9.a) Special Event Permit, Chikos, Ballfieldkw
S A L N -f D I_Zk -
14727 209`"' Street North
Scandia, Minnesota 55073
(651) 433-2274 ivit,,ir.ci.scandia.tnn.ns
Special Evefnt- 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 ol'application of the date for City Council consideration of the request.
-. . . . , . r I
Location address:
Date(s)-
Event starting Time:
Set-up start date and time'.
Dismantle by- date and time,
Anticipated number of participants and/or spectators:
If there is a fee or donation required as a condition of
attendance, please describe-
Event ending time'.
-7
I j
2. Attach sketch or site plan showing the location of the following as applicable:
route (beginning/ end, direction of travel, food concession areas (cooking, serving
traffic control points) sumption)
ticketing/ registration/ entry locations alcoholic beverage concession area
entertainment or stage locations
portable toilet facilities
fencing locations
parking areas for participants/ spectators
sign locations
speaker (sound amplification) locations
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 of Scandia, Special Event Pei-Init Application, Page I of 7
3. Applicant information:
Name: Title:
Address:
Phone:
E -Mail -.
Affiliation/ organization:
Cell:
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:
E -Mail:
ME
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
tempoEV/ polable facilities to be provided. Describe the source of potable (dr ng) water.
I
TV f , - - . — - - I - - - t - . - IXi- - - -
City qj'Scandia, Special Event Permit Application, Page 7 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.
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 -Lip of the site and surrounding area after the event?
Name of trash/ recycling hauler:
10. Lighting:
Descr* anyhemporaryI
orperi-nanent II I that will be added for the event.
City oj'Scandia, Special Event PerinitApplication, 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 buildin ion,
building _g or electrical permits that may be required for such construct'
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.)
14. Fireworks or pyrotechnics:
Will any fireworks or pyrotechnics be used at the event?
If yes, describe in detail. Fire Department approval will be required.
Yes No
City of Scandia, Special Event Permit Application, Page 4 of 7
15. Food and beverages: I
IL
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-.
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. � I I I
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 drdinance 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 on insurance
requirements. Please complete 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 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 PR4CTICESACTrequires that we inform you oj'your rights about the private
data ire are requesting on this form. Private data is available to you, but not to the public. 14,7e are requesting
this data to determine your eligibility for a permitfromthe City of Scandia. Providing the data may disclose
information that could cause your application to he 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 -iii/l he considered public data unless you request this information to be private and provide
an alternative address and telephone number. Please sign heloij, to indicate that you 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:
Acknowledgement/ Signature:
I hereby acknowledge receipt of a copy of this application form and Ordinance No. H 9, 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
Sign Permit
Liquor License
Lawful Gambling Permit
Washington County Dept, of Health and Environment (food)
Reviewed by:
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 oj'Scandia, Special Event Permit Application, Page 7 of 7
Certificate of Compliance
Minnesota Workers' Compensation Lai
PRINT IN INK or TYPE.
Minnesota Statutes, Section 170.182 requires every state and local licensing agency towithhold the issuance or
meD8vv8| of license or permit to operate 8 business or engage in any aoUvhv in Minnesota UDb| the applicant
presents acceptable avidoDCS of compliance with the workers' compensation insurance coverage requirement of
Minnesota 8b]tUteG, Chapter 176. The required workers' cO[DpenGgUOD 1OsunJnCa information is the name of the
iDsU[8DCe CO0pgOV' the policy OuOlbS[. and the dates of coverage, or the permit to self -insure. If the RaqUjr8d
information is not provided Or is falsely stated, it ah8|| result in 8 $2.000 penalty assessed against the applicant by
the commissioner Qfthe Department ofLabor and Industry,
Avalid workers' compensation policy must be kept in effect at all times by employers as required by law.
BUSINESS NAME (individual name only ifnocompany name used
(doing business asname) (it applicable)
BUSINESS ADDRESS (PO Box must include street a
NUMBER 1 COMPLETE THUS PORTION IF YOU ARE INSURED:
INSURANCE COMPANY NAME (not the insurance agent)
[:] I have attached a copy of the permit to self -insure.
NUMBER 3 COMPLETE THUS PORTION IF EXEMPT:
I am not required to have workers' compensation insurance coverage because:
| have no
E]|have employees but they are not covered bythe workers' compensation law
excluded omp|oyooa.)Explain why your employees are not covered:
______
L|CEN8EORPERMIT NO(if applicable)
(See Minn. 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 on behalf of a business, I
certify that I am authorized to sign on behalf of the business.
ANT
M
NOTE: If your Workers' Compensation policy is cancelled within the license or permit period, you must notify the
agency who issued the license resubmitting this form.
This material can be made available in different forms, such as large print, Braille or on a tape. rorequest, call 1'oou-342-sma4(mxL-o1-;Voice mr
Too(oa1)zy7-41oo.
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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)
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)
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)
I
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 OF 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, njury, 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 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.
(Special Events Permit Holder Initials here)
2
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.
PRINTF NAME OF SPECI L EIJYENTS PERMIT HOLDER:
PRINTED NAME AND TITLE OF PERSON SIGNING ON BEHALF OF SPECIAL EVENTS
PERMITHOLDER:
Name
Title
Signature
Date
3
Lei tj " NEW
AN ORDINANCE ESTABLISHING RULES AND •
FOR SPECIAL EVENTS
The City Council of the City of Scandia, Washington County, Minnesota hereby ordains'.
Section 1. PURPOSE. The purpose of this ordinance is to protect the health, safety and welfare of
the citizens of the City of Scandia by regulating the time, place and manner of special events and by
establishing permit requirements for conducting such events.
Section 2. DEFINITIONS. For the purpose of this ordinance, the following definitions shall apply
unless the context clearly indicates or requires a different meaning:
APPLICANT shall mean any person or organization who seeks a permit to conduct
or sponsor a special event within the City.
AMPLIFIED EVENT shall mean any special event that includes electronically
amplified music and/or voices.
NON -AMPLIFIED EVENT shall mean any special event that does not include
electronically amplified music and/or voices.
SPECIAL EVENT shall mean an outdoor gathering of at least 100 individuals
whether on public or private property, assembled with a common purpose for a period of
one hour or longer but may not exceed twelve hours in duration; except, that events held
during the two-day Taco Daze community celebration shall be considered one event.
Special Events include, but are not limited to concerts, theatrical productions, public dances,
fairs, carnivals, circuses, parades, flea markets, auctions, marathons, walkathons, festivals,
races, bicycle events, celebrations, or any other gathering or events of similar nature.
Special Events do not include events that are not open to the public and held on private
property such as graduation parties or social parties.
Section 3. PERMIT REQUIRED. No person shall hold, conduct or participate in a special event
within the city unless a permit has been issued for such event upon timely written application made
to the city.
Subdivision 1. Application for Permit. Each written application for a special event
permit must be made at least 30 days in advance of the event's proposed date in a form prescribed
by the City Clerk. This application period shall not begin to run until a complete application has
been filed with the city. A fee, as established by City Council resolution from time to time, shall be
paid to the city along with the completed application form, In addition to the fee, the applicant shall
pay all additional costs incurred by the city as a direct result of the special event. Failure to provide
a complete application or to pay the fee, as herein required, is sufficient reason to deny the special
event permit.
Ordinance No. 119
Page 2 of 3
Subdivision 2. Issuance of Permit, Conditions. Special event permits will be issued upon
City Council approval, The Council may attach reasonable conditions to the permit as are deemed
necessary to protect the health, safety and welfare of the community and of event participants. Such
conditions may pertain to any of the following:
a) Location and hours during which the event may be held;
b) Sanitation/availability of potable water-,
c) Security/crowd management-,
d) Parking and traffic issues',
e) Emergency and medical services',
f) Clean-up of premises and surrounding area/trash disposal-,
g) Insurance;
h) Lighting;
1) Fire service/safety;
J) Temporary construction, barricades/fencing;
k) Removal of advertising/promotional materials;
1) Noise levels;
in) Alcohol consumption;
n) Notification of residents or businesses"
o) Any other conditions which the Council deems necessary.
Subdivision 3. Exceptions to the Permit Requirement. The permit requirement
contained in this ordinance does not apply to the following:
a) Special events sponsored and managed by the city',
b) Funerals and funeral processions,
c) Events on the grounds of any school, community center, museum, place of worship,
conference center, stadium, athletic field, arena, auditorium or similar place of assembly
when used for regularly established assembly purposes.
d) Events for which the City has issued a Park User Permit as provided by city ordinance.
e) Auctions ending before 8:00 p.m.
Subdivision 4. Restriction on Number of Special Events. No more than four amplified
events shall be permitted at one location in any one calendar year. There shall be no limit on the
number of non -amplified events.
Subdivision 5. Noise Restrictions for Amplified Special Events. Special events shall
comply with all applicable noise ordinances, except that amplified sound audible at the property
line may be permitted until 11:59 p.m. on Friday and Saturday nights
Subdivision 6. Denial of Application. A permit may be denied based upon a
determination that:
a) The event would endanger public health or safety-,
b) The event would unreasonably inconvenience the general public"
c) The event would unreasonably infringe upon adjacent property owners' rights-,
d) The event would conflict with another proximate event or interfere with construction or
maintenance work,
e) There are not sufficient safety personnel or other necessary staff to accommodate the
event;
Ordinance No. I t9
Page 3 of 3
f) The applicant has violated a condition of this ordinance or a special event permit issued
to the applicant within the last 12 months;
g) The property on which the event is to take place or the owners of the property on which
the event is to take place is delinquent in the payment of property taxes, assessments,
employment taxes or other financial claims of the City and or other public agencies,
h) The applicant has failed to present acceptable evidence of compliance with Workers'
compensation insurance requirements, as applicable.
i Other issues in the public interest were identified by the city council.
Subdivision 7. Indemnification and Insurance.
a) The 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.
b) 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.
Section 4. PENALTY. Any person who violates any condition of a special event permit or any
provision of this chapter shall be guilty of a misdemeanor punishable as prescribed by Minnesota
State Law. Enforcement of this ordinance may, at the Council's discretion, take any of the
following forms:
a) Citation/criminal prosecution"
b) Injunctions, declaratory judgments or other civil remedies,
c) Permit revocation, or
d) Disbursement of persons gathered.
Section 5. EFFECTIVE DATE. This ordinance shall be in full force and effect upon its adoption
and publication according to law.
Passed and adopted by the City Council of the City of Scandia this 1st day of September,
N=
Dennis D. Seefeldt, Mayor
Anne Hurlburt, Clerk/Administrator