HomeMy WebLinkAbout*Other - RenewSpecial Event Application
Aloses Lake Par ksRecreation & CulturalServices
PO Box 15 79
Moses Lake, WA 9883 7
(509) 764-3806 www.m1rec.coni
F.MENTS 4, ENTREQUIR Dtr,4�1111THA3PLIC.117"IONSURN117'7AL
1. $75.00 non."refundab-le application fee 2. Map -and/or drawing of the .eveht setup, 3. Letter describfi1g, your -event *'in ftill detail.
Received (staff initials/date: Received (staf f initials1date):
Received (staff initials1date
Event Title Event Date h-j6 12,02,2L.
Summary of Event
Pt b
Location (be specific) VW, 0A( S\f aneerte--k�61r)04.neivCAMly
ma
te ate,, S—) Time c>Q Pm YDay of Week�
Event Starts Date Time 'U0 Day of Week
Event Ends DatO 6/ Time 10�00 Day of Week
Dismantle Date Time 07 06 C Ov r.
,kryl Day of 'Week
Estimated Attendance Will there be a paid admission? Y C5Is your event open to the publie(ZNo
90
Applicant .Name
On -Site Contact
Phone
Cell Phone
Contact Organization Circle One:PjFor Profit
on -Profs vo
Mailing Address��� Y� 0-M�,n Email
0 Alcohol
0 Distribution/Sales
0-Food -5 *NCAC�
N
11Tables/Chairs
Ut&mplified Sound
ElDrawing/Raffles
AtTents/(2!piDes
0 Vehicles
0 Animals
11 Dunk Tank
AP.A. System
0 Vendors
0 Bleachers
0 Electricity/Generator
EKRace
t Water
0 Boats
0 Entertainment
0 Rally/Protest
0 Other
D Carnival Rides
0 Exhibits/Displays
A$ibnage/Banners
11 Other
0 Company Picnic
0 Fencing (temporary)
0 Sporting Event
0 Other
C1 Concert/Live Music
0 Festival
0 Stage
0 Other
0 Cooking/Barbecue
0 Fireworks
0 Street Closures
Cl Other
Provide details for all checked items and describe any "other' items. 'if there will be any food or merchandise/vendors at event, please
indicate if food, merchandise, or services will be provided free of charge or if they will be sold:
(attach additional pages if needed)
Certificate of Liability naming the City of Moses Lake as an additional insured in amount of at least two million dollars ($2,,000,000)
(combined single limits per occurrence), two million dollars ($2,000,000) aggregate naming the City of Moses Lake as additional insured
is required prior to application approval and must be submitted to the Parks and Recreation Office not less than sixty (60) days prior to
your event. See application packet for additional event requirements.
For rental or use offacilW such as community centers facility use
ies -, senior centers, sport or swimming pools, For short term
WCIA, through our broker, offers short term liability insurance for tenantlusers ofmember property or locations. This is called Tenant
Users Liability Insurance Policy (TULIP). The TULIP covers users and the WCJA member as insureds.
Please note that TULIP does not cover certain events and does not cover participant liability for athletic events. Please contact WCZA
for TULIP details.
Indemnification / Hold Harmless
User shall defend, indemnify and hold harmless the City of Moses Lake, its officers, officials, employees and volunteers from and against
any and all claims, suits, actions, or liabilities for injury or death of any person, or for loss or damage to property, which arises out of the
use of Premises or from any activity, work or thing done, permitted, or suffered by User in or about the Premises, except only such injury
or damage as shall have been occasioned by the sole negligence of the Public Entity.
A. Insurance Term:
User shall procure and maintain for the duration of the use or rental period insurance against, claims for injuries to persons
or damage to property which may arise from or in connection with the use of the facilities and the activities of the User
and his or her guests, representatives, volunteers and employees.
B. No Limitation:
*User's maintenance of insurance as required by the Agreement shall not be construed to limit the liability of the User to
the coverage provided by such insurance, or otherwise linn it the *Public Entity's recourse to any remedy available at law or
in equity.
C. Required Insurance:
User's required insurance shall be as follows:
General Liability insurance shall be at least as broad as Insurance Services Office (ISO) occurrence fonn. CG 00 01 covering
premises, operations, products -completed operations and contractual liability. The Public Entity shall be named as an
additional. insured on. User's General Liability 'insurance policy using ISO Additional Insured -Managers or Lessors of
Premises Form CG 20 11. or an endorsement providing at least as broad coverage. The General Liability 'insurance shall
be written with limits no less than $2,000,000 each occurrence, $2,000,000 general aggregate.
The insurance policy shall contain. or be endorsed to contain that the User's insurance coverage shall be primary insurance
as respect the Public Entity. Any 'insurance, self-insurance, or self -insured pool, coverage maintained by the
.Public Entity shall be excess of the User's insurance and shall not contribute with it.
D. Public Entity Full Availability of'User Limits:
If the User maintains higher insurance limits than the minimums shown above, the Public Entity shall be insured for the
full available limits of Commercial General. and Excess or Umbrella liability maintained by the User, irrespective of
whether such limits maintained by the 'User are greater than those required by this contract or whether any certificate of
insurance furnished to the Public Entity evidences limits of liability lower than those maintained by the User,
E. Certificate of Insurance and Acceptability of Insurers:
The User shall provide a certificate of insurance evidencing the required insurance before using the Premises. Insurance
is to be placed with insurers with a current A.M. Best rating of not less than A: V11.
F. Alcohol, Available for Consumption on Premises, Whether Sold or Not:
The User shall procure and maintain for the duration of the agreement Liquor Liability insurance in the amount of
$ 1,000,000 each occurrence. The Public Entity is to be named as an additional insured on Liquor Liability insurance. Host
liquor liability coverage may be substituted when alcohol is consumed and not sold on premises with the prior written
approval of the Public Entity.
G. Athletic Participant Events:
General Liability insurance shall include coverage for participant liability with limits of not less than $1,000,000 per
occurrence.
Now,
won vA�
Event Applicant's Signature teA Dated ,S� l � � Z Z
As planner of the Special Event described in this application, I understand that I and/or the sponsoring organization zation is/are responsible
for adherence to state law, City of Moses Lake rules and regulations including, but not limited to:
e Please be respectful of all park users No amplified sound without special event permit
* No alcohol, tobacco, marijuana or 'illegal drugs 0 No littering
* No inflatable structures, bounce houses, etc. 0 Dogs must be on a leash in. park and you are
• No overnight camping except in designated campground responsible for cleaning up after them.
• No fireworks allowed, 0 No unauthorized commercial activity allowed,
• No unauthorized vehicles beyond parking lot
I also understand that new events and/or unprecedented activities may require advance approval from the City of Moses Lake City
Council and/or City Manager through a request of the Parks and Recreation Department.
I also understand that allowing non -permitted and/or unscheduled activities to occur during the above -described special. event may
jeopardize approval of future Special Event Applications from the City of' Moses Lake to the Event Planner and/or sponsoring
organization.
AWO �'". S
Event Applicant's Name (printe
Event Applicant's Signature e Date
f Noses
OFFICIAL VSE Or"V L Y BEL'O U" ?"HIS POINT (i.e. Th s `.S'et tioll Comj)letetl fill C it j, .*qjj)
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Available for an additional fee: (T'he.,ve items may be an event requireinent.)
Amphitheater $75.00 Garbage Cans $10.00 each # Picnic Fables $20.00 each #
Shelter 4 hrs/$55 8 hrs/$80 Deane Family Shelter 4 hrs/$75 8 hrs/$100
Staff notes
Parks and Recreation Director Application accepted
- Application rejected
Applicant notified
Departmental outing & Revilew
Reviewed R v�eed � .
:1Y al�e �e ed �.
ciranat
Reviewed By:
Financer
en
,.
Bate. Late.
Date:
x x n Date:
Detailed Drawing or Map of Event Layout
(Please be very specific and include all details)
(include Additional ,Pages if Necessary)
City of Moses Lake
COVID-19 Participant Assumption of Risk and Waiver of Liability
Event/Activity: . M"Vk\ 34\4--
On March 11, 2020, COVID-19, a highly contagious disease that is spread through person -to person contact was
declared a worldwide pandemic by the World Health Organization and on February 29, 2020, Washington State
Governor Jay Inslee proclaimed a public health emergency for COVID-19, beginning February 29, 2020. On
March 13, 2020, U.S. President Donald Trump declared the COVID- 19 outbreak a national emergency. On May
31, 2020, Governor Inslee signed Proclamation 20-25.4 implementing the Safe Start plan for a county -by -county
phased reopening. Under the plan, certain activities may be resumed provided adequate social distancing measures
and health standards are in place. However, even with these measures and standards in place, the City cannot
guarantee that participants or spectators at recreational events or activities will not become *infected with COVID-
19.
By signing this form, the Participant agrees that:
Participation in the recreational event or activity is voluntary. The Participant acknowledges the contagious
nature of COVID-19 and understands it is the sole responsibility of the Participant, and his/her
parent/guardian as applicable, to evaluate carefully all risks inherent in participating in the recreational
event or activity. The Participant further understands that the risk of becoming exposed to or infected by
COVID 19 while participating in the recreational event or activity may result from the actions, omissions,
or negligence of the Participant or others, including, but not limited to, City officials, employees, agents,
volunteers, representatives and guests. The Participant, and his/her parent/guardian as applicable,
voluntarily assumes full responsibility for the risk that the Participant may be exposed to or infected by
COVID- 19 by participating in the recreational event or activity, and that such exposure or *Infection may
result in personal injury, illness, permanent disability, death or other damages or expenses.
2. The Participant assumes all. of the foregoing risks and accepts sole responsibility for any injury to the
participants 'including, but not limited to, personal injury, disability, death, illness, damage, loss, claim,
ii liability, or expense, of any kind, that the Participant or their parent/guardian may experience or incur n
connection with Participant's participation in the recreational event or activity ("Claims"). The Participant
releases and agrees to hold harmless and indemnify the City, its officials, employees, agents, volunteers,
and representatives, from any and all liability, arising from negligence or otherwise, and any damages as
a result of the Participant's participation in the recreational event or activity, including but not limited to
property damage and any mental or physical bodily injury, including death. This release includes any
Claims based on the actions. omissions, or negligence of the City, its officials, employees,,, agents,
volunteers, and representatives, whether a COVID- 19 infection occurs before, during, or after participation
in the recreational event or activity. The foregoing waiver and assumption of risk is intended to be as broad
and 'inclusive as is permitted by the laws of the State of Washington and that if any portion thereof is held
invalid, it is agreed that the remaining provisions of this Agreement shall, notwithstanding, continue in full
legal force and effect.
3. The Participant agrees to follow all applicable safety and social distancing protocols while participating in
participating
the recreational event or activity. Failure to follow safety and social distancing protocols may result in the
immediate ejectment from the recreational event or activity without recourse or refund to the Participant.
4. The Participant agrees, represents, and warrants that the Participant SHALL NOT participate in the
recreational event or activity if he or she (i) experiences symptoms of COVID-19, including, without
limitation, fever, cough or shortness of breath, (ii) has a suspected or diagnosed/confirmed case of COVID-
19, or (iii) has been in close contact with any person who has tested positive for COVID-19 in the past
fourteen (14) days from the date of participation in the recreational event or activity. The Participant agrees
to notify the City immediately if any of the foregoing events occur during Participant's participation in the
recreational event or activity.
1, the undersigned, have read the above carefully, understand its significance, and voluntarily agree to all of its
terms. If the Participant is under eighteen. (18) years of age, this form must be signed by the Participant' s parent
or guardian, For divorced/separated parents, the parent/guardian signing below attests that he/she has legal
authority to provide consent for the Participant to participate in the recreational event or activity and to execute
this form.
Event/Activity
7
Participant Printed Name Parfttici 7a-S�iignature Date
Parent or Legal Guardian Printed Parent or Legal Guardian Signature Date
Address Phone
E-mail Address
q :11, III, I Ay"I I !A, 10 KX4 I�, 1 4- N, .1 1 � 11jo I I, q �1 , I n,x ) � III I I , 1; 1 MAMONAUM" I I 1n I I I I I I v 11; Ii I , , A, 1141 AAOMM 6 4; 411 . r6I 11m) 1, 6 1 1
Grounds for Permit Denial
UN I, 01moml I I 40,(iA I,I r1,, I,q, 1 1', to I 1 1,11 1 i, I I 4 I(I,Ici i I 11,n, ii "I I I I YI - 111 11 . II I I . , 111 1 "I'al , 1,1110, qI , I f_ I ii I, III I lii qmffivomw III IIIIIA I I 1 11, 4111
Reasons for denying a permit include, but are- not limited to:
The event, as presented, cannot function safely.
The City was not provided sufficient notice of the event. Special Event Permit Applications must be
submitted a minimum of sixty (60) days prior to the event date,
+ The City did not receive proof of ad e insurance
quate i ce from the applicant a minimum of sixty (0) days
prior to the event.
+ The individual signing the application on behalf of an organization does not have legal authority to make,
1.
legal commitments for the organization. During our review of the documents, we will access the
Washington State Secretary- of State's website to verify signatory authority for the organization. See:
ht!p.s-.-//ccfs.sos.wa.gov/#/
+ The diversion of police and fire resources to support the event would deny reasonable fire and police
protection to other parts of the City.
+ The proposed event would unreasonably disrupt the orderly or safe circulation of traffic as would present
an unreasonable risk of 'Injury or damage to the public.
+ The applicant provides false or misleading information; the applicant fails to complete the application or
to supply other required information or documentation; or the applicant declares or demonstrates an
01 41 * unwillingness or inability to comply with the reasonable terms or conditions contained in the proposed
permit.
The proposed event would conflict With another proximate event, interfere with construction or
maintenance work in the immediate vicinity, or unreasonably infringe upon the rights of abutting prop