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Park Use Permit - Domestic Violence Awareness .0.OF'0 K4,40CyoL CITY OF OKEECHOBEE LL '"" �T` 55 SE THIRD A VENUE •qlk° �� OKEECHOBEE, FL 34974 atit �0 Tele: 863-763-9821 Fax: 863-763-1686 ••••4.79 1�������� e-mail: ldunham(d cityofokeechobee.com Park Use Permit Permit Number: 015 Date(s) of Event: October 26, 2019 10AM — 2PM Permit Expiration:October 26, 2019 11:59PM Purpose of Request: Domestic Violence Awareness Property Owner: City of Okeechobee Address: 55 SE Third Avenue City: Okeechobee State: Florida Zip Code: 34974 Applicant: Martha's House Inc. Applicant's Address: P. O. Box 727, Okeechoee, FL 34973 Phone Number: 863-763-2893 Address of Project: Park#4 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. Comments/Concerns of Fire Chief: 1. Access to businesses in regards to the emergency vehicles in case of emergency. 2. Blocking of hydrants by vehicles or equipment 3. Any tent over 900 square feet requires inspections and the tent requires at the minimum one 2A rated extinguisher and possibly other items. 4. Participants should be familiar with the basic regulations(Fire Dept.gave the building dept.this sheet) 5. Electrical cords should be rated for outdoor use and in good condition. Do not plug extension cords into each other to lengthen. The greatest concern is accessibility by our firefighters and vehicles to address medical,fire,or any other hazard. We just need to make vendors and participants aware of these safety issues. H.Smith,Fire Chief/Marshal(863-467-1586) City of Okeechobee Fire Department Jackie Dunham September 13, 2019 Administrative Secretary/General Services Date Page 1 of 3 Revised 3/5/19 CITY OF OKEECHOBEE 40.0 --_ 55 SE THIRD AVENUE scs- 044 °A: OKEECHOBEE, FL 34974 F� Tele: 863-763-9821 Fax 863-763-1686 . . . '�`` PARK USE AND/OR TEMPORARY STREET/ SIDEWALK CLOSING PERMIT APPLICATION Date Received: fl/ I i Date Issued: Application No: / -GSI S Date(s) &Times of Event: (j Ci 44, / i 9 ~- /6amum Information: Organization: Mar*r*a'5 OL4 e Mailing Address: p, . 8,)c, 7 7 aX e-e ch, h t.e1 r-L 3 Li 7') 3 Contact Name: 5 I, ►'I e G 0 Cr LVIt't r L:// 1 /)a 1&o o E-Mail Address: Sir p rm" m a✓-th,o h.,use•orj ✓ Telephone: Work: V.,3.- 243- 93 Home: Cell: g..4,3- 6 f 7- ‘//94-7 Summary of activities: pow-neck L V D J e n c e r►`r 4(5'5 1st 11-. A 1,0A-)krt1 ler Shoes,: Dario 146 +T ,Ile 1,,r•1I 1r_ se-+ p w t rh in• `). re VII ®vnes4C. Vivlepnee� Pada person �v. /) br,ve -I-z> d)Ipa,t) C��`rPc4ows 4 U 11 ''1ry JYLVP. (a Drn pe to 4-Ne 'e er&Lce.., bet gee/e15 t,t) I pYovt(Ie e1 I&ar ; c., 1- i Set> iutle)1 pv--e d C/ecJ. Proceeds usage: Please check requested Parks: Flagler Parks: o City Hall Park o #1 Memorial Park o #2 1'#3 ❑ #5 ❑ #6 [Park 3 is location of Gazebo. Park 4 is location s :andscan.- (If other private property used in conjunction with this Park Use Perm' p ease 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 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)to be closed: Date(s)to be closed: Time(s)to be closed: Purpose of Closing: Attachments Required for Use of Parks Attachments Required for Street/Sidewalk Closings ► Site Plan OV ► Site Plan ► Copy of liability insurance in the amount of ► Copy of liability insurance in the amount of$1,000,000.00 $1,000,000.00 with the City of Okeechobee as with the City of Okeechobee and R.E. Hamrick Testamentary additional insured. Trust as Additional Insured. ►Proof of non-profit status 'L ► Original signatures of all residents,property owners and 171 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 ► State Alcoholic Beverage License, if applicable.** property owner, 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. 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 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 Testamenta Trust if c osing streets or sidewalks. Applicant Signature Date ••••OFF .E USE ONLY•••• Staff Review Fire Department: r Date: /a-5E/?.2O/9 Building Official: G Date: g•i•/9 Public Works: jor : Date: /'0 Police Department: ® meg, Date: 61 // /ci BTR Department: , Date: / IWO City Administrator: Date: l/;Gt / City Clerk: • t i Curg,, Date: ( d 01(3 NOTE: APPLICATION AND INSURANCE CERTIFICATE MUST BE COMPLETED AND l 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 ruffs% �^'ar �+' 'M •w& a _ APPLICATION FOR SPECIAL EVENT Application#: IQ_Qt .; Date Submitted: CY Permit#: !� Name Of Event: - E Q L elk J-1- 11 e✓ eG. h d e Address Of Event: F Arlie/ Par K Description Of Event: r+}} bt)meJ (, v,0lrglee I*Weve i)e.A. Name Of Sponsor/Organization: Marlivi5 HOR,Se Contact Number before/during event OF RESPONSIBLE PERSON: S-13- 1'`) 7-414 Date(S)And Time(S) Of Event: Date: 10- - 19 Starting Time: /0 oil /6)m Closing Time: v2 b0 /n-1 Date: Starting Time: Closing Time: Date: Starting Time: Closing Time: ARE ANY ROADWAYS TO BE BLOCKED/CLOSED? N 0 LOCATION Will Emergency Apparatus(Fire and Ambulance)have access to area? IF NO, THEN EXPLAIN (provide alternatives): WILL ELECTRICITY BE USED? YES I I NO 121 Locations: Provided By: WILL HEATING/OPEN FLAMES FOR FOOD BE PROVIDED?YES 1. 10 0 Type of Heating Equipment Used: G R;1 W t i Uv Fai; %xtr e AV4114:Ji e4T4�ifl WILL A TENT BE ERECTED? YES© NO 0 Tent Manufacturer: Size l 0 X I 0 fire rating posted: Tent have sides and how many? Nn H g ***ATTACH SITE MAP OF EVENT LAYOUT*** The following items to be completed by Fire Department only FIRE DEPARTMENT LIFE SAFETY&FIRE SERVICES REQUIREMENTS:(See above) O Tents/canopy fire rating certificate required. 0 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. 0 Emergency access must be maintained. (REFERS TO VEHICLES AND EQUIPMENT) (� Fire extinguishers must have current tag,and be operational and readily accessible. 0 Cooking requires LPG outside of tent pointing away from exposures. n 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 Dat 863-467-1586 for any questions. f , r • ----alh...-1 , . 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J my'U Supreme Coume Pizza J Sulas II Hunters'Den Absolutely Art Heartland Okeechobee... - s Screen Print et JuveMle Justice Gallery•&Custom td EmbroideryY De rtment Murray insurance A&D Pool SuppliesDepartment Services N .Bad A le Salon 9 Marathon Gas 9 Smitty s Glass And Mirror PPS 99 SW 2nd sl SW 2nd St Q American Drilling gW T,d or sw rrnd at Se z o C S Services,iec ferreligas ' Countryside i':�` v. aat ' florist&Antiques`� y wh�reli machine - S $ v Big 0 Drive- Pi,>.za Heavrn m i Emory Walker Co.,Inc All About You t% Google The Launge a! : Caregivers Sacred Seamark Love On A Leash Map data©2019 200 ft 1 - ..., -.- 3 d 'tea it 4 x&53 , ,,,-..,,,,*,:,::74:174,1; a� a .tib., >_..'.F • .u'Cf .''...•"Ry Flagler Park 4.4 ,t (195) Park 0 0 Cif (CD+ 0 Directions Save Nearby Send to your Share phone 55 SE 3rd Ave,Okeechobee,FL 34974 • ••• 65V8+9J Okeechobee, Florida cityofokeechobee.com 2019 FLORIDA NOT FOR PROFIT CORPORATION ANNUAL REPORT FILED DOCUMENT#N29452 Feb 14, 2019 Entity Name: MARTHA'S HOUSE, INC. Secretary of State 7336967290CC Current Principal Place of Business: 4134 HWY 441 NORTH OKEECHOBEE, FL 34972 Current Mailing Address: POST OFFICE BOX 727 OKEECHOBEE, FL 34973 US FEI Number: 65-0094350 Certificate of Status Desired: No Name and Address of Current Registered Agent: BEAN,EDGAR J 4134 HWY 441 NORTH OKEECHOBEE,FL 34973 US The above named entity submits this statement for the purpose of changing its registered office or registered agent,or both,in the State of Florida. SIGNATURE: EDGAR J. BEAN 02/14/2019 Electronic Signature of Registered Agent Date Officer/Director Detail : Title PRESIDENT Title TREASURER Name KINDELL,MELISSA D DR. Name ALVAREZ,SAM Address 2029 US HWY 441 N Address 1802 S.PARROTT AVE City-State-Zip: OKEECHOBEE FL 34972 City-State-Zip: OKEECHOBEE FL 34974 Title EXECUTIVE DIRECTOR Title SECRETARY Name BEAN,EDGAR J Name ALVAREZ,SAMUEL Address 506 SW 15TH STREET Address 951 NE 64TH AVE City-State-Zip: OKEECHOBEE FL 34974 City-State-Zip: OKEECHOBEE FL 34974 hereby certify that the information indicated on this report or supplemental report is true and accurate and that my electronic signature shall have the same legal effect as if made under oath;that tam an officer or director of the corporation or the receiver or trustee empowered to execute this report as required by Chapter 617,Florida Statutes;and that my name appears above,or on an attachment with all other like empowered, SIGNATURE:EDGAR BEAN EXECUTIVE DIRECTOR 02/14/2019 Electronic Signature of Signing Officer/Director Detail Date A ® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 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). PRODUCERCONTACT Sherri Britton NAME: Roe Insurance,Inc. PHONE (727 376-0030 FAX (727)376-2262 (A/C,No,Ext): ) (NC,No): 9851 State Road 54 E-MAIL sherri@roeins.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# New Port Richey FL 34655INSURER A: Berkley National Insurance Company 38911 INSUREDINSURER B: New York Marine&General Insurance Company 16608 Martha's House,Inc. INsuRER c: United States Liability Insurance Company 25895 PO Box 727 INSURER D: , INSURER E: Okeechobee FL 34973-0727 INSURER F: 1 COVERAGES CERTIFICATE NUMBER: 2019-2020 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 ADDL SUBRPOLICY EFF I POLICY EXP W LTR TYPE OF INSURANCE INSD VD POLICY NUMBER I,(MM/DD/YYYY) (MMIDDIYYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 II DAMAGE TO RENTED 500,000 CLAIMS-MADE X OCCUR 1 PREMISES(Ea occurrence) $ 20,000 X Professional Liability MED EXP(Any one person) $ A X Abuse&Molestation Liability Y HHS 8562394-13 05/28/2019 05/28/2020 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 X POLICY JPRO- ET LOC PRODUCTS-COMP/OPAGG $ 3,000,000 OTHER: Employee Benefits $ 0 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) X ANY AUTO BODILY INJURY(Per person) $ A OWNED SCHEDULED HHS 8562394-13 05/28/2019 05/28/2020 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) Medical payments $ 5,000 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ _ $ WORKERS COMPENSATION X STATUTE EOTH AND EMPLOYERS'LIABILITY YIN 100,000 B ANY PROPRIETOR/PARTNER/EXECUTIVE N N/A WC201800016123 12/31/2018 12/31/2019 E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? 100,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ Each Occurrence $1,000,000 D&O Liability and EPLI C ND01046831H 03/01/2018 03/01/2021 Aggregate $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Certificate Holder is included as a general liability additional insured,subject to the terms,conditions&exclusions of the policy and only when requested by written contract. Work Comp applies to all projects of the insured in Florida only. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN City of Okeechobee ACCORDANCE WITH THE POLICY PROVISIONS. 55 SE 3rd Ave AUTHORIZED REPRESENTATIVE Okeechobee FL 34974 9i.e it-v7. 9 Oe I v OO v ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD