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HomeMy WebLinkAbout2013-11-06 P & R Packet CITY OF CENTERVILLE PARKS & RECREATION AGENDA Wednesday, November 6, 2013 — 6:30 p.m. I. CALL TO ORDER 1. Roll Call H. SET AGENDA III. APPEARANCES IV. CONSIDERATION OF MINUTES 1. Parks & Recreation Committee Minutes of September 4, 2013 V. COMMITTEE BUSINESS 1. Request Council to allocate the $500 Lions Donation & Proceeds from 2013 Festival of the Lakes Runs to a Reserve Account for the Purchase of Park Benches & Park Amenities 2. Park Benches Update (P. Branch) 3. Basketball Court(s) — LaMotte Park 4. Volleyball Game Challenge Update (B. Peterson) 5. Movie in the Park Update & Possible Additional Movie in the Bay (Fire Department) (B. Peterson) 6. 2014 Ice Skating Parties @ Laurie LaMotte Memorial Park — Dates, Hayride, Popcorn, Hot Chocolate, Etc.? a. Bunker Park Stable, Inc. Contract — Skate Night/Hayride — February 8, 2014 7. Thank You Letter to Ex- Committee Member Mark Haiden for 5 years of Service (P. Branch) 8. Drinking Fountains In Parks 9. Special Event Permit Application — Centerville Lions Use of Laurie LaMotte Memorial Park Warming House and Grounds for their Annual Haunted House Fund Raiser & Hayrides — October 25 & 26, 2013 (Council/Administratively Approved) 10. Special Event Permit Application — Centerville Lions Use of Laurie LaMotte Memorial Park Hockey Rink and Grounds for their Oktoberfest Fund Raiser — October 19, 2013 (Council/Administratively Approved) 11. Park Facility Permit Application — Laurie LaMotte Memorial Park Outfield #3 — Cub Scout Introduction to Soccer — October 7, 2013, 6:30 p.m. — 8:00 p.m. (Administratively Approved) 12. Park Facility Permit Application — Cub Scouts — Use of Laurie LaMotte Memorial Park Grounds for their Annual Rocket Launch — October 12, 2013 with a Rain Date of October 19, 2013 (Administratively Approved) 13. Park Facility Permit Application — Laurie LaMotte Memorial Park Hockey Rink — Oct. 23, 25 & 28, 2013 — 5:30 p.m. — 6:30 p.m. (Administratively Approved) 13. Special Event Permit Application — "Shake Your Shamrock" 5 & 8K Run/Walk VI. UPDATES 1. Council Updates — Council Member Steve King On -Going Items PARKS AND RECREATION COMMITTEE Wednesday, September 4, 2013 — 6:30 p.m. Pursuant to due call and notice thereof, the Parks & Recreation Committee of the City of Centerville held a scheduled meeting on Wednesday, September 4, 2013 at City Hall location. Present: Chairperson Patrick Branch Vice- Chairperson Jon Grahek Committee Member Kevin Amundsen D Committee Member Brian Peterson _- Committee Member Suzanne Seeley Committee Member Kevin Waeghe Also Present: Council Member, Steve King Public Works Director, Paul Palzer Absent: Committee Member Chris Bettinger I. CALL TO ORDER Chairperson Branch called the September 4, 2013 Meeting of the Parks & Recreation Committee to order at 6:34 p.m. at the City Hall location. Roll Call — see above H. SET AGENDA Motion was made by Committee Member Seeley, seconded by Committee Member Wa to set the agenda as presented with the following additions: to Committee Business add 46. "Criteria for Park Permits and #7 "Approval of dates /times for 2014 Festival of Lakes" ; To Updat add 43. "Peltier Lake Update" and #4 "Movie in the Park". All in favor. Motion carried una nimously. III. APPEARANCES — NONE IV. CONSIDERATION OF MINUTES A request was made to amend the meeting minutes as follows: Under Consideration of Minutes: Under Updates: #2. 6 th line add "Hidden Spring Park" between In and Centerville. Motion was made by Committee Member Amundsen, seconded by Committee Member Waeg to approve the minutes of the August 7 2013 meeting as amended. All in favor. Mo tion carried unanimously. V. COMMITTEE BUSINESS 1 1. Use of Hidden Spring Park Motion was made by Committee Member Branch, seconded by Committee Member Grahek to recommend to the City Council to approve the permit application from Mr. Bob Voss for a wedding on September 28 2013 from 11.00 a.m. to 3.00 p.m. All in favor. Motion carried unanimously. 2. Alternative 5K Course After review of the proposed alternative course and discussion, it was the consensus of the Committee to leave the course the same for 2014 with registration in Hidden Springs Park. 3. Basketball Court After discussion about utilizing the hockey rink for a basketball court in the summer, it was mentioned that a resident has a portable basketball pole and net to donate to the parks. After further discussion regarding setbacks, anchoring the portable unit for summer use or possibly having a custom pole and net made, this item was postposed to a later date 4. Status of Volleyball Court The court has been completed but needs some additional sand, which has been delivered and will be added to the court this week. The "Grand Opening" of the new Volleyball Court will commence with a challenge game between the Park and Recreation Committee, City Council and City Staff on Saturday, July 14 at 6:00 p.m. This challenge game will take place just prior to the Movie in the Park scheduled for 7:30 p.m. 5. Park Benches The Committee discussed the addition of park benches with one needed by the tennis court at Eagle Park, two needed at Trailside Park and one needed by the playground at Laurie LaMotte Park; also discussed materials, wood or composite, that would be best suited for park use. Cost for composite would be up to $500 each, with $200 each for installation. The committee also discussed making a possible commitment for 2013, with payment in 2014 as well as to check with Anoka County if the option to piggy back on their bench contract to obtain benches at a lower cost might be possible. 6. Criteria for Park Permits The Centennial Football League has submitted a request to use all the playing fields at Laurie LaMotte Park from August through October, 2014. A suggestion was made to designate fields 1, 2 & 11 for soccer and lay -out two football fields in the baseball outfield for the football league. Consensus of the Committee was to table this item until February, 2014. 7. 2014 Festival of Lakes 2 The dates and times for the 2014 Festival of Lakes will be Friday, July 25 through Sunday, July 27, with the parade and running events scheduled for Saturday, July 26. The runs will begin at 8:00 a.m., with the kids run beginning at 9:30 a.m. The awards ceremony will begin at 9:10 a.m. The registration will be held at Hidden Springs Park. V1. UPDATES 1. Council Updates — Council Member Steve King Port-a -Pot Update — Council Member King and Committee Member Branch both inspected the port-a- potties and reported they were stocked with toilet paper, hand sanitizer and are on a more frequent servicing schedule. Grass on Ball Fields at Laurie LaMotte Park — grass is looking better, but some areas show no roots; will not be able to water them due to the water level in the pond. The Committee recommended keeping the fields closed for the time being. Irrigation System — discussion was had regarding upgrading the existing system, use of cisterns /rain barrels and costs. 2. Mr. Nick Twohy has requested to become a member of the P & R Committee This request will be before the City Council on September 11, 2013. 3. Peltier Lake Update Information given by Mr. Wayne LeBlanc was reviewed and it was determined by the Committee that it should be updated and that additional educational materials could be obtained from the Rice Creek Watershed offices for possibly inclusion in the April water bill. Committee Member Seeley will check with Rice Creek and this item will be tabled until 2014. 4. Movie in the Park Committee Member Peterson gave the Committee an update on the event scheduled at Laurie LaMotte Park for September 14 at 7:30pm, with a rain date of September 21. The movie, "Despicable Me' has been obtained for the viewing. It was determined that a high resolution (3,000 lumens) projector should be rented for $150 as this is a budgeted item. The Committee discussed serving water /cold fruit drinks and /or hot chocolate (depending on the weather) along with popcorn with the possibility of ice cream as well. Committee Member Bettinger has a second popcorn machine available for use. Volunteers need to arrive at 4:30 to 5:00 for set up. This event should be displayed on the City Hall sign, as soon as possible, and also the website; also the schools will be contacted for them to participate in promoting this activity. 3 On -going Items: NONE VII. ACTION ITEMS REVIEW Items that have been completed will be removed; some are still open and additional items discussed at this meeting will be added. A revised Action Item List, as of September 4, 2013 meeting will be included with the minutes to be approved. Items that have been completed as of September 4, 2013 will be removed: • These include item numbers NONE Items that are to be deleted as of September 4, 2013 will be removed: • These include item numbers: 12 -007, 12 -046a 13 -013 13 -020 All remaining current open/in process & tabled items — change date from 9 -4 -13 to 10 -2 -13 * These include item numbers: 12 -006, 12 -13a, 12 -13b, 12 -067d, 13 -022, 13 -026, 13 -027, 13- 028, 13 -029 Corrections/Revisions Change 12 -013b — add "Movie Flyer" Change 13 -013 — change from 9 -4 -13 to "extend to 2015" & "Extended to 2015" to "Open" Change 13 -026 — change from "Info is provided at ......... TO "Ongoing" Items to be added are: 13 -030 — Add "Movie In Park" info to outside City Hall Sign, ASAP, STAFF 13 -031 — Info to "Flash" Centerville Schools, ASAP, P. Branch 13 -032 — Educational materials from Rice Creek Watershed, Spring, 2014, S. Seeley (re: phosphorus in lakes /April water bill) NOTE: Any of these added items that have a Due Date of 10 -2 -13 are Open and the Assigned Person for them is STAFF, unless otherwise stated. Items that are priority items and need to be done ASAP are item numbers: 13 -030 & 13 -031 VIII. ADJOURNMENT Motion was made by Committee Member Grahek seconded by Committee Member Seeley to adjourn the meeting. Meeting was adjourned at 7:57m m. All in favor. Motion carried unanimously. Submitted by: Linda Neudecker, Secretary 4 ACTION ITEMS PARKS RECREATION Assigned Completed # Item Person /Status Date Closed Trailside Park Benches - Bald Eagle Ski 12 -006 Club P. Branch 10/2/2013 Open Kiosk - Cornerstone Park - Create Inserts for 12 -013a Kiosk K. Amundsen 10/2/2013 On -Going Kiosk @ Cornerstone Park - Remove All Outdated Materials & Replace Seasonal 12 -013b Programs /Events Staff 10/2/2013 On -Going Little League - Status of Scoreboard Moving & dragging of fields (Update Given @ April 12 -067d Meeting) Committee 10/2/2013 Open Continued Usage of Board of Water Commissioners Property Abutting Trailside 13 -013 Park Dallas 10/2/2013 Open Investigate Possibility of Hockey Rink as Pat B. & Paul 13 -022 Basketball Court in Summer P. 10/2/2013 Open Staff Place Park Reservations /activities on 13 -026 Calendar in Council Chambers Staff 10/2/2013 On -Going 13 -027 Plan to Upgrade Trailside Park P & R 10/2/2013 Open 13 -028 Plan to Address Signage for Indian Mound P & R 10/2/2013 Open 13 -029 Plan for Parks Irrigation P & R 10/2/2013 Open 09/12 & 09/16/2013 & 13 -030 Movie in the Park Staff Completed Twittered 13 -031 Info to "FLASH" Centerville School Pat B. ASAP Open Educational Materials from RCWD - Phosphorus in Lakes (Spring, 2014) — Utility 13 -032 Billing S. Seeley 10/2/2013 Open Following September 4, 2013 Meeting Page 1 Parks & Rec Parks REVENUE ACTUAL BUDGET R 101 - 45201 -34780 Recreation Fees - - R 101 - 45201 -34781 8K Run 4,431.00 2,300.00 R 101 - 45202 -36200 Miscellaneous Revenues - - R 101 - 45202 -36230 Contributions and Donations 500.00 - TOTAL RECEIPTS 4,931.00 2,300.00 Parks /Rec. Committee EXPENSES E 101 - 45200 -100 Wages and Salaries (GENERAL) - E 101 - 45200 -122 FICA - E 101 - 45200 -438 Meeting Per Diem 780.00 2,800.00 Parks /Rec Programs EXPENSES DIFFERENCE 'Warming House Attendants E 101- 45201 -100 Wages and Salaries (GENERAL) 3,166.26 3,000.00 (166.26) E 101 - 45201 -122 FICA 242.22 200.00 (42.22) E 101 - 45201 -151 Workers Comp Insurance Prem 215.58 200.00 (15.58) E 101 - 45201 -370 Park Programs 821.41 2,350.00 1,528.59 E 101 - 45201 -371 Music in the Park 2,368.99 2,200.00 (168.99) E 101 - 45201 -373 8k Run/Walk 1,889.74 2,300.00 410.26 E 101 - 45201 -374 Movies in the Park 572.84 750.00 177.16 E 101 - 45201 -374 Park and Rec Reserve - - - EXPENSES 8,704.20 11,000.00 2,295.80 TOTAL EXPENSES 9,484.20 13,800.00 4,315.80 Teresa Bender From: Teresa Bender Sent: Tuesday, October 15, 2013 1:41 PM To: Pat Branch Subject: RE: Movie Discount - $175 Dear Pat: If you are utilizing the Fire Station for this movie how about you get the fire fighters involved — either food donation or their other favorite charity is Toys for Joy (Christmas Committee). Involve the Lions? There are always firefighters that have lost their regular jobs (fire fighting only pays $10.00 an hour for calls) or need assistance also — maybe donate food items to them or toys or whatever. Teresa From: Pat Branch Sent: Tuesday, October 15, 2013 1:25 PM To: Brian Peterson; John Grahek Cc: Teresa Bender Subject: Re: Movie Discount - $175 Brian, Sorry for being off line all last week. We had house guest here for 10 days. We still need to make this move by Oct 22nd. So go for it. I think "The Muppet Christmas Carol" would be a good choice. I like you idea on using this as an occasion for doing something nice at Christmas time. But that is a new decision and we can wait for the November meeting and still have time to advertise the idea. We will get it on the agenda for November. To keep the gift concept simple and easy for us to care off, we will want to link up to an established charity. For example the Marine Corps' Toys for Tots. The other committee members may have a better idea. Maybe Jon knows something the St Paul Police are sponsoring. Another idea is to ask people to bring in a holiday food item or candy and donate the items to the Hugo Food Shelf. That is what I have done with my excess garden veggies. they re always very appreciative and helping local people. Pat On Oct 10, 2013, at 1:23 PM, Brian Peterson wrote: I am having a busy day but wanted send you a quick update. 1 See the note below from Swank. They gave some pricing on a short list of Christmas Movies and an extension on deciding. Centennial Fire agreed to Sat Dec 7 for a movie. I think we should try to extend it to a larger Theme (Santa, Present donations, etc). ---- - - - - -- Forwarded message ---- - - - - -- From: Rachael Pickerel < rpickerelgswankmp.com > Date: Thu, Oct 10, 2013 at 11:28 AM Subject: RE: Movie Discount - $175 To: Brian Peterson < briangpetersoncabin.com > Hi there Brian, I have spoken with my manager and I can extend the promotional $175 rate if the movie is booked by October 22. If not, please see my notes below: How The Grinch Stole Christmas ( I assume this is the full length film with Jim Carrey) - $275 The Santa Clause (1994) $250 The Muppet Christmas Carol (1992) $250 Elf (2003 ) $275 A Christmas Carol (2009) $250 Please let me know what questions you have! Rachael Rachael Pickerel I Account Executive I P:800.876.5577 I F:314.909.0879 I Email: rpickerel swankmp.com Swank Motion Pictures, Inc. 1 10795 Watson Road I St. Louis, MO 63127 1 United States of America I www.swank.com This email and any attachments are the property of Swank Motion Pictures, Inc. and are intended solely for the use of the email recipient or entity to whom the email is addressed. Emails are not to be distributed to other parties without the express written permission of the original sender. If you are not the intended recipient of this email, please delete this message. Any other use, retention, or dissemination is strictly prohibited. 2 Please consider the environment before printing this email From: Brian Peterson [ mailto : brianCabpetersoncabin.com ] Sent: Wednesday, October 09, 2013 7:56 AM To: Rachael Pickerel Subject: Re: Movie Discount - $175 Rachel, At your convenience could you please give me a quote for the following movies: How The Grinch Stole Christmas The Santa Clause (1994) The Muppet Christmas Carol (1992) Elf (2003 ) A Christmas Carol (2009) On Fri, Oct 4, 2013 at 11:03 AM, Rachael Pickerel < rpickerel@swankmp.com > wrote: Absolutely understandable. Let me know when you hear back and I'll confirm with my manager that I can extend back the discount. Take care, Rachael 3 Rachael Pickerel I Account Executive I P:800.876.5577 I F:314.909.0879 I Email: rpickerel@swankmp.com Swank Motion Pictures, Inc. 1 10795 Watson Road I St. Louis, MO 63127 1 United States of America I www.swank.com This email and any attachments are the property of Swank Motion Pictures, Inc. and are intended solely for the use of the email recipient or entity to whom the email is addressed. Emails are not to be distributed to other parties without the express written permission of the original sender. If you are not the intended recipient of this email, please delete this message. Any other use, retention, or dissemination is strictly prohibited. Please consider the environment before printing this email From: Brian Peterson [mailto: petersoncabin.com Sent: Friday, October 04, 2013 10:47 AM To: Rachael Pickerel Subject: Re: Movie Discount - $175 Thank you, It would certainly be very beneficial. We don't have our own space to show the move so we are attempting to coordinate with other and not always getting a speedy response. On Fri, Oct 4, 2013 at 10:16 AM, Rachael Pickerel < rpickerel(&,swankmp.com > wrote: Thanks for asking, Brian. Originally the promotion was intended for you to book a movie for fall /winter of 2013. 1 would be happy to extend that book date to October 21, for a show date of today — Dec 31, 2013. Would that give you enough time to buckle down the location? Please let me know how I can help! Rachael 4 Rachael Pickerel I Account Executive I P: 800.876.5577 I F: 314.909.0879 I Email: rpickerel @swankmp.com Swank Motion Pictures, Inc. 1 10795 Watson Road I St. Louis, MO 63127 1 United States of America I www.swank.com This email and any attachments are the property of Swank Motion Pictures, Inc. and are intended solely for the use of the email recipient or entity to whom the email is addressed. Emails are not to be distributed to other parties without the express written permission of the original sender. If you are not the intended recipient of this email, please delete this message. Any other use, retention, or dissemination is strictly prohibited. Please consider the environment before printing this email From: Brian Peterson [ mailto : brian(c)petersoncabin.com ] Sent: Friday, October 04, 2013 9:55 AM To: Rachael Pickerel Subject: Re: Movie Discount - $175 Rachel, Another question on the movie promotion for you. If we reserve a movie for this promotion could we leave the date open or pick a date and reschedule it later if necessary. It is taking longer to secure a location. The location selection could impact the date to show the movie. On Mon, Sep 16, 2013 at 9:34 AM, Rachael Pickerel < rpickerel@swankmp.com > wrote: Sorry that I didn't clarify, Brian! But thanks for the question. If you book an additional movie for the remainder of the year, I can offer the licensing fee at $175. Ideally, this movie (any movie!) should be booked by October 11 for a show date of today — December 31. If this is date is not feasible for you, please let me know and I'll see how I can help. Rachael 5 Rachael Pickerel I Account Executive I P: 800.876.5577 I F: 314.909.0879 Email: rpickerelCeDswankmp.com Swank Motion Pictures, Inc. 1 10795 Watson Road I St. Louis, MO 63127 United States of America I www.swank.com This email and any attachments are the property of Swank Motion Pictures, Inc. and are intended solely for the use of the email recipient or entity to whom the email is addressed. Emails are not to be distributed to other parties without the express written permission of the original sender. If you are not the intended recipient of this email, please delete this message. Any other use, retention, or dissemination is strictly prohibited. Please consider the environment before printing this email From: Brian Peterson [ mailto: brianapetersoncabin.com ] Sent: Monday, September 16, 2013 9:30 AM To: Rachael Pickerel Subject: Re: Movie Discount - $175 Rachael, Thank you. I have one additional question for you regarding the 2nd movie promotion at the $175 discount. Based on the wording it appears we only have to book the movie by Oct 11. Is my assumption correct and what are the requirements of the date of the showing for that movie? On Mon, Sep 16, 2013 at 9:27 AM, Rachael Pickerel < rpickerel@swankmp com wrote: Brian, Thanks so much for letting me know. I have made a note on your account that you will reshow the movie this Saturday. And you are correct, typically you will have 1 year to reshow the movie. Thanks again and better luck this time! Rachael 6 Rachael Pickerel I Account Executive I P: 800.876.5577 I F: 314.909.0879 Email: rpickerel @swankmp.com Swank Motion Pictures, Inc. 1 10795 Watson Road I St. Louis, MO 63127 United States of America I www.swank.com This email and any attachments are the property of Swank Motion Pictures, Inc. and are intended solely for the use of the email recipient or entity to whom the email is addressed. Emails are not to be distributed to other parties without the express written permission of the original sender. If you are not the intended recipient of this email, please delete this message. Any other use, retention, or dissemination is strictly prohibited. Please consider the environment before printing this email From: Brian Peterson [mailto: petersoncabin.com Sent: Sunday, September 15, 2013 9:12 PM To: Rachael Pickerel Subject: Re: Movie Discount - $175 Rachael, We had a rain out on Sat and didn't show the movie. As I under stand it we have a year to show it. We pre planned a rain date for this coming Sat Sept 21. 1 believe that I should keep the movie until this next weekend. Am I correct? On Wed, Sep 11, 2013 at 10:43 AM, Rachael Pickerel < rpickerel(a)swankmp.com > wrote: Brian, Forgive me for not offering this special when you called in! After checking, I see that you qualify for the following: 7 * *If you book a movie by October 11 1h , I can offer a discount of $175 for the licensing fee. ** Please let me know if this is something you'd be interested in doing! It may be a great opportunity for you to show one last movie this summer O All the best, Rachael Rachael Pickerel I Account Executive I P: 800.876.5577 I F: 314.909.0879 I Email: rpickerel@swankmp com Swank Motion Pictures, Inc. 110795 Watson Road I St. Louis, MO 63127 1 United States of America I www.swank.com This email and any attachments are the property of Swank Motion Pictures, Inc. and are intended solely for the use of the email recipient or entity to whom the email is addressed. Emails are not to be distributed to other parties without the express written permission of the original sender. If you are not the intended recipient of this email, please delete this message. Any other use, retention, or dissemination is strictly prohibited. Please consider the environment before printing this email Brian Peterson 1668 Hunters Trail Centerville, MN 55038 Home: 651- 793 -7432 Cell: 651- 247 -3895 Briangpetersoncabin.com 8 Brian Peterson 1668 Hunters Trail Centerville, MN 55038 Home: 651- 793 -7432 Cell: 651- 247 -3895 Brian(&petersoncabin.com Brian Peterson 1668 Hunters Trail Centerville, MN 55038 Home: 651- 793 -7432 Cell: 651- 247 -3895 Brian(a petersoncabin.com Brian Peterson 1668 Hunters Trail Centerville, MN 55038 Home: 651- 793 -7432 Cell: 651- 247 -3895 Brian@petersoncabin.com 9 Brian Peterson 1668 Hunters Trail Centerville, MN 55038 Home: 651- 793 -7432 Cell: 651- 247 -3895 Bri angpetersoncabin. com Brian Peterson 1668 Hunters Trail Centerville, MN 55038 Home: 651- 793 -7432 Cell: 651-247-3895 Briangpetersoncabin.com This email has been scanned by the Symantec Email Security.cloud service. For more information please visit http: / /www.sManteccloud.com 10 Bunker Park Stable, Ine. Entrance at 550 Bunker Lake Blvd. NW, Andover, MN 55304 Mailing Address: P.O. Box 10804 White Bear Lake, MN 55110 Phone: 763 - 757 -9445 Fax: 763 - 757 -8641 www.bunkerparkstable.com / info @bunkerparkstable.com Date: To: V 1 I L _ 1 er_5 a.- Y. aU,y' toS Orgaannizat 1 " N w � Q Contact Name A & (AU w0 `.' �-Ae Address Thank you for choosing Bunker Park Stable! This letter is to confirm your travel reservation: - Date � �`4 Time: L : OD — g: U 1/ Activity: aU�Q VlP:!:A (�J� Location /Address: t. YV�.o� �G �VJ" Please ensure dates, times, and location are correct. 0 1 G . �0 The price is $ �� plus a travel fee of $ and $t4f 13 tax for a total due of $ _'7 `� g • 3 We must receive the following at least one week prior to your event: 1. A signed copy of this form. 2. A deposit of $100.00 or a credit card number. N %�- 3. Detailed directions to the location and a map of the route (route clearance must be at least 12' ,IAA, v high by 12' wide), including where to park and set up (an area of approximately 100' x 60' is needed for this). 4. FOR THOSE WITH SALES TAX EXEMPT STATUS: A copy of your Form ST17 Tax Exempt number, or you will be charged sales tax. 5. Name and cell number of person who will meet us upon arrival. i Please remember YOU ARE RESPONSIBLE to obtain any special permits and fees required for your activity by your city or location. We will be happy to supply you with the needed information. You or your organization will assume all risk and hazards and do hereby release and agree to hold harmless all agents and employees of Bunker Park Stable from all liability for personal injury or property damage. Please review our cancellation policy below: 1. Deposits are fully refundable only if your cancellation is made one week prior to your event. 2. If you choose to cancel on the day of your event, please call at least four hours prior to your reserved time or your deposit will be forfeited. 3. For same day cancels, you will have sixty (60) days to reschedule your event or your deposit will be forfeited. 4. We reserve the right to cancel a travel activity if road and weather conditions dictate. Our goal is to provide you with a safe and fun ride. Our drivers reserve the right to alter any route to ensure its safety. If you have any additional questions, please call us at 763 - 757 -9445. Sincerely, (Bunker Park Stable Staff) I have read the above and agree to its contents. Signature Phone Date �1 Office Use Only Total amount due: ' 7 4 3 CC# Exp. Deposit Amount: Date Received: Check #: Balance Due: Tax Exempt #: C. 1. Bunker Park Stable, Inc-. Entrance at 550 Bunker Lake Boulevard NW, Andover, MN 55304 Mailing address: P.O. Box 10804, White Bear Lake, MN 55110 Phone: 763 - 757 -9445 Fax: 763- 757 -8641 www.bunkerparkstable.com Reservations Required for All Activities! Prices subject to change without notice. $34 per person Rides are approximately one hour long, including mount/dismount. Walk + tax only. Riders must be at least 8 years old and 52 ". One rider per horse. TRAIL RIDES $50 per + tax Rides based on inexperience. Private Ride is just you and your guest(s) and for Private Ride our guide. Open all year; winter hours limited. Wedding Proposals $225 + tax Includes a 1 -1/2 hour private trail ride for two, plus set up and clean up. RIDING LESSONS $110 per person One hour group western lessons for four consecutive weeks. $35 if set of 4 lessonsL purchased individually. Call for availability and scheduling. Spring Break, Summer, Winter, and Women's Equestrian Getaway Day HORSE DAY CAMPS Call for pricing Camps. We fill up fast! Visit website or call for pricing and date availability. $38 per person Cub Scout and Girl Scout Badge: Hands -on educational discussion and SCOUTING BADGES arena lesson. Approximately 2 hours. $48 per person Boy Scout Badge: Hands -on educational discussion and arena lesson. Approxima tel 3 hours. $12 per child Customers must supply one adult to lead each pony on a designated pony PONY TRAIL RIDE path, walk only, approximately 25 minutes. One child per pony. Limited + tax availability in winter. We make it easy for any occasion to be special for you or your horse lover. PARTY PACKAGES Call for pricing We have Horse or Pony Party Packages. Give us a call or visit our website for information and pricing. Don't forget to add the extras! $85 minimum or One hour ride through beautiful Bunker Hills Regional Park. An $85 + tax $8 per person minimum is required for 10 people or less. Wagons can accommodate up to HAY RIDES + tax 35 people, mix of adults & kids; 30 if adults only. Open all year; limited SLEIGH RIDES Late Fee of $25 per winteqnurs. We cannot promise sleigh rides due to snow condition hour applies after requirWents; your sleigh may default to a hay wagon. 7:30 PM Red Bench Seat Sleigh $100 + tax Holds up to 14 riders. Antique Sleigh $75 + tax Half -hour ride. Holds up to 4 riders. TRAVELING $175 first hour Each additional hour is $100. A second pony is $100 per hour. Travel Fee BIRTHDAY PONY + tax applies. A Traveling Horse is $215 first hour. TRAVELING PONIES $750 two hours A two hour minimum is required. Call for pricing on additional hour. Three ( 4 hand-led Ponies) + tax hour maximum. Travel Fee applies. TRAVELING $575 first hour Available throughout the Twin Cities area. Additional hour(s) $125 each. Any + tax special permits are the responsibility of the customer to obtain. Parade Fee HAYRIDE is an additional $100, if applicable. Travel Fee applies. Late Hour Fee may Covered Wagon $600 first hour +tax be applicable. Call for details. $695 first hour Enjoy the charm and romance of a white carriage upholstered in rich CARRIAGE RIDE of travel; $175 burgundy velvet. Second hour is $125. Credit card required for reservations. ride in park Four hour cancellation notice needed. Travel Fee applies. ARENA RENTAL Call for pricing Dances, weddings and parties — call for pricing and availability. ROOM RENTAL $50 per hour 10:00 AM — 7:30 PM. Call for availability. $75 per hour 7:30 PM and later. Call for availability. CAMPFIRE $10 per hour We supply the wood and light your fire; enjoy before or after your activity! Reservations Required with deposits or credit cards on all activities. HELMETS REQUIRED FOR ALL RIDERS UNDER 18. Travel Fee applies to traveling activities, based on mileage to the event. Cancellations must be made at least four hours in advance of your scheduled activity or your credit card will be charged the full amount or deposit will be forfeited. Arrive at least 30 minutes prior to your scheduled event. Dress for the weather. Any special permits are the responsibility of the customer. Tax will be added to all activities unless a tax exempt number is supplied before the activity. We are open all year, but hours will vary with the season. LESSONS AND BADGES ARE HELD RAIN OR SHINE - WE HAVE AN INDOOR ARENA! 9/12/2013 BUNKER PARK STABLE HAYRIDE /SLEIGH RIDE LIABILITY SHEET Organization Name: Contact Name: Address: Phone Number: Date/Time of Ride: NO ALCOHOL, DRUGS or SMOKING ALLOWED ON HAYRIDE. WARNING Under Minnesota Statue 604A.12 of the Sponsor(s) of livestock activities are not liable for the injury or death of a participant, or a spectator in an unauthorized area, arising from the inherent risk of livestock activities. Inherent risk means the dangers arising from the propensity of livestock to behave in unpredictable ways, including kicking, biting, spooking in response to sound, sudden movement, unfamiliar objects, persons and other animals. The undersigned agrees for himself or herself, dependents, heirs, executors, administrators, assigns and for persons coming onto the premises with the undersigned's express or implied permission, invitation or knowledge to assume all risk and hazards and agree to fully INDEMNIFY, DEFEND AND HOLD HARMLESS, Bunker Park Stable, and their shareholders, owners, officers, employees, agents, volunteers, and representatives (hereinafter "Stable "), from: (1) any and all claims, demands, liability injuries, death, property damage or loss or other remedies or damages arising out of or resulting from the INHERENT RISKS of participating in or observing horse related activities including but not limited to, the risk of horses kicking, biting, spooking, tripping and falling, and from (2) any and all claims resulting from the NEGLIGENCE, vicarious or direct, of the stable including but not limited to, hayrides, carriage rides, sleigh rides, trail rides, riding lessons, clinics and exhibitions, leased horses, scout badges, failure to check or maintain equipment, the operation, maintenance and supervision of the premises, improvements to real property or the boarding, training, breeding, or keeping of horses on the premises. I consent to and authorize the use and reproduction by Bunker Park Stable of any and all photographs and any other audio /visual materials taken of me for promotional material, educational activities, exhibitions or other use. I HAVE READ THE FOREGOING AND ASSUME THE RISK: One signature per each participant. 1 14 27 2 15 28 3 16 29 4 17 30 5 18 31 6 19 32 7 20 33 8 21 34 9 22 35 10 23 36 11 24 37 12 25 38 13 26 39 terviffe EstabhAed u;, Centerville Special Event Permit Application 1. TITLE, PURPOSE, AND BRIEF DESCRIPTION OF EVENT: 2013 Centerville Lions Haunted House New Application: _X Renewal of or Change in Application: CONTACT PERSON: Greg Kieselhorst/Terry Sweeney TELEPHONE: 612 - 221 -9122 OR 651- 373 -1554 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: _Greg Kieselhorst Title: Lion Secretary_ Address: 7155 Brian Drive Centerville, MN 55.038 Mailing Address: Same Affiliation: Centerville Lions Club Day Phone: _952- 361 -4159 Evening Phone: 612 - 221 -9122 Emergency Phone: 612 -221 -9141 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: Centerville Lions Club Organization/Business /Agency /Affiliation: Lions International Is this a non -profit organization? X Yes No If you are making application under non - profit status, proof of non - profit status must be attached to this application Non -Profit status should be on file from past events, otherwise it will be provided. Mailing Address: Same Day Phone: _Same Evening Phone: Same Title and functional responsibility with regard to the event: Lion Secretary, as part of said duties permit applications and insurance add -ons etc. Page 1 of 10 4. REQUESTED EVENT COMPONENTS: Date requested: _Oct. 25th, 26th 2013_ Alternate date: None Requested hours of operation: _7pm (a.m. /p.m.) To: _10pm (a.m. /p.m.) Set up beginning date and time: Oct. 19th 2013 Complete dismantle date and time: Oct. 27th 2013 Describe the number and type of animals (if any) to be used in this event: None Attach a draft of the entry form for participants and/or spectators. Anticipated number of participants: 20 Spectators: 100-500 5. INSURANCE: Received and forwarded from Hilb, Rogel & Hobbs. Attach to this application either an insurance policy or a certificate of insurance including the policy number, amount, and the provisions that the City of Centerville is included as an additional insured. (Please note that insurance requirements depend upon the risk level of the event. Also, if your event can be classified as first amendment expressive activity, insurance requirements can be waived under certain circumstances.) 6. SANITATION: Please see note after a deposit of $500. Attach your "Plan for clean -up /Material Preservation ". Include number, type and location of trash containers to be provided for the event. Indicate who and how man will be responsible for emptying and cleaning up around containers during the event. Indicate who and how many will be responsible for cleaning up after animals if they are present during the event. Indicate who and how many will be responsible for cleaning up after the event. Describe the number, type and location of portable toilets to be provided for the event (or permanent toilets to be used in the event.) Include any other plan you have for ensuring post -event cleanliness and material preservation of city facilities, equipment, premises and streets A deposit of $500 will be required for clean -up and restoration. If Premises are left in satisfactory condition, this deposit will be refunded in full following inspection Trash Containers will be provided by the Lions Club. The Lions Club will clean up any left garbage. Please waive deposit, a good standing letter can be provided from Central Bank in needed. 7. LOCATION: Laurie LaMotte Memorial Park in Centerville Please attach a map of your event land design. Check off below items that apply to your event and indicate them on the attached map. Use, where necessary, a "to scale" drawing. A. If a route is involved, the beginning and finish area with arrows. B. _X_ If a route is involved, the places where buses, autos or other motorized vehicles need to be considered. C. If a route is involved, attach separate maps giving two or more alternate routes. D. _X_ Entertainment or stage locations (grandstand operators should provide you with a "to scale" drawing.) E. Alcoholic beverage concession area. F. X Non- alcoholic concession area. G. X Food concession area. H. X General Merchandise concession areas. Page 2 of 10 I. X Portable toilet facilities (indicate number). J. X_ Event participant and /or spectator parking areas. K. X_ Event organizer's command post. L. X First aid facilities. M. Fireworks or pyrotechnics site. N. Vehicle fuel handling sit. O. X Cooking areas. P. _X_ Electrical sources to be used for cooking. Q. _X_ tables, enclosures, etc. R. _X_ Temporary or permanent structures constructed for the event. S. Site of electrical wiring to be installed for the event. T. X Trash receptacles (indicate number) U. Other - Please describe. 8. AVAILABILITY OF FOOD, BEVERAGES AND /OR ENTERTAINMENT: If there will be music, sound amplification or any other noise impact, please describe, including the intended hours of the music, sound or noise: During_ Event Operation, a Stereo System will be used to provide Halloween Music to Spectators inside the Warming House. Will alcoholic beverages be served? Yes No X PLEASE NOTE THAT SALES OF LIQUOR/ALCOHOL IS PROHIBITED IN C ITY PARKS UNLESS THE EVENT IS A CITY CELEBRATION AND PRIOR APPROVAL AND APPROPRIATE LICENSES ARE OBTAINED BY CITY COUNCIL ACTION. If yes, describe what system will be used to ensure that alcoholic beverages will be consumed by persons 21 years and older: If yes, describe how, where, when and by whom the alcoholic beverages will be served: If a casino party, a dance, or live entertainment is part of your event, please describe: Page 3 of 10 Please describe all of the activities of your event for which a license is required, for example: a cabaret license, etc. Attach all required licenses to this application Please note that certain licensing may be required by City, County and State agencies, such as a Large Assembly License for gatherings over 1,000 people, some types of food handling lic ensing, Gambling License, Cabaret License, etc It is your responsibility to check with the C ity Clerk or local authorities to determine what licensing is required prior to submitting this application. Event Noise Will food and/or non - alcoholic beverages be served? Yes _X No If yes, describe sanitation measures, food handling procedures and the nature of the food (such as pre - packaged foods, hot dogs, pre -mixed soda, unpeeled fruit, raw meats, vegetables, fish or peeled and cut fruit.) The Centerville Lions alw use the health guidelines laved down by the Anoka County Health Department in handling, storing_ transporting and cooking, of foods and beverages. If y es, you will need a permit from the Anoka County Department of Environme Health Please attach a copy of the permit to this applica It will be forwarded once applied for, approved and received. 9. SECURITY AND SAFETY PROCEDURES: Describe your proposed procedures for set up, operation, internal security and crowd control: As in the past, the Haunted House Committee plans on working with Centennial Lakes Police and Reserves to insure the whole Haunted House has the proper security and safety for all evenings of operation. If the event is to occur at night, describe how you are going to light the event area in order to increase the safety of participants and spectators coming to and leaving the event: Alrighty installed LaMotte Park lighting. If your event includes vehicles or animals, describe the minimum and maximum speeds of the event and the minimum and maximum intervals of space to be maintained between units: N/A Attach to this application a copy of your building permit(s) if you are installing any electrical wiring on temporary or permanent basis and/or if you are building any temporary or permanent structures such as bleachers, scaffolding, a grandstand, stages or platforms. Page 4 of 10 Attach a copy of your fire department permit(s) to this application if you will use parade floats; an open flame; fireworks or pyrotechnics; vehicle fuel; cooking facilities; enclosures (and tables within those closures); tents, air supported structures, canopies, or fabric shelters. Give the name, address and phone numbers of the agency or agencies which will provide first aid staff and equipment if required. Attach additional sheets if necessary. Name of agency: Centennial Lake Police and Fire Departments Name of Representative: Previous years, Sergeant Pat Aldrich Address: 54 North Road, Circle Pines, MN 55014 Day phone: _763- 784 -2501 Evening phone: Indicate medical services (if required) that will be provided for this event: Ambulances: Doctors: Nurses: Paramedics: 10. VENDORS OR CONCESSIONAIRES: Describe what vendors /concessionaires you will allow in conjunction with the event, and the purpose of these concessions: All Concessions will be run by the Centerville Lions, to help raise funds to help to pay for the Haunted House. Describe how you intend to regulate, monitor and control the type, number and quality of vendors /concessionaires whom you may permit to operate in conjunction with the event: N/A 11. CITY SERVICES /EQUIPMENT: Describe city services and /or equipment requested for this event: City barricades, cones, signs, picnic tables and other equipment which may be borrowed on an as- available basis. You should make advance arrangements to pick up and return this equipment. If you or any volunteers cannot pick up and return this equipment, please attach a letter requesting these services and explaining why your organization cannot perform them. This will be reviewed, then approved or denied by the public works foreman. Street barricades /cones and all LaMotte Park facilities. 12. OTHER PERTINENT INFORMATION: Please list below any other miscellaneous information you feel would be important and have a bearing on the approval of this Special Event Permit request: As in years past, a Food Drive for the local Food Shelf will be done and fee discounts offered to encourage spectators to do so. Page 5of10 13. FEE STRUCTURE / EVENT CHARGES: If there is a fee or donation required as a condition of attendance or participation of this event, please describe the amounts to be collected from various categories of participants or spectators: $7 for all Ages or $5 with a non - perishable Food Donation. 14. If a donation is requested on a purely voluntary basis, describe how you intend to inform participants /spectators or others that they may participate in the event whether they make a donation or not: Event advertizing in local newspapers. Flyers around the City at local Businesses. Centerville Special Event Permit NAME AND TYPE OF EVENT: DAY, DATE AND TIME: 1. PARKS AND RECREATION DEPARTMENT FINAL APPROVAL AND SIGN OFF Signature Title Date: Please check or use N/A (not applicable) where appropriate: 1. Final check has been made of application requirements. 2. Event is approved by City Council. 3. All required permits are issued and on file. 4. Refundable clean up fee has been paid. 5. Insurance Certificate is on file with City Clerk 6. Surety Bond is on file to secure payment for applicant's obligation to the City. 7. Application is complete. 8. Special conditions are attached. REVOCATION: Upon mutual consent, the City Council may revoke a special event permit if the conditions set fourth in the permit application are not being followed. Permit is hereby revoked: Signature Title Page 6 of 10 Date: Reason(s) for revocation: TO BE REVIEWED /APPROVED AND SIGNED BY AFFECTED CITY DEPARTMENT HEADS 2. PARKS AND RECREATION DEPARTMENT Special Events Coordinator: Date: Initial/sign-off- 3. POLICE DEPARTMENT Approved by: Signature Title Date: 1. Emergency vehicle access. 2. Traffic /safety street closures. 3. Appropriate barricades. (# Required) 4. Police personnel required/available. 5. Portable toilet facilities. (# Required) 6. First aid facilities. 7. Internal security and crowd control. 8. nighttime lighting. 9. Other provisions as may be required by this department. 4. LICENSING AND INSURANCE Approved by: Signature Title Page 7of10 Date: 1. Dance and/or live entertainment. List types or permits or licenses required: 2. Alcoholic beverages. 3. Peddlers. 4. Noise abatement. 5. Other provisions as may be required: INSURANCE: Your insurance coverage must be reviewed and approved by the City's insurance carrier. 1. Public liability insurance naming City of Centerville and other public agencies additionally insured is required. 2. Hold harmless forms executed and failed. 3. List and approve /disapprove other insurance coverage as may be required. 5. FIRE DEPARTMENT �� Approved by: � ��� 7; — a' Signature Title Date: /�-��� 1. X Emergency vehicle access. 2. - -- ,Use of fireworks, pyrotechnics, vehicle fuel, open flame. 3. '?�` Cooking facilities. 4. --- Occupancy and spacing of tables, enclosures. 5. Parade, floats. 6. Tents, air supported structures, canopies. 7. Other provisions as my be required by this department: 5� ,C.,;� £y,� " ' ( ^r a T SN s a �� �, n� f r e� E q cl c•� ,� 6. BUILDING DEPARTMENT Approved by: Signature Title Date: Electrical: Page 8of10 1. Plan check/inspection of any wiring installed on a temporary or permit basis. 2. Permit(s) attached. Structural Plan: 1. Plan check/inspection of any temporary or permanent structures, including bleachers, scaffolding, grandstand, reviewing stands, stages, or platforms. 2. Permit(s) attached. 3. Other provisions as may be required by this department: 7. PARKS AND RECREATION DEPARTMENT Approved by: Signature Title Date: 1. Park permit(s) required. (to be attached) 2. Ballfield Usage Permit. 3. Beach permit required. (to be attached) 4. Trash containers required. (# ) 5. Portable toilets required. (# 6. Applicant's plan for cleanup, site restoration and material preservation (recycling) required and attached. 7. 'Other provisions as may be required by this department: 8. PUBLIC WORKNT Approved by: Title Date: q 6 J 1. Trash containers required. (# ) 2. Portable toilets required. (# 3. Special animal clean up required. 4. Barricades provided, as available. (# 5. Cones provided, as available. (# ) 6. No parking signs provided, as available. (# 7. Applicant's plan for clean up and material preservation (recycling) required Page 9 of 10 and attached. 8. Other provisions as may be required by this department: 9. STATE, COUNTY AND CITY HEALTH DEPARTMENT Approved by: Signature Title Date: 1. Food and /or beverage served. 2. Permit(s) attached. 3. Food cooked. 4. Permit(s) attached. 5. List other health licensing obligations as may be require: Page 10 of 10 -- 70A ' 44*W fqX.4 ®� � ►b'�'� I &WOKWOM P# 4 �tP � � S •t g g pDa r g1C Pi 61 � Fe L Z g Pl � 8 S � f ri Q O ll al $ p Lmaus a3[N33 O LI,L mp[ tQOI Mcl �L (IL[ MU Ml ffU ,K[ fill al ` e P t 9 s • f = i NaVd I MAO 3uow 31a St Yd dy� 9l 91 c ll fDB9 c1 fLM aov3 l 99 J g y : 3bao MOCIv3R $ Nm i ♦��$a w�t�9 z t 15 rua ziu +ott Yd s � 3Nr1 nwaY3n Yx ,z>ar+d wads ga y` s9u sPU au ncl Fn cw 0 9£ "130MVd c P g r f z t N3 QIN ° tt „ sQ SN3fl2f`dJ � ��` �,� S Lf t NV9 ),30NnVH A st ���. , f z zL t d " Pw Mn oM[ wft 39V1kL'iN q� a sKl a tau s =F n s ll ft St Lt y Z tt a Q` +u¢ ,lsl y s L of 91 Sa k s P g t LQ . n l t Imas t3aos Ol I { SI l i t\ O S P 1 P e OL K t n t KLl9 —. — --- -- — YSy -- ' — )latla 3NUlSa3MaoO .aVO� I U " �r�.,�,�r►� b+`�`►'1 Atli S11 Npt -opt vat �1 � � fjod-- VkVd 'A;AW 70W-�*4 Q�o oo�XAIV,�7 ft 114M 4 ;/PQP 0 7 1* ARV CERTIFICATE OF LIABILITY INSURANCE D10DrYYYY) 09 /2 013 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). CON PRODUCER NAME; John Adams PHONE 1800- 3166705 C. No: 1- 88867 -2378 Willis of Illinois, Inc. E-MAU- lionsclubs�wiliis.com 425 N. Martingale Road, Suite 1100 ADDRESS: IN I L 60173 SU S AIL AFFORDING COVERAGE N s Schaumburg INSU A. ACE American Insurance Company 22667 INSURED INSURER B: INSURER C : Centerville Lions Club - 5M7 INSURER D: Centerville Minnesota 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 POLK Y EFF POLICY EXP LIMITS L JR TYPE OF INSURANCE POLICY NUMBER MMID (MMOD A GENERAL LIABILITY EACH OCCURRENCE S 1.000.000 r X Col.lr&R GENERAL LIAB ICTY HDOG27022923 09 /01/2013 09/01/2014 PREM ISES E occurrence S 1 ,000,000 CiAMAS MAOE ❑X OCCJR ►0 EXP (ArN ore ) S 1.000 Asag Per Named Insured PERSONAL b ADV INJURY S 1,000,000 Is $2,000,000 GENERAL AGGREGATE S 10,000,000 GENL AGGREGATE LWIT APPLIES PER PRODUCTS - COi�lOP AGG S 2,000,000 X P ICY PRQ LOC S C, A AUTOMOBILE LIABILITY tFa IB SINGLE LIhNT S included apcxieeviti ISAH08721415 /0112013 09/01/2014 BODILYINJURY(PerW,,,) S ANY AUTO ALL OWNED SCHEDULE[) BODILY INJURY (Per accaerr,) S AUTOS PROPERTY DAMAGE NON -OWNED per acacie- 1: S HIRED AUTOS AUTOS $ UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESS LIAR CLAIRIS-MADE AGGREGATE S S DED RETENTIONS WC STATU• O1N- WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y ANY PROPRIETORIPARTNER'EXECU N t A TIVE ❑ E L EACH ACCIDENT S FF Ma CERI y tin NN) EXCLUOED1 E.L. DISEASE - EA EMPLO S DESCRIP OF OPERATIONS Delox E L DISEASE - POLICY LIIAIT S DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule. It more sales is required) Provisions of the policy apply to the named insureds participation in the following activity during the policy period shown above: Centerville Lions Haunted House, Oct. 25, 26 2013 City of Centerville is included as an Additional Insured(s), but only with respect to General Liability arising out of the issuance of permit(s) to the Insured shown above and not out of the sole negligence of said additional insured. PROVISIONS OF THE POLICY DO NOT APPLY TO THE SALE OR SERVING OF ALCOHOLIC BEVERAGES CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Centerville THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1880 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. Centerville Minnesota 55038 AUTHORIZED REPRESENTATIVE ea4-r ©1988 -2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD 6 terviffe kE,qab(uhed 185, Centerville Special Event Permit Application 1. TITLE, PURPOSE, AND BRIEF DESCRIPTION OF EVENT: 2013 Centerville Lions Oktoberfest New Application: _X Renewal of or Change in Application: CONTACT PERSON: Greg Kieselhorst /Terry Sweeney TELEPHONE: 612 - 221 -9122 OR 651- 373 -1554 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: _Greg Kieselhorst Title: _ Lion Secretary Address: 7155 Brian Drive Centerville MN 55038 Mailing Address: Same Affiliation: Centerville Lions Club Day Phone: _952 -361 -4159 Evening Phone: 612 - 221 -9122 Emergency Phone: 612- 221 -9141 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: Centerville Lions Club Organization/Business /Agency /Affiliation: Lions International Is this a non -profit organization? _X Yes No If you are making application under non - profit status, proof of non - profit status must be attached to this application Non -Profit status should be on file from past events, otherwise it will be provided. Mailing Address: Same Day Phone: _Same Evening Phone: Same Title and functional responsibility with regard to the event: Lion Secretary, as part of said duties permit applications and insurance add -ons etc. Page 1 of 10 4. REQUESTED EVENT COMPONENTS: Date requested: _Oct. 19th, ji 2013_ Alternate date: None Requested hours of operation: _5pm (a.m. /p.m.) To: _9pm (a.m. /p.m.) Set up beginning date and time: Oct. 18th 2013 Complete dismantle date and time: Oct. 20th 2013 Describe the number and type of animals (if any) to be used in this event: None Attach a draft of the entry form for participants and /or spectators. Anticipated number of participants: _20 Spectators: 100-500 5. INSURANCE: Received and forwarded from Hilb, Rogel & Hobbs. Attach to this application either an insurance policy or a certificate of insurance including the policy number, amount, and the provisions that the City of Centerville is included as an additional insured. (Please note that insurance requirements depend upon the risk level of the event. Also, if your event can be classified as first amendment expressive activity, insurance requirements can be waived under certain circumstances.) 6. SANITATION: Please see note after a deposit of $500. Attach your "Plan for clean -up /Material Preservation ". Include number, type and location of trash containers to be provided for the event. Indicate who and how man will be responsible for emptying and cleaning up around containers during the event. Indicate who and how many will be responsible for cleaning up after animals if they are present during the event. Indicate who and how many will be responsible for cleaning up after the event. Describe the number, type and location of portable toilets to be provided for the event (or permanent toilets to be used in the event.) Include any other plan you have for ensuring post -event cleanliness and material preservation of city facilities, equipment, premises and streets A deposit of $500 will be required for clean -up and restoration. If premises are left in satisfactory condition, this deposit will be refunded in full followine inspection. Trash Containers will be provided by the Lions Club. The Lions Club will clean up any left garbage. Please waive deposit, a good standing letter can be provided from Central Bank in needed. 7. LOCATION: Laurie LaMotte Memorial Park in Centerville Please attach a map of your event land design. Check off below items that apply to your event and indicate them on the attached map. Use, where necessary, a "to scale" drawing. A. If a route is involved, the beginning and finish area with arrows. B. If a route is involved, the places where buses, autos or other motorized vehicles need to be considered. C. If a route is involved, attach separate maps giving two or more alternate routes. D. Entertainment or stage locations (grandstand operators should provide you with a "to scale" drawing.) E. — X _ Alcoholic beverage concession area. F. X Non- alcoholic concession area. G. X Food concession area. H. X General Merchandise concession areas. Page 2 of 10 I. _X_ Portable toilet facilities (indicate number). J. _X_ Event participant and /or spectator parking areas. K. _X_ Event organizer's command post. L. X First aid facilities. M. Fireworks or pyrotechnics site. N. Vehicle fuel handling sit. O. _X Cooking areas. P. Electrical sources to be used for cooking. Q. _X_ tables, enclosures, etc. R. _X_ Temporary or permanent structures constructed for the event. S. Site of electrical wiring to be installed for the event. T. _X_ Trash receptacles (indicate number) U. Other - Please describe. 8. AVAILABILITY OF FOOD, BEVERAGES AND /OR ENTERTAINMENT: If there will be music, sound amplification or any other noise impact, please describe, including the intended hours of the music, sound or noise: During Event Operation, a Stereo System may be used to provide Oktoberfest type Music to Spectators. Will alcoholic beverages be served? Yes _X_ No PLEASE NOTE THAT SALES OF LIQUOR/ALCOHOL IS PROHIBITED IN CITY PARKS UNLESS THE EVENT IS A CITY CELEBRATION AND PRIOR APPROVAL AND APPROPRIATE LICENSES ARE OBTAINED BY CITY COUNCIL ACTION. If yes, describe what system will be used to ensure that alcoholic beverages will be consumed by persons 21 years and older: Everyone will have to present a valid ID and then they'll be ig ven a wristband when it's confirmed that they can be served. If yes, describe how, where, when and by whom the alcoholic beverages will be served: To be served only by the Vendors and or Centerville Lions. Served from designated Canopies setup on the Hockey Rink from 5pm to 9pm on Saturday October 19 th . If a casino party, a dance, or live entertainment is part of your event, please describe: Please describe all of the activities of your event for which a license is required, for example: a cabaret license, etc. Attach all required licenses to this application Please note that certain Page 3 of 10 licensing may be required by City, County and State agencies, such as a Large Assembly License for gatherings over 1,000 people, some types of food handling licensing, Gambling License, Cabaret License, etc. It is your responsibility to check with the City Clerk or local authorities to determine what licensing is required prior to submitting this application. Event Noise and TemyorM Alcohol. Will food and /or non - alcoholic beverages be served? Yes _X No If yes, describe sanitation measures, food handling procedures and the nature of the food (such as pre - packaged foods, hot dogs, pre -mixed soda, unpeeled fruit, raw meats, vegetables, fish or peeled and cut fruit.) The Centerville Lions always use the health guidelines laved down by Anoka County Health Department, in handling, sag transporting and cooking of foods and beverages. If yes, you will need a permit from the Anoka County Department of Environmental Health. Please attach a copy of the permit to this application. I will be forwarded once applied for, approved and received. 9. SECURITY AND SAFETY PROCEDURES: Describe your proposed procedures for set up, operation, internal security and crowd control: As in the past, the Haunted House Committee plans on working with Centennial Lakes Police and Reserves to insure the whole Haunted House has the proper security and safety for all evenings of operation. If the event is to occur at night, describe how you are going to light the event area in order to increase the safety of participants and spectators coming to and leaving the event: Alrighty installed LaMotte Park lighting. If your event includes vehicles or animals, describe the minimum and maximum speeds of the event and the minimum and maximum intervals of space to be maintained between units: N/A Attach to this application a copy of your building permit(s) if you are installing any electrical wiring on temporary or permanent basis and/or if you are building any temporary or permanent structures such as bleachers, scaffolding, a grandstand, stages or platforms. Attach a copy of your fire department permit(s) to this application if you will use parade floats; an open flame; fireworks or pyrotechnics; vehicle fuel; cooking facilities; enclosures (and tables within those closures); tents, air supported structures, canopies, or fabric shelters. Page 4 of 10 Give the name, address and phone numbers of the agency or agencies which will provide first aid staff and equipment if required. Attach additional sheets if necessary. Name of agency: Centennial Lake Police and Fire Departments. Name of Representative: Previous years, Sergeant Pat Aldrich Address: 54 North Road, Circle Pines, MN 55014 Day phone: _763- 784 -2501 Evening phone: Indicate medical services (if required) that will be provided for this event: Ambulances: Doctors: Nurses: Paramedics: 10. VENDORS OR CONCESSIONAIRES: Describe what vendors /concessionaires you will allow in conjunction with the event, and the purpose of these concessions: All Concessions will be run by the Centerville Lions and or Vendors, to help raise funds to help to pay for Oktoberfest. Describe how you intend to regulate, monitor and control the type, number and quality of vendors /concessionaires whom you may permit to operate in conjunction with the event: Food and Beer Vendors that are helping the Lions Club with Oktoberfest. 11. CITY SERVICES /EQUIPMENT: Describe city services and/or equipment requested for this event: City barricades, cones, signs, picnic tables and other equipment which may be borrowed on an as- available basis. You should make advance arrangements to pick up and return this equipment. If you or any volunteers cannot pick up and return this equipment, please attach a letter requesting these services and explaining why your organization cannot perform them. This will be reviewed, then approved or denied by the public works foreman. Street barricades /cones and all LaMotte Park facilities. 12. OTHER PERTINENT INFORMATION: Please list below any other miscellaneous information you feel would be important and have a bearing on the approval of this Special Event Permit request: 13. FEE STRUCTURE / EVENT CHARGES: Page 5 of 10 If there is a fee or donation required as a condition of attendance or participation of this event, please describe the amounts to be collected from various categories of participants or spectators: $10 for everyone over 21 years of Age. 14. If a donation is requested on a purely voluntary basis, describe how you intend to inform participants /spectators or others that they may participate in the event whether they make a donation or not: Event advertizing in local newspapers. Flyers around the City at local Businesses. Centerville Special Event Permit NAME AND TYPE OF EVENT: DAY, DATE AND TIME: 1. PARKS AND RECREATION DEPARTMENT FINAL APPROVAL AND SIGN OFF Signature Title Date: Please check or use N/A (not applicable) where appropriate: 1. Final check has been made of application requirements. 2. Event is approved by City Council. 3. All required permits are issued and on file. 4. Refundable clean up fee has been paid. 5. Insurance Certificate is on file with City Clerk 6. Surety Bond is on file to secure payment for applicant's obligation to the City. 7. Application is complete. 8. Special conditions are attached. REVOCATION: Upon mutual consent, the City Council may revoke a special event permit if the conditions set fourth in the permit application are not being followed. Permit is hereby revoked: Signature Title Date: Reason(s) for revocation: Page 6 of 10 TO BE REVIEWED /APPROVED AND SIGNED BY AFFECTED CITY DEPARTMENT HEADS 2. PARKS AND RECREATION DEPARTMENT Special Events Coordinator: Date: Initial/sign-off 3. POLICE DEPARTMENT Approved by: Signature Title Date: 1. Emergency vehicle access. 2. Traffic /safety street closures. 3. Appropriate barricades. (# Required) 4. Police personnel required /available. 5. Portable toilet facilities. (# Required) 6. First aid facilities. 7. Internal security and crowd control. 8. nighttime lighting. 9. Other provisions as may be required by this department. 4. LICENSING AND INSURANCE Approved by: Signature Title Date: 1. Dance and/or live entertainment. List types or permits or licenses required: Page 7 of 10 2. Alcoholic beverages. 3. Peddlers. 4. Noise abatement. 5. Other provisions as may be required: INSURANCE: Your insurance coverage must be reviewed and approved by the City's insurance carrier. 1. Public liability insurance naming City of Centerville and other public agencies additionally insured is required. 2. Hold harmless forms executed and failed. 3. List and approve /disapprove other insurance coverage as may be required. 5. FIRE DEPARTMENT Approved by: Signature Title Date: 1. Emergency vehicle access. 2. Use of fireworks, pyrotechnics, vehicle fuel, open flame. 3. Cooking facilities. 4. Occupancy and spacing of tables, enclosures. 5. Parade, floats. 6. Tents, air supported structures, canopies. 7. Other provisions as my be required by this department: 6. BUILDING DEPARTMENT Approved by: Signature Title Date: Electrical: 1. Plan check/inspection of any wiring installed on a temporary or permit basis. 2. Permit(s) attached. Structural Plan: Page 8of10 1. Plan check/inspection of any temporary or permanent structures, including bleachers, scaffolding, grandstand, reviewing stands, stages, or platforms. 2. Permit(s) attached. 3. Other provisions as may be required by this department: 7. PARKS AND RECREATION DEPARTMENT Approved by: Signature Title Date: 1. Park permit(s) required. (to be attached) 2. Ballfield Usage Permit. 3. Beach permit required. (to be attached) 4. Trash containers required. (# ) 5. Portable toilets required. (# 6. Applicant's plan for cleanup, site restoration and material preservation (recycling) required and attached. 7. Other provisions as may be required by this department: 8. PUBLIC WORK E T Approved by: 7 'gn tej Title Date: �(c� \ 1. Trash containers required. (# ) 2. Portable toilets required. (# ) 3. Special animal clean up required. 4. Barricades provided, as available. (# ) 5. Cones provided, as available. (# ) 6. No parking signs provided, as available. (# ) 7. Applicant's plan for clean up and material preservation (recycling) required and attached. 8. Other provisions as may be required by this department: Page 9of10 9. STATE, COUNTY AND CITY HEALTH DEPARTMENT Approved by: Signature Title Date: 1. Food and /or beverage served. 2. Permit(s) attached. 3. Food cooked. 4. Permit(s) attached. 5. List other health licensing obligations as may be require: Page 10 of 10 AFRO® r DATE 9 /16 / 0 CERTIFICATE OF LIABILITY INSURANCE MroDnrrYY) 09/16/2013 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 iieu of such endorsement(s). PRODUCER NAME: John Adams PHONE 11 * 1$00-316-6705 F AI AX C No: 1- 888467 -2378 Willis of Illinois, Inc. MAIL lionsdubs@willis.com 425 N. Martingale Road, Suite 1100 ADDRESS: I L 60173 INSURERS) AFFORDING COVER — # Schaumburg, INSURER A: ACE American Insurance Company 2266 INSURED INSURER 8: INSURER C : Centerville Lions Club - 5M7 INSURER D: Centerville Minnesota 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 REOUIREMENT, 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 MW BRI POLK Y EFF POLICY EXP LIMBS W R TYPE OF INSURANCE POLICY NUMBER MMIDDIYYYY IDO A GENERAL LIABILITY EACH OCCURRENCE S 1 .000,00 X COMMERC AL GENERAL LIABILITY HDOG27022923 09/01/2013 09/01/2014 PREIMSES IE1 occurrence S 1,000 CLA1tASMADE a OCCJR WED EXPI ane ersan) S 1,000 PERSONAL a ADV INJURY s 1,000,000 X Agg Per Named Insured is $2,000,000 GENERAL AGGREGATE S 10,000,000 GENL AGGREGATE LY.!IT APP.IES PER PRODUCTS - COIAPIOP AGG S 2,000,000 X PO. -ICY PRO LOC S A AUTOMOBILE LIABILITY COMBINED accWt SINGLE LIMIT S Included ISAH08721415 09/01/2013 09/0112014 BODILY IN NR2Y (per pe-5)n) s ANY AUTO ALL OWNED SCHEDULED BODI. Y INJURY (Per acedent) 5 AUTOS — NON-OWNED PROPER DAMAGE S NIREDAUTOS AUTOS Peracc 5 UMBRELLA LIAR [ TOCCJR EACH OCClR RENCE S EXCESS LIAR LAItAS4.%DE AGGREGATE S S DEO RETENTIONS tYC STATU• OTH- WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRiETORIPARTNEWEXECUTNE YIN E L EACH ACCIDENT S ^ - OFFICERIMEMBER EXCLUDED? NIA (Mandatory in NN) E.l DISEASE • EA EWLOYEE S ; SdRi TION OF bebv. El DISEASE -POLICY LIAT 5 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101. Additional Remarks Schedule. It more space is required) Provisions of the policy apply to the named insureds participation in the following activity during the policy period shown above. Centerville Lions Oktoberfest, Oct. 19th 2013 City of Centerville is included as an Additional Insured(s), but only with respect to General Liability arising out of the issuance of permit(s) to the Insured shown above and not out of the sole negligence of said additional insured. PROVISIONS OF THE POLICY DO NOT APPLY TO THE SALE OR SERVING OF ALCOHOLIC BEVERAGES CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Centerville THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1880 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. Centerville Minnesota 55038 AUTHORIZED REPRESENTATIVE 01988 -2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD PARK FACILITY PERMIT APPLICATION 1. Name /Address/Phone Number of Individual or Organization responsible for making this application: Joe George 1926 - 72nd Street Name Address Centerville, MN 55038 Telephone Number City, State & Zip 2. Please describe your event/activity and identify the specific facility /field within the park you wish to use along with what you are asking from the City: Laurie LaMotte Park Ballfield 3 unless being used by Centennial Football then Soccer Fields 1 & 2 r � 3. What is the number of people that are involved in your event/activity? 4. What City facilities do you wish to use Acorn Creek Park Eagle Park Laurie LaMotte Memorial Park X Hidden Spring Park (Lighting & Warming House) Trailside Park An adult may be requested to take responsibility to lock & unlock restrooms Cornerstone Park Royal Meadows Park Tracie McBride Memorial Park City Hall 5. Please list the date or dates and times you propose to use the facilities: October 7, 2013 6:30 - 8:00 6. Is anyone charged a fee to watch or participate in your event? No 7. Have you used these facilities before? Yes If so, when? Cub Scout Rocket Launch 8. Are you requesting additional permits or City services? Yes X No (i.e., Road Closure(s), Temporary Liquor License(s), Fireworks Permit or Burning Permit, Use of lights, bathrooms or ports potties, Park Buildings) Please describe Depending upon the nature of your event, or if you are requesting City services, you may be required complete a different application and/or make a deposit to cover city costs. r 9- 242013 Printed Perso g Date Signafure -Coe Office Use Only Permit approved by: -��, Date: l Deposit required: $ iG a , O Receipt # .3�l0 `7 Form number: 2013.01 PU io /g /r.3 7-..f PARK F -kCILITY PERMIT APPLICATION 1. Name :address Phone Number of Individual or Orgwuization responsible for making flu, ap - catio11: , n CUP ��u'` rL4Q Name i ess Teleplione Nulnbe'r tCit"I Mate (L Zip O / q Please describe your event. activity sold identity the,peclfic facility field wrtlun the park. you wish to use along with what 3-ou are asking fioln the c 'rty Oul 3 %N 10t v the 11111 ber of people that are Llivolved In your event acti"ah" What City fac itie, do you wish to use Acorn Creek Park Eagle Purl: Laurie LaMotte Memorial Park _A_ Hidden Spring Park (Lighting ,k NVaimMg House) Tralkslde Park An adult may be requested to take responsibility to lock & unlock restrooms Cornerstone Pak Roval Meadows Park: Tracie McBride Memorial Park Cis Hakl Please list the date or elate: and time: you propose to use tine facilities - 1 41 AI 42 1 142e, 6 Is anyone charged a fee to watch or participate in your event' ✓VO l0,14 j4 Have you used these facilities before" _Nj If,o, wheli' 5. Are you requestMg additional penuits or City ser- •ices' Yes No t e.. Roa(l Closrrr•ers). Ten rj ?orrrr.• Liquor Licerrsersr. Fn Per711it or Bur•r»rrg Permit, Uye of Irghrs, brrthroorrrs or•lrortri ironies• Part, Buil(hugs') Please clescnbe Depending upon the nature of your eve11t, or if you are requesting City s emces, yo11111ay be required complete a different application and or slake a deposit to corer cit " cost Printed Nwne Person Signing Date �' ignahlre rwwwwrrwrrrwrrwwwwrwrwrwwrwrwwwrwrrrrrwwwrwwwwrwwrrwrrwwrrrrwrrrrwwrrwrrr Office i_?,e Permit approved by Date• Ad�911,3 Deposit required. $ /40. Pf)5 Receipt == Forniitumlier: 2013.01 PU LA PARK FACILITY PERMIT APPLICATION 1. Name /Address/Phone Number of Individual or Organization responsible for making this application: Jeff Paar 6984 Meadow Cr. Name Address 612 - 799 -0958 Centerville, MN 55038 Telephone Number City, State & Zip 2. Please describe your event/activity and identify the specific facility /field within the park you wish to use along with what you are asking from the City: Dryland hockey practice at Lamotte Park outdoor ice rink. I just need access to turn on the lights 3. What is the number of people that are involved in your event/activity? 18 4. What City facilities do you wish to use Acorn Creek Park Eagle Park Laurie LaMotte Memorial Park X Hidden Spring Park (Lighting & Warming House) Trailside Park An adult may be requested to take responsibility to lock & unlock restrooms Cornerstone Park Royal Meadows Park Tracie McBride Memorial Park City Hall 5. Please list the date or dates and times you propose to use the facilities: 10/23, 10/25, 10/28 5:30 -6:30 pm 6. Is anyone charged a fee to watch or participate in your event? No 7. Have you used these facilities before? Yes If so, when? Past years for hockey dry land. 8. Are you requesting additional permits or City services? Yes X No (i.e., Road Closure(s), Temporary Liquor License(s), Fireworks Permit or Burning Permit, Use of lights, bathrooms or porta potties, Park Buildings) Please describe Depending upon the nature of your event, or if you are requesting City services, you may be required complete a different application and/or make a deposit to cover city costs. Jeff Paar 10/15/13 Printed Name o erson Signing Date Sin t e ... . . .................................. ............................... Office Use Only a Permit approved by: Date: 1d i 71J,3 O° Recei t # Deposit required: $ / 00• p Form number: 2013.01 PU / /& BE ADVISED THAT YOU ARE REQUIRED TO LEAVE THE PARK AS CLEAN AS YOU FOUND IT PLEASE! YOU ARE NOT AUTHORIZED TO STORE ATHLETIC OR OTHER EQUIPMENT IN THE PARK OR FACILITIES. Hidden Spring Park 1 — Picnic Shelter 1601 LaMotte Drive 1875 Fox Run Tracie McBride Park Open Field 6955 Eagle Trail Eagle Parkr 1 — Tennis Court, Laurie LaMotte Memorial Park 1-2 — Football Practice Fields 3 -5 — Baseball Fields 8 6 — Picnic Shelter 7 — Pleasure Ice Rink 8 — Hockey Rink 9 — Warming House 10 — Wheels /Skate Park 1874 Revoir Street 11 — Soccer Field 6970 LaMotte Drive Form number: :l Centerville Special Event Permit Application 1. TI TLE, PURPO E, AND BRIEF DESCRIPTION 2F EVENT: New Application: Renewal / of or Change in Application: CONTACT PERSON: y _ "l p-so /`� TELEPHONE: / OR 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: 0/V" �' L7� �✓ Title: i!g�qmT Address: �(�' /,y.� S Thy :5;r GU#i 7"r✓"�>g2 CA AZ Mailing Address: :5414F Affiliation: Day Phone: 7oS� -74 D / Evening Phone: �v Emergency Phone: Lr�/ '6 `1 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: r Organization/Business /Agency /Affiliation: ✓ /�AC.� ! !?,�G�o2 Is this a non - profit organization? Yes _X_ No If you are making application under non -profit status, proof of non- grofit status must be attached to this application Mailing Address: Day Phone: Evening Phone: Title and functional responsibility with regard to the event: �'i A L`c iD /R ' 014 A) t 1LL11 A/U �Sl -25l -5 �jGL - oR/V fin` --oN 708 4'.N2vc jc4rn: MvAa Page 1 of 10 4. REQUESTED EVENT COMPONENTS: Date requested: 11449Q4 (�l 2-0 Alternate date: O Requested hours of operation: 'W �p.m.) To: (a.m. Set up beginning date and time: o /® AW Complete dismantle date and time: Describe the number and type of animals (if any) to be used in this event: Attach a draft of the entry form for partici ants and/or spectators. Anticipated number of participants: Z?a Spectators: Ze..) 5. INSURANCE: Attach to this application either an insurance policy or a certificate of insurance including the policy number, amount, and the provisions that the City of Centerville is included as an additional insured. (Please note that insurance requirements depend upon the risk level of the event. Also, if your event can be classified as first amendment expressive activity, insurance requirements can be waived under certain circumstances.) 6. SANITATION: Attach your "Plan for clean- up/Material Preservation ". Include number, type and location of trash containers to be provided for the event. Indicate who and how man will be responsible for emptying and cleaning up around containers during the event. Indicate who and how many will be responsible for cleaning up after animals if they are present during the event. Indicate who and how many will be responsible for cleaning up after the event. Describe the number, type and location of portable toilets to be provided for the event (or permanent toilets to be used in the event.) Include any other plan you have for ensuring post-event cleanliness and material preservation of city facilities, equipment, premises and streets A deposit of $500 will be required for clean -up and restoration If premises are left in satisfactory condition this deposit will be refunded in full following inspection 7. LOCATION: Please attach a map of your event land design. Check off below items that apply to your event and indicate them on the attached map. Use, where necessary, a "to scale" drawing. A. �V If a route is involved, the beginning and finish area with arrows. B. If a route is involved, the places where buses, autos or other motorized vehicles need to be considered. C. If a route is involved, attach separate maps giving two or more alternate routes. D. Entertainment or stage locations (grandstand operators should provide you with a "to scale" drawing.) E. Alcoholic beverage concession area. F. Non - alcoholic concession area. G. Food concession area. H. General Merchandise concession areas. I. Portable toilet facilities (indicate number). J. j, Event participant and/or spectator parking areas. K. Event organizer's command post. KELL`f'S 1 "eoR►.�E2 '642 Page 2 of 10 L. First aid facilities. 0- STAC - r FNiSz{ UtJF- M. Fireworks or pyrotechnics site. N. Vehicle fuel handling sit. O. Cooking areas. P. Electrical sources to be used for cooking. Q. tables, enclosures, etc. R. Temporary or permanent structures constructed for the event. S. Site of electrical wiring to be installed for the event. T. Trash receptacles (indicate number) U. Other - Please describe. 8. AVAILABILITY OF FOOD, BEVERAGES AND /OR ENTERTAINMENT: If there will be music, sound amplification or any other noise impact, please describe, including the intended hours of the music, sound or noise: PA SV-S I 41JZJ MOS/ C, �2cSyt !/o 4 Tb ! •' �� �v.4'1 Will alcoholic beverages be served? Yes No 9 PLEASE NOTE THAT SALES OF LIOUOR/ALCOHOL IS PROHIBITED IN CITY PARKS UNLESS THE EVENT IS A CITY CELEBRATION AND PRIOR APPROVAL AND APPROPRIATE LICENSES ARE OBTAINED BY CITY COUNCIL ACTION. If yes, describe what system will be used to ensure that alcoholic beverages will be consumed by persons 21 years and older: If yes, describe how, where, when and by whom the alcoholic beverages will be served: If a casino party, a dance, or live entertainment is part of your event, please describe: Please describe all of the activities of your event for which a license is required, for example: a cabaret license, etc. Attach all required licenses to this application Please note that certain licensing may be required by City, County and State agencies, such as a Lame Assembly License for gatherings over 1,000 people, some types of food handling licensing, Gambling License, Cabaret License, etc. It is Your responsibility to check with the City Clerk or local authorities to determine what licensing is required prior to submitting this application. Page 3 of 10 Will food and /or non - alcoholic beverages be served? Yes No If yes, describe sanitation measures, food handling procedures and the nature of the food (such as pre - packaged foods, hot dogs, pre -mixed soda, unpeeled fruit, raw meats, vegetables, fish or peeled and cut fruit.) f <1466E 0 _541AGK WA7n1L 4 —Ae U COFFEE' el ✓iPer/J GY CA2r(3ou Col� If yes, you will need a permit from the Anoka County Department of Environmental Health. Please attach a copy of the permit to this application. 9. SECURITY AND SAFETY PROCEDURES: Describe your proposed procedures for set up, operation, internal security and crowd control: _ If the event is to occur at night, describe how you are going to light the event area in order to increase the safety of participants and spectators coming to and leaving the event: If your event includes vehicles or animals, describe the minimum and maximum speeds of the event and the minimum and maximum intervals of space to be maintained between units: Attach to this application a copy of your building permit(s) if you are installing any electrical wiring on temporary or permanent basis and/or if you are building any temporary or permanent structures such as bleachers, scaffolding, a grandstand, stages or platforms. Attach a copy of your fire department permit(s) to this application if you will use parade floats; an open flame; fireworks or pyrotechnics; vehicle fuel; cooking facilities; enclosures (and tables within those closures); tents, air supported structures, canopies, or fabric shelters. Give the name, address and phone numbers of the agency or agencies which will provide first aid staff and equipment if required. Attach additional sheets if necessary. Name of agency: Name of Representative: Address: Day phone; Evening phone; Indicate medical services (if required) that will be provided for this event: Page 4 of 10 Ambulances: Doctors: Nurses: Paramedics: 10, VENDORS OR CONCESSIONAIRES: Describe what vendors /concessionaires you will allow in conjunction with the event, and the purpose of these concessions: Describe how you intend to regulate, monitor and control the type, number and quality of vendors /concessionaires whom you may permit to operate in conjunction with the event: 11. CITY SERVICES/EQUIPMENT: Describe city services and/or equipment requested for this event: City barricades, cones, signs, picnic tables and other equipment which may be borrowed on an as- available basis. You should make advance arrangements to pick up and return this equipment. If you or any volunteers .cannot pick up and return this equipment, please attach a letter requesting these services and explaining why your organization cannot perform them. This will be reviewed, then approved or denied by the public works foreman. 12. OTHER PERTINENT INFORMATION: Please list below any other miscellaneous information you feel would be important and have a bearing on the approval of this Special Event Permit request: 13. FEE STRUCTURE / EVENT CHARGES: If there is a fee or donation required as a condition of attendance or participation of this event, please describe the amounts to be collected from various categories of participants or spectators: 14. If a donation is requested on a purely voluntary basis, describe how you intend to inform participants /spectators or others that they may participate in the event whether they make 'a donation or not: Page 5 of 10 Centerville Special Event Permit NAME AND TYPE OF EVENT: DAY, DATE AND TIME: 1. PARKS AND RECREATION DEPARTMENT FINAL APPROVAL AND SIGN OFF Signature Title Date: Please check or use N/A (not applicable) where appropriate: 1. Final check has been made of application requirements. 2. Event is approved by City Council. 3. All required permits are issued and on file. 4. Refundable clean up fee has been paid. 5. Insurance Certificate is on file with City Clerk 6. Surety Bond is on file to secure payment for applicant's obligation to the City. 7. Application is complete. 8. Special conditions are attached. REVOCATION: Upon mutual consent, the City Council may revoke a special event permit if the conditions set fourth in the permit application are not being followed. Permit is hereby revoked: Signature Title Date: Reason(s) for revocation: TO BE REVIEWED /APPROVED AND SIGNED BY AFFECTED CITY DEPARTMENT HEADS Page 6 of 10 2. PARKS AND RECREATION DEPARTMENT Special Events Coordinator: Date: Initial/sign-off 3. POLICE DEPARTMENT Approved by: Signature Title Date: 1. Emergency vehicle access. 2. Traffic /safety street closures. 3. Appropriate barricades. (# Required) 4. Police personnel required/available. 5. Portable toilet facilities. (# Required) 6. First aid facilities. 7. Internal security and crowd control. 8. nighttime lighting. 9. Other provisions as may be required by this department. 4. LICENSING AND INSURANCE Approved by: Signature Title Date: 1. Dance and /or live entertainment. List types or permits or licenses required: 2. Alcoholic beverages. 3. Peddlers. 4. Noise abatement. 5. Other provisions as may be required: INSURANCE: Your insurance coverage must be reviewed and approved by the City's insurance carrier. Page 7 of 10 1. Public liability insurance naming City of - Centerville and other public agencies- additionally insured is required. 2. Hold harmless forms executed and failed. 3. Fist and apprQVe /disappruve -ether insurance coverage as may be required. 5. FIRE DEPARTMENT Approved by: Signature Title Date: 1. Emergency vehicle access. 2. Use of fireworks, pyrotechnics, vehicle fuel, open flame. 3. Cooking facilities. 4. Occupancy and spacing of tables, enclosures. 5. Parade, floats. 6. Tents, air supported structures, canopies. 7. Other provi-sions as my he requi-red- by this dep 6. BUILDING DEPARTMENT Approved by: Signature Title Date: Electrical: 1. Plan shc-.sk/inspe-ction of any wiring installed on a temporary or perm-it basis-. 2. Permit(s) attached. Structural Pla -n: 1. Plan check/inspection of any temporary or permanent structures, including bleachers-, scaffolding, grandstand, reviewing stands, stages, or platforms -. 2. Permit(s) attached. 3. Other provisions as may be required by this department: Page 8 of 10 7. PARKS AND RECREATION DEPARTMENT Approved by: Signature Title Date: 1. Park permit(s) required. (to be attached) 2. Ballfield Usage Permit. 3. Beach permit required. (to be attached) 4. Trash containers required. (# 5. Portable toilets required. (# ) 6. Applicant's plan for cleanup, site restoration and material preservation (recycling) required and attached. 7. Other provisions as may be required by this department: 8. PUBLIC WORKS DEPARTMENT Approved by: Signature Title Date: I . Trash containers required. (# 2. Portable toilets required. (# 3. Special animal clean up required. 4. Barricades provided, as available. (# 5. Cones provided,- as available. (# 6. No parking signs provided, as available. (# ) 7. Applicant's plan for clean up and material preservation (recycling) required and attached. 8. Other provisions as may be required by this department: 9. STATE, COUNTY AND CITY HEALTH DEPARTMENT Approved by: Signature Title Date: 1. Food and /or beverage served. 2. Permit(s) attached. Page 9 of 10 3. Food cooked. 4. Permit(s) attached. 5. List other health licensing obligations as may be require: Page 10 of 10 WATER STOP SK 5K START r v 1 + i r4Y llYY,) i' Jily!!v i C,1 +ill fl $K STAka Ld10 Lake$ Yc-�Y y . IaY. Mi i rn �•. � ® • jj�I 4s