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9.a) apple Away 5k applicationI VAID SEP � A 2014 SCANDIA �a s C1T (OF S�1At�C 14 72 7 209" Street North Scandia, Minnesota 55073 (651) 433-2274 mt-mci.scandia.mmus 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: &6f kma t SK ('u1tkcbr\ ij ratfe Ayer,4-(,LL)tir1iw �q-r hoo C©cA( /vOaL is — A- AA 5k /tel110AX la QAI'Ch CACIA t741'�il' 'o0iim, to, (( (e PUL Location address: tCGt/im®�Gi*\ Altockm *20 qb Date(s): J Gt Ca /LL(Il _ Oc,&o6Pi qt -A, jol q Event starting Time: g 30ei m Event ending time: Set-up start date and time: 10/Lt h Ll 7.004/1 Dismantle by- date and time: Anticipated number of participants and/or spectators: 100 If there is a fee or donation required as a condition of 2 �� attendance, please describe: � J 2. Attach sketch or site plan showing the location of the following as applicable: X 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 _ fust aid facilities other as may be applicable City of Scandia; Special Event Permit Application, Page I of 7 A 5 73 3. Applicant information: Name: (jaw, w✓wcco Title: Address: 3H/q/ Krle /Ve 8/6,16A 41A/ S' Phone: 6 / --3V(25 Cell: G5/- L/O2-31/0,5 E -Mail: �'L''PCG:/L�Meg6(ldR'�.Gots'� Affiliation/ organization: vtimMe,Iar,'I-A1, !"IhSPiQ 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: 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. Two Mei imd ya/i ,`s 6(,AroomS rn 6aM.k1el�11rdQti /N,6eO ��`� f-oi'le&d-- Sink, f- t>o(tg6[e `let" iS 6o AvA,`la6(e F;r hse ()n H& 120 5t'e tilside Gave rde %Lo die Wnia fou e there ru,rlf be o i 6fe k,600o , 4P firer &1d OF �k no �kere ot`ff 6e bo�,( 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. f (4Lk fr (ol Ci¢5c�ro(,A ConMrM, Cin{+ra ZOO4�A�n� 5?065' llotwleeK r44&( 011 -AP W('11 /�,`r>ar_� Hlq�c 7. Emergency/ medical services: Describe measures that will be taken to ensure emergency vehicle access (police, fire, ambulance) to the event area. Eyed SERE m 4W Pjl mfe I. t'It Ce(I Phogf inti^ SG qll i'5 ��eedert 5K NW16 w,`ll 6V6 We, L144f- d/sen A�- al( 6e3- Air 8. Security/ crowd management: Describe your proposed procedures and staffing for the event operations and crowd control. fvkr people- w. 'I( 6e 56t'wk At tete %fW.44 cf,-f& -Por �(e 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? 1746 ft4J l ca4 a.f Etie, coMer er' Otc( Ajrt`n*- r`�CN Oy"borc 04e, fritS4 uiA f titt COraer dF bt^b(`(l AdAl4dx(,oro he Al Fvkr fr,451 cans PA mv6 foft{ ,4MMel�tard&l. 7o -L) (tee b(rac7fAs 6,,m'scoaa`s Name of trash/ recycling hauler: 10. Lighting: Describe any temporary or permanent lighting that will be added for the event. City ofScandia, 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. V 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. AMes6gfA� cj,`ll be- d{olie Pard Of -1.10R W AtcibeoK (acq( A paSf s >�� cup 1A cocof( bust'�ess 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.) The, oo t 0,r*, ta,`11 come koM,vb,,4>16 4-11o&-4&0 *er,n an G2e / icber c ShotW 40 exceed OGUA4ticL L.e,V613 14. Fireworks or pyrotechnics: Will any fireworks or pyrotechnics be used at the event? Yes No x If yes, describe in detail. Fire Department approval will be required. City ofScand,a, 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: 1.j Il be, 5e(-Vec( crECP f A1515le CCCq�� 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 No X 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 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. K 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 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 andprovide an alternative address and telephone number. Please sign below to indicate thatyou have read this notice: Signature: /�� Date: I request that my residence address and telephone number be considered private data. My alternative address and telephone number are as follows: Address: Telephone: Acknowledgementl 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: Q Z'0/ / City ofScandiq Special Event Permit Application, Page 6 of 7 MapQuest Maps - Driving Directions - Map Notes 1; mapquest This map doesn't contain any items. 4�47�C GF fvrt� /1 �`��5f rV m 1� 2 � IR1 5� - o>fbar+�gire j� Copast lzztt't' ""i urj;xr � Stv! Pah ' t © (t amuest. SOOOft 1000m W ®2014 MapQuest -Portions (5014 TomTc,0 4erms I len acv 022014 MapQuest, Inc. Use of directions and maps is subject to the MapQuest Terms of Use. We make no guarantee of the accoacy of their content road conditions or route usability. You assume all risk of use. %yew Term^ i ° U' J� 6c,rh6aXx cG� DD" 1lor l Gu y e,,tw to /�A of SK w" X i' http://www.mapquest.com/print?a=app.core.f3745633980147cfe67690cc Page 1 of 1 8/23/2014 APPLE AWAY 5k October 4, 2014 RELEASE AND INDEMNIFICATION AGREEMENT to be signed by participants A. By signing this RELEASE AND INDEMNIFICATION AGREEMENT, I hereby expressly assume all 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 ornot caused by the act, omission, negligence, or other fault ofthe Gammelgarden Museum/Elim Lutheran Church, its officers, its employees, or any other cause. Participant Initials B. By signing this RELEASE AND INDEMNIFICATION AGREEMENT, we further hereby exempt, release and discharge the Gammelgarden Museum/Elim Lutheran Church, its officers, and its employees from any and all claims, demands, and actions for such injury, loss or damage to us or to any thrid party, arising out of or in any way related to the above event whether or not caused by the act, omission, negligence, or any fault of Gammelgarden Museum/Elim Lutheran Church its officers, its employees, or by any other cause. Participant Initials C: We further agree to defend, indemnify and hold harmless Gammelgarden Museum/Elim Lutheran Church, its officers, employees, insurers, and self insurance pool, from and afgainst all liability, claims, and demands, court costs and attorneys fees, including those arising from any third party claim asserted against the Gammelgarden Museum/Elim Lutheran Church, 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 event whether or not caused by our act, omission, negligence, or other fault of Gammelgarden Museum/Elim Lutheran Church, its officers, its employees, or by any other cause. Participant Initials D. 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 Gammelgarden Museum/Elim Lutheran Church, its officers, and/or its employees, and that said Agreement is entended 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. Participant Initials E. Lunderstand 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. Participant Initials F. This RELEASE AND INDEMNIFICATION AGREEMENT shall be effective as of the date or dates of the applicable 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 transferee. Participant Initials PARTICIPANT. Phone