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5.i) Staff Report-Scandia-Marine-Lions Taco Daze Special Event Permit . � , ��. :,��%.. SCANDIA Stuff Report Date of Meeting: July 16, 2013 To: City Council From: Brenda Eklund, Deputy Clerk Re: Scandia-Marine Lions Special Event Permit Agenda Item #: S.i ) Background: Taco Daze will be held on Saturday, September 7, 2013. The Scandia-Marine Lions Club has applied for a Special Event Permit for this community celebration under the provisions of Ordinance No. 1 15. Issue: Should the Council approve a Special Event Permit for the Scandia-Marine Lions Club Taco Daze activities on September 7, 2013? Proposal Details: The Lions permit covers the parade, the activities occurring on the Community Center grounds, and the Gammelgarden "Running of the Meatballs". The Gammelgarden Museum will need to apply for a gambling permit for this event. The Boy Scouts are responsible for taco sales inside the Community Center. The event application describes the planned activities. Events at the Community Center begin at 9:00 a.m. and end at 6:00 p.m. Outdoor music will be provided by a DJ from 1:00 to 4:00 p.m. New this year will be a beer garden within a roped off area south of the old maintenance garage (a separate license for liquor sales has been applied for). An antique car show will again be held in the parking lot, so parking here will be restricted, although there will be reserved space for emergency vehicles. Shuttle rides from remote parking locations will be offered. The Lions will need to obtain a permit from Washington County for the parade along Oakhill Road. The Special Event Permit application has been reviewed by the Maintenance Superintendent, Fire Department and Police Deputy. Fiscal Impact: None Options: 1) Approve the Special Event Permit for the Scandia-Marine Lions Club for September 7, 2013 during Taco Daze with the following conditions: • The event shall be held as described in the application received on June 25, 2013 except as required by the conditions of approval. • A parade route permit shall be obtained from the Washington County Public Works Department and all conditions shall be complied with, including the hiring of off-duty officers for traffic control and posting of signs as recommended by the Sheriff s Department. • Parade participants shall not use water cannons or similar devices on their floats, or throw items from floats that could endanger the safety of parade watchers. • Both sides of 209th Street between Oakhill Rd. and Olinda Trail shall be posted "no parking." • Parking in the west bay of the Community Center parking lot may be restricted to the antique car show, official vehicles and handicapped parking. Access and circulation for emergency vehicles to and through the parking lot shall be maintained at all times. • The location of any tents, stakes, signs etc. shall be approved in advance by the Maintenance Superintendent. Event organizers shall request any utility locates that may be required. • Any signs or banners shall comply with the Scandia Development Code. • Any vendors shall possess a sales and use tax permit if required by Minnesota law. • There shall be no animal rides provided by any vendor on the Community Center grounds. • The required certificate of insurance, naming the City of Scandia as an additional insured, shall be submitted prior to the event. 2) Amend conditions listed above and then approve. 3) Do not approve the request far a Special Event Permit. Recommendation: Option 1. Special Event Permit Checklist for office use only �a �v ��Ze. � 0 � 3 �- 7- 13 Event Name and Date Application Form and Attachments ✓ Signed application form ✓ Sketch/site plan ✓ Warkers Compensation Certificate of Compliance ✓ Release and Indemnification Agreement Certificate of Insurance �i�. ;'.-;�� '" ` �: � Other Permits/ Licenses as Applicable _ � �l. Building Permit Sign Permit Liquor License i,� ��t�'���' SQiy� -�v �-� 7-17 -13 Lawful Gambling Permit Washington County Dept. of Health and Environment(food) Reviewed by: ✓ 8b1�(�171�anc� C'nc�P Fnfnrr�+*��:*n,--ff;=;aj '�A'.vwr�n4vY`!�. �l�i�I r���%r`1Llv+"1 � u ¢,� 'r` �3 ✓ Fire Department �.� � Police/Sheriffls Department ✓ City Administrator City Council Review/ Permit Issuance 6- 2 7- / Date application found to be complete - � � 3City Council Meeting Date Approved V Denied Resolution No.: 7� ( 7"/ � Transmitted to applicant Ciry of Scandia,Special Event Permit Application,Page 7 of 7 PAID '.�" K ,. JUN 2 5 7013 � � �- ��.�.������ C1�O SCANDIA . . 14727 209'h Street,North Scandia, Minnesota 55073 (651)433-3274 rvivii�.ci.scanc�ia.nan.z�s 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: , �j�, ;; . � ,,.�. ;� �-'��,` �.. �,� i,.:�-'-�,,-t'9,�.�u.�r �, �;,y �—' �:.%�Y'j::..:2i7'`'r }� ✓�,. � ✓ �"i, � ����. ;i jy ' j � �I J l .:�"�i/"�:% �l '�'YI ��/l���� �i`�i — i .s'y�y, .T J//" ��_ y" :�'y'�✓„" v / „ a r i , � > > � f ✓ r—� ' \ % � '�/ './�—�'T � � „�(+�1' ����r :�/� J-:�� �;i .� /`�-i�' �.r y�./ .�� � :,> l � � � �� �� ,%._ i ' ,i -1 '� >�� ri `i Location address: �:��.� :�d %� �yr ;�'���!�; %:'���' ;%:r�. %7��--�''��'-T��.'�^��� �, , Date(s): � [� �' � � , __ � r � : , Event starting Time: '�' ��^��-- Event ending time: �,, " �.�Y� Gr / j � � / l'! ° Set-up start date and time: - (��a t�� .X/��' � /A� Dismantle by-date and time: �-1 �� � � ; ��`�_ ' r Anticipated number of participants and/or spectators:�-f,s, �,�� ,,. �i�,-;�,.,-�:, ��, � If there is a fee or donation required as a condition of ;� � , , •� attendance, please describe: �-� �,-� '�.�: � ;..,:- e ;, � ✓ 2�ttach 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) con mption) �...��� ticketing/registration/entry locations �alcoholic beverage concession area ntertainment or stage locations �other concession areas portable toilet facilities / size and location of any tents or structures fencing locations � trash/recycling receptacle area :s�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 1 of 7 3. Applicant information: ,�-_ ' � / /-j�. -" '' ; _ ��- = ; � � ,N Name: .'' �'�;; .� �,..�;-� %:--;'- Title: �- :.:•�.�`�^�''s--`�'�',,�-..-,- ;°5 =' � � : ,� � �-r � � ; ; ,:: � . /��� � Address: � �/.� �;'� ;y= � d7✓r' ji i �'�:�q� :� r�� �1/ - �. ;� Phone: 'L✓-.��� =j��—'�"'�'� " Cell: � � �j .� E-Mai1: �� I :�� .�:�-�;�Ji� i ?.��":�" � .- :�� �� '_ � , / , Affiliation/oroanization: � � '� � �' yj�-r 4 b �.� ✓✓L: 'r� ^i � ��%i/'��.:/� s� �� ,�:{ SI' a''�t:r31' / 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: �� VGLh ��{-y� Title: .I- ��e � , d��-v --��✓�-� Address: 1� ��� j ��"�� �l�/t,� ����ih�,�,��x/ .f�v� Phone: �C S�.� ��,�� ,t 7;� � Cell: E-Mail: b ✓ � �/�`t�i� �/�ci �, '��� 4. Entertainment: Describe entertainment plans. If there will be music, sound amplification or any other noise impact, please describe including the intended hours. � �c� � � c��, Q'w �, �.✓ ,� � � � � � r� � �e ��, �c� << j — �1 -�-- 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. ° 'r ,� f,r � �-� � L', � � '� 2 � r � / ��� `"�'�; �/'�i�i c� � � ,"— �� %,✓ %'I i_! �% � l �rL �- Lt/;'� /�a ;;�ry.�— .��.Ci � � � � /.'..L-.'..«�l�%�d '% /.�i .�' %- ` �+� �-t� /'�„/� '� �'y,�; �"�bs� �] %'� � ✓� '�� � /' � �i ' /� �':�%`-�'°,,�.�f,1/�+'Y /J�/��..r' „r�r.�'a..i v'— ''� �✓�'i`':�'�%y�(:i ?,e�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. �-..� /, �', ,� � -� " ' � .=% ,�- ,'3 r;. � r, �r � -� ,✓ r? •Y </ �� �': '✓` v, � � i r 1 �::✓'./iY �s i- �.���Y y'� 'i T� �1 ��i�'T.���. -'J/ �-�� /"'L7� - '' b 1 "'TX/r .��Y� Le%� ✓ �,.%� ��iry`%�r''�A'/:i-"17 ."7`!� "),'r �6�/+� i,��.�/ ✓�.CitG �•✓'� � %f''J %����--�_ � �"�iL-C'i�" ' ✓- � Y`�' ,i��'a� :—i'✓i �/"f"-y',�„r �� -�,,. /., �- ��_ , 7. Emergency/medical services: - Describe measures that will be taken to ensure emergency vehicle access (police, fire, ambulance) to the event area. ���✓� '..,y',`%=rr �'"�/:i�'.,��'T' �=� °-�'-'�' �,7-r�_.,%�� �� �%� �il�/�,�; "� ,J ��� � ,,,� ( �:i��i's�',�'�•"°-�a. y,' ���v�^�.�y�/� � � ,;� / �� .�l�"�,-�,�, .�r.�^�y � � -- r'"' � ���? ��r/�-u�.x�✓� s'�"''��'�� �j .i .i�n s�/��' � ,�% %� �.� v°'�--s^: ��—��' - � i w:.+;�� 8. Security/crowd management: Describe your proposed procedures and staffing for the event operations and crowd control. %�/ ..l�'t'; �/r 'I - " /�'�I.�l ✓F ✓ ;r' '"�•'�-��✓,;-� � '�C��i'��i�.7��:X��`� ✓�✓�'`r -'s'�,,'�!`-'�'� i'✓�"�'' �r�y�.c/� � ' / / /.. � ��._ ��_"� ��`y.✓'.'r�- �� ,, ���,._/�:J' j/ � y � !.�-''"J "�y ���. � ��� ;` �' t .. } ' ✓ �� , ; � ��%i_.� :.a' '..�%i';.a� 3 :��i _� 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? ,��i �� � �- / �,��''��'��J �.i�-�-y.� �`� �!1.��'f �v�';J �v�'w'�'�'�.�'. � , ; �' :1J �� �, �, nJ� l �' :� � � ,,�s'�i,..� r� -''� "'ti`. r ''� �,_/l ,J�' f�s � �%�'�� / /� i/� ��+� �- '_ _ Ol � V � . — 1 � . , ,, � ; � �, , � , , , i , � ;� ���� o ��� � � � :� � � �.�� � '' r� r � i ��� . , /y � Name of trash/recycling hauler: ��/ � ' '' ��,�'.;��,�=�:�,,� ;�:�_,�� `'� 10. Lighting: Describe any temporary or permanent lighting that will be added for the event. .�1��-=—c���_ - � City of Scandia, Specia!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�, a. /` � �, � ' , � '% o � G � .J i = �+.�� �; �;� "�'� ::,�''✓ '7 y�.�-�., �:� ,;+�"S� -� �2 /�� �" ' ''�d a't .%� � � 7 � r lI �, r��/ y'��"'_6--ril y/ �L�'-,�/"a-''`a� ./��i ��j L � t���� %�(—� ��!'�� K/G.l��� (.t� t�� � ,.� � ✓ta U+G � O J�� �ic.�� �►� 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. ,� �- � � ,. �" e 1 / //I ..%��-Y/ � �'%' ,A!�6;%'.G%/� ,9 `���j��, �:�'�.� r ;��_..%�� �y �-CJ /�� ,? :f� _q f, �'`�� /✓"��? r � 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� _ �• cT - ,��-�' ;' � �� ��� � � � ,� ,��,,.� �-�„��� . �IiL% ! �Y Y�� i.J� � �i%%��/-- � // ;�W� . , '�+ � i 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. Ciry of Scandia, Special Event Permit Application, Page 4 of 7 15. Food and beverages: ��ill alcoholic�e��era�es be seived? Yes_�%_ No_�� If'yes, describe the�pe of bevera�es and tlie stat�.is of the liq�xor license: o � � ��r._�_-�t'_'�t�_ �r.__��L'�r,�a-=--��'_�'Z"��--����''tl��� _. . _ _ .._. . . _�.. __...._.. .._...._. _.._��__ .. .__�.__ __��....__-__. .__._.._.� __�.v..._ ._._._ .. .. .. ._... _� �__�._. .._ ___..�_._._ Will foc�d ar�cU'or nai7-alcoholic beverages be seived? Yes �! No If y�es, desc��il�e���t;at t�ill be seived and au}�plans for coc�laug fovd in the evei�t area,irtcludirig fiiel sotu-ce ta be�ised: . ' - �, ���... .�r a.r,.�. . t�1�l _..��..__ ��ivYih _ __�_ .... � _�s�_�.. ..4.�.G�_.r.��m� ..�_�!"�_ �p ��j � .;. t��������_...1�►�c�_,...I'�''+��.1��lr���_�__v...._,�J-��'---���.J�..��?`z'����_,� .._ Has a lice�ise been abtaiciecl fi-om the Washi�igtoii Counh- Depart�neiat of Health aitd E�ivironi�ient? (please attncli) Z'es � No 16. Other concessions: Describe w11at veiidc�rs or concessionaires you will allo�v at the event, and how you intenci to regulate aud inanitor theu�activities. 17. Gaml�ling: Will t�zere be�yr ganibling(raffles,pull-tabs,bi��go, etc.) at tiie event? I'es No If}res, � lawfi�l garr�blin��er�nit will be i•equired as provided l�y� state Iav�r and Scandia{)rc�i�r�ai�ce Nn. l OQ. �escribe t�e�at�bling activity and tlie�tatus of the�arnbli�ig pen�it. �/ . h� ��'yh-�, � �l' �✓��7•�- ��'J�.L� t,�c;t�-- �//���,- -e��in-�t -�-�T-e-�;� �.--�.1 `)'� '� I i�,-�A iS � ��n�''f�—�G �l� , ��_,._��✓G- ..� � � �,,� ..7�/ --�-� , . . .... . .� . . _..�� . ��_�..��.Cr r .... .. . Y r 18.R'orkers compensation compliance: In accordance uritli��Iii�iesota Statzites all a�plicants for license aiicl perniits tn operate a business iu Minr�esota int�st subixiit acceptable evideuce uf carnpliance witt����arkers' conip�zlsation instu-ar�ce reqiiireinents. Please conaplete tlre certificate of contplia��ce a�rd attacti to this applicntion. C'rtv ojSc•cnrd�n, Sj�eerctl Eve»r Pe+•tni�.4pplrcntrolr,Pnge?of :' 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 PRACTICESACT 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 eligibiliry for a permit from the Ciry of Scandia. P��oviding the data may disclose information that could cause your application to be denied. You are not legally reguired 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: �'j,�,�; ��,,..`/'��''.�.�� Date: <.���i1�LL.��,�i �' , ! � I reguest 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. 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: -�'�.�%J—�'' �,.�i� Date: �y►-��i�/ ,� � � - City of Scandia, Special Event Permit Application, Page 6 of 7 2413 Scandia Taco Daze Event activities ]. Arts & Crafts displays from local artists 2. Kids games on the grass on side of ice rink 3. Music provided by a DJ, west side of parking lot, 12 noon to 3:00 4. Antique Car and Tractor show, Community Center parking lot 5. Running of the Meat Balls (golf balls) sponsored by the Gammelgarden Museum (just prior to the parade at approx. 1:15 to 2:30) 6. Annual Taco Daze Parade— 3:00 to 4:00 The parade route will be the same as in past years. (see copy of route map attached) 7. Food - a. Tacos served by the Local Boy Scout Troop starting at 11:00 b. Soda and water will be available for sale c. Cheese Curds, Corn Dogs, and Fry Bread served by the Scandia Marine Lions Club 8. Beer Garden—will be located in the tent in the roped off area on the south side of the Scandia Maintenance Garage ------ _.. � _ __` uo►me�� ��,. �`""° \ �<.. � s.aRdb r,��hwy��� � �.�� s,� �� � .,A.,.�.�,, ,.�. � ��� � �„�.ae� , �sa��s,��mu� � � '��'3 Fia�a , ; C►It � I Paradb at8rt � �. 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' � � � i ': -�---, ���`� � � � " ; �'��t ��z✓ � ��� � � � , � � � `h� � �.�r, � d ;� �' � ���� � �� � ,F,,,� � � `�� \� - ;� � , �_ � � . � � ;� � � ' -- , � �e r J � � 3��'� � ...9'►O ��r+ �,o� �� °� �� s4 ' �'�. �%i � ..�,,!� ,_ ,� —� � ( �� � � j ; .�- ;� �^.�-;�;� � � � '� � ;R�.��:���� 1 ,�-��,��'r�c..�,� � � �`� � -� � �' �--. � � � �.� ?�-- ,._. .�,...-.._- . ` _�� ����� � � -- � `,y``_ Cer�ificate of Compliance Minnesota Workers' �ompensation Law PRINT IN INK orTYPE. Minnesata Sfatutes, Section 176.182 r�quires every state and local licensing agency to withhold the issuance or renewal of a lieense or perrr�it to operate a business ar engage in any activity in Minnesota until the applicant presents acceptable evidence of campliance with the workers' eompensation insurance coverage requirement af Minnesota Statutes, Chapter 176. The required workers' compensadon insurance information is fhe name r�f the insurance campany, the policy number, and the dates of coverage, or the permik to seif-insure. If the required information is not provided or is falsely stated, it shall result in a $2,000 penaity assessed against the applicant by #he cammissioner of the Department of Labor and Industry. A valid wo�kers'cornpensation palicy must be kep#in effect at all tirrtes by employers as required by law. Bl1SINESS NAME(Individuat name only if np company ame used} �I�CENSE Ot2 PERMlT NO(itappGcahte) e � � �� �..� '� 3� l�' ��-�- � DBA{daing business as neme)(if applicahle) BUSINE�S ADDRESS(PO Box must lnclude street address) C1TY STATE ZIP CC7DE �� ��!�' � _T� � � ���� .� �� � , /�' �.��'���3 YC3Ui2 LICENSE OR CERTIFICATE WILL NOT BE ISSUECI WITHOUT THE FOLLOWING INF�RMATIC3N. You must complete nurnber '�, 2 or 3 below. NUMBER 1 COMPLETE THIS PORTtQN IF YOU ARE lNSURED: INSURANCE COMPANY NAME(not the insura�ce agent) WORKERS'COMPENSATIOhf INSURANCE POUCY NO. EFFECTNE DATE EXPIRATION DAT£ NUMBE#�2 2 C�UMPLETE THIS PC}RTlt3N IF SELF-INSURED: �]I have attached a capy ai the permit to self-Irtsure. NUMBER 3 COMPLETE TH1S PORTION IF EXEMPT: I am not required to have woricers'cornpensatian insurance coverage because: �ave no employees. ❑1 have smployees but they are nat cavered by the workers'compensation law_ (See Minn.Stat.§ 176.041 for e tist of excluded ernployees.)Explain wfiy your employees are nof covered: ❑Other: — _ _� _ - ALL APPLICANTS COMPLE7E TFf1S Pt�RTiON: 1 certify that the information pravided nn this farrn is accurate and complete.lf 1 am signing on behaif af a busIness,I certify that 1 am authorized fo sign on behal#of the business. APP ANT SIGNATURE(mand o ) T17LE DATE ' � � Y�jr� c h, � i��—�w � �� �� `� � NOTE: 1#your Worker �Gampensation pol�cy is cancelled within the Ilcense or perrr�it period,you must natify the agency who issued the license or permft by resubmtt#ing this form. This mater(al can be made availablo in different tarms,such as iarge print,Braille or on a t�pe.To requQst,call 1-800-342-5354(OtAL-OLI�Voice or TOD(fi51)297-4198. MN LIC 04{11/48} -SPECIAL EVENT SPONSOR- RELEASE AN� INQEMNIFICATION AGREEMENT ClTY �F SCANDIA, MINNESC}TA THIS IS A RELE.�SE OF LI�BILITY I�DE�ZIVIFICATI�N AGREE�VIE�TT.SPECIAL EVEVT PER:1�iIT HOLDER MUST READ CAREFL;L,LY BEFORE SIGNING. I .considerati n for be� permitted to enrag in the foilo�vinQ special evei�t ac[ivities Scandia: � � � ,,� c" �-�1, ���� �i�'�-�.r�.� � ��d:.- �` ���, ���,��'� d c�r � �Z � ����'��7'►�iL K 1�C/ C � l�� I'''C L+ �l.t. �l/�_��_�,C ��.1� � � 1�z��� Special Event Pen�lit Holder l�ereby acl.�io��ledg�s,represents, and aga�ees as follows: �. We uiideistand that tlie above descr�ibed activities are or i�iay be daiigerous and da o��may iuvolve risks of iiijury, loss,ar d�mage to us�ici/or tl�ird parties. �ue fui`t��er ackno�vledge that sucl�risks may uiclude but not be linlited to bodily IIljlll'y�,�]CI'SOIle�I irijtuy, sickx2e�s, disease. deatli,a�id property loss ar da�iiage, arisii�g froin the followiu� circ�mistances. a�nang otliers: {Spe�cial Eveuts Pei•n�it Hn1de�•initiats het�e) � B. If t�eq�iired by this pu�a�-ap}i, we agi-ee to i-eqiiire eaeti partici�ant i�i our special eve�if to execnte a KELLASE r'�ND IND�R'tNIFICA?IO'_�1 AGK�El4'IE:��I' for ourselves and for the City of Scandia, on a fo��n approved by tl�e tity. Partici��nt Release and Indeimiification required?YES NO {Special Events Peru�it Haldet•ivitials here) C. We a�a-ee to procl.ue, keep i�l force,and pay for special event insurance covera�e. fran�an itisurer acceptal�le to tl�e Ciry of Seandia. for tl�e duration of tl�e aUove deseriF�ed TCt1V1T1�'S. � (Special E��ents Pei�uait Holdei•iuitials here) 1 D. By si�luig this RELEASE A1�TD INDE�ZNIFICATIOl�T AGREE�IE:�TT,�ve hereby expressly assume all such��isks of iujury, loss, or datuage ta us or at�y�related tliird pa�-ty, arising out of or irr any way r-elated t�the above described activities,wl�etl�er or not caused Uv the act, ouzissio��_ne�ligence.or ot�ier fauit�f the City�of Sca�idia, 1T5 Off1C�1�S, its en�zployees, or by az�y atl�er cause. (S�ecial E��ents Permit Iiolder Initials 6ere) ��� E. Bv si�iin�this RELE�SE AND INDEh•iVIFICATI01�ACGI2EE��ZEVT,���e furfllei� hereby eaempt,release and discharge the City of Sca�dia, its officei-s, and its eu3ployees, frozn ariy acid all claiins,der��ai�ds, a�id actio��s for sueti it�j�fry, loss, or daina�e to��s oz�to aii}r third�arty, arising aut c�f or in any way related tc�the above descrihed activities, wtietlier or not caused by the act, omission,iregligence, oY-otl�er fault of°tlie City of � Scanc�ia iis o�ccrs, its e�nplayees, or by any otl�er cause. � (Special Events Permit Holder Iuitials here) �. We fiu�ther a�-ee to defend, indenuiify atid hold li�rmless tlie City of 5ca�Idia, its of�icers, employees, insurers,aud self iustirance pool, from aiid agau�st all]iabilit_y> clauns, uad ciec�ia�icis, coutt costs az�d att�r�zeys fees, il�cludiz��tt�ose ai•isin�fi�o��i airy t�iird party claun asserted agai�lst the city. its officers, e�npl�yees, uisiu-e��s or self insuran�e�ool, on aceo���t of ixijuiy, loss o�da�nage, incli�ding�ritliout lii�iitatior�clavns a�-isi�g 2i-om bodily lll]lU3r'.�Je1�SO11AI ltl�llly. S1CkIl0SS_ CI1Se8S8_ C�8fl�I1,�T0�81'��J(�81I1il�e QI'IOSS, OT r`lll�j�othe�� lass of atiy l�ind whatsoever,wtiicli arise out of or are in any way related to tlie above dascribed aetivities,wlietl�e��ar not caused Uy o�ir act_ airiissiati,negtigence, or otl�er fault of the City of Scat�ciia,its afficers, its employees, �r i�y airy other cause. {Special Events Permit Holde��Initials here) / , G. By sigYiuig this RELEASE AND INDE:4�VIFIC�TION AGREE?VIE:�TT,tive lrerel�}r ackiiow�ledge and agree�l1at said Agreei�ieni exteiids co ali acts_orriissioiis,nagligence, or atl�er fault of the City of Scandia, its officers, anc3��or its einployees,a�id that said A�a�eeiiieut is 'vitended to be as broad aiid inclusive as is pei7nitt�d by the laws�f the ��ate of lV�imiesota. If aiiv pUi�ion tl�ereof is tield invalid, it is fiiitlaei a�ieeci that tlie balauce shall.uonvithstandiug,contifnie ui fiill legal force and effect. l (Special Even#s Hatder Iuitials hei•e) H. Vi,�e l�xiderstaiid a.nci ag�-ee tliat this RELEASE�ND I1�TDEA�TNIFICATIOiV AGR.EEMENT sllall t�e�oErexY�ed by ttie laws of tY�e St�te of Miru�esota ai�ci tx�at jlu-isdiction aud venue fe�r any si�it or cause of action�u�der-this agreement sliall ii� in the catuts. (Special Even[s Pei•mit Holder Iuitials here) I. This RELEASE�iIlD INDE�iNI�ICATI01�r'iGREEMENT shall b�effective as of the date or dates of the a�plica�le special event, shall cotitiriue iti fi►11 force untii our respo�isibilities hereizncier a�-e fiilly discharged, and sliall Ue bit3duig upoii l�s. ow� s�icc�ssors,repres�nt�tiv�s;lieirs, exectitors, assigus, and traiisferees. (Speeial Eveuts Pe�•ruit Holdea•Iaitials t�e�•e),__ - -_- 2 Iv WI"ThESS T-HER�+OF,THI�RELE�iSE Ai�D INDE�VTNIFICATION AGREE:��IENT is executed by lhe special eve�its pei�nit holc�er, acling by ancl tl�rol�gh Clie undersi�ie�cl_ �vlio regresents that he or slie is propei-ly aiitlio�-ized to binci the Speciat Ev��its Pennit Hold�r hereto. PRINTED�ARIE OF SPECIAL E�'ENT5 PER�IIT HOLDER: � � � o � � � � a � I'RII�'I"�:D�A1��E�1VD'I'I7'LE 01+"�'EI2SON SIGN�:�iG bN gEII.AL�OT+SP�Ct.�1�L�,�'�.�''I'S PER'VIIT HOLDER: � ��' �tan�e �/ � . � � �� Tit}e �/ v h � �Z�2��-• ,� O � Signat�ire �� Date _ /f���� ��—f>.,/�.�._..�____ .�_..�...�_ _.. 3