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7.a)1) Cub Scout Pack 173 Special Event Permit Application�""�, SCAN DIA .-.iiRl www 14711109 -Sew Yorrh Srondia. Minnesota 550-3 /0511433-1174 Special Event Permit Application INSTRUCTIONS Fill out this form completely, nem sign it and include all required anaclus. Ifadditional space is needed, aaach additional sheets. Submitto the Cir, of Scandia at least 30 days prior to the date of the event with the $25.00 permit fee. You will be notified m the time otapplication ofthe date for Cin' Council consideration ofthe request. 1. Name, purpose and description of event: Location address:�'�' ��/�`.ri.C. - 6 •( _�.i1�h�;Y iW.)r (isi 1(C 111 n( Date(s): c r? ( 5 Event sterling Time: r s_� Event ending time: Set-up start date and time: j z Dal Dismantle by. date and time: G) ( Vvi Anticipated number of participants and/or spectators: MO If there is a fee or donation required as a condition of 9 attendance. please describe: 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 participan& 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 CM,q(Sranem Special Erenr Permir Apefienrioe. Page 1 of - � N N L C O O. v a-' u'1 d a) of O ifT 7 aL+ m rr T ' i 7 3 CL m cu OO. L N Y a' y E 'N E O O C Y .i1 E O y, a.r O OU m m in w. (0 -0 N t `w c 'ova > ua 13,j a+ 0 a) — — L f0 0 0 3 fn 0 L ._ (0 010. O H > Q) _ (n C O o L N i a) N (0 w pO Q ILO yE o O N U C N.r O C -i.. w E w C N N L �O L .L O U Q a"I C C >1 a/ a > fo-M lWn a) "0 0 uu N fl U O N "0 _0 C C T wL 0 O E O a) C L yf/1 t v U C C O �j E U Vl i y L 0 al 0 L0 -FN cr- � Ln L a) o -0 -0 C 3 O O a)O N N OwE —_3C rt if1 flit a)C_'NO �G a 0 y Y Q O�.Q ^ V1 0 '- a E L s+ 7 �= O C 3 01 •a) p L y C N N N Q 7 6 E�m o 3orq +, L �srO.vo a d'0+ m ocv yv}v C sN Lf0 E (� lzaa E C O N 0 3 _o o1m >va m E (0 t' C C fY '— i w N m �"� U •a1 V1 O y = L C fn :e 3 U U •- m 00 ad (a 0 a,3 v �g�w m a) =1 (n 3 =_ ��LL�L o v0m }+ .N u OclCnTL O.�"NwL-+ 3 ~ L 0 v-.>"aU dNmoo=o mcg - a, moo f�a da �� (5 m r- �o�muw o o (DLnot ?� co o 0 o 0 v�� o+Pr 3 L c (Ln E r-Nvii+� L +' >� cu 0 CU p� m O C) Ln m>2 m L N L N N O O a O 0 f`) O C E j S N C f+'6 C O O m O d Y L vinic m- m 3 0 0 3 0 0" 0't'i c o 9 ? C N fn 0.2- w N a) o, u U u U V) V) O fa - p o ._ ._ u ._ . O O C C O T'0 a) f0 U LD '0> w °w ° Q,�m v o` o E rt" o E `m o E � v" �' o cj G•� 7 N`m ZC c - Lv1J LNJ U a O Civ -�- fn E��$tL°)� ami° o o ° O O a) Eo Lufno �! IA C 0) 0 LLN 'a' a) a) L � al ai V " 4- V) •Q d cJ N UOL!FnF F Z yLL LL p a� }' CL C (a a) .-i M V1 E O O E •- a) •� (n Q. a) L a) z V) L a) N L ++ Q VV (1 Li O CL ate+ N VI E ` ■ ■■ a) m "0 O m .� V ■ tin Lc3 LL Q. a �L .mmt w 0 # , Sl wm,e» ! I ].&}fo / ru OL . m\\=[ 2 \ § \{ /r \ & J / C: a) / & fa§///\ c W ƒ \�\\k ,g )�\k{ 0 U)6 C-07, 0 §00c �2E�°§ �.,.L=&°//t zmuzm I/\&32 # , Sl wm,e» ! I 3. Applicant information: Name: i Je--,Lt. _POJhe,i11 Title: Cl a)VYl(1 CA'- pGi x 177 Address: �QjJ? 01111JA :T4d N So and Io, dmN 1550173 Phone: DCII ' � .1-2 9 '� Cell: C?c)-! - 'W1 E -Mail: Affiliation/ organization: 'V it O CI 1 A G I l) SC Oi Lf6i RK(' K Are you an authorized applicant for this organization? Yes No Will this person have authority to cancel or modify event plans? Yes X No Will this person be present at the event and in charge of the event at all times? Yes_ (X 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. N Oyl(d 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. ► 0lyQ 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? � C k( -e P -)O - Y -Q Cf. — 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. Isle t Ina vg �;;r;; �(jnsc rJ 4ra i 14r fly- -411 , . 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.) N wac 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. ntiy City ofScandia, 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_x_ 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_X_ 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 /� 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. 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 that you have read this notice: Signature: 4.,so, A but, t, Date: I request that my residence address and telephone number be considered private data. My alternative address and telephone number are gals follows: / vl Address: (11�(X Qf ( d tV ck Telephone: 60 -OC [>_ VV\,N SSO-�-2) 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: A 0, a A i.tl, , i Date: /l (p • /V City ofSeandia, Special Event Permit Application, Page 6 of 7 -SPECIAL EVENT SPONSOR - RELEASE AND INDEMNIFICATION AGREEMENT CITY OF SCANDIA, MINNESOTA THIS 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: 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 property loss or damage, arising from the following circumstances, among others: (Special Events Permit Holder initials here) [,P 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 NO (Special Events Permit Holder initials here)_120_ 2 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) 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) hp - 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. fi— (Special Events Permit Holder Initials here) A 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) r`p 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 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. I j% (Special Events Permit Holder Initials here) r"r 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: !_._it 0 - Po+her,, PRINTED NAME AND TITLE OF PERSON SIGNING ON BEHALF OF SPECIAL EVENTS PERMIT HOLDER: Name hSot�, IP0+6m— Title 0 L.b 0WA� f- ?aC,K t q � Signature Certificate of Compliance Minnesota Workers' Compensation Law PRINT IN INK or TYPE. Minnesota Statutes, Section 176.162 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 of coverage, or the permit to self -insure. If the required information is not provided or is falsely stated, it shall result in a $2,000 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. no company name as YOUR LICENSE OR CERTIFICA7'%WILL NOT BE ISSUED WITHOUT THE FOLLOWING INFORMATION. Youlniust complete number 1, 2 or 3 below. NUMBER 1 COMPLETE THIS NUMBER 2 COMPLETE THIS PORTION IF SELF-INSU)4,ED: NUMBER 3 COMPLETE THIS I am not required to have workers' compensation Insurance coverage because: XIhave no employees. \ have employees but they are not covered by the workers' compensation law. (See excluded employees.) Explain why your employees are not covered: ❑ Other. ('d applicable) DATE Stat. § 176.041 for a list of ALL APPLICANTS COMPLETE THIS PORTION: I certify that the information provided on this form is accurate and complete. If I am signing oQ behalf of a business, I certify that I am authorized to sign on behalf of the business. \ 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 made available In different forms, such as large print, Braille or on a tape. To request call 1-898.342.5354 (DIAL -DLI) Voice or TDD (651) 297-4198. MN LIG 04 (11108) DATE (MMIDD(YYYY) CERTIFICATE OF LABILITY INSURANCE ' 93/01/2014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER 10UNTACT NAME: u1HBT Inc.PHONE FAX 3144 Walnut Hill Lane, 16th FI E AIL 770-1699 - -1600 AIC No: - )allas TX 75231 ADoREss: INSURER A -.Old Republic Insurance Co. 24147 INSURED Boy Scouts of America, National Council and INSURER B: All of its affiliates and subsidiaries including: INSURER c: . Northern Star Council, BSA INSURER D: 393 Marshall Avenue St Paul MN 55102 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 90231 R8R1 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR rypE OF INSURANCE ADDL INSR B WWD POLICYNUMBER POLICY EFF (MMADDrYYYYI POLICY EXP IMMIDDA`YrnLIMITS A GENERALUABIUTY xCOMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR MWZY301262 3/1/2014 3/1/2015 EACH OCCURRENCE $1,000,000 PREMISES(Ea occurrence $ MED UP (Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: x POLICY PRO- LOC JECT PRODUCTS -COMP/OPAGG $ $ AUTOMOBILE LIABILITY ANY AUTO ALLOWNED SCHEDULED AUTOS AUTOS NON -OWNED HIREDAUTOS AUTOS Eaacddent $ BODI LY INJURY (Per person) $ BODILY INJURY (Par eccidem) $ PROPERTY DAMAGE $ Per aecitlent b UMBRELLA LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ rEXCESSUAB OED RETENTION$ $ WORMERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNEWEXECUTIVE❑ OFFIGERIMEMBER EXCLUDED'! (Mandatory In NH) H yes, desNibeunder DESCRIPTION OF OPERATIONS below NIA WC STATU- OTH- I TORY LIMITS E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ E.L DISEASE -POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, B mare apace Is required) Certificate holder is named as an additional insured by vitue of a written or oral contract or by the issuance/existence of a permit or certificate of insurance but only with respect to operations b or on behalf of the Insured, or to facilities of, Or facilities used by the Insured and then only for the limits of liability specified in such contracttor the event specified herein. Northern Star Council's Pack 9173 will be holding its Youth Fishing Tournament on February 7, 2015 on Goose Lake near the City of Scandia. City Of SCandia SHOULD ANY OF THE ABOVE DESCRIBEQ POLICIES BE CANCELLED BEFORE 14727 209th Street N THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Scandla MN 55073 1 ACCORDANCE WITH THE POLICY PROVISIONS. ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD nameand logpafe registered-mtaFks.4f AWORp -., ,