Park Use Permit - Girls Scouts of SE FloridaCITY OF OKEECHOBEE
55 SE THIRD AVENUE
OKEECHOBEE, FL 34974
Tele: 863-763-3372 ext. 9821 Fax: 863-763-1686
e-mail: Idunham(citvofokeechobee. com
Park Use Permit
Permit Number: 012 Date(s) of Event: November 16, 2018 3:OOpm — 11:OOpm
Permit Expiration: November 16, 2018 11:59PM
Purpose of Request: Girl Scouts of SE FL showcase ending with free movie and snacks
Property Owner: City of Okeechobee
Address: 55 SE Third Avenue
City: Okeechobee State: Florida Zip Code: 34974
Applicant: GSSEF Applicant's Address: 6944 Lake Worth Rd., Lake Worth FL 33467
Phone Number: 561-402-4781 Address of Project: Park 3 of Flagler Park
Current Zoning: P FLU Designation: Public
Subdivision: City of Okeechobee
Restrictions/Remarks: All debris must be removed within 24 hours of expiration date.
.Ta c,k e'
Administrative Secretary/General Services
10/24/18
Date
Page 1 of 3
Revised 3-21-17
CITY OF OKEECHOBEE
y OF O 7-. 55 SE THIRD AVENUE
cyVzt OKEECHOBEE, FL 34974
LL ' , ` `• Tele: 863-763-9821 Fax: 863-763-1686
-_ �-;�• PARK USE AND/OR TEMPORARY STREET/
''�--..;,,,.��'' SIDEWALK CLOSING
PERMIT APPLICATION
Date Received:
10 - 12,- I $
Date Issued: lc -a,/ 1 g
Application No:
i irr -p t
Date(s) & Times of Event: November 16, 2018 3:00 pm- 11:00 pm
Information:
Organization: Girl Scouts of Southeast Florida (GSSEF)
Mailing Address:6944 Lake Worth Rd Lake Worth FL 33467
Contact Name: Sabrina Seme
E-Mail Address: sseme@gssef.org
Telephone:
Work:
561.402.4781
Home:
Cell:
Summary of activities:
GSSEF will host a Girl Scouts showcase and complete the day with a movie and snacks. This event is free and open to the public.
Proceeds usage:
Any and allgirl scout registration fees ($40) will g0 tnwards the memhership of the girl that registers
Please check requested Parks:
Flagler Parks: o City Hall Park o #1 Memorial Park o #2 X #3 o #4 o #5 o #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
Parcel 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:
Time(s) to be closed:
Purpose of Closi • :.
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.
o 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.
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 11/4/16
I hereby acknowledge that I
04-03, concerning the use and
duly authorized agent of the
regulations, which may be lawfully
the issuance
Certificate of Insurance must
Test. -, entary Trust if closin•
-��
have read and completed this application, the attached Resolutions
the rules of using City property, that the information is correct,
organization. I agree to conform with, abide by and obey all
prescribed by the City Council of the City of Okeechobee,
name City of Okeechobee as Additional Insured as well as
streets or sidewalks.
,
and
the rules
or
R.E. Hamrick
No.(s) 03-8 and
that I am the
and
its officers, for
= - /O/z jg
• • pplicant Signature Date
•••• I FJ SE ONLY••••
Staff Review
Fire Department:
It
Date:
Aq OCT/t
Building Official:
Date:
)O.15•iB
Public Works:1
Date:
/0' 17-1 j
Police Department:
,,...1.---'
Date:
47, // /63
BTR Department:
`C 1 1 •+
Date:
/O hang
City Administrator:
•
Date:
l c-171-4"--
City Clerk:
•'
� CIA
Date:
('(]IIb` �Ip
U
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
®
A CGRO
v CERTIFICATE OF LIABILITY INSURANCE
DATE (MMIDD/YYYY)
10/25/2018
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
Palmer & Cay LLC
22 Barnard Steet
Suite 200
Savannah, GA 31401
CONTACT
NAME:
PHONE FAX
(NC No. EM): (A/C, No):
ADDRESS: gssolutions@palmerandcay.com
INSURER(S)AFFORDINGCOVERAGE
NAIC#
INSURER A : National Casualty Company
11991
INSURED 200
Girl Scouts of Southeast Florida, Inc.
6944 Lake Worth Road
Lake Worth FL 33467
INSURER B
KK022396200
INSURER C :
10/1/2019
INSURER D:
$ 1,000,000
INSURER E :
$ 1,000,000
INSURER F :
CERTIFICATE NUMBER: 1745014722
REVISION NUMBER:
vTHIS 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 POLICIES 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
SUBR
WVD
POLICY NUMBER
POLICY EFF
(MM/DD/YYYY)
POLICY EXP
(MM/DDYYY)
IY
LIMITS
A
X
COMMERCIAL GENERAL LIABILITY
KK022396200
10/1/2018
10/1/2019
EACH OCCURRENCE
$ 1,000,000
DAMAGE TO RENTED
PREMISES (Ea occurrence)
$ 1,000,000
CLAIMS -MADE
X
OCCUR
MED EXP (Any one person)
$ 10,000
PERSONAL & ADV INJURY
$1,000,000
GENERAL AGGREGATE
$ 5,000,000
GE
X
'L AGGREGATE
POLICY
OTHER:
LIMIT APPLIES
JECT
PER:
LOC
PRODUCTS - COMP/OP AGG
$ 5,000,000
AUTOMOBILE
LIABILITY
ANY AUTO
OWNED
AUTOS ONLY
HIRED
AUTOS ONLY
SCHEDULED
AUTOS
NON -OWNED
AUTOS ONLY
COMBINED SINGLE LIMIT
(Ea accident)
$
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
ANYPROPRIETOR/PARTNER/EXECUTIVEN
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
YIN
/ A
PER
STATUTE
OTH-
ER
E.L. EACH ACCIDENT
$
E.L. DISEASE - EA EMPLOYEE
$
E.L. DISEASE - POLICY LIMIT
$
DESCRIPTION OF OPERATIONS 1 LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required)
The Certificate Holder named below is an Additional Insured on the general liability policy with respect to the use of its premises for Girl Scout activities of the
insured Girl Scout Council.
For use of premise for Girl Scout activities of the insured Girl Scout Council.
1..cK I IrIt..m I c nvLucrc
City of Okeechobee
55 SE 3rd Ave
Okeechobee FL 34974
USA
.........___...._..
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
�.y rk.. �.� �i�r.�......,
ACORD 25 (2016/03)
�Lll-1a Hl.V RV VVRf"Vf�M 1IV,�. •
The ACORD name and logo are registered marks of ACORD
0000024 12/28/13
DEPARTMENT
OF REVENUE
Consumer's Certificate of Exemption
Issued Pursuant to Chapter 212, Florida Statutes
DR -14
R. 04/11
85-8012646598C-6
01/31/2014
01/31/2019
501(C)(3) ORGANIZATION
Certificate Number
This certifies that
Effective Date
GIRL SCOUTS OF SOUTHEAST FLORIDA INC
4701 NW 33RD AVE
OAKLAND PARK FL 33309-6807
Expiration Date
Exemption Category
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.
FLORIDA
11'l \.
DEPARTMENT
OF REVENUE
Important Information for Exempt Organizations
DR -14
R. 04/11
1. You must provide all vendors and suppliers witt an exemption certificate before raking 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 organization 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 6480,
Tallahassee, FL 32314-6480.
DIVISION OF CORPORATIONS
Jsv.c i0:;
t�rJ .at'g ,CD2LPD1 ,,,,,rtI ►`r
R i i !! flori lr: i.:f!iif!C
department of State / Division of Corporations / Search Records / petail By Document Number /
Detail by Entity Name
Florida Not For Profit Corporation
GIRL SCOUTS OF SOUTHEAST FLORIDA, INC.
Ening Information
Document Number N16801
FEI/EIN Number 59-0657327
Date Filed 09/15/1986
State FL
Status ACTIVE
Last Event AMENDMENT
Event Date Filed 01/10/2018
Event Effective Date NONE
Principal Address
6944 LAKE WORTH ROAD
LAKE WORTH, FL 33467
Changed: 01/10/2018
Mailing Address
6944 LAKE WORTH ROAD
LAKE WORTH, FL 33467
Changed: 01/10/2018
Registered Agent Name & Address
JOHNSON, LISA Y
6944 LAKE WORTH RD
LAKE WORTH, FL 33467
Name Changed: 01/17/2017
Address Changed: 01/10/2018
Officer/Director Detail
Name & Address
Title C,D
BROWN -BURTON, LORNA E
6944 LAKE WORTH ROAD
LAKE WORTH, FL 33467