2015-01-07 P & R Agenda Packet - Laserfiche WebLink

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Centerville Special Event Permit Application 1. TITLE, PURPOSE, AND BRIEF DESCRIPTION OF EVENT: Shake Your Shamrock 5K, 8K&Kid's 1/3K Walk/Runs New Application: X Renewal of or Change in Application: CONTACT PERSON: Terry Thompson TELEPHONE: 651-251-5494 OR 651-245-2707 2. IDENTIFYING INFORMATION: Attach a written communication from the organization(s) in whose name the event will be advertised which authorizes you,the applicant,to apply for this special event permit on its/their behalf. Applicant's Name: Randy Fulton Title: FrontRunner- Owner Address: 1665 9th St. White Bear Lake Mailing Address: Same Affiliation: Day Phone: 651-653-7401 Evening Phone: 651-428-9697 Emergency Phone: 651-428-9697 3. EVENT PRINCIPALS: Following, please list the names, addresses and telephone numbers of all the principals involved in any of the proposed special event. Include professional event organizers, event promoters, financial underwriters,commercial sponsors, charitable agencies for whose benefit the event is being produced,the organization(s) in whose name the event is being advertised, and all others administratively, financially and organizationally involved as principals in the production of the proposed special event. Make additional copies of the following as needed to include as of the principals involved in the proposed special event. Name: Front Runner Organization/Business/Agency/Affiliation: Event Organizer/Race Director Is this a non-profit organization? Yes X No If you are making application under non-profit status,proof of non-profit status must be attached to this agpylication Mailing Address: Day Phone: Evening Phone: Title and functional responsibility with regard to the event: Race Director Midwest Events- Event Promoter 1890 Whitaker St.,White Bear Lake, MN 55110 651-2515494 Kelly's Korner Bar- Sponsor 7098 Centerville Rd 651-493-6626 Page 1 of 10