HomeMy WebLinkAboutDocumentation_Regular_Tab 10_08/10/2017 VILLAGE OF TEQUESTA 0
COMMUNITY DEVELOPMENT DEPARTMENT P � -
Submittal Date::-44
9J'�. , 345 Tequesta Drive Deposit Amount:
I. �, Tequesta, Florida 33469
`° Phone: (561)768-0450 Fax: (561)768-0698
" Coo, "TEQUESTA
SPECIAL EVENT PERMIT APPLICATION
JUL 0 2 2017
Any Village resident,or any Village business holding a current Village business tax receipt pursuant to Chapter 70,Article II, is eligible
to apply for anlittEinREffemt permit pursuant to Sec. 78-561. Any such resident or business that desires to conduct any
type of special event within the ail age must obtain a permit from the Village in order that the Village may adequately provide for
the potential impacts created by the proposed event. A maximum of four (4) such permits shall be allowed per address or per
business in any single calendar year. A special event that includes multiple addresses,for example within a shopping center, shall
count as one event for each address captured by the special event permit.
"Special Event" is any outdoor activity, gathering or group of persons, vehicles or both, organized and having a common
purpose, upon public or private property,which is likely to inhibit the usual flow of vehicular or pedestrian traffic,which is
likely to create noise in excess of that typically associated with the areas upon which the event is to occur,or which is likely
to preempt or restrict use of property typically accessible by the general public. Examples of Special Events include,but are
not limited to block parties,parades,races or walks,grand opening events,charity fundraisers,and other similar events not
specifically permitted by the Village's zoning ordinance. Special Events that are sponsored by the Village and held on Village
property shall be exempt from the provisions of this section.
Written application must be submitted to the Village Community Development Department at least forty five (45) days prior to the
date for which the Special Event is proposed;which application shall contain the following information:
DATE OF SALE/EVENT: ,J o U ,� HOURS: FROM: 1,, o J 44 w. T0: \
TYPE OF EVENT: iTh.'t*4. 4.• u -"Z .e ;
C—Th LOCATION OF EVENT: n a,N . • .. t oti } F.v,tt Q-4`,\c•
PROPERTY OWNER: `.,) \\ ,• .t •A (Attach written consent of property owner of record.)
Print Name
CONTACT INFORMATION: _
SPONSOR or PERSON(S)RESPONSIBLE FOR EVENT:�c� —7 p< tiC�(l?�a t�z ,�� ��n �v,�+ \\ H )\,\.1a.k J.c r,,.a
�Nt•J :Au tv EMAIL:Nat,' �.p�\..n .tkfel P_��N �\ir ,,• •�
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MAILING ADDRESS: \. \ PHONE NO.: ~ �,>,— “V•
-w._1/4-1. T L ', s-1 V '_ FAX NO.:
PROJECTED NUMBER OF ATTENDEES: COUNCIL APPROVAL REQUIRED: (t7)YES ( )NO
• Any proposed Special Event whose attendance is contemplated to exceed 200 people in total shall require final approval by
the Village Council which, after considering the recommendations of the Community Development Director, the Police
Chief and the Village Manager, may approve the application, deny the application in whole or in part, or approve the
application with conditions.
IS ALCOHOL BEING SERVED? ( )YES (I/NO
• The service of alcoholic beverages at any Special Event shall require the issuance of the appropriate state alcoholic
beverage permit,a copy of which must be provided to the Village in conjunction with the Special Event permit application.
• The Village may require the use of physical barriers to define and contain the outdoor area within which alcoholic
beverages may be consumed and/or the use of security or off-duty law enforcement personnel at the Special Event.
• It is the applicant's responsibility to monitor for and prevent excessive as well as underage consumption of alcoholic
beverages at all times.
Page 1 of 2
INDEMNIFICATION:
• By submitting a complete application, the Special Event holder/applicant and property owner (if different) expressly agree
that they shall indemnify, defend and hold the Village harmless from any and all damage to any real or personal property,
and from any and all injury or death suffered by any person directly or indirectly related to attendance at or participation in
any activity in conjunction with the Special Event, including the consumption of alcoholic beverages.
NON-PROFIT ENTERPRISES:
• The Village may issue non-profit permits to any person or organization for the conduct or operation of occasional sales
and/or fundraising projects held by non-profit enterprises, either regularly or temporarily, when the applicant signs an
affidavit that the applicant operates without private profit, for a civic, public, charitable, youth, service, educational,
literary,fraternal,or religious purpose.
• A person making application under this section must comply with all rules and procedures for the granting of Special Event
permits as set forth in this section. All persons operating under a non-profit permit shall operate their non-profit enterprise
in compliance with this section and all other rules and regulations of the Village.
THE FOLLOWING ITEMS ARE REQUIRED TO BE SUBMITTED AT TIME OF APPLICATION:
• Proof of insurance in amounts acceptable to the Village for the type of event. The Village shall be named as an additional
insured on all liability insurance.
s Expected traffic,fire-rescue,and utilities impact, if any,and proposed mitigation plans.
• Copy of all required state and county permits if event will be held on or utilize state and/or county-controlled property.
• A refundable deposit is required if the event is held on any Village property.
• Site Plan required with each application accompanied with drawing indicating layout for event.
• All sale sites shall be left in a clean and orderly manner upon completion of sale.
•.- Should the sale/event include the use of one or more tents, a $35.00 Fire Inspection Fee, due at time of application, and a
certificate of flame resistance is required for each tent. Inspection to be done on the first day of event.
SPECIAL EVENT FEES:
• Under 200 attendees:$40.00.
• Over 200 attendees:$100.00.
r---
SIGNATURE OFHOLDER/APPLICANT: �� _c ,o C DATE: (, -T
Print Na Signature
SIGNATURE OF PROPERTY OWNER: • ATE: e t."2-b 1 V
7
Pri N e Signature
***********************************************************************************************
RECOMMEND FOR APPROVAL:
COMMUNITY DEV. DIRECTOR: 2\114,1 DATE: 6 /30//
BUILDING DIR TOR: DATE:
POLICE CHIE . DATE: flpy)7
FIRE CHIEF: DATE: 7 ' SQ'
PARKS/REC E • / DATE: / / 0
APPROVED BY:
VILLAGE MANAGER: DATE: 11Y/.5 A,
Approval/Review Notes:
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Course Proposal F: http.://www.mappedometer.com/?maproute=293975
Start near Constitution Park gate on Dover Rd.
Right on Tequesta Dr. and over bridge
Through Tequesta Country Club gate and right on Yacht Club Place
Left on Palmetto Way
Right on Fairview East, around U-turn which switches to Fairview West
Right onto El Portal
Right onto Golfview Drive
Left onto Golf Place
Left onto River Drive
Veer right onto Point Circle and back on River Drive
Left on El Portal to Tequesta Country Club gate
Straight onto Tequesta Drive and over bridge
Left onto Dover Rd. to the start/finish area.
Contact: Bob Anderson, Race Director- (561)313-6099-bob@palmbeachmarathontraining.com
•
e0000t4 01,30,13 ,
bra-14
rConsumer's Certificate of Exemption R.
Issued Pursuant to Chapter 212,Florida Statutes
L_
85-8013958606C-3 _ ( 12/31/2012 ` 12/31/2017 501(C)(3)ORGANIZATION I
Certificate Number Effective Date Expiration Date Exemption Category. •
This certifies that
•
•
PALM BEACH ROADRUNNERS INC
c01 N FI_AGLER DR
WEST PALM BEACH FL 33401-4305 -
•
is exempt from the payment of Florida sales and use tax on real property rented,transient rental property-rented,tangible
personal property purchased or rented,or services purchased.
o. DR-14
11 Important Information for Exempt Organizations R.04/11
1. You must provide all vendors and suppliers with an exemption certificate before making tax-exempt purchases.
See Rule 12A-1.038,Florida Administrative Code(F.A.C.).
2. Your Consunlert Certificate of Exemption is to be used solely by your organization for your organization's
customary nonprofit activities.
3. Purchases made by an individual on behalf of the organization are taxable,even if the individual will be
reimbursed by the organization.
4. This exemption applies only to purchases your organization makes. The sale or lease to others of tangible
personal property,sleeping accommodations,or other real property is taxable. Your organization must register,
and collect and remit sales and use tax on such taxable transactions. Note: Churches are exempt from this
requirement except.when they are the lessor of real property(Rule 12A-1.070,FA.C.).
5. It is a criminal offense to fraudulently present this certificate to evade the payment of sales tax. Under no
circumstances should this certificate be used for the personal benefit of any individual. Violators will be liable for
payment of the sales tax plus a penalty of 200%of the tax,and may be subject to conviction of a thW-degree
felony. Any violation will require the revocation of this certificate.
6. If you have questions regarding your exemption certificate,please contact the Exemption Unit of Account
Management at 800-352-3671. From the available options,select'Registration of Taxes,"then`Registration
information,"and finally"Exemption Certificates and Nonprofit Entities.° The mailing address Is PO Box 6480,
Talahassee,FL 32314-6480.
DATE
ACC1R13® CERTIFICATE OF LIABILITY INSURANCE 6/13/2�0 7)THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER NAME CT Margaret Mayers
STAR Insurance - Fort Wayne Office UPUHCONtE ) (260)467-5690 1� No):(260)467-5691
2130 East Dupont Road imam:margaret.mayers@starfinancial.com
INSURERS)AFFORDING COVERAGE NAIC/
Fort Wayne IN 46825 INSURER A National Casualty Company 11991
INSURED mmmeR B Nationwide Life Insurance Co. 66869
Road Runners Club of America/2017 and Its Member INSURER C:
Member Clubs INSURER D:
1501 Lee highway, Suite 140 INSURER E:
Arlington VA 22209 INSURER F: ,
COVERAGES CERTIFICATE NUMBER:2017 $1M A.I. REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR TYPE OF INSURANCE ADM SUER POUCY EFF POUCY EXPW LIMITS
LTR WSD WVD POUCY NUMBER IMDDNYYYI BAWDDIYYYYI
X COMMERCIAL GENERAL UABIUTY EACH OCCURRENCE = 1,000,000
A CLAIMS-MADE X OCCUR DAMAGE PREMISES(S(RENTED 500,000
Ea occurrence) $
X Legal Liability to XR00000006655200 12/31/2016 12/31/2017 MEDEXP(Any one person) S 5,000
Participant $1,000,000 12:01 AM 12:01 AM PERSONAL aADVINJURY = 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S Unlimi ted
X POUCYI I Tel, LOC Abuse i Molestation PRODUCTS-COMP/OP AGG = 1,000,000
OTHER: Aggregate $5,000,000 Abuse and Molestation = 500,000
AUTOMOBILE LIABILITY COMBINED SINGLE LIMB = 1,000,000
(Ea acdderal _
A _ ANY AUTO BODILY INJURY(Per person) S
ALL O SCHEDULED
AUTOS
AUTOS 1Ri00000006655200 12/31/2016 12/31/2017 BODILY INJURY(Per accideNON-Ont)
i
_
DAMAGE
X HIRED AUTOS X AUTOS�EO 12:01 AM 12:01 AM (P�xdA t) S
S
UMBRELLA LIAB OCCUR EACH OCCURRENCE S
EXCESS UAB CLAIMS-MADE AGGREGATE i
DED , [RETENTION S
WORKERS COMPENSATION _- PER OTH-
AND EMPLOYERS'LIABILITY Y/N STATUTE ER
ANY PROPRIETOR/PARTNER/EXECUTIVE N/A E.L.EACH ACCIDENT S
OFFICER/MEMBER EXCLUDED?
(Mandatory In NH) E.L.DISEASE-EA EMPLOYEE S
M Yyss desati:e uMer
DESG�RIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S
B Excess Medical 6 Accident SPX0000027889600 12/31/2016 12/31/2017 Excess Medical $10,000
($250 Deductible/Clain 12:01 AM 12:01 AM ADBSped6cLoss $2,500
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks SeheduM,may be attached H more space Is required)
CERTIFICATE HOLDER IS NAMED AS AN ADDITIONAL INSURED AS RESPECTS TO THEIR INTEREST IN THE OPERATIONS OF
THE NAMED INSURED. DATE OF EVENT(S) : 11/18/17 Race 4 the Pies Thanksgiving Day 4 Mile Run INSURED
RRCA CLUB/EVENT MEMBER: Palm Beach Roadrunners, Att'n: Dianne Lavado, 14341 Evelyn Drive, Palm Beach
Gardena, FL 33410
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
11/23/17 Village of Tequesta THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
345 Tequesta Drive ACCORDANCE WITH THE POLICY PROVISIONS.
Tequesta, FL 33469
AUTHORIZED REPRESENTATIVE
Terry Diller/MMA - ��� t�Pc U
01988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
INS025 roman
PERMIT NUMBER
Contractor's Name PALM BEACH ROADRUNNERS INC
Project Address SPECIAL EVENT- 11/23/17
VILLAGE OF TEQUESTA
BUILDING DEVELOPMENT
Account# Description Amount
001-000-208.201 PBC Impact Fees (PRIMP)
001-000-208.202 DCA Building Permit Surcharge(.015) (BLDSC) 0.00
001-000-208.203 BCAIF (BCAIF) 0.00
001-000-208.500 Sales Tax Payable (STAR)
001-000-223.100 Prepaid Local Business Tax (P-LBT)
001-000-223.110 Prepaid Home Business Tax (P-HB)
001-000-321.000 Local Business Tax (LBTX)
001-000-321.001 Home Business Tax (HBTX)
001-000-341.101 Certification/Copy Fees (COPY)
001-000-341.105 Charges for services(PBC Impact Fees) (2%) (CFS2%)
001-000-341.105 Charges for services(Bldg Permit Surch (5%) (CFS5%)
001-000-341.105 Charges for services(Bldg Code) (CFS10)
001-150-341.150 Land Development Fees (P&Z)
Zoning (P&Z)
PLAN REVIEW(BLDPM) 100.00
001-150-369.000 Other Miscellaneous Revenue P&Z
001-171-354.102 Code Enforcement-Fines&Court Costs (CFINE)
001-171-362.221 Police Impact Fees (POIMP)
001-180-322.000 Building Permit Fees (BLDPM) 0.00
001-192-362.222 Fire Impact Fees (FIMP)
001-231-363.271 Park& Rec Impact Fees (PRIMP)
401-000-343.700 Water Conservation (WC401)
401-000-369.110 Capital Connect Charge-Cust
Total DUE $100.00
Application Fee Prep: MM
2% $0.00 PAID Date: 6/22/17
Plan Review Fee $0.00
Total $0.00 uega Paid by:
*mop 4es
Check#
Cash
Contract Price Credit card
PERMIT NUMBER
Contractor's Name PALM BEACH ROADRUNNERS INC
Project Address SPECIAL EVENT- 11/23/17
VILLAGE OF TEQUESTA
BUILDING DEVELOPMENT
Account# Description Amount
001-000-208.201 PBC Impact Fees (PRIMP)
001-000-208.202 DCA Building Permit Surcharge(.015) (BLDSC) 0.00
001-000-208.203 BCAIF (BCAIF) 0.00
001-000-208.500 Sales Tax Payable (STAX)
001-000-223.100 Prepaid Local Business Tax (P-LBT)
001-000-223.110 Prepaid Home Business Tax (P-HB)
001-000-321.000 Local Business Tax (LBTX)
001-000-321.001 Home Business Tax (HBTX)
001-000-341.101 Certification/Copy Fees (COPY)
001-000-341.105 Charges for services(PBC Impact Fees) (2%) (CFS2%)
001-000-341.105 Charges for services(Bldg Permit Surch (5%) (CFS5%)
001-000-341.105 Charges for services(Bldg Code) (CFS10)
001-150-341.150 Land Development Fees (P&Z)
Zoning (P&Z)
PLAN REVIEW(BLDPM) 100.00
001-150-369.000 Other Miscellaneous Revenue P&Z
001-171-354.102 Code Enforcement-Fines&Court Costs (CFINE)
001-171-362.221 Police Impact Fees (POIMP)
001-180-322.000 Building Permit Fees (BLDPM) 0.00
001-192-362.222 Fire Impact Fees (FIMP)
001-231-363.271 Park& Rec Impact Fees (PRIMP)
401-000-343.700 Water Conservation (WC401)
401-000-369.110 Capital Connect Charge-Cust
Total DUE $100.00
Application Fee Prep: MM
2% $0.001(-( 3 Date: 6/22/17
Plan Review Fee $0.00
Total $0.00T. , PA
ID Paid by:
Check# a 6 1
vuiWa� pf tec�Uebtd Cash
Contract Price Credit card