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HomeMy WebLinkAboutTHE EURO DISTRICT .I�-Iu '-"-, -- ., 4,7,„;,,..0�Qe'r Act C sc 1 CITY EVENT PERMIT APPLICATION Ss]`�t�S g ���t For events,block parties,parades,walks,runs and public rallies CcN lllt�il'i"'`` Return to:Jeffersonville Parks Department,.500 Quartermaster Ct.,Jeffersonville,.IN 47130 I '- Additional information contact:812-285-6440,Fax:812-285-648.1 Nei F EVENT NAME:.7.Tht .0‘ ..ky....\,(..,;- Offi'al me ott fe11tiva .r event S CONTACT/PRODUCER 1 `� I\s, t t' , Applicant&!orPro eventucer/Plannertoecontactedregardingi . .. i CONTACT ADDRESS:111 ``' 1, .&& 1 i tOV I iiX-ti - dityin 4 Street •City State z, C CONTACT INFO: 90/1M17,-ASO -1154;301A Z - W,�:��o l5 t+ r ct‘t Day Phone Cell Phone Fax E-mail EVENT IN FORM TION 9 . � ��i�� t . Event I eation address: . 1 (�51 VL .6 - �� Date: /. /.19 Day f- eek: '_ Y Time: . : M Ending Date: / / Day of week:. (d 06 Tim : :OD M Total attendance expected: Rain/Cancellation Policy Oriti. Provide alternative dates,times and locations of event,if applicable.Must contact city cOordutatorASAP if day of event FEE to be paid at time of application made payable to Jeffersonville Parks Department—SMALL EVENT$150(500&under) (IF ATTENDANCE OVER 500 Oft EVENT ENCOMPASSES MORE THAN(4)CITY BLOCKS OR MAJOR THOROUGHFARE . DIFFERENT EVENT APPLICATION AND FEES MAYAPPLE Block Party Parade Motorcade Rally/Public Gathering Walk/Run Other STREET CLOSINGS OR AREA TO BE USED Additional Infornaation.REQUIRED from event producer/planner/contact: o Notify affected business and residents of street closures • e Provide your own barricades for all blocked&Nor street closures.Check Yellow Pages under"B.arricades" O Provide map showingstreets to be blocked,or if a run/walk a map of your route Provide a Certificate of Insurance listing the City of Jeffersonville as an additional Insured for$1,000,000 U O Provide'a cleanup plan.Producer/Planner is required to leave City property and surrounding area clean ''-)-C(--I cl and litter free after the event 1101.3)HARMLESS AND IDE CATION CLAUSE The applicant/Event Producer/Planner shall indemnify,hold harmless and defend the City of Jeffersonville and the Jeffersonville Parks.&Recreation Department,their elected and appointed officials,employees,agents and successors in interest from all claims,damages,losses and expenses including attorneys'fees;arising out of or resulting,directly or indirectly,from.the Applicant/Event Producer's(or Applicant/Event Producer's subcontractors,if any)performance or breach of the contract provided that Such claim;damage,loss of expenses is:(1)attributable to personal injury, bodily injury,sickness;death;or to injury or destruction of property,including the.loss of use resulting there from,or breach of:contract,and(2)not caused by the negligent act or omission or willful misconduct of the City of Jeffersonville or the Jeffersonville Parks&Recreation Department,their elected and appointed officials and employees acting within the scope of their employment.This Hold Harmless and Indemnification Clause shall in. no way be limited by any financialresponsibility or insurance'requirements and shall survive the termination of the Small Event Permit Application. Only applicants in good standing with the City of Jeffersonville will be considered for Approval.Any misrepresentation in this application or deviation from the final approval speifi-ations and activities described herein or failure to abide by all Federal,State and City of Jeffersonville laws, ordina. • • i i d. .cedures . = a It in th; immediate revocation of the approved peanit and/or refusal to issue a permit in the future. " X 1::,_.,_ ..-.-4.71:* ' '' Fa VII Le 0,g,ja_ i, SIGNAT I = --• :I' Date Receipt# " it• 2 - Lid C�i r, 1..':I // . i ' G Police' ( Fire Public Works/Street mks Safety ATE ACERTIFICATE OF LIABILITY INSURANCE D03/29/20 9Y) 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 cooREPRESENTATIVE 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: HCC Specialty PHONE FAX (EA/C.No.Ext): (A/C,No): 401 Edgewater Place,Suite 400 ADDRESS: PRODUCER Wakefield, MA 01880 CUSTOMER ID#: INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURERA: U.S.Specialty Insurance Company 29599 Dinah Chmielewski INSURER B: United States Fire Insurance Company 21113 8801 High Point Circle INSURER C: Louisville, KY 40299 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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 NSR ADDL SWVD POLICY NUMBER (UBR MM/DD/YYYY) (MM/DD/YYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY X SEL333131381 03/14/2019 04/23/2019 DAMAGE TO RENTED 300,000 PREMISES(Ea occurrence) $ CLAIMS-MADE X OCCUR MED EXP(Any one person) $ 5,000 X Host Liquor PERSONAL&ADV INJURY $ 1,000,000 g x Medical Expense US1105159 03/14/2019 04/23/2019 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1,000,000 POLICY PROT LOG $ JEC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE HIRED AUTOS (Per accident) $ _ NON-OWNED AUTOS $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION TORY II A I U- UERH AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE 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(Attach ACORD 101,Additional Remarks Schedule,if more space is required) The Certificate Holder is added as Additional Insured with respects to our Insured's operations only. This insurance is primary and non-contributory as required by written contract. This coverage is with respect to THE EURO DISTRICT event to be held 04/20/2019-04/20/2019 at RIVERSIDE DRIVE JEFFERSONVILLE IN. CERTIFICATE HOLDER CANCELLATION City of Jeffersonville SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED City Hall Suite 250-500 Quartermaster Court IN ACCORDANCE WITH THE POLICY PROVISIONS. Li Jeffersonville, IN 47130 AUTHORIZED REPRESENTATIVE ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved.