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Park Use Permit - March of DimesCITY OF OKEECHOBEE 55 SE THIRD A VENUE OKEECHOBEE, FL 34974 Tele: 863 - 763 -3372 ext. 217 Fax: 863 - 763 -1686 e -mail: jdunham@cityofokeechobee.com Park Use Permit Permit Number: 007 Permit Expiration: April 2, 2016 11:59PM Purpose of Request: March of Dimes walk -a -thon Property Owner: City of Okeechobee Address: 55 SE Third Avenue City: Okeechobee Applicant: Pam Crowley Phone Number: 772 - 410 -5460 Current Zoning: P Subdivision: City of Okeechobee Date(s) of Event: April 2, 2016 State: Florida Zip Code: 34974 Applicant's address: 112 43rd Avenue SW Vero Beach, FL 32968 Address of Project: Park #4 FLU Designation: Public Restrictions /Remarks: All debris must be removed within 24 hours of expiration date. Tc C1 i& T wifiltouvw January 19, 2016 General Services Assistant 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 USE AND /OR TEMPORARY STREET/ SIDEWALK CLOSING PERMIT APPLICATION *�' �� PARK ;;1 0► Date Received: jt r 5 Date Issued: 1 1(i - 1 4i Application No: 1(7- c.0-1 Date(s) of Event: t -DI RO P Information: Organization: 1\4(4(11 4 , nU' V Tax Exempt No: Mailing Address: I i c Li . -'� tr 'i%_1. ) \(f \() r 0 rl C L .ic�CR(. 3 Contact Person: -pan') _ 't' r E -Mail Address: -00 LX \CA C C"Y Cfl i "rN r)- Of C Telephone: Work: 11,-)--t—‘10- c71-11 DD Hone: Cell: —77). Wit' 1-i -C-3( °LI Summa of activities: I NE i>r if "irk l u all Proceeds usage: Please check requested Flagler Parks: Address of event: Parcel ID: Parks: ❑ City Hall Park ❑ #1 Memorial Park ❑ #2 ❑ #3 341 ❑ #5 ❑ OR #6 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: Date(s) to be closed:, Time(s) to be closed: Purpose of Closing: Attachments Required: Charitable Function Temporary Street and Sidewalk Closing • Site Plan ► Original signatures of all residents, property owners and business owners affected by the closing. • Copy of liability insurance in the amount of $1,000,000.00 with the City of Okeechobee as additional insured. • Copy of liability insurance in the amount of $1,000,000.00 with the City of Okeechobee as additional insured. •Proof of non - profit status •Letter of Authorization from Property Owner ■ If any items are being sold on City streets or sidewalks, a Temporary Use Permit (TUP) must be attached for each business. TUP can be obtained from the General Services Department. • State Food Service License, if applicable. • State Food Service 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 08 and 04 -03, concerning the use and the rules of using City property, that the information that I am the duly authorized agent of the organization. I agree to conform with, abide by rules and regulation, which may be lawfully prescribed by the City Council of the City of its officers, for the issuance of this Charitable Function Permit. CERTIFICATE OF INSURANCE MUST NAME CITY OF OKEECHOBEE AS ADDITIONAL INSURED. 26 June 2015 No.(s) 03- is correct, and and obey all the Okeechobee, or Applicant Signature Date ••••OFFICE USE ONLY•••• Staff Review Fire Department: Date: ''"" V aal6 Building Official: �' .. Date: .1/ 1.14. ( Public Works: � � Date: /— /U - fix.. Police Department: Date: i / BTR Department: { i) d 74, , - r ', -J Date: / /I 1 City Administrator: L._ _::_,------- Date: 1/ /6 City Clerk: /' 1 \ Date: I -(q- j` Q t'7 NOTE: APPLICATION AND INSURANCE CERTIFICATE MUST BE COMPLETED RETURNED TO THE GENERAL SERVICES DEPARTMENT THIRTY (30) DAYS EVENT FOR PERMITTING. Temporary Street and Sidewalk Closing submitted for review by City Council on Temporary Street and Sidewalk Closing reviewed by City Council and approved AND PRIOR TO Date Date MO, ID oO\ Co )-AarelYCIVII \--- 90 v. (30 '5E 3fl 5\rcel-- C ertificate of Name tp t wcoIsreIsan W• hereby certify this to boo tru• copy of the original "CIRTIrIC*YE OF FLAME ftI$l$TAMCE" loomed to us, "orl«inrl copy" of which hi, been filed with the California hate Fire Merehal. *Wiwi by Lori Wdiker *Wiwi 12/11/2015 7:28:27 PM Faxserver 847 - 953 -5390 Page 3 ACQKLa CERTIFICATE OF LIABILITY INSURANCE DATE(MM /DDIYYYY) 12/11/2015 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 rnnriitinns of the pnliry, certain nnliries may rerp lire an enrinrsement A statement nn this rertifirate rives not rnnfer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Aon Risk Services Northeast, Inc. New York NY Office 199 Water Street New York NY 10038 -3551 USA CONTACT NAME: A/CC.NNo. Ext): (866) 283 -7122 I FAX No.): (80 0) 363 -0105 E -MAIL ADDRESS: In ounnrgo) Mr rumumm, I.0 V tRM ,t INMn. R INSURED March of Dimes Foundation 1275 Mamaroneck Ave White Plains NY 10605 USA INSURER A: Great Northern Insurance Co. 20303 INSURER B: Vigilant Ins CO 20397 INSURER C: The Travelers Indemnity Co. 25658 INSURER D: 51,000,000 INSURER E: INSURER F: DAMAGE IO RENIED PREMISES (Ea occurrence) COVERAGES CERTIFICATE NUMBER: 570060401098 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 INInIr ATM-) RIr1T1M1 /ITLJCTAAIIIIrIr_ AMY AC11 IIAFRAFNIT TFARA rlL r'r mnn-IC1M CIF AMY 00)NITAA0T rlP ('TI.JFP nrlr I IRAFNIT IOIITLJ ACCP(`T TC1 IAIF110IJ T1--11C 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. Limits shown are as requested INSR LTR TYPE OF INSURANCE ADDU INSD SUER WVD POLICY NUMBER POLICY EFF (MMIDDIYYYY) POLICY EXP SMMIDD/YYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY C 35812529 10/31/2015 10/31/2016 EACH OCCURRENCE 51,000,000 CLAIMS -MADE X OCCUR DAMAGE IO RENIED PREMISES (Ea occurrence) 51,000,000 MED EXP (Any one person) 510,000 PERSONAL & ADV INJURY 51,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 52, 000, 000 X JPRO- POLICY X LOC PRODUCTS - COMPIOPAGG 52,000,000 OTHER: A AUTOMOBILE LIABILITY 73525021 10/31/2015 10/31/2016 COMBINED SINGLE LIMIT (Ea a.oE dent) 51,000,000 X — X X ANY AUTO BODILY INJURY ( Per person) ALL OWNED AUTOS HIRED AUTOS Coll Ded 81,000 — _ X SCHEDULED AUTOS NON -OWNED AUTOS Comp Ded 81,000 BODILY INJURY (Per oocdcnt) Per 000dYDAMAGE (Per accident) C X UMBRELLA DAB EXCESS LIAB X OCCUR CLAIMS -MADE ZUP71M1676715NF 10/31/2015 10/31/2016 EACHOCCLIRRFNCF 55,000,000 AGGREGAI E 55,000,000 DEO X !RETENTION 810 000 Products /Completed 0 55, 000, 000 B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY N t A 1671737006 10/31/2015 10/31/2016 X I STATUTE I OTH ANY PROPRIETOR /PARTNER /EXECUTIVE Y/N OFFICER/MEMBER EXCLUDED, N (Mandatory in NH) E.L. EACH ACCIDENT 51,000,000 E.L. DISEASE -EA EMPLOYEE 51, 000, 000 It yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT 51, 000, 000 DESCRIPTION OF OPERATIONS/ LOCATIONS 1 VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) RE: Event Name: March for Babies 2016 - Okeechobee County, Event Location: Flagler Park, Event Date: 4/2/2016. Certificate Holder is included as Additional Insured in accordance with the policy provisions of the General Liability policy. CERTIFICATE HOLDER CANCELLATION Holder Identifier : 570060401098 Certificate No ACORD 25(2014/01) ©1988 -2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Okeechobee AUTHORIZED REPRESENTATIVE 55 SE Third Avenue Okeechobee FL 34974 USA C ACORD 25(2014/01) ©1988 -2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 12/11/2015 7:28:25 PM Faxserver 847 -953 -5390 Page 2 Page 1 of 1 Attached, please find the Certificate(s) of Insurance that you have requested. Should you have any questions, please call 866- 2.83 -7122. (See attached file: March Of Dimes Foundation_City of Okeechobee_1512115649699.pdf) Aon Client Services Aon Risk Services Central, Inc. dba Aon Risk Insurance Services Central, Inc. CA License 0D04043 4 Overlook Point 1 Lincolnshire, IL 1 60069 t: 866 283.7122 If: 800.363.0105 w: aon.com file:// \ \uschdcls006s \omdata\Messages\ 0129\ e578d739- 8d3c- 40ee- a453- d39e46a28266 -in... 12/11/2015 12/11/2015 7:28:23 PM Faxserver Aon Risk Services Hon client services 4 Overlook Point Lincolnshire, IL 60069 Phone: 866-283-7122 Fax: 847 - 953 -5390 Fax 847 - 953 -5390 Page 1 Date: 12/11/2015 7:21:49 PM Pgs: 4 To: 'Cyndi Hernandez - March Of Dimes Foundation' Fax: 7725670854 Comments: March Of Dimes Foundation - City of Okeechobee [1512115649699] NOTICE: The information contained in this message is proprietary information belonging to Aon Risk Services and is intended for the personal and confidential use of the addressee. If you are not the addressee or an agent of the addressee, you are hereby notified that you have received this message in error and that any review, dissemination, distribution or copying of this message is strictly prohibited. If you have received this message in error, please notify Aon Risk Services immediately by telephone and return the original by mail. Continuation of partially transmitted fax. Jackie Dunham From: Jackie Dunham < jdunham @cityofokeechobee.com> Sent: Tuesday, January 19, 2016 11:38 AM To: 'perowley @marchofdimes.org' Subject: March of Dimes Walk -a -thon Attachments: 007 -March of Dimes.pdf Please find attached your 2016 Park Use Permit for the annual March of Dimes walk -a -thon. Hoping this will be a successful year for your organization. Should you have any questions or changes please let me know. Jackie' (Du.v hanyv eneva.'Sevvice , 4 to nit City of Okeechobee/ 55 SE T rdMvesi e/ Okeechobee/, EL 34974 Telex 863 - 763 -33 72 east. 217 J c— - 863 -763 -1686 jdunham @cityofokeechobee.com Website: http:/ /www.cityofokeechobee.com NOTICE: Due to Florida's broad public laws, this email may be subject to public disclosure. i