Special Event Permit Application – City of Chamberlain, South Dakota

Today's Date *

Instructions

To apply for a Street Dance/Special Event Permit, please complete this application. Submit your application, including required attachments, no later than forty-five (45) days before your event. Facility Use Agreements should also be completed at this time (if applicable).

This application is subject to Chamberlain City Council Approval. Any violations of the approved permit will be grounds for law enforcement to require the immediate termination of the event.

EVENT INFORMATION

Event Type *

If Other Please Specify

Event Title *

Event Dates

Date / Time *

Date

Time

Date / Time

Date

Time

Please fill out if more than one date.

Date / Time *

Date

Time

Please fill out if more than one date

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Total Anticipated Participants *

Put N/A if none

Set Up Time Start *

Total Anticipated Spectators *

Put N/A if none

Set Up Time Finish *

Dances, bands, amplified noise must end no later than 12:00 a.m.

Location/Staging Area *

Put full address below if needed

Address

Address Line 1

Address Line 2

City

State

Zip Code

BANDS ONLY

EVERYONE ELSE PLEASE GO TO NEXT PAGE

Band Name

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Set Up/Assembly/Construction Start Time

Date

Time

Please describe the scope of your setup / assembly work (specific details):

Dismantle Date / Completion Time

Date

Time

List any street(s) requiring closure as a result of this event. Include street name(s), day, date and time of closing and time of re-opening:

APPLICANT AND SPONSORING ORGANIZATION INFORMATION

Please type of sponsored event

Non-commercial, (nonprofit)
Commercial (for profit)

Sponsoring Organization

Chief Officer of Organization

First

Last

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Applicant Name

First

Last

Business Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Layout

Daytime Phone

Evening Phone

Fax

Please list any professional event organizer or event service provider hired by you who is authorized to work on your behalf to produce this event.

Name

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Layout

Contact/on site person day of event or facility use *

First

Last

Mobile Phone *

(Note: This person must be in attendance for the duration of the event and immediately available to city officials)

REQUIRED: Attach a written communication from the Chief Officer of the organization which authorizes the applicant or professional event organizer to apply for this Special Event Permit on their behalf.

File Upload *

Click or drag a file to this area to upload.

FEES / PROCEEDS / REPORTING

Is your organization a “Tax Exempt, nonprofit” organization? If YES, you must attach a copy of your IRS 501C Tax Exemption Letter to this Special Event Permit application (providing proof and certifying your current tax exempt, non profit status). *

Yes
No

Are admission, entry, vendor or participant fees required? *

Yes
No

If YES, please explain the purpose and provide amount(s)

OVERALL EVENT DESCRIPTION: ROUTE MAP / SITE DIAGRAM / SANITATION

Please provide a detailed description of your proposed event. Include details regarding any components of your event such as use of vehicles, animals, rides or any other pertinent information about the event: *

Consumption permit requested – $500 fee *

Yes
No

Consumption permits end at 12:30 a.m.

Special event license requested *

Yes
No

Special event licenses end at 12:30 am and applies to non-profit only

Does the event involve the sale or use of alcoholic beverages? *

Yes
No

If YES, please provide or attach your liquor liability insurance information to the last page of this application.

Liquor Liability Insurance

Click or drag a file to this area to upload.

Will items or services be sold at the event? *

Yes
No

If YES, please describe

Does this event involve rerouting traffic of any kind along streets, sidewalks or highways? *

Yes
No

If YES, attach a detailed map of your proposed route, indicating the direction of travel and provide a written narrative to explain your route.

File Upload for proposed route

Click or drag a file to this area to upload.

Does this event involve a fixed venue site? *

Yes
No

If YES, attach a detailed site map showing all streets impacted by the event.

Click or drag a file to this area to upload.

In addition to the route map required above, please attach a diagram showing the overall lay-out and set-up locations for the following items:

 Alcoholic and Non-alcoholic Concession and/or Beer Garden Areas.

Click or drag a file to this area to upload.

 Food Concession and/or Food Preparation Area(s).

Click or drag a file to this area to upload.

Please describe how food will be served at the event.

If you intend to cook food in the event area, please specify the method to be used:

Gas
Electric
Charcoal
Other

If Other please specify

 First Aid Facilities and Ambulance locations

Click or drag a file to this area to upload.

 Tables and Chairs

Click or drag a file to this area to upload.

 Fencing, Barriers and/or Barricades

Click or drag a file to this area to upload.

 Generator Locations and/or Source of Electricity

Click or drag a file to this area to upload.

 Canopies or Tent Locations

Click or drag a file to this area to upload.

 Booths, Exhibits, Displays or Enclosures

Click or drag a file to this area to upload.

 Scaffolding, Bleachers, Platforms, Stages, Grandstands or Related Structures

Click or drag a file to this area to upload.

 Vehicles and/or Trailers

Click or drag a file to this area to upload.

 Trash Containers and Dumpsters

Click or drag a file to this area to upload.

NOTE

You must properly dispose of waste and garbage throughout the term of your event and

immediately upon conclusion of the event, the area must be returned to a clean condition.

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Number of Trash Cans

Number of Trash Cans with Lids

Describe your plan for clean-up and removal of waste and garbage during and after the event or use of facility.

 Other Related Event Components not covered above

Click or drag a file to this area to upload.

ADDITIONAL INFORMATION REQUIRED FOR FACILITIES USE

Date/Time requested for set up or preparation of facility:

Date

Time

Date/Time clean up and restoration of facility will be completed:

Date

Time

Please indicate number of bleachers

Please indicate number of traffic cones needed

Please indicate any other facilities usage needed

Please indicate set up by sponsor:

Please describe preparation or set-up required for your activity in detail:

SAFETY / SECURITY / ACCESSIBILITY

Please describe your procedures for both Crowd Control and Internal Security

Please describe your Accessibility Plan for access at your event by individuals with disabilities

REQUIRED: It is the applicant’s esponsibility to comply with all City, County, State and Federal.

Disability Access Requirements applicable to this event.

PRIVATE SECURITY IS REQUIRED AS APPROVED BY THE CHIEF OF POLICE

Have you hired any Professional Security organization to handle security arrangements for this event? *

Yes
No

If YES, please list Security Organization

Security Organization Address

Address Line 1

Address Line 2

City

State

Zip Code

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Security Director Name *

First

Last

Phone

Is this a night event?

Yes
No

If YES, please state how the event and surrounding area will be illuminated to ensure the safety of the participants and spectators:

Please indicate what arrangements you have made for providing First Aid Equipment?

PARKING PLAN / SHUTTLE PLAN / MITIGATION OF IMPACT

Please describe your plans to notify all residents, businesses and churches impacted by the event:

ENTERTAINMENT / ATTRACTIONS / RELATED EVENT ACTIVITIES

Are there any musical entertainment features related to your event or facilities rental?

Yes
No

If YES, please state the number of bands and type of music.

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Number Of Stages

Number Of Bands

Type of Music/Entertainers Name

Will sound amplification be used?

Yes
No

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If YES, please indicate start time

End time (copy)

Will sound checks be conducted prior to the event?

Yes
No

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If YES, please indicate start time

End time

Please describe the sound equipment that will be used for your event:

Will any fireworks, rockets or other pyrotechnics be used? If YES, please attach a copy of your permit (issued by the City Commission) to this application.

Yes
No

City permit for fireworks

Click or drag a file to this area to upload.

Will any signs, banners, decorations or special lighting be used?

Yes
No

If YES, please describe:

PROMOTION / ADVERTISING / MARKETING / INTERNET INFORMATION

Will this event be promoted, advertised or marketed in any manner?

Yes
No

If YES, please describe:

Will there be any live media coverage during your event?

Yes
No

If YES, please describe:

Website / URL

Applicant acknowledges and agrees to allow the City to publish the contact person and media referral telephone numbers on the internet in conjunction with the Calendar of Upcoming Events in the City of Chamberlain. If you have a home page and want us to link with our Calendar, please provide the URL for your homepage:

Refer all event public inquiries and / or media inquiries for this event to:

First

Last

Phone

INSURANCE REQUIREMENTS

REQUIRED: Insurance for your event will be required before final permit approval.

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Name of Insurance Company

Agent's Name *

First

Last

Business Phone

Layout (copy)

Policy Number

Policy Type

Address

Address Line 1

Address Line 2

City

State

Zip Code

For final permit approval, you will need $2,000,000 commercial general liability insurance that names “the City of Chamberlain, its officers, employees and agents” as an additional insured. Insurance coverage must be maintained for the duration of the event. For insurance related questions, please contact the Finance Office at (605) 234-4401 – Fax # (605) 234-4403.

The City must be named as an “additional insured.” Please obtain the required insurance and mail an original insurance certificate to:

City of Chamberlain, Finance Office, 715 North Main Street, Chamberlain, SD 57325.

LIQUOR LIABILITY INSURANCE

Please go here: https://cityofchamberlain.com/malt-beverage-wine-liquor-license/

AFFIDAVIT OF APPLICANT

ADVANCE CANCELLATION NOTICE REQUIRED: If this event is cancelled, notify the Chamberlain City Offices. Otherwise, City personnel and equipment may be needlessly dispatched.

I certify that the information in the foregoing application is true and correct to the best of my knowledge and belief and that I have read, understand and agree to abide by the rules and regulations governing the proposed Special Event and I understand that this application is made subject to the rules and regulations established by the City Commission of Chamberlain. I agree to abide by these rules and further certify that I, on behalf of the organization, am also authorized to commit that organization, and therefore agree to be financially responsible for any cost and fees that may be incurred by or on behalf of the event to the City of Chamberlain.

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Name of Applicant *

First

Last

Title *

Date *