HomeMy WebLinkAboutSpecial Event Application - Eastside VocationalKittitas County, Washington
BOARD or COUNTY COMMISSIONERS
EVENT APPLICATION
i]i' r -il"Ililif!'.:! :
Event Information
Name of event: Overcoming Obstacles: Fighting MS
8t2112021Date(s) of
,;ii.,t--.-.-
1.1. . I'l urJlJlivli- \)r .. -Hours of opera . 11:00am - 4:00 pm .;i r'i1:,iii'l'i'i
Description of the event: Fundraiser lor Multiple Sclerosis research, donations designated lor
National MS Society.
Has this event taken place before? Yes 116 Dates:
Estimated attendance' <1 00
How is your event being publicized z Online (Eventbrite), social media,
printed flyer (attached)
Please attach any flyerc, posterc, etc. uith your application submission.
tact Information
Name of the organizet/contact person:Michelle Jensen / Eastside Vocational
Address: 1570 Robinson Canyon Rd, Ellensburg, WA 98926
Phone number(s)509-962-1 950
Email address: mjensen @eastsidevocational.com
Date of birth of applicant:12-08-1976
KITTITAS COUNTY COURTHOUSE. 205 WEST 5d . SUITE 108 ELIENSBURG. WA 98926
(5O9)962:7s08 FAX(509)962:7679
www.co.kittitas.wa,us
If the application is made on behalf of a partnership, please submit full names with their
residence and post office address for a period of six months prior to the date of
application together with the location of principal office or place of business of such
corporation.
Emergency contact name(s) and phone number(s) that can be contacted during the
event:
Michelle Jensen, CEO 5O9-889-22GT
Name
Kathryn Harms, Executive Asst.
Phone Number
971-400-9912
Name Phone Number
WRITTEN PERMISSION TO ENTER EVENT SITE
I/We hereby permit law enforcement andf or County officials to enter the site for which
the Event Application has been granted at the time of the event and up to five days
prior to the event for the purposes of inspecting and enforcement of County Code and
other applicable laws, and pursuant to my agreement and representations made in
connection with this Event Application.
SWORN STATEMENT OF COMPLIANCE
I/We hereby acknowledge that I/We have read Kittitas County Code, have
familiafized myself with County requirements. I/We agree that either my designated
agent orlf we shall be on site at all times and shall be responsible for the operation of
the event and for compliance with all legal requirements in connection with this event.
I/We understand that failure to comply with the rules, regulations and conditions set
forth in Code may be deemed a gross misdemeanor and that drug or narcotics
violations are crimes under RCW
Michelle Jensen
Applicant Name (PrinQ
Applicant Name (Print)Applicant Signature
KITTITAS COUNTY COURTHoUSE. 205 WEST 5* . SUnE 108 EIIENSBURG, wA 98926
(s09)962-7s08 FAX (509) 962:7679
www.co.kittitas.wa.us
If more than 50 people are expected at your event, you must complete a separate
application process which can be obtained through the Kittitas County Fire Marshal's
office. You may contact the Fire Marshal's office at509-962-7000.
Kittitas County, Washington
BOARD opCOUNTY COMMISSIONERS
Fire Saf and Protection
Will there be a temporary structure erected for the event? Yes U6
If yes, you must attach a drawing including the dimensions. The structure may
require an inspecfion by County staff prior to the event.
Public Health/En vironmental Health
Will there be food served at the event? \t1 No
If no food will be served at the event thery no permit or application is required
If yes, is the food and beverage that you intend on preparing and serving at the event
exempt from permit reou1remenIts htto: / /www.co.kittita wa.us / health / food.aso ?
- If yes, please submit an application for exemption from permit and proof of food
handlers training to the Kittitas County Public Health Department (KCPHD).
If yes, and the food or beverage is not considered exempt from permif then does the
Person or organization preparing and serving the food have a food service permit,
temporary food service permit, or catering permit from KCPHD?
- If yes, please provide a list of foods and beverages that you intend on having
prepared and served at the event along with the name and phone number(s) of
the permitted person or organization.
If yes, and the person or organization preparing and serving the food does not already
have a food service permit.
- Then a temporary food service permit or catering permit will need to be acquired
from KCPHD prior to the event.
Please allow at least 2 weeks to complete the food service permitting process.
KITTITAS COUNTY COURTHOUSE. 205 WEST 5* , SUnE 108 ELLENSBURG, wA 98926
(509)962-7s08 FAX (s09) 962:7679
www.co.kittitas.wa.us
If no, please provide an estimated attendance for the event, specific information
related to the number of portable restrooms that will be provided, the distance from
the event that patrons must walk, and a service plan to ensure that sani-cans remain in
a sanitary condition. You must include the location of the portable restrooms on a
map/ diagram of the event.
Are there permanent or fixed bathroom facilities already available at the location of
the event?
V" No
If_yes,please provide an estimated attendance for the event, a detailed map that
identifies the name and address of the physical facility that will provide lavatory
facilities for the event, quantity of toilette facilities available for each gender, and the
distance from the event that patrons must walk.
KITTITAS coLrNTy couRTHousE. 205 WEST 5* , sulfE 108 Er r F.NSBLRG, wA 98926
(509) 962-7s08 FAX (s09) 962:76',19
www.co.kittitas.wa.us
Kittitas County, Washington
BOARD op COUNTY COMMISSIONERS
Law Enforcemen ecurr Medical Services
WilI there be security on site during the event? Yes ry6
If yes, please provide a complete list of names and contact information for who will be
providing the security.
will Emergency Medical Services (EMS) be on site during the event? Yes N/
If yes, please provide written verification from the providers.
Will there be music, sound amplification or any other noise impacts? V" No
If yes, Kittitas County has a noise ordinance in effect (see County Code for details). If
your event is scheduled for outside of the allowed time, you must submit a written
letter to the Board of County Commissioners requesting a waiver and it must be
included with your application materials.
Will you have traffic control? Yes ry6
If yes, please provide documentation on how the tra-ffic control will be addressed.
Will there be off-site parking? Yes V
If yes, please provide the location and a parking plan.
Will there be shuttle buses provided for attendees? Yes V6
If yes, provide a map of their route.
Will there be alcohol served at the event? Yes V
If yes, a State permit is required from the WA State Liquor Control Board and must
submitted with your application materials.
KITTITAS couNTy couRTHousE. 205 wEST 5* , sUITE 108 ELLENSBURG. wA 98926
(509) 962-7508 FAX (s09) 962-7679
www.co.kittitas.wa.us
Kittitas County, Washington
BOARD or COUNTY COMMISSIONERS
Public Roads
Will the event obstruct, interfere or require the closure and free use of any public
road, street or right-of-way? Yes ry6
If yes, please provide a detailed adequate traffic and detour plans at the time of
submission of the application.
WiIl there need to be road closure or detour signs posted? Yes #
KITTmAS couNTycouRTHousE. 205WEST56. sunE 108 ELLENSBURG,wA 98926
i509) 962-7s08 FAX (509) 962:7679
www,co.kittitas.wa.us
Kittitas County, Washington
BOARD or COUNTY COMMISSIONERS
Garb lin
Do you have a plan for garbage and recycling? V" No
A written plan for garbage and recycling must be attached to your application
materials. For questions or assistance contact the Kittitas County Solid Waste
Department at 509-9 62-7542.
Insurance
Have you obtained a Certificate of Insurance and endorsements, specifically
naming "Kittitas Count5r" as an insured? V, No
A copy of the Certificate of Insurance amd endorsements must be included with your
application materials. Kittitas County must be named as an additional insured inthe
amount of $1,000,000.00 per occurrence and $2,000,000.00 aggregate coveraee. This
insurance must apply first and on a primary non-cbntributih"g bHsis in relation to any
other insurance or self-insurance available to Kittitas County.
Penal Bond - Bond of Indemnitv
A $5,000.00 Penal Bond - Bond of Indemnity is required to be deposited with the
Counfy Treasurer to save and protect the streets, pavements, bridges, etc. from
damage. The deposit or its balance will be returned once the event has been held and
the Board of County Commissioners has certified no damage has been done and that
the County has not incurred additional expenses
Are you submitting a $5,000.00 Penal Bond - Bond of Indemnify with your EventApplication? -Yes
VG
If no, you must request a letter in writing to the Board of County Commissioners
requesting a waiver to the Penal Bond - Bond of Indemnity and outline the specific
reasons why it should not be required of your event.
Coun F strationand
Is there a cost to attend the event? V
How much are you charging to attend your event?
No
KrrrtrAs couNTy couRTHousE. 205 wEST 5,h , SUITE 108 ELLENSBURG, wA 98926
(s09)962-7s08 FAX (s09) 962:7679
www.co.kittitas.wa.us
G.tHrstsIDEVocerIoNAL
SER,VICES, IhIC.
ADDITIONAL EVENT INFORMATION
Flre Safety: Special Event Application submitted to Kittitas County Fire Marshall.
Food Safety: Permit application submitted to Department of Health.
Bathroom Facilities: Event location equipped with five permanent restroom facilities.
Renting additional ADA-compliant toilet from Brown and Jackson to be placed in easily
accessible and safe location on the property.
Security: No professional security will be on-site. Staff and volunteers will be on-site
Emergency Medical Services: EMS will not be on-site during event; however, the staff
Licensed Practical Nurse will be on-site at the First Aid station to provide first aid as
needed and facilitate/coordinate any medical emergency response needed.
Music/Sound/Noise: There will be music during the event from 11:00am-4:00pm, but
property is more than 1,000 from neighbors and within the allowed time of the county
noise ordinance.
Traffic Control/Parking/Shuttle Bus: Owner's property will supply parking, no shuttle
bus provided. No traffic control needed, and event is far enough off the main roads and
out of city limits that it will not affect traffic, no detour or road closures needed.
Garbage: Host will provide garbage and recycling receptacles, and will clean, manage,
and store waste until hauling to dump/recycle center after event,
lnsurance: Certificate of Liability lnsurance listing Kittitas County as a Certificate
Holder/Additional lnsu red attached.
Penal Bond: Not submitted due to event being on private property outside of city limits
with minimal impact on traffic and public services.
Attendance Cost: Suggested donation for admission is $10, all proceeds are donated to
National MS Society. Admissions Tax Registration completed with the Kittitas County
Auditor.
Our Home Office is located at
902 N Enterprise Way, Ellensburg, WA 98926 r (509) 962-1950 r Fax (866) 243-7009
Yakima o Kennewick o Spokone o llenatchee o Issaquah t Tacoma
www.eastsidevocationalservices. com
ACORD^
COVERAGES
CERTIFICATE OF LIABILITY INSURANCE DATE (MM'DD/YYYY}
6D2/2021
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE OOES NOT CONSTTTUTE A CONTRACT BETWEEN THE ISSU|NG TNSURER(S), AUTHORIZED
LqPRESENTATTVE OR pEOpUgEB,AlllD THE CERTTFTCATE HOLDER.
IMPORTANT:
the terms and
the certiflcate
lf the ts an ADDITIONAL lNsuRED,the must b€tf ls wAlvED,subject to
conditions of the policy certain policies may require an endorcement.A statement on this certificate does not confer rights to
ln
Special Markets lnsurance Gonsultants, lnc.
'1055 Main Strcct, Ste 101
Stovens Point, Wl 64481
80v727-7642 7',t5-3&6216
oolicvissue@amwins.com
AFFORDING COVERAGE NAIC #
INSUR.ED:
Eastside Vocational Services
902 N Entemrise Wav
Ellensburg, WA 98926
INSURER A:Philadelphia lnsulance Companies
INSURER B:
INSURER C:
INSURER D:
IN$tJRER E:
INSURER F:
lHlSlsloUE'F(Ilt,YlHAltHEPoLlclESoFlNsURANcELlSTEDBELoWHAVEBEENlssUEDToTHElNs
INDICATED. NOTWTHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT wlTH RESPECf TO IANIICN fUSCERrlFlcArE MAY BE lssuED ^o3^144I !-EnIA!!, THE INSURANCE AFFORDED By rHE polrctEs DESCR|BED HEREiN rS SuetECi ro nLi ine tenurs,EXCLUSIONSAND CONDITIONS OF SUCH POLICIES. LIMITS SHO\I\N MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INJK
ITR TYPE OF INSURANCE POLICY NUMBER P(JLIUY EFF
IMM'OD/YYYYI
],OLICY EXF
II'I"DDIYYYYT LIMITS
EACH OCCURRENCE $1,000,000
$ 300,000
MED EXP (Any on6 p€rson)$0
PERSONAL & ADV INJURY $r,000,000
GENERAL AGGREGATE $2,000,000
PRODUCTS.COMP/OP AGG $1,000,000
A
COMMERCIAL GENERAL LIABILIry
Host Liquor Liabllity lncluded
GEN'L AGGREGATE LIMIT APPLIES PER:
X
X POLICY
x
CLAIM$-MADE
LOCPROJECT
GENERAL LIABILITY
Y PHPI<2212107 12:01 Alt
8t21t2021
12:01 AM
8t22r2021
BOOILY INJURY (Per person)
BODILY INJURY (Per accidsnt)
PKUPTK I Y UAMALits
fPer aeidstl
ANYAUTO
ALL OW{ED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON.O\^NED AUTOS
LIABILITY
EACH OCCURRENCE
AGGREGATE
UMBRELLA LIAB
EXCESS LIAB
DEDUCTIBLE
RETENTION
OCCUR
CLAIMS.MADE
twuStAtu- |ItonY rrnrrs I OTHER
E.L. EACH ACCIDENT
E.L. DISEASE _ EA EMPLOYEE
WORKERS COMPENSATION
ANDEMPLOYERS LIABLITY
ANY PROPRIETORSH IP/PARTNER/
EXECUTIVE OFFICER'MEMBER
EXCLUDED?
(Mandatory in NHI
lf yes, describe under
DESCRIPTION OF OPERATIONS bolow
T N/A
E.L. DISEASE - POLICY LIMIT
DESCRIPTION OF OPERATIONS / LOCATTONS / VEHICLES (Attach ACORD 101, Additional Remarks Scheduls, lf more Bpace is requirsd)'l he Certllicate Holder ls added as an addltronal lnsured but only wrth resp€ct to hablhty aristng out oflhe operatrons ofthe above named tnsured
Coverage is primary in accordance with the Commercial General Liability form CG0001 as respects the insured's operations
Sponsors
CERTIFICATE HOLDER
Kittitas County ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
EXPIRATION DATE THEREOF, NOTICE WLL BE DELIVERED IN
W 5th Ave Suite 108 IIVITH THE POLICY PROVISIONS,
Ellensburg, WA 98926 REPRESENTANVE
Tttlh
@ 1988-2009 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
ACORD 25 (2009/09)
Pr-APG-002 (01t07)
CERTIFIGATE OF INSURANCE. PURCHASING GROUP LIABILITY
INSURANCE POLICY
This insurance is provided by:
Philadelphia lnsurance Companies
Master Pof icy Number: pHpK22t2407
Master Policy Holder:
Special Markets Purchasing Group lnc
General Aggregate Limit:
(Other than Products Completed-Operations)
Products-Completed Operations Aggregate Limit:
Personal and Advertising lnjury Limit:
Each Occurrence Limit:
Damages to Premises Rented to You Limit:
Medical Expense Limit:
Item 1: Eastside Vocational Services
Item 2: 902 N Enterprise Way
Ellensburg, WA 98926
$2,000,000
Any One Premises
Any One Person
Producer Name: Special Markets lnsurance
Consultants, lnc
Producer Address: 1055 Main St, Ste 101
Stevens Point, Wl 54481
Producer Number: 27286
Certificate Number: MPMI 01286
As consideration of the payment of premium and subject to all terms of the master policy, we agree to
provide the insurance as stated in this certificate.
Item 3: Named Certificate Holder Association (if applicable):
Item 4: Mailing Address:
Item 5: Form of Business: Organization
Item 6: Business Description: Fundraising on Campus
Item 7: Location of all Premises you own, rent or occupy:
Location Address:
ftem 8: Policy Period: From: 8l2ll202l To:812212021
12:01 A.M. Standard Time at the mailing address shown in ltem 2
Item 9: Forms and Endorsements: Forms and Endorsements attached to this certificate - See Schedule of Forms
and Endorsements attached to the Master Policy. Copies are available upon request.
Item 10: Limits of lnsurance: This policy provides for the Limits of lnsurance below.
$t
$t
$t
$
$
000,000
000,000
000,000
300,000
0
Page 1 of 2
P|-APG-002 (01t07)
Hired and Nonowned Auto Liability: Applies only if a limit is shown below.
Liability $ run
Uninsured Motorists Coverage (lL and LA) $ run
Underinsured Motorists Coverage (lL only) $ Nn
Stop Gap Liability: Applies only if a limit is shown below (OH, ND, WA, WV, WY).
Each Person $ N/A
Each Occurrence $ N/A
Bodily lnjury by Disease Aggregate $ N/A
Item 11: Coverage and Premiuml
Your policy consists of the following coverage when a premium is indicated. lf a premium is not shown,
there is no insurance coverage. This premium may be subject to adjustments.
covERAGE PART(S) PREM|UM FOR pOLtCy pERtOD
Commercial General Liability Coverage $1 15.00
Hired and Nonowned Auto Liability Coverage $
Stop Gap (OH, ND, WA, WV, WY), if applicable $
State Tax, Fees, Surcharges $ 35.00
TOTAL CERTIFICATE PREMIUM including State Tax, Fees, Surcharges $150.00
Countersigned
{J* U,tA
Date: 06/2212021 By:
THIS CERTIFICATE OF INSURANCE, TOGETHER WITH THE COMMON POLICY CONDITIONS, COVERAGE
PART(S), COVERAGE FORM(S) AND ENDORSEMENT(S) ATTACHED TO THE MASTER pOLtCy, COMPLETE
THE ABOVE NUMBERED POLICY.
The following notice is provided pursuant to the Texas lnsurance Code Article 21.54. The insurer may not be
subject to all insurance laws and regulations of this state. The member benefits described are guaranteed through
an insurance contract. The Special Markets Purchasing Group, lnc's insurance policy is underwritten by
Philadelphia lndemnity lnsurance Company and rated A+ X by the A.M. Best Co. in 2006.
Page 2 of 2
EASTSIDE VOCATIONAL SERVICES
lST ANNUAL
OVERCOMING
OBSTACLES:
FIGHTING MS
{t 3tF
t@{G
t@
AUGUST 21, 2A2l
It- 4 PM
I57O ROBINSON CANYON
RD ELLENSBURG, WA
Join us for a fanrily friendly fundrraising event to
sulpport those with N4urltiple
Scleros,is (MS).
(''t
\r.'v.
,fr/7
,/&{/o
Featur,ingi
Overrco,mi ng Obstacles cou,rse
food
5O/5O raffle and auction
live m,usic iby Micah J.
Register orn Faceboolk-
Eastside Vocatiotnarl Servrices.
*" .r.. F
"".'.n/
All proceeds donated to the National tMS Society to
ilrelp fund rMS research, prograrns and servtices so
that people affected by MS ca,n live their ibest l,ives.
B@
Kittitas County Office Of The Treasu.rer
Any Cziske, Trensurer
2ll5 ltrI stlr $$rrur, $ultr, lUl
Elenshurg,lile 98926
Plurc (509)962-7535 rex(509) 933-S212
Cash Receipts
Receipt Number: 2021-3637 Date:
Received From: MANDY BUCHHOLZ, ADMIN SUPERVISOR
CheckAmount: $200.00
CashAmount: $0.00
OtherAmount: $0.00
TotalAmount: $200.00
Deputy: KYLEEW Receipt Type: CHK
Template:
Comments:
csr 2021-2630
SPECIAL EVENT APPLICATION FROM EASTSIDE VOCATIONAL CHECKI6643
06/22/2021
FundCode
001
GlCode
1632171
TotalAmount:
Kittitas County Treasurer's Office
Submiued By: KYLEE WUESTHOFF
Amount
$200.00
$200.00
Description
SPECIAL EVENTS FEE
(c) 2002 Cashtax AII Rights Reserved 0612212021 1 6:00:1 3 KYLEEW