HomeMy WebLinkAboutSpecial Event - Ellsworth Block Party-July 2APPLICATION FOR USE OF
PUBLIC RIGHT-OF-WAY FOR EVENT
The following special events have been approved by the Special Events Committee
Submitted by: Denise Miller
Event name: Ellsworth Block P
Event Date: 712121
Street Closure: Ellsworth P1 from Washington to Wilson
Closure Times: 5:30 pm to 10:00 pm
Sidewalk Closure: ❑ Yes ❑ X No
Comments: _Neighborhood block party picnic together and play games.
CITY OF SOUTH BEND, INDIANA
BOARD OF PUBLIC WORKS
81ry
Elizabeth A. Maradik, President
Gary A. Gilot, Member
e2_ 7Tt
Joseph R. Molnar, Member
Jordan V. Gathers, Member
Murray L. Miller, Member
Attest: Anne Fuchs, Clerk
0
City of South Bend Special Event Application
Neighborhood Event
$25 application fee if filed 30 days or greater (up to 180 days) in advance of event.
Review the Instructions on the Special Events page before completing the application. Neighborhood Special
Event applications must be submitted more than 30 days in advance of the event date or the application will not
be accepted.
Section A - Applicant Information
Date of Application: ��_�_ — Organization Name:
Applicant (Contact) --_--
Applicant (Contact) Phone: ��=.� I �__�_ Contact Email: GAG n rJ q VvI An . cv
Address: 1__LV_ _ City/State/ZIP: _ rrj Q� SIy_ 4 ac IT
Secondary Contact Name:
Contact Phone:
Address:
Contact Email:
City/State/ZIP:
Section B - Event Information
Event Name: ___ ��i1�✓C9i? _ Gtt. t Expected Attendance:
Requested Street Closure:__—_Q,(i
From (Cross
To (Cross Street):
Provide a brief description of the event:
0-�
Date of Event Setup [mm/dd/yy]: _—W- �Q�� 2021 — Time:
Begin Date of Event [mm/dd/yy]: S�� Q2 7 2 I —_ Time:
End Date of Event [mm/dd/yy]: --���� Z 1 fTime: I l� ' m _______
-------------
Event Cleanup Completion [mm/dd/yy]: Time: —(L OL) ron
T --------------------
Have all residents on the affected block have been notified and invited? OYes [:]No
Please attach a copy of the door hanger or letter used to notify residents in addition to signature attachment.
Number of households fronting the proposed street closure: _________---______—_—____ --
Number of households represented by signatures on attached sheet:
Will this event have music (live or other)? 0( Yes 0 No
F (1 swfl,,t
A.,� st�� A(,ara r Strrvt P; "'
pLALJ
0-�
Date of Event Setup [mm/dd/yy]: _—W- �Q�� 2021 — Time:
Begin Date of Event [mm/dd/yy]: S�� Q2 7 2 I —_ Time:
End Date of Event [mm/dd/yy]: --���� Z 1 fTime: I l� ' m _______
-------------
Event Cleanup Completion [mm/dd/yy]: Time: —(L OL) ron
T --------------------
Have all residents on the affected block have been notified and invited? OYes [:]No
Please attach a copy of the door hanger or letter used to notify residents in addition to signature attachment.
Number of households fronting the proposed street closure: _________---______—_—____ --
Number of households represented by signatures on attached sheet:
Will this event have music (live or other)? 0( Yes 0 No
Section C - Alcohol
Will alcohol be served or sold? ❑ Yes f9 No
If Yes:
o The applicant must apply for and receive a temporary liquor license from the Alcohol & Tobacco
Commission.
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.
o Deposit will be returned upon inspection of event area by the Board of Public Works.
o The applicant must submit a map or drawing of:
o Fencing around serving area
o Trash receptacles
o Events that will 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) Security Company Information
Company Name:________________________________ Contact Name:
Contact Phone: ------ — -------- ___-------- Email:
City/State/ZIP:
(b) Independent Security Information
Name: __ Contact Phone:
Name: _ Contact Phone:
Qualifications: __
Name: _ Contact Phone:
Qualifications:
s
Section D - Food
Will your event have food sales (food vendors, caterers, food trucks, etc.)? ❑ Yes 0( No
If yes, the event coordinator must apply for and receive a St Joseph County Health Department
Temporary Event Permit.
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.
All applications and guidelines can be found on the St. Joseph County Health Department Food Service
website at sichd.org/food-service.
Please select food types: ❑ Food Vendor ❑ Caterer ❑ Food Truck ❑ Other:
If a Food Truck, please list company name(s):
t
Please describe how food will be cooked and served:
Section E - Indemnity & Hold Harmless Agreement
City of South Bend Special Events Committee
Indemnity & Hold Harmless Agreement
Date: lEvent Date:
Event Name: GI I .( it o -+tom R I A 1-1/ D ill -!-f .
Organization:
--- --_—_ —__
-----------------------------------------
---
-------------------
Applicant (Contact) Name: _—lejz�"rL��v_h_
— ----------------
Applicant (Contact) Phone: 57- Alt. Phone:
Email: -1i l Ica A 9 vrn &i I r nm
Address: _LLI W. `I If Q++RL --------- City/State/ZIP:
Event Location (Please describe):
e^ -fKt IA I Uc D(f1.
Length of Event (Dates/Times): ___��_�w�----�—
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 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.
Signed on this Date:_(4- 14-21-1-t_
Organizer Signature
Printed Name and Title
Section F - Permit & Agreement
1. Pursuant to Local Ordinance No. 10628-18, there is a $25.00 non-refundable fee for applications filed 30
days or greater in advance of the event date. Applications filed less than 30 days in advance of the event
date will not be accepted.
2. All residents within the affected area must be notified of this event. The APPLICANT must obtain
signatures from at least 10 residents that reside along the closed right-of-way and make an attempt to
notify all other affected residents. APPLICANTS must Include a copy of a brochure or letter of invitation
distributed to all affected neighbors describing the event purpose, date, and time.
3. The APPLICANT is responsible, prior to the event, for determining if there are any affected residents that
need assistance accessing their residence. The APPLICANT Is responsible for providing said resident(s)
access or transportation to their property.
4. The cones will be delivered to the APPLICANT's address. The APPLICANT assumes full responsibility for
clean-up and assures the City that all cones will be maintained and returned undamaged. The APPLICANT
will be liable for the replacement cost of $50.00 per cone as a result of any missing or damaged cones.
5. Block parties must end by 8:00 p.m.
6. A street will be blocked off from intersection to intersection only. No half -blocks or alleys can be blocked
off.
7. The Special Events Committee reserves the right to deny any block party application based on traffic and
speed limit records. No street may be closed with a speed limit over 30 MPH or considered to be a major
arterial.
8. The Special Events Committee reserves the right to deny any block party application based on information
gathered from the South Bend Police Department or other sources.
9. The APPLICANT agrees to allow residents that live on the above -referenced block access in and out of the
restricted area as needed.
10. The APPLICANT agrees to abide by all terms and conditions of the South Bend Municipal Code and Board
of Public Works' policy adopted in Resolution No. 10628-18 on December, 11, 2018.
11. Notification of approval/denial of this request will be issued by return of this form, upon signed
authorization by the Board of Public Works.
12. The City of South Bend Noise Ordinance 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 stereos, speakers, musical
Instruments, 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).
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:—S2� 1��ZL---------------
Applicant Signature:
Printed Name:
Pre � dent C -
Mem er
SPECIAL EVENTS COMMITTEE APPROVAL
:4 `
Member
Member
Membe;
6 /i5/a 1
Date
Neighbor Signature Sheet - Neighborhood Special Event
We have been informed, agree to, and request that the Special Events Committee of the City of South Bend authorize a
party in the area described as:
�bbllock
from S6/ to
Street Name Cross Street Cross Str t
Date of Event:
1.
Signature
6.
Signature
Name
LC,vr� Cid ✓ham
Name
bcLi:C�--
C""-' 1 ;�
Address
t 2( 1f t 1 P(
Address
(� t1,SU.�.o:7h
Phone No.
"4Y - 3 r _ t7 `7'
Phone No.
Sly 2S.2
Date
` (?-0 Z I
! (;
Date
2•
Signature
7•
Signature
Name
9 C
Name
f
4-1
Address
-
Address
iO3 S EEls�vcr PC.
Phone No.Phone
.. ..
No.
(r- J -79--7 t -7
J F l,.•' i
Date
Date
3.
Signature
J
8•
Signature
n C9 -C_
Name
/
Name
Address
l3 r /�
Address
V,
Phone No.
3�/
Phone No.
Date/Date
4.
Signature
`7l J
�
9•
Signature
1
.
Name
�.j ' `1
Name
Q S < CIn
Address
i e-li� ; / I
Address
h4�C�4+�
Phone No.
i 7'� ,- �:? � �
Phone No.
Date
�C�!�
Date
�c
5.
Signature
A
nature
Signature
g
Name
/ ,
C
Name
L
Address
J
Address
Phone No.
G
Phone No.
Date
�r r,�
Date
A4y
Ellsworth Place
Family
BLOCK PARTY
July 2
6:00pm to dark
Food
Bouncy House
Fireworks
Bring your own picnic dinner
and optional dessert to share.
New this year:
Dessert Bake -off!
Please contact Laura Salmon 574-315-8271
Questions? Contact Matt Ingle 574-714-8430
Donations accepted to help cover costs
oro/zuz I
Google Maps 134 S Ellsworth PI
I a4 � taswonn -1 - uoogle maps
lllT
134 S Ellsworth
PI
6uoding
O G
Directions Save
Nearby
Send to your Share
phone
0 134 S Ellsworth
PI, South
Bend, IN 46617
Photos
It134 S Ells. qT PI
BerM. IN 46617
Map data ®2021 200 ft
hanc/A...... nnnnln nnm/mune/nlennN9A+CaFIlm.mrlh+Gl aCn�dhaCnnAa1A1.ARR17ltRA4R79AnO9-RR 991999117 /Aala-19m11AM1Am91'4mAHeMRR 1l9
{a0t01ngna'OveY iBYO-121-]6tt
GREG M.OLEN OR MARY OLEN
134 S. ELLSWORTH PL
SOUTH BEND, IN 46617,3427
574-282-2743
1� I T- -.P
(NEMC
1: 2 ?129068 1a:
71M 2712 5399
w muem nue rxu�rew
Keaxao� aio �iomm� .,
i -
DATE
43
819090912tim 5399
7AARS B —=I as