5.a) Special Event Permit, Scandia Fire Relief Assoc. Fun Run Meeting Date: 8/3/2010
Agenda Item: �
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City Council Agenda Report
City of Scandia
14727 209`h St. North
Scandia, MN 55073 (651) 433-2274
Action Requested: Consider approving a Special Event Permit for the Scandia Fire Relief
Association Fun Run on September I 1, 2010.
Deadline/ Timeline: N/A
Background: • The Fire Relief Association will be holding a SK and l OK run as a
fundraiser on Saturday, September 11, 2010, coordinated with the
annual Taco Daze event. A run was held in 2009. This is the first
time a permit has been required for this event under the provisions
of Ordinance No. 115 which became effective on September 17,
2009.
• The Relief Association has reserved the Warming House on the
Community Center grounds, where registrations and toilet
facilities for the event would be located. (Additional portable
toilets will be available on site in conjunction with the Lions' Taco
Daze event, for which a separate permit will be issued.) Sanitation
and water will be provided at the l OK halfway point, and at the T-
Ball Field (the ending of the race.)
• Between 75 and 250 participants are expected. The run will follow
a route south on Olinda Trail to 202°d Street,then east to Oxboro
Ave., then north to Oakhill Rd, with the finish line near the city T-
Ball field (for the SK route.) The longer l OK route will follow a
route south on Olinda Trail to 185`h Street, east to Old Marine
Trail, then north on Old Marine Trail/ Oxboro to Oakhill.
• Washington County will require an "obstruction permiY' since this
event will use Washington County roads. The Sheriff's
Department may also have traffic control requirements.
• No tents or temporary structures would be used for this event. No
vendors will be on site.
• T'he City of Scandia's insurance covers events of the Relief
Association.
Recommendation: Staff recommends that the following conditions be attached to the
permit:
1. The event shall be held as described in the application received
dated on February 16, 2010, except as may be provided by the
conditions of approval.
Page 1 of 2
07/28/10
2. The route and traffic control shall be approved by the
Washington County Sheriff s Department and a permit issued
by the Washington County Public Works Department.
3. Event organizers shall coordinate with the Scandia Marine
Lions Club concerning their use of the Community Center
grounds.
4. The Relief Association shall pay the $25.00 Special Event
Permit fee.
Attachments/ • Special Event Permit Application
Materials provided: . Flyer
• Route Map
Contact(s): Jeff Biebl, Fire Relief Association President
651 295-1573
Prepared by: Anne Hurlburt,Administrator
(Relief Association Fun Run Event Permit)
Page 2 of 2
07/28/10
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14727 209`h 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:
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Location address:
Date(s): �q - < < - �o
Event starting Time: p��p Event ending time: l c�U O
Set-up start date and time: p�t- � �-i O ���:-�-,
Dismantle by-date and time: 0�t-1�l - i� � /�fgovt
Anticipated number of participants and/or spectators: �,� -�5(�
If there is a fee or donation required as a condition of /�
attendance,please describe: �a� - � 3� �'r 11 i 5`fi'���o!^ -! .�P._
2. Attach sketch or site plan showing the location of the following as applicable:
� route(begi.nning/end, direction of travel, _ food concession azeas(cooking, serving,
traffic control points) consumption)
� ticketing/registration/entry locations _ alcoholic beverage concession area
_ entertainrnent 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
Ciry of Scandia,Special Event Permit Application,Page 1 of 7
3. Applicant information:
Name: Je� �',�( � Title: �v��,,� �c�,�7r,a�,-
Address: I.jo�v Sc�,a�odZ,ti., �1 r ( !(/
Phone: Lf 3 3-�-E 3 83 Cell: �� �t 5-i S � 3
E-Mail: S'cc,,,uQ�..�-s�Q 5(�'i�( cr -�r�i-w-�,..t. .,a f
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Affiliation/organization: S�� �"�,.p ���
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 � No
If no,provide contact information for person who will be the
responsible party on the day of this event
Name: Title:
Address:
Phone: Cell:
E-Mail:
4. Entertainment:
Describe entertainment plans. If there will be music, sound amplification or any other noise impact,
please describe including the intended hours.
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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 traftic 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 sunounding area after the event?
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Name of trash/recycling hauler: ..�.�l�
10. Lighting:
Describe any temporary or permanent lighting that will be added for the event.
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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.
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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 pernut 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.)
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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 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:
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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.
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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 pernut 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 S 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 pernut for a special event conducted on public property or public
streets or parking lots,the pernut 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 eligibility for 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:
�---� �
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Signature: �-�-/:- Date: �- �CG! i D
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
Regularions 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: 2 � /� � �l)
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City of Scandia, Special Event Permit Application,Page 6 of 7
-SPECIAL EVENT SPONSOR-
RELEASE AND INDEMNIFICATION AGREEMENT
CITY OF SCANDIA, MINNESOTA
TffiS IS A RELEASE OF 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:
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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 further
acknowledge that such risks may include but not be limited to bodily injury,personal
injury, sickness,disease,death,and properiy loss or damage,arising from the following
circumstances,among others:
(Special Events Permit Holder initials here)
B. If required by this paragraph,we agree to require each participant in our special event to
execute a RELEASE AND INDENiNIFICATION AGREEMENT for ourselves and
for the City of Scandia,on a form approved by the city.
Participant Release and Indemnification required?YES�NO_
(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.�
1
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 here)
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.
(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
claim 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 here)
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 IniNals here) �
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
responsibilities hereunder are fully 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,TffiS 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:
��-� �;e� �
PRINTED NAME AND TITLE OF PERSON SIGNING ON BEHALF OF SPECIAL EVENTS
PERMIT HOLDER:
Name___`J c-1'� � ;P do j
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Title I r+ts�c�1�' c5 t17 �a�� ���.5oc_cw—�'�v v�
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Signature ,
Date �-`f�3- �D
3
SCANDIA FfRE DEPARTMENT
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RELIEF ASSOCIATI�N 2010 FUN RUN
WHEN: Saturday, September 11, 2010 - Rain or Shine
TIME: Check-in begins at 7:00 a.m.
10K race begins at 8:15 a.m.
5K race begins at. 8:30 a.m.
WHERE: Warming house - next to the Scandia Community Center
th
14727 209 Street North
Scandia, MN 55073
Everyone is invited to the second annual Scandia Fire Department Relief Association
Fun Run! Come and take in the beautiful countryside, get some exercise and support
the Scandia Fire Department Relief Association. This event offers both a 5K (certified)
and a 10K. All proceeds will go directly to support the Scandia Firefighters' equipment
needs. All participants will receive ribbons; with the top finishers of the 5K and 10k will
receive medals. All participants who register in advance are guaranteed a t-shirt. There
will be some additional t-shirts for participants that do not pre-register.
Award ceremony immediately after the race has finished.
Registration can be done online: www.active.com (keyword: Scandia)
Remember to stay and have fun at the Scandia Taco Daze celebration, featuring
tacos, parade, live music, farmer's market, beer garden, dodge ball tournament, arts
and crafts, and so much more!
This event is sponsored by the Scandia Fire Department Relief Association.
REGISTRA7101� FORM
The Scandia Fire Department Relief Association Fun Run/Walk will take place rain or shine on
September 11, 2010. Both the 5k and 10k races will start just south of the warming house on CR-3.
No pets, rollerblades, or skateboards will be permitted.
Participant Information: Choose one event: 10K 5K
Name F M
DOB / /
Address City State
Zip
Email @
Circle t-shirt size: Youth M Youth L Adult M Adult L Adult XL Adult XXL
Non-Refundable Reqistration Fee:
Pre-registration: $20.00 for 5k, $25.00 for 10k. Day of race $25.00/$30.00
Amount enclosed $
Waiver and Release
I agree that if I participate in the Scandia Fire Relief Association Race/Fun Run, referred to here as the"Event"or use any
Event facility or Event Premises, I acknowledge it is a physical activity and do so at my own risk. I agree that I am
participating in the Event and using Event facilities or premises and assume all risk of injury, illness, damage or loss to me
or my property that might result, including, without limitation, any loss or theft of personal property. I hereby consent to
receive medical treatment in the event of an injury, accident and/or illness during the Event. I agree on behalf of myself
(and my personal representatives, heirs, executors, administrators, agents and assigns)to release and discharge Scandia
Fire Relief Association, the Scandia Fire Department, the City of Scandia, volunteers, affitiates, all Event sponsors (and
their affiliates, employees, agents, representatives, successors and assigns) from any and all claims or causes of action
(known or unknown) arising out of their negligence. I acknowledge that I have carefully read this Waiver and Release and
fully understand that it is a release of liability. By my signature below, I am waiving any right that I may have to bring legal
action to assert a claim against Scandia Fire Relief Association, the Scandia Fire Department, the City of Scandia,
volunteers, affiliates, all Event sponsors (and their a�liates, employees, agents, representatives, successors and assigns)
for their negligence. No pets, rollerblades or skateboards will be permitted.
Signature Date
(Parent or legal guardian's signature required if under 18 years of age.)
Return completed and signed form, along with check or money order payable to:
SFD Relief Association
Attn: Jeff Biebt
15040 Scandia Trail North
Scandia, MN 55073
This event is sponsored by the Scandia Fire Department Relief Association.
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