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Park Use Permit - Food Truck Event (5)CITY OF OKEECHOBEE 55 SE THIRD AVENUE OKEECHOBEE, FL 34974 Tele: 863 - 763 -3372 ext. 217 Fax: 863 - 763 -1686 e-mail: id, i77l: :rrla_%oi;.o Park Use Permit Permit Number: 026 Date(s) of Event: December 8, 2016 3:30pm- 10:OOpm Permit Expiration: December 8, 2016 11:59PM Purpose of Request: Food Truck Event, Movie & Snow Area Property Owner: City of Okeechobee Address: 55 SE Third Avenue City: Okeechobee State: Florida Zip Code: 34974 Applicant: Okeechobee Main Street Phone Number: 863 - 357 -6246 Current Zoning: P Subdivision: City of Okeechobee Applicant's Address: 55 S. Parrott Avenue Address of Project: Park #3 FLU Designation: Public Restrictions /Remarks: All debris must be removed within 24 hours of expiration date. Main Street volunteers, will assist trash :;lean u p City water sources vvill not be utilized ** *i ER FRE CHF EF, FIRE DEPART- ART- ENT NEED Jaud General Services Secretary November 16, 2016 Date r 0F -01. i Z •. , `!', -4' 4,0 Page 1 of 3 Revised 1 1/4/16 CITY OF OKEECHOBEE 55 SE THIRD AVENUE OKEECHOBEE, FL 34974 Tele: 863 - 763 -3372 ext. 217 Fax: 863 -763 -1686 PARK USE AND /OR TEMPORARY STREET/ SIDEWALK CLOSING PERMIT APPLICATION Date Received: )t /,q / Ic /6 _0 ,.Lv, Date Issued: (1 .1 Q -1(, Date(s) & Times of Event: 12. - 8-- ( Li 3 ' / o ', c o ,t l Application No: Information: Organization: ' t ' A,AC...)e�". VI CO t Y7 .S'. -f Yc'C Mailing Address: ( So f1 P Kroll- % fi t ' . il t4e C;, = i°cliel?r� J L--L. 3 q 7 72_ Contact Name: (2 CL' E -Mail Address: brit, Gtyi v a) OeX. =r2Q Lti L k t 1 +r"ee --t . . r Telephone: Work: 1 54. 3.. c , 7. (,)94-I (j;. Home: I Cell: 1 Summary of activities: pi, 4 _d Tut, Y)4.- r x + ,' ( &reef Uf t u.° ", t :'� ' , t, `1t 1)c /r.' . z < tl� (- - `a"t Lot4 j\ tQrc c-.-let { m (( . TYi, `i r 1 tti, 1/ i lc /iL% rc c )"r C.r " r s: -C+ !er> 1f c tCT - ('L . J!t fi c )/ k titail �` .+ ikr l l hat' V iiii..ii kc i i -ct nisi). ' 1 ,q -1 t,t p c.nd P ii + i L 1 S - h t` &t h e:A1 ,+ r\.42-1 +v -f- Ci ti- t< . j a L . , t CAA, i 0 . n46-- Proceeds usage: oceeLb. -kr -o :'s- ev €r1f- t L H1' t 4''d t L�t t Ut?.S a./ . C lY 'i/lLl.dl., -lit C OK-PiLd. bri' MCA a ii ..� 4 re.e. 1 `. i J ;iriC DO wii +e Li1,7 « rec., -%11rz. }1x"6Y-- #41-:ta4_ 04 f/1. Carh Multi h ty Please check requested Parks: Flagler Parks: ❑ City Hall Park ❑ #1 Memorial Park ❑ #2 i a• 3 ❑ #4 ❑ #5 ❑ #6 [Park 3 is location of Gazebo. Park 4 is location of t andstand] (If other private property used in conjunction with this Park Use Permit please provide the address and parcel number below along with notarized letter of authorization from property owner) Additional Addresses, if applicable Parcel ID: Page 2 of 3 Revised 11/4/16 TEMPORARY STREET AND SIDEWALK CLOSING INFORMATION (Street Closings require City Council approval. Meetings lst & 3rd Tuesdays but subject to change) Address of Event: Street(s) to be closed: 1 f r-b. A-Vent,t 5 /,.1 -t riL✓E Nu is 13.6 7t,) &c ,•t // Q„o „> z';; Date(s) to be closed: 1 ) i (,c Time(s) to be closed: �; Ca -r 1 -' ' t) ? f n Purpose of Closing: C r i ) t: v" r , pi(At4 a rem a " r J O +'J t Attachments Required for Use of Parks Attachments Required for Street /Sidewalk Closings ► Site Plan ■ Site Plan ■ 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 and R.E. Hamrick Testamentary Trust as Additional Insured. ■ Proof of non - profit status (IRS Determination Letter) ► Original signatures of all residents, property owners and business owners affected by the closing. • State Food Service License if > 3 days. ■ State Food Service License if > 3 days. ► Notarized letter of authorization from property owner, if applicable.* • State Alcoholic Beverage License, if applicable. ** * Required if private property used in conjunction with a Park Use application. ** Alcoholic beverages can be served only on private property. Alcoholic beverages NOT ALLOWED in City Parks, City streets or City sidewalks. See additional note below. ❑ Please check if items will be sold on City streets /sidewalks. Each business will need to apply for a Temporary Use Permit 667 along with the Street Closing application. 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. V i (!-14 t1J r ‘scOttr Cat. (.../01)1 fit~ U +f1, 2eci 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 arises 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 costs 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 cashier's check or 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 of this Park Use /Street Closing Permit. Page 3 of 3 Revised 1114116 I hereby acknowledge that I have read and completed this application, the attached Resolutions 04 -03, concerning the use and the rules of using City property, that the information is correct, and duly authorized agent of the organization. I agree to conform with, abide by and obey all the rules regulations, which may be lawfully prescribed by the City Council of the City of Okeechobee, or the issuance Certificate of Insurance must name City of Okeechobee as Additional Insured as well as R.E. Hamrick Testamentary Trust if closing streets or sidewalks. ;AP 4412P► IAALAiir 1/ 10 / No.(s) 03 -8 and that I am the and its officers, for Applicant Signature Date ••••OFFICE USE ONLY *••• Staff Review Fire Department: / ./ Date: /574v, 020 ` Building Official: - * • — Date: l l ' t s4 ' IL.. Public Works: ir ` _ Amor Date: Police Department: Date: // 1 ' ----71 � BTR Department: 4 Date: 8-6-46 k /0 //G 11 Aka. City Administrator: Date: Date: City Clerk: , / 1 'j, G�/�2 QQ,� 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 / / - /6-- - Date /1 . 1 5 -1 ce Date 27.>- ,..+/),-.) Detail by Entity Name FLORIDA DEPARTMENT OF STATE DIVISION or CORPORAL IONS Detail by Entity Name Florida Not For Profit Corporation OKEECHOBEE MAIN STREET, INC. Filing Information Document Number N99000000045 FEI /EIN Number 65- 0887929 Date Filed 01/05/1999 State FL Status ACTIVE Last Event REINSTATEMENT Event Date Filed 10/18/2000 Principal Address 55 S. Parrott Ave OKEECHOBEE, FL 34972 Changed: 01/30/2013 Mailing Address 55 S. Parrott Ave OKEECHOBEE, FL 34972 Changed: 01/30/2013 Registered Agent Name & Address Fitzwater, Jayce L 55 S. Parrott Ave OKEECHOBEE, FL 34972 Name Changed: 03/16/2016 Address Changed: 01/30/2013 Officer /Director Detail Name & Address Title P Burroughs, Maureen 2661 SE 24th Blvd OKEECHOBEE, FL 34974 Title VP Griffin, Angie 313 SW Park St OKEECHOBEE, FL 34974 Title S Bragel, Paulette 55 SOUTH PARROTT AVENUE OKEECHOBEE, FL 34972 Title T Scherrer, Gary 55 S. Parrott Ave OKEECHOBEE, FL 34972 Annual Reports Report Year Filed Date 2014 01/22/2014 2015 01/12/2015 2016 03/16/2016 Document Images Page 1 of 2 http:/ /search sunbiz. org/ Inquiry/ CorporationSearch/ SearchResultDetail ?inquirytype= Entit... 11/14/2016 AC.-C: I? I:3 OKEEMAI -01 CERTIFICATE OF LIABILITY INSURANCE SOFIA RE DATE (MMIDDIVYYY) 11/14/2016 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 have ADDITIONAL INSURED provisions or 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 Maury, Donnelly & Parr 24 Commerce St. Baltimore, MD 21202 INSURED Okeechobee Main Street 55 S. Parrott Avenue Okeechobee, FL 34972 CONTACT NAME: PHONE No, Extk (410) 685 -4625 Fax (NC, ): 410 685 -3071 c, No( ) ADDRESS: INSURER(S) AFFORDING COVERAGE INSURER A : Transportation Insurance Services, Inc INSURER 8 : NAIL • 20494 INSURER C • INSURER D : INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: 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 FOLIC ES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL INSD SUER WVD POLICY NUMBER POUCY EFF (MMIDDIYYYY) POLICY EXP (MWDDIYYYYi MISTS A X COMMERCIAL GENERAL LIABILITY X 4025933977 07/01/2016 07!01!2017 EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE 1 X I OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ 1,000,000 GEN'L X MED EXP (Any one person) _ $ 10,000 PERSONAL 8 ADV INJURY $ 1,000,000 AGGREGATE POLICY OTHER: LIMIT APPLIES JECTT PER: LOC GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMPIOPAGG $ 2,000,000 $ AUTOMOBILE LIABILITY ANY AUTO OWNED AUTOS ONLY ALTOS ONLY SCHEDULED AUTOS A UTOS O COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ (PROPERTY ntDAMAGE $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION ANI) EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below Y I N N / A I SEA J I ERR- E.L. EACH ACCIDENT $ E1. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS f LOCATIONS 1 VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) City of Okeechobee is named as Additional Insured. CERTIFICATE HOLDER CANCELLATION City of Okeechobee y 55 SE 3rd Avenue Okeechobee, FL 34874 I 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 Cf�cZL ACORD 25 (2016/03) ©1988 -2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD OKEEMAI -01 CERTIFICATE OF LIABILITY INSURANCE SOHARE DATE (MM /DDIYYYY) 11/14/2016 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 have ADDITIONAL INSURED provisions or 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 Maury, Donnelly & Parr 24 Commerce St. Baltimore, MD 21202 INSURED Okeechobee Main Street 55 S. Parrott Avenue Okeechobee, FL 34972 CONTACT NAME: PHONE (AIC, No Ext): (410) 685-4625 FAx 410 685 -3071 CRESS: INSURER(S) AFFORDING COVERAGE NAIC f INSURER A : Transportation Insurance Services, Inc INSURER B: 20494 INSURER C : INSURER D: INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: 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 POLIC ES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADCL INSD SUBR WVD POLICY NUMBER _ POLICY EFF /DYYYY) (MMDI POLICY EXP (MMIDD(YY11Yi LIMITS A X COMMERCIAL GENERAL LIABILITY X 4025933977 07/01/2016 07/01/2017 EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE X OCCUR PREMISES (TO occurrence) $ 1,000,000 MED EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ 1,000,000 GENL X AGOREGATE POLICY OTHER: LIMIT APPLIES JET PER: LCC GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG $ 2,000,000 $ UTOMOBILE AUTOMOBILE LIABILITY ANY AUTO OWNED AUTOS ONLY A�T0.S ONLY SCHEDULED AUTOS AUTOSS ONt � COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ BODILY BODILY INJURY (Per accident) $ (Per cc�T DAMAGE $ $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS be Y / N NIA PER STATUTE OTH- ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS !LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) The R.E. Hamrick Trust is listed as an additional insured. The R.E. Hamrick Trust owns the property that Okeechobee Main Street occupies. CERTIFICATE HOLDER CANCELLATION I R.E. Hamrick Trust 55 SE 3rd Avenue Okeechobee, FL 34974 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 ACORD 25 (2016/03) © 1988 -2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD