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HomeMy WebLinkAboutSpecial Event - SBC-5K Peace Run - August 24APPLICATION FOR USE OF PUBLIC RIGHT-OF-WAY FOR EVENT The following special event has been approved by the Special Events Committee. Submitted by: Denise Miller Event name: SBC-5K Peace Run Event Date: August 24 2024 Street Closure: Start/Finish on Notre Dame Ave, Northeast Neighborhood near Notre Dame Closure Times: 8:00 am to 12:00 Sidewalk Closure: ❑ Yes ❑■ No Comments: Family friendly walk/run thru the Northeast Neighborhood near Notre Dame. CITY OF SOUTH BEND, INDIANA BOARD OF PUBLIC WORKS Elizabeth A. Maradik, President Gary A. Gilot, Member unto 0171 Joseph R. Molnar, Vice President Briana Micou, Member Murray L. Miller, Member Attest: Theresa M. Heffiier, Clerk Date: August 13, 2024 City of South Bend Special Event Application City and Regional Event $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 Please Bring Completed Application and Payment to: Public Works Service Center, 731S. 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. Section A - Applicant Information Date of Application:SoA* L .L- , Organization Name: 0 • Yat itµE C_l..L-ye L% Applicant (Contact) Applicant (Contact) Phone: Contact Email: 8'V'T'A*t7 f /off Address: SQ3S 0e City/State/ZIP: 2xc"ak,T 4'(a010 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 A el Event Name : 5 3L- S K rc..(e [,s. K Event Type: (Festival, Race, Parade, Other): +� K Event Classification: 0 Non -Profit- ❑ For -Profit g4`ti�g�At 17vcsbry{^✓✓^ G4.u.� ❑ City (Civic) Sponsored M Other (If Other, please describe): 50. k CL"'E f : S `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]: 'l c' Q � �� Time: -7 w w-, Begin Date of Event [mm/dd/yy]: Pt k eq 7-4�Time: a at End Date of Event [mm/dd/yy]: V 2 Time: L t .5e� ,awe Event Cleanup Completion [mm/dd/yy]: rcL. VVZ Time: l/y� • Total anticipated attendance: -)-C✓ 0 The proposed event will require the closing of: ON Streets ❑ Sidewalks Is the event ticketed or include fees? ff Yes ❑ No If yes, list fees and fee groups below: 40 Does the event have any partnered sponsorships? Or Yes ❑ No If yes, list the number of sponsors at each level of partnered sponsorship: Is this a returning special event or part of a series of special events? $1 Yes ❑ No If yes, provide the date, location, and attendance of past special events and/or future planned events in the series: 0 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? Describe any sound equipment that will be used in the parade/race: E C, J `J 0 Does the event have participant categories? For example, a run that has different race divisions or a parade with separate walking/marching groups. Of Yes ❑ 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 Loeistics Are you hiring a company to provide entertainment, games or inflatables? ❑ Yes I& 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, inf latables, portable restrooms or any other anchorings? ❑ Yes w 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 io 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 x No o If yes, describe the type of music, schedule of sound check/performances, and the names of any artists • performing. For stage inspections, contact the Department of Homeland Security at 317-232-2222. If your route crosses over a state road or abridge please contact the following for permission: State, IN DOT. 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 11 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: sichd.ore/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 41 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 in.eov/atc/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. 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 Name: Contact Name: • Contact Phone: Email: 3 Qualifications: Name: Qualifications: City/State/ZIP: Contact Phone: Contact Phone: 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. 0 • Inclement Weather Plan - This plan should include, but is not limited to: o Safety measures that will betaken 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: o A description of the use of signage, announcements on public address systems or pre -event handouts. RMOMIUMMUFTMAZ M-Mu isFor 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: Cl 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. • 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 $1,000,000 aggregate, which specifically names the City of South Bend, IN as an additionally insured for the event must be submitted. Copy of Certificate of Insurance must be submitted two (2) weeks prior to the date of the event. 0 Section K - Indemnity & Hold Harmless Agreement • City of South Bend Special Events Committee Indemnity & Hold Harmless Agreement Date:T",.., s-4�loi-4 Event Date: ir'-u 2.LEI2.02-Lf Event Name: -6 C-jK ?ehre -Qt�%,tCyvn�w+�V.ar/-arA'VY--' Organization: l', u,� P Jk&iE C-L. , wr L-t Applicant (Contact) Name: Applicant (Contact) Phone: Alt. Phone: C11601) a T2- - tfZ( Email: PtLO\'-0AA G tt A.)-_4 Address: l$D'bS City/State/ZIP: C JG>tiJ:L% Event Location (Please describe): Length of Event (Dates/Times): Y-2— V-, c, /1 �kG �-2, L', 202-4 �q 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. O k ', V L'V N N E (_ V�%ti V'C k 1 I al iV tli'✓e i�>r-i. %,-- < Organization Name: A"J-*- !n kt-t% 11 a6 MLc;A 'KQ t 7 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: Tw �\ K —VC% o AA - Jr' Ca "`s 1..4/:-�� Cf Authorized Organizer Signature • Printed Name and Title Section L - Pe 1. Pursuant to Local Ordinance No. 10628-18, there is a $50.00 non-refundable fee for Tier 11 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. r1 U 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: Applii Printed Name: cL cR-Y y AA, A C SPECIAL EVENTS COMMITTEE APPROVAL / Member Member Member Date Pointer#7 Hydration St Teddy Barns Updated August 15,2023/10:00pm Pointer #6 Hydration St Sharon Manley I cowl ro m I N a Pointer #5 Donna Rehbein Pointer#4 Hammock Start and Finish line Pointe #2 Kent A • Black Finish<< Pointer#3 Hydration St Stacy Zurat • 0 6749401 CITY OF SB SPECIAL EVE 731 S LAFAYETTE BLVD SOUTH BEND, IN 46601 0626,2024 15:39:31 MID: XXXXXXXXXXXX401 TID: XXXXX371 CREDIT CARD MC SALE d a XXXXXXXXXXXX iCaid Mastercard A000000004 )ICE wal Code: 32: Meftd: Contac Mode: Is—er SALE AMOUNT poo S"kfe Not Required MERCHANT COPY AC oe CERTIFICATE OF LIABILITY INSURANCE GATE (MM DDMYY) 12/5/2023 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 01 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 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 endorsement(s). PRODUCER Arthur J. Gallagher Risk Management Services, LLC 9155 South Dadeland Boulevard, Suite 1112 Miami FL 33156 NAME: Mabel Beltran PHONE FAX - 786-331-1267 ,: Ef4AIL _ mabel beltran a' .com INSURERS AFFORDING COVERAGE NAIL$ INSURER A: Philadelphia Indemnity Insurance Company_18058 INSURED FOUREPI-03 INSURER B: Technology Insurance Company Inc 42376 Fourth Episcopal District AME Church Olivet AME Church INSURERC: INSURER D: 719 N. Notre Dame Ave. INSURER E South Bend IN 46617- INSURER F COVERAGES CERTIFICATE NUMBER: 1975989730 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. INSIR TYPE OF INSURANCE AOOL im USR POUCYNUMBER POLICY OFF POLICY EX Rk%UDQffWi, LIMITS A X COMMERCIAL GENERAL UABUJTY PHPK2629079 12/1Y2023 12/1/2024 EACH OCCURRENCE $1,000,000 CI -AIMS -MADE rx] OCCUR PREMISESEe occurrence $100,000 MED EXP (Any one peel $ 5,000 PERSONAL B ADV INJURY $1.000.000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $3,000.000 POLICY JET FX LOC PRODUCTS-COMP/OPAGG $3,000.000 X I sexual Ma(XndUC1 $1,000,000 OTHER: Par Member AUTOMOBILE LIABILITY PHPK2629079 12h/2023 12/1/2024 COMBINED SINGLE LIMIT Ea awdeml $1,000,000 BODILY INJURY (Per Parson) $ ANY AUTO OWNED X SCHEDULED AUTOS ONLY AUTO $ BODILY INJURY (Per ectldent) E PROPERTY DAMAGE Per 'dart $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY A UMBRELLA LIAR X OCCUR PHUBS91064 12/12023 12/1/2024 EACH OCCURRENCE $1,000,000 X AGGREGATE $1,000,000 EXCESS LIAR CLMMS-MADE DED RETENTION$ $ B WORKERS COMPENSATION ANDEMPLOYERS'LIABILITY YIN KWC1339064 12/1/2023 12/1/2024 X STAME ER E.L. EACH ACCIDENT $1,000,000 ANYPROPRIETORIPARTNERIEXECUTNE R/M OFFICEEMBEREXCLUOED9 ❑ NIA E.L. DISEASE -EA EMPLOYEE $1,000,000 (Mandatory In NH) _ If yes, describe under DESCRIPTION OF OPERATIONS beloe :r^ E.L. DISEASE -POLICY LIMIT $1,000,000 A O&O and EPL PHSD1941376 12/1/2023 12/1/2024 Omasmnce $1,000,000 Aeepeeeae Urns $2,000,000 R tteenntltl D80$7,500/EPLI$15 K DESCRIPTION OF OPERATIONS I LOCATxINS I VEHICLES (ACORD 101, Additional Remarks Schedule, maybe atechad N more span is required) Automobile coverage applicable to members with scheduled automobiles on file with company. All affiliated members receive Hired and Non -Owned Autos coverage. Claims Made coverage for D&O. EBL and EPL. Retro Date: 12/112014 Sexual Misconduct Liability is excluded in the Excess Liability policy. Evidence of Insurance SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Olivet AME Church ACCORDANCE WITH THE POLICY PROVISIONS. ' 719 N. Notre Dame Ave. South Bend IN 46617 AUn10RMEOREPRESENTATNE USA ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD � 11 i t • .. 1 , � I WEI 4-1 .0 1 r; U 1 C V i— °° o a a E d u 'a s o o rn d° _ E POP r ... d N F. o >_ a- N O c V a a I- � + cC C 3 O O = E � � � S C Imw NLn Yl N a N a: O O C -O 6 ui £ a o c rn o d o= m om v w a c s ... o y d d v� +- u o o a .� — o Rai+ C C O C UJ OQ 'Ta ooaJ �_ }O opco o t ? U > C r- V N O 3 a E c o O� O u 0 00 �' e o s o ran N V C OV i C m .d-. V O d N¢ D 4J � (� Q Ln O /.1 O 7 C S d vc =[] C) Q Ln O ) Q S .... 3 .� -a In Q- o u 3 ° 0 3 V) U a, f -H4-b4 O ivlc1 Q ++ a W d [EN. ; = COMMUNE M:%L;15 IN QD51M0 ` Heroes Camp.Unk SBC-5kWebsite Olivet AME Church/ SBC SK Peace Run, Walk, or Stroll/Registration/Waiver & Release Form. (print name), acknowledge that my participation in the SBC SK Peace Run, Walk or Stroll involves risk of injury, including bodily injury, and assume the risk for same. On my behalf and on behalf of my heirs and legal representatives and to the fullest extent permitted by law, I hereby release and discharge Olivet AME Church and their respective directors, officers, employees, affiliates, members, agents and representatives, from any, and all liability for injury, death, or damage and /or any other claims, demands, losses or damages, incurred by me in connection with any aspect of the SBC 5K Peace Run, Walk or Stroll. Signature: Signature of Parent: Date: • (If under age of 18) Registration Info: circle your choice / Runner / Walker/ (Participation Rt / Less challenging) First Name Cell/Ph #_ Email Last Street Address City (Circle Below) State $30.00 Registration/ Adults $35.00 Registration/ Adults with Tee -Shirt (S) (M) (L) (XL) (2X) $20.00 / Youth /Under 18 years of age $25 Under 18 with Tee -Shirt / Kids (XS) (S) (M) (L) Contact Info: (574) 386-6038 / Email: Awltomcast80@att.net SBC-5K Peace Run, has something for everyone. It's a great event to help prepare for a larger race. It can be your own personal challenge or goal. No pressure, you can run, walk or stroll through the northeast neighborhood near the Univ of Notre Dame. We also have a participation route for slow movers. Walk two blocks north down Notre Dame Ave, towards the Golden Dome to Howard Street, and return to the finish line. The SBC 5K, starts and ends at 719 Notre Dame Ave. Race Day, Sat August 24,2024. Same day registration 8am / The SBC 5K will start at 9:00am. Please join us for a day of wellness and fun. And support peace in all forms. Donations will go towards the support of Heroes Camp of South Bend. 0 Thank you