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HomeMy WebLinkAboutSpecial Event - 34th Annual Stand by Me Walk - June 8, 2024APPLICATION FOR USE OF PUBLIC RIGHT-OF-WAY FOR EVENT- The following special event has been approved by the Special Events Committee. fir' 1965 Submitted by: Denise Miller Event name: 34th Annual Stand by Me Walk Event Date: June 8 2024 Street Closure: Intermittent crossings at intersections beginning at Howard Park then continuing thru the downtown area and back to Howard Park, Closure Times: 9:00 am to 12:00 pm Sidewalk Closure: ❑ Yes x❑ No Comments: Annual walk sponsored by Real Services to support Alzheimers and Dementia Services. CITY OF SOUTH BEND, INDIANA BOARD OF PUBLIC WORKS tatL(4 Elizabeth A. Maradik, President Gary A. Gilot, Member Murray L. Miller, Member Joseph R. Molnar, Vice President Briana Micou, Member �4 Attest: Theresa M. Heffner, Clerk Date: November 28, 2023 1 City of South Bend Special Event Application 04 City and Regional Event $SO application fee if filed 60 days or greater (up to 360 days) in advance of event ^INfiS $100 expedited application fee if filed 30-59 days in advance of event Please Brine Completed Application and Payment to: Public Works Service Center, 731 S. Lafayette Blvd., South Bend, IN 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: l0' Z 1. 2-3 Organization Name: (tee 3, ICGiy \ C 2 S Applicant (Contact) Name: _3 'm _?-�\C.\e \ Applicant (Contact) Phone: 51A- Z-M -1 k 45 Contact Email: � \ m Address: IkS\ c)Odt\r\ mttA\epn .City/State/ZIP: SOUiAbeYl� Ub1 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 Phone: • Address: Contact Name: Contact Email: City/State/ZIP: Section B - Event Information \ Event Name :e3y — tti ww%i( Event Type: (Festival, Race, Parade, Other):�,��\-�� Event Classification:-KNon-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.) Date of Event Setup [mm/dd/yy]: U -L ILA Time: t (S •s�)G Am Begin Date of Event [mm/dd/yy]: �o - 6 .- Z`\ Time: q ' CZ End Date of Event [mm/dd/yy]: kD-g - 2A 1 Time: 1 Z • GG jzA Event Cleanup Completion [mm/dd/yy]: 6- 2S - 2-�1 Time: ` 1JG i CA • Total anticipated attendance: 360 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: E E -VY\e,c-e, ',s a Zo ,cLo C eg�S�ra:F ee der- WA\ker Does the event have any partnered sponsorships? Yes ❑ No If yes, list the number of sponsors at each level of partnered sponsorship: S�oY�Socsh;� 1%st. (No-�C_ yeAz Cb�La\ne� 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: Th\'s annoa\ Sn - Zo23 F\)e. e-vev*_ was \G F�"o,nn goCw1- 12�rn 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? 00 Describe any sound equipment that will be used in the parade/race: C �kj a`e eM (_ee. W :fin A SAf)\e, Does the event have participant categories? For example, a run that has different race divisions or a parade with separate walking/marching groups. • ❑ Yes XNo 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 - Eaufoment. Set-up, and Logistics ��/ Are you hiring a company to provide entertainment, games or inflatables? ❑ Yes ]p No 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 1 Jo 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? Cl YesI 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: 0 • Will there be any musical entertainment features at the event? *Yes ❑ No If yes, describe the type of music, schedule of sound check/performances, and the names of any artists performing: -"Ae k_o \\\ aV_ -me_ �: kzo2p For stage inspections, contact the Department of Homeland Security at 317-232-2222. If your route crosses over a state road or a bridge please contact the following for permission: State, INDOT: County bridges: Michael Hurt Andy Hayes 219-235-7528, Mhurtl@indot.in.gov 574-235-9626, ahayes@co.st-joseph.in.us Section E - Food Are you having food at your event (food vendors, caterers, food trucks, etc.)? ❑ Yes ld� No MQCU -\ L 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 at the St. Joseph County Health Department Food Service website: 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: IN Will alcohol be served or sold? ❑ Yes XO 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 _ ,t M. (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. o 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 Contact Name: • Contact Phone: Email: C� (b) Qualifications: Name: Qualifications: City/State/ZIP: Contact Phone: Contact Contact Phone: Section G -Contingency and Strategic Planning 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. • Proposed Cleanup Plan - This plan should include, but is not limited to: o Measures in place to collect and remove trash, litter and recyclables. Inclement Weather Plan - This plan should include, but is not limited to: Safety measures that will be taken in the event of a tornado warning. tornado watch, thunderstorm, and extreme temperatures. Proposed Lost and Found Plan - This plan should include, but is not limited to: c A description of the use of signage. announcements on public address systems or pre -event handouts. Section H - Site Plan / Route Mao • For parades, races and other processional events: �.,/ Are you selecting one of South Bend Police Department's (SBPD) pre -approved race routes? ElYes I� 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: 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 - Mitigation 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. • 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. 0 Section K - Indemnity & Hold Harmless Agreement 40 • • City of South Bend Special Events Committee Indemnity & Hold Harmless Agreement Date: 1 b - Z1- 23 Event Date: in " A " `-4 Event Name: y M C r S nnc, \ e\lu lC-e S �Cay\n\ Organization: Rea` Sekuwe-SIR\'ZY\e�CA��S QY\U Z�--M2t\V\dSeo'U\cebOS Applicant (Contact) Name: �77Mk Ke \ Applicant (Contact) Phone: ��� Y ' 1 \�5 Alt. Phone: Email\M lea\ SeWJ\C eS •Qn) \ Address: 1\N .F)M� MV)AtCtav\ .• City/State/ZIP: )inn Prd� ice• ���oU'\ Event Location (Please describe): -\C�r � A \G aoWf\�W�\ area � �aa� - Length of Event (Dates/Times), - P, - 8 y �p ' 3O AM- � -bO '!�V Qn� 4\eh e.r\a 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. Organization Name: Y'ca\ !�eq�U\C.eS . �(_ 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. Signed on this Date: L' a\- 0313 Signature Printed Name and Title 1. 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 ina • 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: l9- CD \ - a Applicant Sign: Printed Name: • res' ent SPECIAL EVENTS COMMITTEE APPROVAL Member Member /l-9-a3 Member Member Date U 1"..11.. M.p. C,o yle 4 � � F"iN�SHx Q CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 11 /30/2022 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(les) must have ADDITIONAL INSURED provisions or be endorsed. R 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/al- PRODUCER Gibson Insurance Agency Inc 202 South Michigan St., Suite 1400 South Bend IN 46601 PRONE We xe - 574-245.3500 Wc. No1: 574-236.6399 INSURED REALSER411 Services, Inc. xaIAeERs: Real S 1151 S Michigan St INSURER C PO Box 1835 INSURER D: South Bend IN 46634 COVERAGES CERTIFICATE NUMBER: 2124897635 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. INSLTR TYPE OF INSURANCE L'WIND POLOYNUMBER POLICY FFF POLICY EKP LDS B X COMMERCIAL GENERAL LIABILITY CILMMS-MADE "" OCCUR PHPK2436533 7/1/2022 7/l/2023 EACH OCCURRENCE $1,000.000 PREMISES Ea ocwnerKe $100,000 MED EXP (Any one person) $5.000 PERSONAL f ADV INJURY $1.000.000 GENT AGGREGATE LIMB APPLIES PER: POLICY n JJEEC L] LOC OTHER GENERAL AGGREGATE f3,000,000 PRODUCTS - COMP/OP AGO S3.000.000 S AUTOMOe1LELUBILRY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED X NON -OWNED AUTOS ONLY AUTOS ONLY PHPK2436533 7112022 7/1/2023 COMBINEDLE LM Es a denl ING BODILY INJURY(Per pemon) BODILY INJURY (Per ecddenu PROPERTY DAMAGE (Per eryldenl i11000,000 X S S X _ S _. S B X UMSRELLAUAB EXCESS LIAB X OCCUR CLAIMS -MADE PHUS822607 7/12022 7/1/2023 EACH OCCURRENCE AGGREGATE $2.000.000 $2.000,000 f DED RETENTION A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANYPROPRIETORAPARTNEREXECUTIVE OFFICERMEMBER EXCLUDED? ❑ (MAndalory In NH) X yes, desc lm under DESCRIPTION OF OPERATIONS W. N/A WCV6146654 7112022 71112023 ',X BE I STATUTE ER E.L. EACH ACCIDENT S500,000 E.L. DISEASE -EA EMPLOYEE S500,DD0 6 500,DDO EA_ DISEASE -POLICY LIMIT DESCRIPTON OF OPERATONS I LOCATIONS I VEHICLES (ACORD 101, AdlNoml Remar o SCMdYM, may be eeeeMd N m apace le rpeired) 'FOR INFORMATION ONLY' SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. coihson x,rr711i#7A _.!i jT710 © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD 4 ACORO CERTIFICATE OF LIABILITY INSURANCE DATE (MM DD YY Y) 1`� 11/30/2022 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 INSURERS), 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. H 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 Gibson Insurance Agency Inc 202 South Michigan St., Suite 1400 South Bend IN 46601 INSURED Real Services, Inc. 1151 S Michigan St PO Box 1835 South Bend IN 46634 COVERAGES CERTIFICATE NUMBER: 2124897635 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. NSR TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF POLICY UP LOArr$ B X COMMERCIAL GENERAL LUURLITY CLNJ.I MSADE JFV- I OCCUR PHPK2435533 7/1I2022 7/1/2023 EACH OCCURRENCE S1,OOD,ODO PREMISES Ea ocweanrs $100,000 MED UP ass, rem) S 5,000 PERSONAL S ADV INJURY 111,000,000 GEN'L AGGREGATE LIMIT APPLIES PER POLICY JEC LOC OTHER GENERAL AGGREGATE $3,000,000 PRODUCTS-COMP/OP AGO s3,Doo,000 S AUTOMOBILELIABILT' ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED X NON -OWNED ONLY AUTOS ONLY PHPK2435533 7/1/2022 7/1/2023 COMBINED SINGLE LIMIT Ea accident s10000D0 X BODILY INJURY (Par pawl) $ BODILY INJURY(PMaodENR) S X PROPERTY DAMAGE flow accident It S B X UMBRELLALIAB X OCCUR EXCESS LWB CLAIMS -MADE DED RETENTION PHUB822607 7/1/2022 711/2023 EACHOCCURRENCE s2,000,000 AGGREGATE 52,000,ODO S q WORKERSCOMPENSATION AND EMPLOYERS'LMBLLITY YIN ANYPROPRIETOR/PARTNERIFJ(ECUTIVE OFFICERIMEMBER EXCLUDED? (Mandatory In NH) ff yex s, deribe under DESCRIPTION OF OPERATIONS below NIA WCV6146654 7/l/2022 7/1/2023 X STATUTE ER E.L. EACH ACCIDENT s500,000 E.L. DISEASE -EA EMPLOYEE S500,000 E.L DISEASE -POLICY OMIT S 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule. may be aUached K more space is required) CFRTIFICATF Hint DER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. -FOR INFORMATION ONLY` AUTHORIZED REPRESENTATIVE 9)1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD �J S THIS CHECK HAS A COLORED BACKGROUND AND CONTAINS MULTIPLE SECURITY FEATURES - SEE BACK FORD TAILS 8 REAL Services, Inc. aQa REAL 1151 S. Michigan St. • P.O. Bo> 1835 dp SERVICES South Bend, IN46634 574-233-8205 ****Fifty and 00/100 Dollars Public Works Service Center 731 S.Lafayette Blvd. South Bend, IN 46601 III i4i767111 1:0749028?81: 0 0 s= centier 141767 /b28?/]i9 141767 7/18/2023 50.00 DA Z E 111102277923119 REAL Services, Inc.