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Park Use Permit - CASTLE Memory FlagsCITY OF OKEECHOBEE 55 SE THIRD AVENUE OKEECHOBEE, FL 34974 Tele: 863-763-9821 Fax: 863-763-1686 e-mail: jdunham(c�citvofokeechobee.com Park Use Permit Permit Number: 004 Date(s) of Event: March 23 — March 30, 2018 Permit Expiration: March 30, 2018 11:59PM Dedication March 27th 5:30PM — 6:30PM Purpose of Request: Memory Flags Child Abuse Victims Property Owner: City of Okeechobee Address: 55 SE Third Avenue City: Okeechobee Applicant: C.A.S.T.L.E. Phone Number: 772-567-5700 X246 State: Florida Zip Code: 34974 Applicant's Address: 3525 W Midway Rd Ft. Pierce, FL 34981 Address of Project: City Hall Park Current Zoning: P FLU Designation: Public Subdivision: City of Okeechobee Restrictions/Remarks: All debris must be removed within 24 hours of expiration date. Clean-up of all garbage from the event including emptying the trash cans in the park(s) used and placing clean trash can liners in cans after the event. February 1, 2018 Administrative Secretary Date Page 1 of 3 Revised 12-11-17 CITY OF OKEECHOBEE Of""'" = 55 SE THIRD AVENUE ; OKEECHOBEE, FL 34974 ,;� `' Tele: 863-763-9821 Fax: 863-763-1686 =� �:;%'� PARK USE AND/OR TEMPORARY STREET/ !''._--..,,, og SIDEWALK CLOSING PERMIT APPLICATION Date Received:r// l4 ,'3 Date Issued: l -/ -1 r Application No: l - 00 lly. Date(s) & Times of Event: Flax) Hos-ch 23 -36 2� orc z7 Information: , �� Organization: CASTLE `'C' �' Mailing Address: 352_5. e- -i d.wc ,earl F..{_. t� ; e�-c-P'- =1— 3 -� I t Contact Name: ce_l DA0e (- 1 E -Mail Address: 5.4- bn &)c..�. -t , p Telephone: t 1 2 Work: 7 72) 56-7-5--m Home: Cell: C770 ) I„,,1 --1 -TN,, -'Summary of activities: Eve,q 9 Pm CA TL ni ms --t-fro fLtrnb^ *- 1lAf -r \n_SA— - CIi-,% ld �t tn Q. c ir'A vmP�, iC_-� (csL C� i 'kEi L-\ ' CCk � C.Y� .cS • �1i_LY`"SL L.L QJ_K-' �'-,P -PlSltd iii-)-{-tt� i e -n- --tc C r�ec' e Oc. 1, n i cel -{� y� k i l- 1.t31Q t - - 1r UNI -c,5 . ' I . o ' P .0z,. L. Oft a IA l i V2. k_ Sv Ck kV OZANP c)S , , L.OL_ t4cu- ch �3 - -o t. S7-�, c� Zcoa.-h(� U(1 '-VU '2.21-M ‘--&)-(_-:)0 . k . ` 1 2c, s' \C__ )I( \ vc,....t, 63Niv.n tibs---Nc--v-\-.4k_s/___ -S:=0-e Proceeds usage: pt Please check requested Parks: Flagler Parks: Ci Hall Par l o #1 Memorial Park o #2 o #3 ❑ #4 ❑ #5 ❑ #6 [Park 3 is location of Gazebo. Park 4 is location of Bandstand] (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 'arcel ID: Page 2 of 3 Revised 11/4/16 TEMPORARY STREET AND SIDEWALK CLOSING INFORMATION (Street Closings require City Council approval. Meetings 1St & 3rd Tuesdays but subject to change) Address of Event: Street(s) to be closed: Date(s) to be closed: Pr Time(s) to be closed: Purpose of Closing: 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 ** Alcoholic beverages can be served only on private Parks, City streets or City sidewalks. See additional o Please check if items will be sold on City streets/sidewalks. Use Permit 667 along with the Street Closing application. with a Park Use application. property. Alcoholic beverages NOT ALLOWED in City note below. Each business will need to apply for a Temporary streets or sidewalks. beverages are served on private Beverage License. Please note there are inside You must have the appropriate license(s). for delivering the appropriate barricades. a street for more than three (3) hours. Note: ► Clean-up is required within 24 hours. ► No alcoholic beverages permitted on City property, ► No donations can be requested if any type of alcoholic property/business unless you possess a State Alcoholic consumption and outside consumption licenses. ► The Department of Public Works will be responsible ► Dumpsters and port -o -lets are required when closing Applicant must meet any insurance coverage and of other governmental regulatory agencies. The applicant code compliance requirements of the City and other regulations will be responsible for costs associated with the event, the applicant agrees and shall hold the City harmless for out of applicant's use of location for such event, and shall including attorney fees. The applicant shall be subject to incurred by the City pertaining to the event including, but not expenses. The City reserves the right to require from in the sum approximated by the City to be incurred in providing be refunded to the applicant of this Park Use/Street Closing including damage of property. By receipt of this permit, any accident, injury, claim or demand whatever arises indemnify and defend the City for such incident, demand fpr, and payment of, all of the actual costs limited to, Police, Fire; Public Works or other departmental an applicant a cashier's check or advance. deposit City services. Any such sum not incurred shall Permit. Page 3 of 3 Revised 12-11-17 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 Trus if closing streets or sidewalks. ( S C Air 1(9,1 l�5 No.(s) 03-8 and that I am the and its officers, for Applicant gna e Date, ••••OFFICE USE ONLY•••• Staff Review Fire Department: /1. (� Date: 31 J gp/r Building Official: IIPPAP G. Date: 1 , Z4' 1 Public Works: \ Wz6---; Date: 1-Z4 -)13 PPolice De artment: Date: /-20 -(P BTR Department: 11. ()Ilk Date: i I 31 I g City Administrator: ,= " Date: 2"(( f City Clerk: ''l % / $ '�►r (�N�d.. Date: 1 Ile 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 I Client#: 1414828 CASTLI 1-1L/LJ1 /4L#UIWTM c;ERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 103/26/2017 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 USI Insurance Services, LLC CL 1120 Madison Avenue Toledo, OH 43604-7589 419 243-1191 CONTACT NAME: Michele Merritt PHONE) 419 243-1191 FAX (A/C, No, Ext): A/C, No): 419 255-5928 E-MAIL DD RIESS: michele.merritt@usi.Com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Philadelphia Indemnity lnsuranc 18058 INSURED CASTLE P.O. Box 12908 Fort Pierce, FL 34979 C(VFRACIFS INSURER B : COMMERCIAL GENERAL LIABILITY INSURER C : INSURERD: 03/26/2017 INSURER E : INSURER F : ... KCvIJIVIV NUMtitK: THIS INDICATED. CERTIFICATE EXCLUSIONS INSR IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE ADDL INSR SUBR VI/VD POLICY NUMBER POLICY EFF (MM/DD/YYYY) POLICY EXP (MM/DD/YYYY) UMITS A X COMMERCIAL GENERAL LIABILITY PHPK1604956 03/26/2017 03/26/2018 $1,000,000 CLAIMS -MADE X OCCUR ppEACH��OEECTCppURRENCE PREMISES(EaEorccuErrence) $1,000,000 MED EXP (Any one person) $ 20,000 PERSONAL & ADV INJURY $1,000,000 $3,000,000 GE 'L AGGREGATE POLICY OTHER: LIMIT APPLIES PRO - J CT X PER: LOC GENERAL AGGREGATE PRODUCTS-COMP/OPAGG s3,000,000 $ A AUTOMOBILE X LIABILITY ANY AUTO ALL OWNED AUTOS HIRED AUTOS — X SCHEDULED AUTOS NON -OWNED AUTOS PHPK1604956 03/26/2017 03/26/2018 COMBINED SINGLE OMIT (Ea accident) $1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ 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 below Y / N N / A PER STATUTE OTH- ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ A A Professional Liab Sexual Abuse PHPK1604956 PHPK1604956 03/26/2017 03/26/2017 03/26/2018 03/26/2018 $1,000,000/$3,000,000 $1,000,000/$2,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) City of Okeechobee is an additional insured ATIMA per form CG2026 7/04. CANCELLATION City of Okeechobee 55 SE Third 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 © 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) 1 of 1 The ACORD name and logo are registered marks of ACORD #S20361357/M20361336 MXMAH 0000010 09/29/11 DEPARTMENT OF REVENUE 85-8012614531C-1 Consumer's Certificate of Exemption issued Pursuant to Chapter 212, Florida Statutes 09/30/2014 DR -14 R. 04/11 09/30/2019 Certificate Number This certifies that Effective pate EXCHANGE CLUB CENTER FOR _THE PRrVENTIDN OF CHILD ABUSE OF THE TREASURE COAST INC 3525 W MIDWAY RD FORT PIERCE FL 349814962 Expinaton Date 501(0)(3)-{ ROANIZA11ON is exempt from the payment of Florida sales and use tax on real property rented, transient rental property rented, tangible personal property purchased or rented, or services purchased. Important Information for Exempt Organizations DR -14 R. 04/11 1. -You must provide all vendors and suppliers with an exemption certificate before making tax-exempt purchases. See Rule 12A-1.038, Florida Administrative Code (F.A.C.). 2_ Your Consumer's Certificate of Exemption is to be used solely by your organization for your organization's customary nonprofit activities. 3. Purchases made by an individual on behalf of the organization are taxable, even if the individual will be reimbursed by the organization_ 4. This exemption applies only to purchases your organization makes. The sale or lease to others of tangible personal property, sleeping accommodations, or other real property is taxable. Your organi7afion must register, and collect and remit sales and use tax on such taxable transactions_ Note: Churches are exempt from this requirement except when they are the lessor of real property (Rule 12A-1.070, F.A.C.). 5. It is a criminal offense to fraudulently present this certificate to evade the payment of sales tax. Under no circumstances should this certificate be used for the personal benefit of any individual. Violators will be liable for payment of the sales tax plus a penalty of 200% of the tax, and may be subject to conviction of a third-degree felony. Any violation will require the revocation of this certificate. 6_ If you have questions regarding your exemption certificate, please contact the Exemption Unit of Account Management at 800-352-3671_ From the available options, select "Registration of Taxes," then 'Registration Information," and finally "Exemption Certificates and Nonprofit Entities.' The mailing address is PO Box 64B0, Tallahassee, EL 32314-6480.