
apply to the
Commercial Liability coverage part
Endt#
Revised
Description of Endorsements
21101N
10/19
Indiana Service of Suit
CG0001
12/07
Commercial General Liability Coverage Form
C00068
05/09
Recording And Distribution Of Material Or Information In Violation Of
Law Exclusion
CG2011
04/13
Additional Insured - Managers or Lessors of Premises
CG2107
05/14
Exclusion - Access Or Disclosure Of Confidential Or Personal
Information And Data -Related Liability - Limited Bodily Injury Exception
Not Included
CG2109
06/15
Exclusion - Unmanned Aircraft
CG2136
03/05
Exclusion - New Entities
CG2139
10/93
Contractual Liability Limitation
CG2144
07/98
Limitation Of Coverage To Designated Premises Or Project
CG2147
12/07
Employment -Related Practices Exclusion
CG2173
01/15
Exclusion Of Certified Acts Of Terrorism
IL0017
11/98
Common Policy Conditions
IL0021
09/08
Nuclear Energy Liability Exclusion Endorsement
IL0272
09/07
Indiana Changes - Cancellation And Nonrenewal
Jacket
07/19
Policy Jacket
L 427
01/20
Exclusion for Fireworks and Other Pyrotechnic Devices
L 535
03/15
Exclusion - Products -Completed Operations Hazard Other Than Food
Or Beverage Products
L-206
02/11
Fully Earned Premium Endorsement
L-224
10/10
Punitive Or Exemplary Damages Exclusion
L-387
03/06
Exclusion - Mechanical Rides
L-423
02/11
Exclusion For Structure Collapse
L-428
04/15
Absolute Firearms Exclusion
L-472
07/08
Exclusion - Injury To Performers Or Entertainers
L-536
09/09
Exclusion - Participation In Athletic Activity, Physical Activity Or Sports
L-599
10/07
Absolute Exclusion For Pollution, Organic Pathogen, Silica, Asbestos
And Lead With A Hostile Fire Exception
L-607
02/11
Exclusion For Climbing, Rebounding And Interactive Games And
Devices
L-609
02/11
Animal Exclusion
L-610
11/04
Expanded Definition Of Bodily Injury
L-656
02/06
Extension Of Coverage - Committee Members
L-686
10/12
Absolute Exclusion for Liquor and Other Related Liability
L-816
11/18
Amendments of Conditions - Limits of Insurance Under Multiple
Coverage Parts
L-820
12/18
Special Events Blanket Additional Insured Endorsement
LLQ 102
02/15
Event Vendor, Exhibitor And Contractor Exclusion
Policy No. SE 2004000
FORMS AND ENDORSEMENTS
LLQ101
08/06
LLQ368
08/10
SPE 300
05/09
SPE 312
03/15
TRIADN
12/20
rnri inr enc%
EXTENSION OF DECLARATIONS
Effective Date: 06/19/2021
12:01 AM STANDARD TIME AT YOUR MAILING ADDRESS
Expanded Definition Of Employee
Separation Of Insureds Clarification Endorsement
Special Events Property Damage Amendment
Who Is An Insured
Disclosure Notice of Terrorism Insurance Coverage
COMMERCIAL GENERAL LIABILITY COVERAGE PART DECLARATIONS
Policy No. SE 2004000 Effective Date: 06/19/2021
12:01 STANDARD TIME
LIMITS OF INSURANCE
Each Occurrence Limit $1,000,000
Personal & Advertising Injury Limit (Any One Person/Organization) $1,000,000
Medical Expense Limit (Any One Person) $1,000
Damages To Premises Rented To You (Any One Premises) $100,000
Products/Completed Operations Aggregate Limit See L-535
General Aggregate Limit $3,000,000
LIABILITY DEDUCTIBLE $0
LOCATIONS OF ALL PREMISES YOU OWN, RENT OR OCCUPY
Location Address Territory
1 533 N Niles Ave, South Bend, IN 46617 004
PREMIUM COMPUTATION
Advance Premium
Evr # Classification Code No. Premium Basis Pr/Co All Other Pr/Co All Other
1 Sporting Event / Tournament - Running Events (5K, 00413 500 Attendees N/A 253.000 N/A
$253
8K, & 1 OK) (applicant is the host of the event)
1 Additional Insured - Blanket - Special Events 49950 1 Per Additional N/A 0 000 N/A
$0
Insured
1 Additional Insured - Property Owner or Lessors of 49950 1 Per Additional N/A 0.000 N/A
$0
Premises Insured
MINIMUM PREMIUM FOR GENERAL LIABILITY COVERAGE PART:
$195
TOTAL PREMIUM FOR GENERAL LIABILITY COVERAGE PART:
$253
(This Premium may be subject to adjustment.) MP - minimum premium
Coverage Form(s)/Part(s) and Endorsement(s) made a part of this policy at time of issue:
See Form EOD (01/95) and Form SOE (03/10)
THESE DECLARATIONS ARE PART OF THE POLICY DECLARATIONS CONTAINING THE NAME OF THE INSURED AND THE POLICY PERIOD.
Includes copyrighted material of ISO Commercial Risk Services, Inc., with its permission.
Starting at Family Justice Center 533 N. Niles Ave,
South on Niles to Madison Street,
West on Madison to the East Race Bank Trail,
North on the East Race Bank crossing Howard onto the foot bridge to Pokagon Street,
West on Pokagon to Hillcrest,
South on Hillcrest to Parkovash,
West on Parkovash to Lafayette,
South on Lafayette to Tonti,
East on Tonti to Hillcrest,
North on Hillcrest to Pokagon and back down the foot bridge to the East Race Bank Trail,
East on East Race Bank Trail South of Niles Ave. dog park to Niles Ave,
South on Niles to Corby's Irish Pub 441 E. LaSalle Ave
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