7.a)2) Vintage Snowmobile Event ApplicationS A NDIA
14727 200 Street North
Scandia, Minnesota 55073
(651) 433-2274 wwtiv.ci.scandia.mn.its
Special Event Pen nit 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:
Ul
n4 rl- '�;'T IJ1�in ,ld, " n(yu IVyl.ohi1'Q' E1j'P_11j
kq& lu►1) b, ikg arid-�ntr4lA it U1'r4a(V <'-a WM0bi tJ6 Q skaw wft 1�24
rcl f lau winr is . Edmn.-k Cua Os6 brig �f_m.s 4c swa p -rRP c . [zL ijz 9tA --k
Ltf anal Shar-c I iris of LtLky_ -for Awce ujctnArn, 4c O-Ze -4cw .
Location address: Luker SAO— tr U'}S C(.rkf? b n I il/lairri-e_ Lake
Date(s):
Event starting Time: ID am Event ending time: 5 prn
Set-up start date and time: Urika.rc� [ 1 ) CL q..y
Dismantle by- date and time: �Ycky*L ,LU Rf 15+ , (o em
Anticipated number of participants and/or spectators: �io — l oo
If there is a fee or donation required as a condition of
attendance, please describe: ( (Xu, -1 OCR
L A K,e 4VS -30c a-'k or
2. Attach sketch or site plan showing the location of the following as applicable:
route (beginning/ end, direction of travel, X food concession areas (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 of Scandia, Special Event Permit Application, Page I of 7
3. Applicant information:
Name: `Inao- Mai +Z62_ Title: FundyatStrtqlE►t-i Ooardo-Aor
Address: � g�[AI 4VP_ �S, 5camas a__ , A&3 ALL rl
Phone: Cell:
E-Mail: ICY\QrDIY° �� In�S�+rUIC�.l •Lom
Affiliation/ organization: j� yy� �{ rZtn�2 L O ke I sSDC t a-�( on
Are you an authorized applicant for this organization? Yes X No
Will this person have authority to cancel or modify event plans? Yes )1, 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.
i
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.
+wo per4_� 5 - ctm � R fresI) wL11 be to sh,cr-e_.
ReuP_ 1 Q k-e_ ct ccess . �eS-I-Yoom also in Oa,n4tticam.
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.
Lq,M
cu ea s
(fir, -�-e.
�cLk� i 4 � c u� � � ar �, n . I-F 4 h-e
\C e
S 1-65
41,aan
k 11 i I 1 t oor�a_s n
II-,,3r1��
7. Emergency/ medical services:
Describe measures that will be taken to ensure emergency vehicle access (police, fire, ambulance) to
the event area.
1r < weft_ no-i-Pu -)h� in acLUq rLcL trf -VKP- .L e.n f
8. Security/ crowd management:
Describe your proposed procedures and staffing for the event operations and crowd control.
LA,rti torn 46-e— ' i �r� ' L a- & on
SAa-4 mom V-t4s
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?
__-+\ clock arrouvvJ k� -eu-tkC,y\cl access Aa mcf& 41rorn4h,-P__ U,�_+s
-ever KttAC, A d'UM
Name of trash/ recycling hauler: '``e`�'
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.
W'0- U�L
SLd �P �P k 0a-e5 S f\Q a c c�AL(3aoi
is Yl-ef cLeJ
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.
�C,
13. Noise:
kn ll 1'Jrbrxo-k-a
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.)
kP- rnai If- v-ce k s in a a rzea ei 4—h� a.ke 4h cc� cE o els n'4 � a v,e
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
YM
15. Food and beverages: �f►
Will alcoholic beverages be served? Yes No
If yes, describe the type of beverages and the status of the liquor license:
No -�oex o o,r b-e u _cras wm h� m a V-,e or 1' - rn Sha 2e .
L— W-P_ _Ui 1 s 0 t"nA o a yt �i f cis hx t,t_a 31 -_-� 116=u,e
cru Auu,Aabt N Will food and/or non-alcoholic beverages be served? Yes
If yes, describe what will be served and any plans for cooking food in the event area, including fuel
source to be used:
0 - u. Ll 1 Cal f , v ur j � ' M CL A ke ) UeL
J�re_ l 5 -6cl ( le otnr4 I S prxIWL -- � a U C t 1
�nu. \ �pu (L (uk nc)
I
Has a license been obtained from the Washington County
Department of Health and Environment? (please attach) Yes No 4 L_
16. Other concessions:
Describe what vendors or concessionaires you will allow at the event, and how you intend to regulate
and monitor their activities.
R
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 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 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:
��LSignature. Gf 7ylDate: ) U
I request that my residence address and telephone number be considered private data.
My alternative address and telephone number are as follows:
Address: S` 1 f �`,,: !. r, f:� E. t J Cu nd trt Telephone: b5 ' L 7 O 8 f
- - 6S1- L133-115-b0
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: /o/ a-3 6ts
City of Scandia, Special Event Permit Application, Page 6 of 7
CERTIFICATE OF INSURANCE
T
STATE FARM FIRE AND CASUALTY COMPANY, Bloomington, Illinois
❑
STATE FARM GENERAL INSURANCE COMPANY, Bloomington, Illinois
❑
STATE FARM FIRE AND CASUALTY COMPANY, Scarborough, Ontario
[]
STATE FARM FLORIDA INSURANCE COMPANY, Winter Haven, Florida
[]
STATE FARM LLOYDS, Dallas, Texas
insures the following policyholder for the coverages indicated below:
Policyholder
Big Lake Marine Association
.Address of policyholder 12970 182nd Ave No, New Scanida Twnshp MN 55047
Location of operations
Description of operations Homeowners Association
The policies listed below have been issued to the policyholder for the policy periods shown. The insurance described in these policies is
subject to all the terms exclusions, and conditions of those policies. The limits of liability shown may have been reduced by any paid claims.
POLICY PERIOD LIMITS OF LIABILITY
POLICY NUMBER TYPE OF INSURANCE Effective Date ; Expiration Date (at beginning of policy period)
Pending Comprehensive V 05/11/2015 05i1 1 /9n1 r, BODILY INJURY
Ho Assoc Policy Business Liability
---.-....- ----.. ..------------ p - .
This insurance includes: ❑ Products - Completed Operations
I ❑ Contractual Liability
❑ Underground Hazard Coverage
❑ Personal Injury
❑ Advertising Injury
❑ Explosion Hazard Coverage
❑ Collapse Hazard Coverage
i❑
POLICY NUMBER
EXCESS LIABILITY
❑ Umbrella
❑ Other
Workers' Compensation
and Employers Liability
POLICY PERIOD
Effective Date ; Expiration Date
POLICY PERIOD
TYPE OF INSURANCE Effective Date Expiration Dale
Each Occurrence
General Aggregate
Products — Completed
Operations Aggregate
AND
PROPERTY DAMAGE
$2,000,000
$4,000,000
$4,000,000
BODILY INJURY AND PROPERTY DAMAGE
(Combined Single Limit)
Each Occurrence $
Aggregate $
Part 1 STATUTORY
Part 2 BODILY INJURY
Each Accident $
Disease - Each Employee $
Disease - Policy Limit $
LIMITS OF LIABILITY
eginning of policy pei
THE CERTIFICATE OF INSURANCE IS NOT A CONTRACT OF INSURANCE AND NEITHER AFFIRMATIVELY NOR NEGATIVELY
AMENDS, EXTENDS OR ALTERS THE COVERAGE APPROVED BY ANY POLICY DESCRIBED HEREIN.
Annual Premium: $500. 00 Paid in full If any of the described policies are canceled before
its expiration date, State Farm will try to mail a written
notice to the certificate holder 30 days before
Name and Address of Certificate Holder cancellation. If however, we fail to mail such notice,
no obligation or liability w I be imposed on State
and Additional Insured Washington County Farm or i e s,o repr ntatives.
14949 62°d Street North
Stillwater MN 55082 Signature honied Representative
Agent 05/15/2015
Title Date
Agent's Code Stamp
AFO Cdde //►�►�
NELSON INS. t GI iy INC. 3870
556-9lYI e.4 11-12-2002 Printed in U.S.A. S.W. MEMO, MN F728
-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:
(a ri�l to 4+h C)
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) 9 W
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)
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 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.
PRINTED NAME OF SPECIAL EVENTS PERMIT HOLDER:
�Y
PRINTED NAME AND TITLE OF PERSON SIGNING ON BEHALF OF SPECIAL EVENTS
PERMIT HOLDER:
Name LRC& Maaf7-lck'
r r
Titles r�f�t Sena, L- n aYtS1C
Signature
Date l % 1 1 'a6 l !�-
3