5.d) Car Show AppMAID
SCANDIA CIN CF SCANDI
14727209'" Street North
ScanA2, Minnesota 55073
(651) 433-2274 www.ci.scandia.maus
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:
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Location address:
Date(s): `
t
Event starting Time:
Set-up start date and time:
Event ending time: l a �GGI Ck vYI
Dismantle by- date and time:
Anticipated number of participants and/or spectators: 5-0 caZou
If there is a fee or donation required as a condition of
attendance, please describe: h Q -Fe ',
2. jkttach sketch or site plan showing the location of the following as applicable:
route (beginning/ end, direction of travel,
c 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
City ofScandia, Special Event Perm it Application, Page 1 of 7
3. Applicant information:
Name:
Address:
Phone:
E -Mail:
C\k) V)CC
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 be present at the event and in charge of the event
at all times? Yes,
If no, provide contact information for person who will be the
responsible party on the day of this event
Name:
Address:
Phone:
E -Mail:
Title:
Cell:
4. Entertainment:
Describe entertainment plans. If there will be music, sound amplification or any other noise 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.
City ofScandia, 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. ,
7. Emergency/ medical services:
Describe measures that will be taken to ensure emergency vehicle access (police, fire, ambulance) to
the event area.
8. 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 permits that may be required for such construction.
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. I _ I
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 N6�--7
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
�ftYes, describe the typ f pf 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
event? Yes N
If yes, a lawful gambling permit will be required as provided by state law and Scan
dia 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 ofScandia, 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 all 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 ofyour 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 ofScandia. 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
yand t�eleph�one number. Please sign below to indicate that you have read this notice:
Signature: / ' Date: C
I request that my residence address and telephone number be considered private data.
My alternative address and telephone number are as follows:
Address:
Telephone:
Acknowledgement/ Signature:
I hereby acknowledge receipt of a copy of this application form and Ordinance No. 119, 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
City ofScandia, Special Event Permit Application, Page 6 of 7
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