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Park Use Permit_Pregnancy Center_Chili Cookoff ecroiTk- CITY OF OKEECHOBEE 55 SE THIRD AVENUE �o� o OKEECHOBEE, FL 34974 a ''�� Tele: 863-763-9821 Fax 863-763-1686 91 toll .11 e-mail: permit(a�cityofokeechobee.corn Park Use Permit Permit Number: 24-019 Date(s) of Event: January 11 , 2025, 11:30 a.m. — 3:00 p.m. Permit Expiration: January 11, 2025 11:59 P.M. Purpose of Request: Chili Cookoff Property Owner: City of Okeechobee Address: 55 SE 3rd Ave City: Okeechobee State: Florida Zip Code: 34974 Applicant: Pregnancy Center of Okeechobee Applicant's Address: 808 NE Park Street Okeechobee, FL 34974 Phone Number: 863-467-8748 Address of Project: Settlers Square Current Zoning: PUB FLU Designation: PF Subdivision: City of Okeechobee Restrictions/Remarks: • All debris must be removed within 24 hours of expiration date. • Contact the Okeechobee County Fire Department at 863-763-5544 to schedule a final field inspection before event. ?4e�zeda 7onde September 20,2024 General Services Administrative Secretary Date Page 1 of 3 Revised 5/13/24 CITY OF OKEECHOBEE a• -k-A• �k�--am 55 SE THIRD AVENUE • °cP OKEECHOBEE, FL 34974 �" rZ Tele: 863-763-9821 Fax: 863-763-1686 ' ,o,.•• PARK USE AND/OR TEMPORARY STREET/ ' '��• SIDEWALK CLOSING PERMIT APPLICATION Date Received: jig j244 Date Issued: q f 2Q/2o2'-' Application No: 2y-019 Date(s) &Times of Event: 0 I In/z0z5 1/;300411 - 3' to r,., SeA of $:DOem r` Information: Organization: Prea hGU1C C t-e- of 0 Ketcho ou, 1ic • Mailing Address: )gQ' JW o I< 61-re Contact Name: Li s a 1.407106 n E-Mail Address: II S Q QK Le prL, ( ',1-fr. ()um Telephone: JJ Work: `i -L ]- <flL' Home: Cell: Pa 3-4341—/I95 Summary of activities: Sbu J - I � cofirbr 7- l+eDrS rpare +h LI ( o wn chili hil; rwci� gn d 6-fU-�br7-f- t -oi L h[ ikb Fad) Qo i Kir havt 10 >ID an a r_ L,,, ptopant anK - I I ha e. se'e � min orsdace fa.' n - ANSIC - cfri()lfs - Proceeds usage: C1.11 procei.s rom i/ s £✓e.7f goes badK 141 i0 Q Preijrarn dr or'VIa S Please check requested Parks: Flagler Parks: o City Hall Plaza o #1 Veterans Memorial Square o #2-Speckled Perch Square o #3-Seminole Square W#4-Settlers Square o #5-Cattlemen's Square o #6-Butterfly Square [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 5/13/24 TEMPORARY STREET AND SIDEWALK CLOSING INFORMATION (Street Closings require City Council approval. Meetings lst& 3rd Tuesdays but subject to change) Address of Event: PGA 1 \ lI- n 05(110 Street(s)to be closed: Date(s) to be closed: Time(s) to be closed: 1\) \-PC 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 ► 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 v ► 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 ► 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. 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 5/13/24 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. (-)9t,..vt .41/4"-,/ '490) 24 Applicant Signature Date ••••OFFICE USE ONLY•••• Staff Review Fire Department: \L „r, ,, \� Date: c Building Official: Date:Public Works: !AO Date: I /2 Police Department: Date: q, � BTR Department: ; Date: 9//041 / City Administrator: e Date: q-C4-�� City Clerk: ( p-- Date: q 115/d09,4_ 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 Af k' Date Temporary Street and Sidewalk Closing reviewed by City Council and approved Al I k Date PREGNANCY CENTER CHILI COOK-OFF EXHIBIT FLAGLER PARK A'1, SQ-fKe-tr>f Stu 0—(e- 1 STATE ROAD 70 STATF.ROAD 70 a PREP AKE:\ GRAPHIC SCALE �l J L J L J L J L J L J L J 60 Tzropo IoNto'mwr LP.VN R:c J ____ _= r— Feet I INCH 30 I.I. 100 (INTENDED DISPLAY SCALE • rii IW(m TENT ri r i rD r rDi r r' J// I I I / H J I'HEI'.\RE.i L JItYX1u.TENT a..\lo — rPREP.ARE:A 03, FLAG LER PARK N3 i Frog�');16' — i PREP AREA��� f� III , t I L,[41 PREP AREA I I i_J L L J J L `4 PI y r — ."' I wxurnxr ; 10/(1C TENT ,J ''�'*s` I 10'\IO iE\"1 rli r---1 LI--IJ L_--IJ LI_ IJ L_---J L J L_--IJ L— _ 2, a'<IM1'i _ PREP AREA SW PARK STREET SW PARK STREET' ACORD® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 9/13/2024 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 CONTACT NAME: Johnson-Witkemper PHONE 8 FAX 12-372 7829 305 Washington St (A/C.No.Extl: (A/C,No):812-372-0026 Columbus IN 47201 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Midwest Insurance Group,Inc. INSURED PREGCEN-07 INSURER B Pregnancy Center of Okeechobee Inc 808 Northeast Park Street INSURER C: Okeechobee FL 34972 INSURER D: INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: 1701893247 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LTR INSD WVD, POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY Y PL-CPC-FL-23-0001012 10/25/2023 10/25/2024 EACH OCCURRENCE $1,000,000 X CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $100,000 MED EXP(Any one person) $ PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $3,000,000 POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $1,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) _ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS HIRED AUTOS NON-OWNED PROPERTY DAMAGE AUTOS (Per accident) UMBRELLA LIAB ^ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) For The Great Chili Cook off-Saturday,January 11,2025. City of Okeechobee as additional insured. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Okeechobee 55 SE Third Avenue Okeechobee FL 34974 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INTERNAL REVENUE SERVICE DEPARTMENT OF THE TREASURY P. 0. BOX 2508 CINCINNATI, OH 45201 Date: !S/T 19 .20 7 Employer Identification Number: 33-1164762 DLN: 17053176001027 PREGNANCY CENTER OF OKEECHOBEE ContactI Person: INC EDjARD S SCHLAACK ID# 31536 1517 SW 7TH AVE Co Iltact Telephone Number: OKEECHOBEE, FL 34974 (8 7) 829-5500 Acc unting Period Ending: Di cember 31 Public Charity Status: 170(b) (1) (A) (vi) Fotjn 990 Required: YI s Eff ctive Date of Exemption: A ril 23, 2007 contribution Deductibility: Yrz Advance Ruling Ending Date: D cember 31, 2011 Add dum Applies: N Dear Applicant: We are pleased to inform you that upon re iew of your application for tax exempt status we have determined that you are exempt from Federal income tax under section 501 (c) (3) of the Internal R venue Code. Contributions to you are deductible under section 170 of the Code. You are also qualified to receive tax deductible bequests, devises, transfe s or gifts under section 2055, 2106 or 2522 of the Code. Because this letter could help resolve any questions regarding your exempt status, you should eep it in your permanent records. Organizatio or ^�� ;�� the Code are further classified as either ublic charities or private foundations During your advance ruling period, you will be treated as a public c-arity. Your advance ruling period begins with the effective date of you'r_ exemption and ends with advance ruling ending date shown in the heading of the letter. Shortly before ttie end of your advance ruling period, we will send you Form 8734, Support Schedule for Advance Ruling Period. You will have 90 days after the end of your advance ruling period to eturn the completed form. We will then notify you, in writing, about your p lic charity status. Please see enclosed Publication 4221-PC, Compliance Guide for 501(c) (3) Public Charities, for some helpful information about your responsibilities as an exempt organization. • Letter 1045 (DO/CG) -2- PREGNANCY CENTER OF OKEECHOBEE Sincerely, Fcryirar• - R.I.ert Choi D. ector, Exempt Organizations R ings and Agreements Enclosures: Publication 4221-PC 1 Statute Extension Letter 1045 (DO/CO) Form 1023(ijev,5-2006) Name: EIN: — /((p 5x R Paga 11 Part X Public Charity Status (Continued) • e 509(a)(4)—an organization organized and operated exclusively for testing for public safety. ❑ f 509(a)(1) and 170(b)(1)(A)(iv)—an organization operated for the benefit of a college or university that is owned or CI operated by a governmental unit. g 509(a)(1)and 170(b)(1)(A)(vi) an organization that receives a substantial part of its financial support in the form • of contributions from publicly supported organizations, from a governmental unit, or from the general public. h 509(a)(2)—an organization that normally receives not more than ne-thlyd of its financial support from gross ❑ lo Investment income and receives more than one-third of its fin nclal support from contributions, membership fees, and gross receipts from activities related to its exempt functions (subject to certain exceptions). I A publicly supported organization, but unsure if it is described in 5g or 5h.The organization would like the IRS to ❑ decide the correct status. 6 If you checked box g, h, or I In question S above,you must request either an advance or a definitive ruling by selecting one of the boxes below. Refer to the instructions to determine which type of ruling you are eligible to receive. a Request for Advance Ruling: By checking this box-and signing the consent, pursuant to section 6501(c)(4)of 10 the Code you request an advance ruling and agree to extend the statute of limitations on the assessment of - excise tax under section 4940 of the Code.The tax will apply o ly if you do not establish public support status at the end of the 5-year advance ruling period. The assessment period will be extended for the 5 advance ruling years to 8 years, 4 months, and 15 days beyond the end of theF first year.You have the right to refuse or limit the extension to a mutually agreed-upon period of time orissue(s). Publication 1035,Extending the Tax Assessment Period,provides a more detailed explanation of vodr rights and the consequences of the choices ,ee .'nake. You may obtain P'ubiicatioe 1035 tree of change from the IRS web site at www.irs.gov or by calling • toll-free 1-800-829-3676. Signing this consent will not deprive you of any appeal rights to which you would otherwise be entitled. If you decide not to extend the statute of limitations, you are not eligible for an advance ruling. • •- _ re 'i.'. _ ,! 4 S i3� a ^� - For Organization 6-7-.-tp4g6( k eci,g c/d/CIP it t (Signature of Officer,Director,Trustee,or other (Typo or print Ytamo ot s.gn r) (Date) authorized official) ( jaEf eelp' (Type or print Ire or authorfty of signer) For Use Only , i OCT 19 2007 IRS Director,Exempt QrOanizations (Date) b Request for Definitive Ruling:Check this bbx if you have corn feted one tax year of at least 8 full months and ❑ you are requesting a definitive ruling. To confirm your public support status, answer line 6b(i) if you checked box g in line 5 above. Answer line 66(i) if you checked box h in line above. if you checked box i in line 5 above, answer both lines 6b() and (ii). (I) (a) Enter 2% of line 8, column (e) on Part IX-A. Statement o i Revenues and Expenses. (b) Attach a list showing the name and amount contributed by each person, company, or organization whose ❑ gifts totaled more than the 2% amount. If the answer is ",None," check this box. (ii) (a) For each year amounts are included on lines 1, 2, and 9 f Part IX-A- Statement of Revenues and Expenses, attach a list showing the name of and amoun received from each disqualified person. If the answer is `None," check this box. ❑ (b) For each year amounts are included on line 9 of Part IX- . Statement of Revenues and Expenses, attach a list showing the name of and amount received from each payer, other than a disqualified person, whose payments were more than the larger of(1) 1% of line 10, Part IX-A. Statement of Revenues and Expenses, or(2)$5,000. If the answer is "None,"check tits box. ❑ 7 Did you receive any unusual grants during any of the years shown on Part IX-A. Statement of ❑ Yes It No Revenues and Expenses? If'Yes," attach a list including the name of the contributor,the date and amount of the grant, a brief description of the grant, and explair why it is unusual. Form 1023 (Rev.52006)