9.a) Fat Cat Tri AppSCANDIA
14727107" Street North
Smndm, Mimrewta 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 he notified at the time of application of the date for City Council consideration ofthe request.
1. Name, purpose and description of event: ?-
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Location address:Gae4� r, Yt�� .-✓' y -{a Zi7i2 S'
Date(s):T 4C*
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Event starting Time: Fi 4-G p� s, y- 6e�- 3Q Event ending time:
Set-up start date and time: `_P" e�p7t C�—
Dismantle by- date and time: .Sa - 41 ,
Anticipated number of participants and/or spectators:
If there is a fee or donation required as a condition of
attendance, please describe: r� y•c ' ae it �n
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2. Attach sketch or site plan showing the location of the following as applicable:
route (beginning/ end, direction of travel, _ food concession area (cooking, serving,
traffic control points) consumption)
_ ticketing/ registration/ entry locations _ alcoholic beverage concession area
entertainment or stage locations _ other concession areas
portable toilet facilities _ size and location of any tents or structures
fencing locations _ trash/recycling receptacle area
parking areas for participants/ spectators _ fireworks or pyrotechnics site
sign locations _ first aid facilities
_ speaker (sound amplification) locations _ other as may be applicable
City afScandia, Special Event Permit dpplicarion, Page 1 of 7
Paddle Segment (Blue Line on Map):
The race will begin at the Loa House Landine on the St. Croix RivEr in Scandia. This segment will total approximately 3.
miles of paddling (mostly downstream) on the dver and around Greenburg Island. Participants will exit the dver at W illian
O'Brien State Park.
Run Segment (Red Line on Map):
The running portion of the treiathalon will take you through the scenic trails at William O'Brien State Park. Participants w
exit the park on the western border and will then follow Oxboro Avenue south to Old Marine Trail. The course then follows
Old Madne Trail to the west and ends at the Scandia-Marine Lions Park (next to the Hav Lake School Museum). Total
running distance is approximately 5.2 miles.
Biking Segment (Green Line on Map):
The biking segment will be an 11 mile circuit made up of two "loops" that begin and end at the Scandia-Marine Lions Pai
Participants will begin the first loop by tmeelling south on Olinda Trail (County Road 3) to 185th Street. From there the
course will head west and follow the roads along the shores of Big Madne Lake. The first loop will follow Meadowrdige Tn
Maxwill A�nue and Mayberry Trails, then to 195th Street and back out to Olinda Tmil where riders will traeel north to 20:
Street to complete the second, smaller loop. The course will follow 202nd Street to Orwell Avenue where riders will traee
along the shores of Sand Lake, heading south to Old Marine Trail. The final stretch will follow Old Marine Trail back to th
west, finishing at the Lions Park.
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3. Applicant Information:
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Name:
Title:
Address: r. / it ._ . _
Phone:
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Affiliation/ organization: < ,A4 L 4
Are you an authorized applicant for this organization?
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Will this person have authority to cancel or modify event plans?
Will this person be present at the vent and in charge of the event at
all times?
If no, provide contact information for person who will be the
responsible party on the day of this event
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Name: JAh,,'ei, .&edi:e_OV% Title:
Address:
Phone:
E -Mail:
Yes -' No
Yes ./ No
Yes No
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4. Entertainment:
Describe entertainment plans. If there will be music, sound amplification or any other noise impact,
please describe including the intended hours.
5. Sanitary Facilities:
Describe the facilities present on the site (type, number & location) as well as temporary/ portable
facilities to be provided.
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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.
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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?
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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 advertises 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.
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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.) /J
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14. Fireworks or pyrotechnics:
Will any fireworks or pyrotechnics be used at the event? Yes No
If yes, describe in detail. Fire Department approval will be required.
City of Scandia, Special Event Pennit Application, Page 4 of 7
15. Food and beverages:
Will alcoholic beverages be served? Yes V*"' No
If yes, describe the type of beverages and the status of the liquor license:
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Will food and/or non-alcoholic beverages be served? Yes No
If yes, describe what will be served an any plans for cooking food in the event area, including fuel
source to be used:
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Has a license been obtained from the Washington County
Department of Health and Environment? (please attach) Yes No r,"'
16. Other concessions: Ia ���&rS-
Describe what vendors or concessionaires you will allow at the event, and how you intend to regulate
and monitor their activities.
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17. Gambling:
Will there be any gambling (raffles, pull -tabs, bingo, etc.) at the
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.
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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 comtplete 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 all loss caused in any way be reason of the failure of the event promoter to fully perform all
obligations under this ordinance. Please complete t1:e 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 ive 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 of 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: y
ZZ
I request that my residence address and telephone ntimber 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:
City of Scandia, Special Event Permit Application, Page 6 of 7
Special Event Permit Checklist
for office use only
Event Name and Date
Application Form and Attachments
✓ Signed application form
✓ Sketch/ site plan
Workers Compensation Certificate of Compliance
✓ Release and Indemnification Agreement
Certificate of Insurance
Other Permits/ Licenses as Applicable
Building Permit
Reviewed by:
Sign Permit
Liquor License
Lawful Gambling Permit
Washington County Dept. of Health and Environment (food)
Building and Code Enforcement Official
Fire Department
Police/ Sheriffs Department
City Administrator
City Council Review/ Permit Issuance
Date application found to be complete
City Council Meeting Date
Approved Denied
Resolution No.:
Transmitted to applicant
City of Scandia, Special Event Permit Application. Page 7 of 7