5.i Scanley Cup-Special Event Permit ApplicationOCT 12 2017
CITY OF SCANDIA
W
SCANDIAA
14727 209'x' Street North
Scandia, Minnesota 55073
(651) 433-2274 www.ci.scandia.mn.us
Special Event Permit Application
INSTRUCTIONS: Fill out this form completely, sign it and include all required attachments. If additional space is
needed, attach additional sheets. Submit to the City of Scandia at least 30 days prior to the date of the event with the $25.00
permit fee. You will be notified at the time of application of the date for City Council consideration of the request.
1. Name, purpose and description of event:
A
Location address:
Date(s):
Event starting Time:
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Event ending time: Z ,-71'fW.17,f y'ht
Set-up stark date and time:.
Dismantle by- date and time: Z
Anticipated number of participants and/or spectators: J- Cc)
If there is a fee or donation required as a condition of
attendance, please describe: /-,/ o
2. Attach sketch or site plan showing the location of the following as applicable:
_ route (beginning/ end, direction of travel,
traffic control points)
ticketing/ registration/ entry locations
entertainment or stage locations
— portable toilet facilities
fencing locations
parking areas for participants/ spectators
sign locations
speaker (sound amplification) locations
food concession areas (cooking, serving,
consumption)
alcoholic beverage concession area
other concession areas
size and location of any tents or structures
trash/recycling receptacle area
fireworks or pyrotechnics site
first aid facilities
other as may be applicable
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City of Scandia, Special Event Permit Application, Page I of 7
3. Applicant information:
Name:egg �� 2� Title:
Address: S5 4_7 -fin.,.'
Phone: 7SS- (ya 1 Cell:
E -Mail: iii r 1 r71? 1 0
Affiliation/ organization:
Are you an authorized applicant for this organization? Yes No
Will this person have authority to cancel or modify event plans? Yes No
Will this person bepresent -atthe event and in -charge •of -the event
at all times? Yes '--�No
If no, provide contact information for person who will be the
responsible party on the day of this event
Name: Title
Address:
Phone:
E -Mail:
Cell:
4. Entertainment:
Describe entertainment :plans. If there will be music, sound amplification .or -any :other raise impact,
please describe including the intended hours.
5. Sanitation/ potable water:
Describe the toilet and hand washing facilities present on the site (type, number & location) as well as
temporary/ portable facilities to be provided. Describe the source of potable (drinking) water.
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City of Scandia, Special Event Permit Application, Page 2 of 7
6. Parking and traffic control:
Describe the location and number of parking spaces available. Describe arrangements that have been
made for traffic control.
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7. Emergency/ medical services:
Describe measures that will be taken to ensure emergency vehicle access (police, fire, ambulance) to
the event area.
S. Security/ crowd management:
Describe your proposed procedures and staffing for the event operations and crowd control,
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9. Trash/recycling, event clean-up:
Describe the number, type and location of trash/ recycling containers to be provided. What provisions
have been made for clean-up of the site and surrounding area after the event?
Name of trash/ recycling hauler:
10. Lighting:
Describe any temporary or permanent lighting that will be added for the event.
City of Scandia, Special Event Permit Application, Page 3 of 7
11, Temporary structures or construction.
Describe any tents, canopies, enclosures, stages, platforms, scaffolding, risers, bleachers, fences, and
any other type of temporary structure or construction for the event. Event sponsor is responsible to
obtain any building or electrical perm/its that may be required for such construction.
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12. Advertising and promotion.
Describe how this event will be advertised and promoted. Describe any signs (size, type, location.)
All signs must comply with Scandia Development Code Chapter 2 Section 9.13 including a permit if
required.
13. Noise:
Describe expected type, duration and timing of any noise sources. Describe measures to be taken to
ensure compliance with city noise ordinance (Ordinance No. 65.)
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14. Fireworks or pyrotechnics:
Will any fireworks or pyrotechnics be used at the event? Yes 2-,� No
If yes, describe in detail. Fire Department approval will be required.
City of Scandia, Special Event Permit Application, Page 4 of 7
15. Food and beverages:
Will alcoholic beverages be served? Yes No
If yes, describe the type of beverages and the status of the liquor license:
Will food and/or non-alcoholic beverages be served? Yes / No
If yes, describe what will be served and any plans for cooking food in the event area, including fuel
source to be used:
Has a license been obtained from the Washington County
Department of Health and Environment? (please attach) Yes No
16. Other concessions:
Describe what vendors or concessionaires you will allow at the event, and how you intend to regulate
and monitor their activities.
17, Gambling:
Will there be any gambling (raffles, pull -tabs, bingo, etc.) at the I�
event? Yes No
If yes, a lawful gambling permit will be required as provided by state law and Scandia Ordinance No.
100. Describe the gambling activity and the status of the gambling permit.
18. Workers compensation compliance:
In accordance with Minnesota Statutes all applicants for license and permits to operate a business in
Minnesota must submit acceptable evidence of compliance with workers' compensation insurance
requirements. Please complete the certificate of compliance and attach to this application.
City of Scandia, Special Event Permit Application, Page 5 of 7
19. Indemnification:
Ordinance No. 119 requires that a special event permit holder shall agree to defend, indemnify and
hold the City, its officers and employees harmless from any liability, claim, damages, costs, judgments,
or expenses, including attorney's fees, resulting directly or indirectly from an act or omission
including, without limitation, professional errors and omissions of event promoter, its agents,
employees, arising out of or by any reason of the conduct of the activity authorized by such permit and
against ail loss caused in any way by reason of the -failure of the event promoter to -fully perform all
obligations under this ordinance. Please complete the release and indemnification agreement and
attach to this application.
20. Insurance
As a condition of the granting of a permit for a special event conducted on public property or public
streets or parking lots, the permit holder shall provide to the City a public liability insurance policy
naming -the City as an additional insured entity -with limits of -not less than one million dollars per
occurrence. Please attach the certificate of insurance to this application.
THE MINNESOTA DATA PRACTICES ACT requires that we inform you of your rights about the private
data we are requesting on this form. Private data is available to you, but not to the public. We are requesting
this data to determine your eligibilityfor a permit, from the City oJ'Scandia. Providing the data may disclose
information that could cause your application to be denied. You are not legally required to provide the data;
however, refusing to supply the data may cause your permit to not be processed. Your residence address and
telephone number will be considered public data unless you request this information to be private and provide
an alternative address and telephone number. Please sign below to indicate that you have read this notice:
Signature: Date. o
I request that my residence address and telephone number be considered private data.
My alternative address and telephone number are as follows:
Address: ,�,�'�' J%.) (,l t"�l t e, a.� Z�/Z .5'UAelephone: 6.5-1— %
Zwer M,t/ 5So 2S
Acknowledgement/ Signature:
1 hereby acknowledge receipt of a copy of this application form and Ordinance No. 1191 Establishing Rules and
Regulations for Special Events, and agree to abide by the ordinance and any other conditions that the City of
Scandia.may,place upon issuance.of.this permit.
Signature: Date: l d /t r
City of Seandia, Special Event Permit Application, Page 6 of 7
Certificate of Compliance
Minnesota Workers' Compensation Law
PRINT IN INK or TYPE.
Minnesota Statutes, Section 176.182 requires every state and local licensing agency to withhold the issuance or
renewal of a license or permit to operate a business or engage in any activity in. Minnesota until the applicant
presents acceptable evidence of compliance with the workers' compensation insurance coverage requirement of
Minnesota Statutes, Chapter 176. The required workers' compensation insurance information is the name of the
insurance company, the policy number, and the dates ofcoverage, or the permit to self -insure. If the required
information is not provided or is falsely stated, it shall result in a $200 penalty assessed against the applicant by
the -commissioner of the'Department of Labor and Industry.
A valid workers' compensation policy must be kept in effect at all times by employers as required by law.
USINESS NAME (Individual name only if no company name used) I LICENSE OR PERMIT NO (if ap
Ca
as
ADDRESS (PO'Box must Include street a
YOUR LICENSE OR CERTIFICATE WILL, NOT BE ISSUED WITHOUT THE
FOLLOWING INFORMATION. You must complete number 1, 2 or 3 below.
NUMBER 1 COMPLETE THIS PORTION IF YOU ARE INSURED:
INSURANCE COMPANY -NAME (not the insurance agent)
IRATION DA
NUMBER 2 COMPLETE THIS PORTION IF SELF-INSURED:
I have attached a copy of the 2armit to self -Insure. _
NUMBER 3 COMPLETE THIS PORTION IF EXEMPT:
I am no�wqulred to have workers' compensation insurance Coverage
T have no employees.
I have employees but they.are not covered by the workers' compensation law. (See Minn. Stat. § 176:041 for a list of
excluded employees.) Explain why your employees are not covered,
0 Other:.—__
ALL APPLICANTS COMPLETE THIS PORTION:
1 certify that the information provided on this. form is accurate and complete, if 1 am signing on behalf of a business, I
certify that l am authorized to sign on behalf of the business.
APPLICANT SIGNATURE (mandatory) I I s Lt= UA t t
l/-� jp_! r —7 lb////%
NOTE: If your Workers' Compensation policy Is cancelled within the license or permit period, you must notify the
agency who Issued the license or permit by resubmitting this form.
This material can be mads avallablo in different forms, such as large print, Braille or on a tape. To request; call 1.800.342.5354 (DIAL -DLI) voice or
Too (651)12974198.
MN LIC; 04 (11108)
-SPECIAL EVENT SPONSOR -
RELEASE AND INDEMNIFICATION AGREEMENT
CITY OF SCANDIA, MINNESOTA
TATS IS A RELEASE DF LIABILITY INDEMNIFICATION .AGREEMENT..SPECIAL
EVENT PERMIT HOLDER MUST READ CAREFULLY BEFORE SIGNING.
In consideration for being permitted to engage in the following special event activities in Scandia:
Special Event Permit Holder hereby acknowledges, represents, and agrees as follows:
A. We understand that the above described activities are or may be dangerous and do or may
involve risks of injury, loss, or damage to us and/or third parties. We fiuther
acknowledge that such risks may include but not be limited to bodily injury, personal
injury, sickness, disease, death, and property'loss or damage, arising from the following
circumstances, among others:
(Special Events Permit Holder initials here) eL
B. If required by this paragraph, we agree to require each participant in our special event to
execute a RELEASE AND INDEMNIFICATION AGREEMENT for ourselves and
for the City of Scandia, on a form approved by the city.
Participant Release ,and Indemnification.required? YES "ILIO
(Special Events Permit Holder initials here)
C. We agree to procure, keep in force, and pay for special event insurance coverage, from an
insurer acceptable to the City of Scandia, for the duration of the above described
activities.
(Special Events Permit holder .initials here)__! %` C— -
D. By signing this RELEASE AND INDEMNIFICATION AGREEMENT, we hereby
expressly assume all such risks of injury, loss, or damage to us or any related third party,
arising out of or in any way related to the above described activities, whether or not
caused by the act, omission, negligence, or other fault of the City of Scandia, its officers,
its employees, or by any other cause.
(Special Events Permit Holder Initials h e re)
E. By signing this RELEASE AND INDEMNIFICATION AGREEMENT, we further
hereby exempt, release and discharge the City of Scandia, its officers, and its employees,
from any and all claims, demands, and actions for such injury, loss, or damage to us or to
any third party, arising out of or in any way related to the above described activities,
whether or not caused by the act, omission, negligence, or other fault of the City of
Scandia its officers, its employees, or by any other cause. n
(Special Events Permit Holder Initials here)
F. We further agree to defend, indemnify and hold harmless the City of Scandia, its officers,
employees, insurers, and self insurance pool, from and against all liability, claims, and
demands, court costs and attorneys fees, including those arising from any third party
claire asserted against the city, its officers, employees, insurers or self insurance pool, on
account of injury, loss or damage, including without limitation claims arising from bodily
injury, personal injury, sickness, disease, death, property damage or loss, or any other
loss of any kind whatsoever, which arise out of or are in any way related to the above
described activities, whether or not caused by our act, omission, negligence, or other fault
of the City of Scandia, its officers, its employees, or by any other cause.
(Special Events Permit Holder Initials here)
G. By signing this RELEASE AND INDEMNIFICATION AGREEMENT, we hereby
acknowledge and agree that said Agreement extends to all acts, omissions, negligence, or
other fault of the City of Scandia, its officers, and/or its employees, and that said
Agreement is intended to be as broad and inclusive as is permitted by the laws of the
State of Minnesota. If any portion thereof is held invalid, it is further agreed that the
balance shall, notwithstanding, continue in full legal force and effect.
(Special Events Holder Initials .her -e)
H. We understand and agree that this RELEASE AND INDEMNIFICATION
AGREEMENT shall be governed by the laws of the State of Minnesota and that
jurisdiction and venue for any suit or cause of action under this agreement shall lie in the
courts.
(Special Events Permit Holder Initials Isere) CC_
I. This RELEASE AND INDEMNIFICATION AGREEMENT shall be effective as of
the date or dates of the applicable special event, shall continue in full force until our
ivsponsibiIities liereunder are frilly discharged, and shall be binding upon us, our
successors, representatives, heirs, executors, assigns, and transferees.
(Special Events Permit Holder Initials here)
2
IN WITNESS THEREOF, THIS RELEASE AND INDEMNIFICATION AGREEMENT is
executed by the special events permit holder, acting by and through the undersigned, who represents
that he or she is properly authorized to bind the Special Events Permit Holder hereto.
PRINTED NAME OF SPECIAL EVENTS PERMIT HOLDER:
PRINTED NAME AND TITLE OF PERSON SIGNING ON BEHALF OF SPECIAL EVENTS
PERMIT HOLDER:
Name opo rG
Title4' 4�Z
Signature
Date ! l