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Park Use Permit - Pregnancy Center Fish Fry/Bake SaleCITY OF OKEECHOBEE 55 SE THIRD AVENUE OKEECHOBEE, FL 34974 Tele: 863-763-9821 Fax: 863-763-1686 e-mail: ldunham(a�cityofokeechobee. com Park Use Permit Permit Number: 005 Permit Expiration: April 19, 2019 11:59PM Purpose of Request: Fish Fry Fundraiser and Bake Sale Property Owner: City of Okeechobee Address: 55 SE Third Avenue City: Okeechobee State: Florida Date(s) of Event: April 19th, 2019 8AM — 2PM Applicant: Pregnancy Center of Okeechobee Phone Number: 863-467-8748 Current Zoning:P 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 Zip Code: 34974 Applicant's Address: 808 NE Park St. Address of Project: Park #3 FLU Designation: Public clean trash can liners in cans after the event. Ensure emergency vehicles have access to site and fire extinguishers are on site or available nearby. ,T acic.>?,e/ March 29, 2019 Administrative Secretary/General Services Date Page 1 of 3 Revised 3/5/19 CITY OF OKEECHOBEE 55 SE THIRD AVENUE OKEECHOBEE, FL 34974 Tele: 863-763-9821 Fax: 863-763-1686 PARK USE AND/OR TEMPORARY STREET/ SIDEWALK CLOSING PERMIT APPLICATION Date Received: S 10 .1 G/ Date Issued: 3-24_, f Application No: I Cj _c ei f� Date(s) & Times of Event: f - 3,,t y ; y -ns i 1 1 "1 *II - ,20 f q 0,114. rmation: Organization: Pryqn-nc C DF DKeetabee- Mailing Address: ion AiJE Pa_rK S'Ireet- Contact Name: Li g4 j_Utmpkin E -Mail Address: 0/(upa4eenl-ere MVP. COM Telephone: Work: (L(03- 11/7 - Home: Home: Cell: SO -4,34-11 S5 I-164 fry randra'ser - becKe SKI Ten' 0/ cha *tS. iryGrs a leg) siTera Rac-iion i4e is. Proceeds usage: 1 Please check requested Parks: Flagler Parks: o City Hall Park El #1 Memorial Park ❑ #2 d#3 o #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 Parcel ID: Page2of3 Revised 3/5/19 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) Street(s)to be closed: Date(s) to be closed: (� Time(s) to be closed: 1(4 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. 10 -Proof of non-profit status ► 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). P 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 othk:r departmental expenses. The City reserves the right to r;quire from an applicant a cashier's check or advance deposit in the surn 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 3/5/19 I hereby acknowledge that I have read and completed this application, the attached Resolutions No.(s) 03-8 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 regulations, which may be lawfully prescribed by the City Council of the City of Okeechobee, or its officers, for 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. ApOcant Signature cl) & AM Date ••••OFFICE USE ONLY•••• Ques44." (gill Ccntt'av t _rcA �+wc. ctecest �► aer_..- ;V3•.%? E `�C� fb� s7 ars Armed- 4aw - Fire Department: €7 Fi�E ` Iii ta,Snlwcra . i SES pvm'� Date: ag/�qq Building Official: Date: 'ZJ •7d• lat Public Works: Police Department:1 Adm,�( MNI i 1 r Ifirt U�.- " G Date: 3— Zt-r Date: ''l BTR De s artment: City Administrator: . III 6 ' /4 Date: 3/26)//9 1 f% ( Date: y "Z.�/ 5tgeliq City Clerk: 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 Jackie Dunham From: Jackie Dunham Sent: Thursday, March 28, 2019 2:35 PM To: Herb Smith Cc: Patty Burnette Subject: Park Use Permit for Pregnancy Center Fish Fry Tracking: Recipient Read Herb Smith Patty Burnette Read: 3/28/2019 3:00 PM I contacted Lisa Lumpkin. She said 1) Emergency Vehicles will have access. 2) They are not using electric 3) They will have 3 fire extinguishers on site. Can you mark this information on your Special Event Form please. I have marked it on my copy for my records. I apologize but I'm not sure I know what information you require be filled out on your Special Event Form. Maybe I need to have a discussion with you so in the future I make sure the applicant has filled it out completely. Jc ckde.Duaihaim' Amara t'wei Secret -awry City OMR-echo-1e& 55 SE Thixd/Avevwce. OkeechoiYee,, EL 34974 863-763-3372 (Maivv) 863-763-9821 (Di.rect) 863-763-/686 (Fc(40 jdunham@cityofokeechobee.com Website: http://www.cityofokeechobee.com NOTICE: Due to Florida's broad public laws, this email may be subject to public disclosure. 1 APPLICATION FOR SPECIAL EVENT Application #: 1 q -00 5 Date Submitted: 3' 16Pq Permit #: Name Of Event: PrLflaJ1CL1 ( +'1t Cy1�C.C.Df chc b 1, (Ivo d R -i d ory ;sal fry/ Address Of Event: 1" 1 a9cr cur K Description Eve t: 61' dimers Tv a fbuicla..iser Name Of Sponsor/Organization: 143na-nr Caller of Ok i kiob& Contact Number before/during event OF RESPONSltLE PERSON: VLQ J- I 3t1- 1 i g 5 Date(S) And Time(S) Of Event: Date: `) j I 0 1 hl Starting Time: .UV ,1 01 Closing Time: .00 p m Date: Starting Time: Closing Time: Date: Starting Time: Closing Time: ARE ANY ROADWAYS TO BE BLOCKED/CLOSED? LOCATION Will Emergency Apparatus (Fire and Ambulance) have access to area? YES IF NO, THEN EXPLAIN (provide alternatives): WILL ELECTRICITY BE USED? YES 1 I NO Locations: Provided By: WILL HEATING/OPEN FLAMES FCIR FOOD BE PROVIDED? YES WINO D Type of Heating Equipment Used: f Ora.,f) 1 I WILL A TENT BE ERECTED? Tent Manufacturer: Tent have sides and how many? YES al NO 4dieriPI' 2( . TCI)+ . Size {9..13- /Ox /0 - fire rating posted: No Sides ***ATTACH SITE MAP OF EVENT LAYOUT*** The following items to be completed by Vire Department only FIRE DEPARTMENT LIFE SAFETY & FIRE SERVICES REQUIREMENTS: (See above) O Tents/canopy fire rating certificate required. O Tent Size require life safety inspection (900 square feet or less then no permit is required) O Floor plan / seating / setup drawing required showing exits, etc. O Emergency access must be maintained. (REFERS TO VEHICLES AND EQUIPMENT) Fire extinguishers must have current tag, and be operational and readily accessible. (.'J i It Itv V 3 O Cooking requires LPG outside of tent pointing away from exposures. O Electrical wiring exterior rated, not overloaded. O Fire Services inspection required. O Fire watch or inspector(s) REQUIRED? FIRE WATCH Amount: O Firefighter/Inspector Amount: 0 Other: FIRE DEPARTMENT OFFICIAL (PRINT): SIGNATURE: Please call the FD at 863-467-1586 for any questions. Alan. AU. .. .10 0.-1.tt.. ' -.' . t . , . .. ,..i., • ,,, t• t t r 1..ir ' )ti rr.) , 4($.r7..X1:'7,.'?:•,::,.L'-...--‘-A.,-"0"...-;:i2„.-.;,r,-.,-'—,.;1""'-.2;';';i:i:-.l:..:.-,,::i..-'-.y-„,;:k-.:‘,,-,1--;r.;<. ,_Y.._.._1_-A_i i, i4..T . , niuJeorteeta 2- IJ1 i.A.)0/865-5061 I ( .( ; ,1c141Augu2011 ) 1F419.01 #29261 ) g 0AmpaL Fax813r4070 r .. 1.1 Thi: i:; it) Ciiry ii% -ii ftm ii)i'f (CI i614: 11t:ff twi iiii; ceilr:; ;:' IC:, /hive bi".-eii flo;_ ,,..., r , I i.; '1 6.1 i. t? la 1 lja qiNi SZ a ii'il. "I areelist.eraitiv.nauffanunabie i )1ray Nvp4si crNAME: viceeclicibee o sne ins o ice ,,,-t 804 -- - • • L 34972----------- ry Okebotiotee---- Pi) Gertiiicoion is hoo,kby rmoie !'f''bil-k.ti: (tot I. rt If ilk The articles described on this G4Jilific‘,•.ttf:. have been treated with a tianie-retai-dant approved Ine ehemic;Aand that the .arwlication of .•.==.z.,:d 4:;tierriica1conformance with Federal (E(f liAK - F- N PA 701 1)) 1 Speci! ication kis, method olappvcation: InherentlyFlame resistant ‘);?°S, r)r) Tvg,:tn wows: of tlame-resistnnl fai.:1ric.nr material 4ised .1.*Gloss . r f`i r..(g( Chem, Reg. Is.10_ F-419.01 ''-it)'1 ..„..,, IV,k ill not V The Hanle Retardant Proces,--:. Li6ed_w. fiviit at will non Lie ilii-,:moveici 1-iy Wasithig )')7ti Description of item certified: Thomas Sciortino Sunblock White 15-16 oz. psy _(11.20_'...xAD' Frame Tent Top Sy froduction Supenfisor ) \ 11 1 ( ( and is good for the life, of the tabrie. Renewal Certification unnecessary. ')i ( i 5 () N:ifile vf AunircAtor of Production Stopennten-dent Idle sti''' W 1.,64-6.4 thlu utivhsal "CERTIFICATE OF FLAME iiESISTANCE" !amuse/ to tis„, "r‘tipinal copy" ut which has boom Mad with the California 5tifts Firs Marha Lori Walker 1h / cc* tvx►o Polis 111J QQQ -Fish -Fr jet's -)Ay mg INTERNAL REVENUE SERVICE P. 0, BOX 2508 CINCINNATI, OH 45201 Date: OCT 1 9 2001 PREGNANCY CENTER OP OKEECHOBEE INC 1517 SW 7TH AVE OKEECHOBEE, PL 34974 Dear Applicant: DEPARTMENT OF THE TREASURY oyer identification Number: 33-1164762 D . 17453176001027 Co, act Person: cu "• • • S SCHLAACK act Telephone Number: 7) 829-5500 unting Period lending cember 31 is Charity statue: 1 0(b) (1) (A) (vi) Po 990 Required: Eff-ctive Date of Exemption: ril 23, 2007 ribution Dcdirctj bil ity: Co (8 icc D Con Y Adv Add N We are pleased to inform you that upon re exempt status we have determined that you under section 501(c) (3) of the internal. R deductible under section 170 of the Code. tax deductible bequests, devises, tranafe or 2522 of the Code. Because this letter regarding your exempt status, you should ce Ruling Ending Date: cember 31, 2011 dum Applies: ID# 31536 iew of your application for tax are exempt from Federal income tax venue Code. Contributions to you are You are also qualified to receive s or gifts under section 2055, 2106 could help resolve any questions eep it in your permanent records. Organizations exempt under Section 501(o)i3) of the Code are further classified as either public charities or private foundations, During your advance ruling period, you will be treated as a public e$arity. Your advance ruling period begins with the effective date of youb.ex tion and ends with advance ruling ending date shown in the heading of the *ter. Shortly before the end of your advance ru 8734, Support Schedule for Advance Ruling the end of your advance ruling period to then notify you, in writing, about your p Please see enclosed Publication 4221 -PC, Charities, for some helpful information exempt organization. ing period, we will send you Parra Period. You will have 90 days after eturn the completed form. We will •lic charity status. ospliance guide for 501(C)(3) Public out your responsibilities as an Letter 1045 (DO/CGS) PRBONAUCT CENTER OF ORBECHOBEE Enclosures: Publication 4221 -PC Statute Extension Letter 3.045 (DO/C0) ASR®® CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 03/15/2019 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 po icy, 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 Patriot Insurance Agency, Inc.HONNo, PO Box 1298 Sonoita AZ 85637-1298 CONTACT Erika Hill NAME: Ext): (520) 455-9252 FAX No): (520) 455-9358 E-MAIL ehill@patriot-insurance.com ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURERA: Spirit Mountain Ins Co RRG Inc 10754 INSURED Pregnancy Center of Okeechobee 808 North East Park Street Okeechobee FL 34972 INSURER B : SMIC-LPP2018-CPP109 INSURER C : 07/01/2019 INSURER D : $ 1 000,000 INSURER E : 100,000 $ INSURER F: X COVERAGES CERTIFICATE NUMBER: PKG 18/19 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 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 NSD SUBR WVBD POLICY NUMBER POLICY EFF POLICY EFF {MMIDD/YYYY) POLICY EXP POLICY EXP (MM/DD/YYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY Y SMIC-LPP2018-CPP109 07/01/2018 07/01/2019 EACH OCCURRENCE $ 1 000,000 DAMAGE TO RENTED PREMISES (Ea occurrence) 100,000 $ X CLAIMS -MADE OCCUR EXP (Any one person) $ 0 X PROF. LIAB. INCLUDEDMED • PERSONAL &ADV INJURY $ 1,000,000 X DED: $2500 GENERAL AGGREGATE $ 3,000,000 GEN'L AGGREGATE POLICY OTHER: RETRODATE: LIMIT APPLIES PRO JECT 11/19/2010 PER: LOC PRODUCTS - COMP/OPAGG $ 1,000,000 Professional Liability $ 1,000,000 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) $ S UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE - EACH OCCURRENCE $ AGGREGATE $ c 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 II I STATUTE f J EORH- E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) EVENT: Pregnancy Center of Okeechobee Good Friday Fish Fry Fundraiser help on April 19th, 2019 City of Okeechobee and R l . Hamrick lestamentary I rust are listed as Additional Insured. CERTIFICATE HOLDER CANCELLATION City of Okeechobee and R.E.- 55 Southeast 3rd Street Okeechobee st 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 ACS AGENCY CUSTOMER ID: 00004272 LOC #: ADDITIONAL REMARKS SCHEDULE Page of AGENCY Patriot Insurance Agency, Inc. NAMED INSURED Pregnancy Center of Okeechobee POLICY NUMBER CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM ISA SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance: Notes CERTIFICATE HOLDER TO BE NAMED AS ADDITIONAL INSURED UNDER THE ABOVE POLICY BUT ONLY AS THEIR INTERESTS MAY APPEAR AND ONLY WITH RESPECT TO THE OPERATIONS OFTHE NAMED INSURED. NOTICE:THIS CERTIFICATE OF INSURANCE IS BASED ON POLICY COVERAGE ISSUED BY SPIRIT MOUNTAININSURANCE COMPANY RISK RETENTION GROUP, INC., TO ALL MEMBERS OF THE INTERNATIONALASSOCATION OF THE COMMUNITY SERVICES ORGANIZATIONS. SPIRIT MOUNTAIN INSURANCE COMPANYRISK RETENTION GROUP MAY NOT BE SUBJECT TO ALL OF THE INSURANCE LAWS AND REGULATIONS OFYOUR STATE. STATE INSURANCE INSOLVENCY GUARANTY FUNDS ARE NOT AVAILABLE FOR SPIRIT MOUNTAIN INSURANCE COMPANY RISK RETENTION GROUP ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD