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Park Use Permit - Mason's Fundraiser
CITY OF OKEECHOBEE 55 SE THIRD AVENUE OKEECHOBEE, FL 34974 Tele: 863 - 763 -3372 ext. 217 Fax: 863 - 763 -1686 e -mail: idunham@cityofokeechobee.com Park Use Permit Permit Number: 010 Date(s) of Event: March 11, 2016 5A -10P Permit Expiration: March 11, 2016 11:59 A.M. Purpose of Request: Mason's Lodge 237 Bail 'n Jail Fundraiser Property Owner: City of Okeechobee Address: 55 SE Third Avenue City: Okeechobee State: Florida Zip Code: 34974 Applicant: Okee Lodge 237 F & AM Phone Number: 863 - 634 -9990 Current Zoning: P Subdivision: City of Okeechobee Applicant's Address: 107 NW 5th Avenue Address of Project: Park 4 FLU Designation: Public Restrictions /Remarks: All debris must be removed within 24 hours of expiration date. facki-e■Dwytham General Services Assistant February 23, 2016 Date Page 1 of 3 CITY OF OKEECHOBEE ,��'' "' "' "' - -__ 55 SE THIRD AVENUE OKEECHOBEE, FL 34974 .�� Tele: 863 - 763 -3372 ext. 218 Fax: 863 - 763 -1686 ∎ PARK USE AND /OR TEMPORARY STREET/ SIDEWALK CLOSING PERMIT APPLICATION Date Received: :2 -/-7 / (a Date Issued: :z 1 5 / v Application No: hi. or Date(s) of Event: 114 iv, 1 Do 1 cf. j iuc, ; 54 - i C Information: Organization: iitCcch,Le lju ;ri.;_ _"3- 7'4►1.1 Tax Exempt No _ 57 g'0 1 .3 -L3'- 1/ " 7 Mailing Address: 10 7 "0,f:J 5 t a, (Avg— 0 et--c- (' : Le e- ['t > -['f L/ Contact Person: , 5 l ,-)1t1 E -Mail Address: CLA c c co,A 1 h \�.k--„,„,, l L c, ,,... Telephone: Work: Home: Cell: gt,3 E, 3 L (- 4 4 6 Summary of activities: 'c_ \ - tit - IjQ: k I-3Q r _ i1 C�e. ,Ack rG;.Sp4- Proceeds usage: e Glu a Q,,\ -C',-, ,-, of Please check requested Parks: Flagler Parks: ❑ City Hall Park ❑ #1 Memorial Park ❑ #2 ❑ #3 X#4 OR Address of event: ❑ #5 ❑ #6 Parcel ID: Page 2 of 3 TEMPORARY STREET AND SIDEWALK CLOSING INFORMATION (If not using Park(s), provide event address) Street Address City State Zip Code Street(s) to be closed: 14 Date(s) to be closed: Time(s) to be closed: /--- Purpose of Closing: Attachments Required: Ch • unction Temporary Street and Sidewalk Closing Site Pla • Origina •gnatures of all residents, property owners nd business owners affected by the closing. e,--1 ► opy of liability insurance in the amount of a ,000,000.00 with the City of Okeechobee as additional insured. • Copy of liability insurance in the amount of $1,000,000.00 the City of Okeechobee as additional i usred. (9roof of non -profit status S O'- ' C t v •Lettere Authorization from Property Owner ■ If any items are being sold on City streets or sidewalks, a TJetfiporary Use Permit (TUP) must be attached for each business. TUP can be obtained from the General Services Department. • State F Service License, if applicable. • State Fooc ervice License, if applicable. • State Alcoholic Beverage License, if applicable. (Alcoholic beverage can be served only on private property. No alcoholic beverages are allowed on City property, this included streets and sidewalks.) Note: • Clean -up is required within 24 hours. • No alcoholic beverages permitted on City property, streets or sidewalks. • No donations can be requested if any type of alcoholic beverages are served on private property /business unless you possess a State Alcoholic Beverage License. Please note there are inside consumption and outside consumption licenses. You must have the appropriate license(s). • The Department of Public Works will be responsible for delivering the appropriate barricades. • Dumpsters and port -o -lets are required when closing a street for more than three (3) hours. Applicant must meet any insurance coverage and code compliance requirements of the City and other regulations of other governmental regulatory agencies. The applicant will be responsible for costs associated with the event, including damage of property. By receipt of this permit, the applicant agrees and shall hold the City harmless for any accident, injury, claim or demand whatever arising out of applicant's use of location for such event, and shall indemnify and defend the City for such incident, including attorney fees. The applicant shall be subject to demand for, and payment of, all of the actual cost incurred by the City pertaining to the event including, but not limited to, Police, Fire, Public Works or other departmental expenses. The City reserves the right to require from an applicant a cash or cashier's check advance deposit in the sum approximated by the City to be incurred in providing City services. Any such sum not incurred shall be refunded to the applicant. Page 3 of 3 I hereby acknowledge that I have read and completed this application, the attached Resolutions No.(s) 03- 08 and 04 -03, concerning the use and the rules of using City property, that the information is correct, and that I am the duly authorized agent of the organization. I agree to conform with, abide by and obey all the rules and regulation, which may be lawfully prescribed by the City Council of the City of Okeechobee, or its officers, for the issuance of this Charitable Function Permit. CERTIFICATE OF INSURANCE MUST NAME CITY OF OKEECHOBEE AS ADDITIONAL INSURED. ,'i Applicant Signature Date ••••OFFICE USE ONLY•••• Staff Review Fire Department: Date: a3 F -eb ao1(o Building Official: � � � C , � ! Date: •/i3 • I6 Public Works: -L`�"p Date: ,- 17- /.4. Po lice Department: � Date: a2 / BTR Department: , J Ii lit /1-41-64-' Date: C9 /9 /c,..- City Administrator: Date: . 2 7-.../4. hci,,e, City Clerk: ciait°` e c--- Date: NOTE: APPLICATION AND INSURANCE CERTIFICATE MUST BE COMPLETED AND RETURNED TO THE GENERAL SERVICES DEPARTMENT THIRTY (30) DAYS PRIOR TO EVENT FOR PERMITTING. Temporary Street and Sidewalk Closing submitted for review by City Council on Date Temporary Street and Sidewalk Closing reviewed by City Council and approved Date Lanitai pawn c u c a, o_ U 0 a) L State Road 7 a t0 d' d' 00 d' 441 -443 d' M 00 M d' 416 -417 M N M 428 Ql N 425 - 427 M N d N d' 470 -419 Pi uIcrenn Berger Rent Fctata ti Gentlemen Internal Revenru�e? Service FEB g - 1972 jT:NS:E0:R:1 '[ The J: -ost Worshipful Grand Lodge Free and Accepted Masons of t}: State of Florida Grand Lodge Building 220 Ocean Street . Jacksonville, Florida 32202 You indicated in a letter dated -- December 17, that you wished for us to modify your. original group ruling letter to show that you are recognized to be exempt from Federal income tax under new section 501(c) (10) of the Internal Revenue Code. Further, you stated that you do not provide for life, accident or other benefits to your members. Further, on October 20, 1971 you submitted a list of newly. chartered lodges and lodges which ceased to exist during 1970 -1971, and requested a supplemental group ruling letter to include them. Our records show that you were tion letter on November 10, 1941, re your subordinate lodges to-be exempt tax under section 101(3) :of the 1939 now corresponds to section 501(c)(8) issued a group exemp- cognizing you and from Federal income Code,_(this section of the 1954 Code). Based on the information supplied, we rule that eff eciive January 1, 1970, you and your subordinate lodges, (including those recently submitted for addition to your group exemption letter), are recognized as being exempt under "new- section 501(c)(10) of the Internal Revenue Code. You are required to file the annual return, Form 990, on or before the 15th day of the 5th month after the end of your annual accounting period if your annual gross receipts are normally more than $5,000. Failure to file the Form 990 by this date may subject you to a penalty of $10 for each day during which.=such failure continues, up - _to a maximum of $5, -000. -.Your subordinates will have -to file an annual information return, Form 990, if their - gross receipts in each taxable year_are normally more than $5, 000 -2- The Most Worshipful Florida and Accepted Masons If you do not include the subordinates in a group return, each must file an annual return by the 15th day of the 5th month after its annual accounting period closes. You and your subordinates are not orequiredutorfile Federal income tax returns unless you under subject to the tax on unrelated business income ubordinates section 511 of the Code, if so, you � 0 0 must file an income tax return on�Form s 99 of your, In , this your letter we are not determining whether any subordinates, present or proposed activitiesishunrelated trade or business as defined in section 513 of Unless specifically excepted, you and your subordinate lodges are liable for taxes under the Federal 1nsuuaiCe Contributions Act (social security -� x lodges are liable for excepZed, you and your subordinate g liable ore Tax Act if, during tax under the Federal Unemploy`mear, you have one or more current or preceding calendar year, y time in each of 20 weeks, or you pay employees at any �y wages of $1,500 or more in any calendar ouarter. or other Federal concerning excise, employment, eral taxes should be .submitted to your key District Director in Atlanta, Georgia. you or your subordinates are Contributions made to y rovided in section 170 of deductible by such donors as provided the Code, but only if to be used exclusively for the charitable purposes specified idesectiont177_r0i(Ce( )o of the Code. Bequests, legacies, gift for gifts are deductible-for Federal estate and gift tax 2522 purposes as provided in stotb °nused5exclussvely for the of the Code, but only if charitable purposes specified in sections 2055(a) (3), 2106(a)(2)(iii), and. 2522(a)(3). inconsistent with T the extent odifies this our ruling" issued to you on it, thi s ruling November 10, 19 41. -3- The Most Worshipful Grand Lodge of Free and Accepted Masons of the State of Florida You should advise each subordinates of provisions of this ruling, including the filing information or other returns. • Each year, within 45 days after your annual accounting period closes, please send us two copies of the following information about your subordinates: 1. A statement describing any changes during the year in the purposes, character, or method of operation of your subordinates. 2. A list of the names, mailing addresses including ZIP Codes, and employer identifi- cation numbers (if required for group exemption letter purposes) of subordinates on your group exemption roster that during the year: a. changed names or addresses; b. were deleted from the roster; c. were added to the roster. • A directory of subordinates may be substituted for this list if it includes the required infor- mation and identifies the affected subordinates according to the three categories above. 3. For subordinates added to the roster, a letter signed by one of your principal officers con- taining or attaching: a. a statement that the information which your present group exemption letter is based applies to the new subordinates; b. a statement that each has given you written authorization to add its name to the roster. c. a list of those to Which the Service previously issued rulings or determi- nation letters relating to exemption. • -4- The Most Worshipful Grand Lodge of Free and Accepted Masons of the State of Florida 4. If applicable, a statement that your group exemption roster did not change during the year. Your key District Director is being advised of this action: Sincerely yours, 4/724/01- Director, Miscellaneous and Special Provisions Tax Division ACORL, CERTIFICATE OF LIABILITY INSURANCE DATE I,MM'ODNYYr, 02/11/2016 440 9550 F 3% (407) 957 0)751 HUMPHREYS INSURANCE AGENCY, INC. 4950 HALL ROAD STE. C ORLANDO FL 32817 Ag.encybcst L024438 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE INSIJRELI OKEECHOBEE LODGE NO. 237, F & AM P 0 BOX 814 OKEECHOBEE FL 34973 INSURER A PRAETORIAN INS CO NAIC # -■ INSURER B INSURER C INSURER D INSURER E. COVERAGES 00, v.._.1_,:-.; or INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED NOTWITHSTANDING AN" R[i..)01Lt.ILNI a PM ON CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT 10 WHICH THIS CERTIFICATE MAY BE ISSUED OR MA,' Pl.?, AIN If IL INSURANCE AFFORDED BY THE POLACIE S DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS EXCLUSIONS ANC) CONDITIONS OF SUCH I'0: I( it S A,.;C,RLGA IL I 'MI IS SHOWN MAY HAVE BEEN REDUCED BY PAIL) CLAIMS ..,:.Fe 1, ttt,,,,l TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE pArt (11M,DOIYTI POLICY EXPtFIATION DATE IMM/Oarrn UNITS A GENERAL LIABILITY H984000178-00 05118/15 05/18/16 , EACH OCCURRENCE $ 1,000,000 El COMMERCIAL GENERAL I IABILITY DAMAGE TO RENTED priF,vistS (Ex ,-.-xe-er.cej $ 100,000 MICl AIMS MADE El OCCUR MED EXP (Any One Pii-SOn; 5,000 III PERSONAL & ADY INJURY 1,000,000 GENF.RAl AGGREGATE 5,000,000 Gi.N'L 40";C,REGATE I. MIT APPI IES PER, u.■ I 111-1»l PRO t n LOC PRODUCTS - COMP'OP AGG 1,000,000 AUTOMD6Il E t IAEM. ITT COMBINED 1411401 E LIMIT ( F. a' cncent 1."," 4 Ai ; k):,'NE,t) AU1OS BODIl 1 114.1111414 (Pnr pe-s on) I R SCI Di); ID AUTOS lllkC._' All 03 NON OWNED AOTOS I 80011 Y INLIRst J (Pof 3,:c-Cer,I) $ PROPERTY DAMAGE 1,Per accident: . GARAGE LIABILITY AN , AO I 0 i AUTO 0141 14 EA ACCIDENT 9 OTHER THAN EA ACC AU10 ONLY AGG EXCESS/UMBRELLA LIABILITY OCCOR L CLAIMS MADE UL DOC; rIBLE RE T ENTION S EACH OCCURRENCE $ AGGREGATE $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY TIN AMY PROI'lilt 101teel'ARTNElitE:4ECUTWE pi OFFICAKA■HelFitl DeCi. VDU), illelArtcloNtey let Ntij :.-...,C:.<.....-::;,:i`,..;,-,„1...-,... L I ,,,,,,-;,A,,,,,,-,,, r E L EACH ACCIDENT P1 DISEASE-EA EMPLOYEE . ISEASE-POCY LIMIT E 1 D LI OTHER DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY THE CERTIFICATE HOLDER IS ADDITIONAL INSURED WITH RESPECTS TO "JAIL AND PARK 4, Lot 439, CITY OF OKEECHOBEE ENDORSEMENT/ SPECIAL PROVISIONS BAIL" EVENT BEING HELD ON MARCH 11, 2016 AT CERTIFICATE HOLDER CANCELLATION CITY OF OKEECHOBEE 55 SE 3RD AVENUE OKEECHOBEE, FL 34974 Attention SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO 00 50 SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES AUTHORIZED REI'RE / L / N ATIVE - i - , 4:, ACORD 25 (2009101) Certificate # 27308 ©>l'988.2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD