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5.g) Pack 173 Ice Fishing Contest-Special Event Permit ApplicationSpecial Event Permit Checklist for office use only Event Name and Application Form and Attachments Signed application form Sketch/ site plan Workers Compensation Certificate of Compliance Release and Indemnification Agreement Certificate of Insurance uoszg. +0 ,V4-ij 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/ Sheriff's 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 of Scandia, Special Event Permit Application, Page 7 of 7 RECEIVED NOV 17 Z015 CITY OF SCANDIA 1�4 SCANDIA 14727 209`4 Street North Scandia, Minnesota 55073 (651) 433-2274 wwwxi.scandia.mn.us Special Event Permit Application r PAW Nau� 17 015 ITY Oi SCANDIA 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: Location address: Guos& Lxft Date(s): I ; o - 1 10 Event starting Time: Event ending time: i Set-up start date and time: —A Dismantle by- date and time: 'j ' 11 Anticipated number of participants and/or spectators: �an If there is a fee or donation required as a condition of attendance, please describe: I n P& V ► CAI I I'1 CA 01,,1 11 r1 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 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 first aid facilities other as may be applicable City of Scandia, Special Event Permit Application, Page I of 7 3. Applicant information: ii{' 1 _ 6 �1 } P '1 Title: Name: L, Address: " t U (I 4 ! f � TL 0 ' C 4�l f f i f j fl. Phone: �pS.1 { ti }� Cell: E-Mail: f `' Affiliation/ organization: -PA 115 SU1 dLG- CUb 566(11j Are you an authorized applicant for this organization? Yes No Will this person have authority to cancel or modify event plans? Yes V/ 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. 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. CAI Ord 11, J k dyy f i L 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. Pr► v-Ki inr„ Lvi I I Ie WaLi InkIt on lreP tX Zr� -I ti i(,k ( 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. �I 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? -1 r, n ®T 0� Name of trash/ recycling hauler: C 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. 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.) NIA 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 k 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. 17. Gambling: Will there be any gambling (raffles, pull -tabs, bingo, etc.) at the event? Yes No V 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 MIAWESOTA 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: Signature:R 1� I Date: I request that my residence address and telephone number be considered private data. My alternative address and telephone number are as follows: Address: . l%; �� (�L P I Telephone: fro Pal 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: � a P �-4� Date- k City of Scandia, Special Event Permit Application, Page 6 of 7 MN Washington_GooseLake_9708 725_0_0_l.jpg (JPEG Image, 727... httP://www.lake-link.com/images/-cnmagc V"uvlDu'_.,.. ACORO® DATE(MMIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 03/01/2014 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(ies) 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 CONTACT NAME: _ MHBT Inc. PHONE FAX 8144 Walnut Hill Lane, 16th FI M Lo, ext):972-7 00 lath, N61.37`1-770 169J . Dallas TX 75231 ADDRESS: NAIC # _ INSURERA:QId Republic Insurance Co... 24147 INSURED Boy Scouts of America, National Council and INSURER B: All of its affiliates and subsidiaries including: INSURERC: Northern Star Council, BSA INSURER D : 393 Marshall Avenue St Paul MN 55102 INSURERS: INSURER F : COVERAGES CERTIFICATE NUMBER: t102318861 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 TYPE OF INSURANCE ADDLISUBn POLICY EFF POLICY EXP LIMITS LTR INSR! WVD POLICY NUMBER MMIDD (MMID.D/VWYI A _ GENERAL LIABILITY _ MWZY301262 3/1/2014 3/1/2015 EACH OCCURRENCE 1 $ 1,000.000 X 1 DAMAGE TO R� EU COMMERCIAL GENERAL LIABILITY PREMISES IEa occurrence) S CLAIMS -MADE X I OCCUR MED EXP (Any one person) S PERSONAL & ADV INJURY S _ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMITAPPLILS PER: PRODUCTS - COMP/OP AGGS X PRO- POLICY LOC $ (_ AUTOMOBILE LIABILITY ( CO BIKED - UNIT JEa_ ANY AUTO BODILY INJURY (Per person) S ALL OWNED l SCHEDULED AUTOS AUTOS ! BODILY INJURY (Per accident) $ __ NON -OWNED 1 PROPERTY DAMAGE S HIRED AUTOS L._ AUTOS {Per accident) UMBRELLA LIAB OCCUR'. EACH OCCURRENCE EXCESS LIAB ! CLAIMS MADE AGGREGATE $ DED RETENTION S WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS' LIABILITY YIN ,, TORY LIMNS.;_ _: ER_ ANY PROPRIETOR/PARTNER/EXECUTIVE EL EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? NIA (Mandatory in NH) — - - - - -- E.L DISEASE - EA EMPLOYEF) - - $ If yes, describe under IS DESCRIPTION OF OPERATIONS below E L DISEASE -POLICY LIMIT I I l DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Certificate holder is named as an additional insured by vilue Of a written or oral contract or by the issuance/existence of a permit or certificate of insurance but only with respect to operations by or on behalf of the Insured, or to facilities of, or facilities used by the Insured and then only for the limils Of liability specified In such contract for 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 14727 209th Street N Scandia MN 55073 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD ONE FORM REQUIRED FOR EACH CONTEST ENTERED. EACH PARENT AND CONTESTANT MUST EXECUTE THIS APPLICATION. Part I As valid consideration for entry into and participation in activities (the "Activities") with the SCANDIA CUB SCOUTS PACK 173 - 2015 FISHING CONTEST, (collectively, "SCSP-FC 2015", the undersigned hereby enter into this RELEASE OF LIABILITY AND INDEMNITY AGREEMENT (this "Agreement"). 1. KIDS FISHING CONTEST: The SCSP-FC 2015 is a public event and reserves the right to extend or withhold an invitation to any Contestant. 2. ACKNOWLEDGMENT OF RISKS: The undersigned recognize and understand there are risks associated with entry into and participation in the Activities including, but not limited to, bodily injury or death, and damage to property or privacy rights. The undersigned further acknowledge that they will be liable for all damage to persons, livestock, or property that is caused by them or any persons (including, but not limited to, minors) under their care and control, and that arise out of, or are related to, the undersigned's entry into and participation in the Activities. 3. RELEASE FROM LIABILITY: The undersigned hereby RELEASE, ACQUIT, AND FOREVER DISCHARGE and WAIVE any and all Claims against any of the Released Parties that arise from or relate to their entry and participation in the Activities and agree not to sue any of the Released Parties. The undersigned agree that the Released Parties shall not be liable to them, their family, or their guests, for personal injury, property damage, or any other Claims arising from or related to the Activities. 4. AGREEMENT TO INDEMNIFY AND HOLD HARMLESS: The undersigned agree to INDEMNIFY and HOLD HARMLESS the Released Parties against any and all Claims arising from or related to the Activities —including, but not limited to all costs, expenses, liabilities, demands, (including attorneys' fees) ("Claims"), regardless of whether the Claims are found or alleged to arise in whole or in part from (1) any NEGLIGENCE, GROSS NEGLIGENCE, NEGLIGENCE PER SE, or STRICT LIABILITY, of HLSR or their present and former officers, directors, members, volunteers, affiliates, employees, agents and any other person, firm, or corporation bound to defend or pay judgments against them (the "Released Parties"); This indemnity includes without "-i`-- " --- for (ii) personal injury, death, intellectual property privacy Fights, dVfa:.a;io E, WF �«��v, 5. PHOTOGRAPH/INTERVIEW RELEASE AND INDEMNITY: The undersigned GRANT PERMISSION to be PHOTOGRAPHED or INTERVIEWED in connection with the Activities. The undersigned understand that photographs or interviews may be used by Released Parties or television, film, video, visual, or printed media. The undersigned agree to RELEASE and INDEMNIFY Released Parties for any Claims related to photographs or interviews by the Released Parties or any media. 6. MINNESOTA LAW AND ARBITRATION: The undersigned understands that this agreement shall be binding on their heirs, executors, successors and assigns, that the Agreement will be governed by the laws of Texas, and that jurisdiction and venue for any dispute regarding this Agreement shall lie in a State Court in Washington County, Minnesota. If any part of this Agreement is determined to be invalid or unenforceable, it does not affect the validity of the remainder of this Agreement. This Agreement controls notwithstanding any conflicting terms or conditions of any other agreement between the parties. The undersigned agrees to these terms and conditions and acknowledges receipt of this Agreement. SCSP-FC 2015 may require that all claims or disputes between Exhibitor and SCSP-FC 2015 and/or its agents, officers, directors volunteers, members and assigns, in any way arising out of or related to this Agreement, shall be decided by binding arbitration administered by the American Arbitration Association ("AAA") pursuant to the Federal Arbitration Act, 0 U.S.C., 1, et seq. and in accordance with the Commercial Arbitration Rules of the AAA that are in effect at the time the demand for arbitration is filed, unless the parties mutually agree otherwise in writing. The decision of the arbitrator(s), which shall state findings of fact and conclusions of law, shall be final, conclusive and binding on the parties and judgment may be entered thereon in the District Court of Washington 0rluri , -aci �i � :�U r ter) i ne i i I i i ii : o .3gi :iy -: 3 ac �i i a is � i ;8 i� � __ i IM; a.. final M'rese and Enciemnity agreement, that they we vole____ y itF � t��FLf! FL-�f rr cf eE -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) Vi 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 V 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) L1el 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) Lip 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) f _, _" 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) LP 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: PRINTED NAME AND TITLE OF PERSON SIGNING ON BEHALF OF SPECIAL EVENTS PERMIT HOLDER: Name Title Signature Date 3