Fill - Free fillable Form 140 (Town of Milton, Vermont) PDF form

If a one-time event and you are requesting a rain date (provide date)

Do you re

quire use of Town: (answer yes or no to each) Water Electricity Lining of fields

Updated 05/09/18

Application for Facility Use

TOWN OF MILTON

43 Bombardier Rd. Milton, VT 05468 miltonvt.gov/recreation

Contact: Milton Recreation Department 802-893-4922

Email: bnappi@miltonvt.gov

Application must be submitted to the Town of Milton at least 21 days prior to the event with all sections completed.

(The Town requires 48 hours’ notice if you cancel an event)

Applicant and Event Information

Applicant: DBA:

Address:_ _Town/City:

Daytime Contact Numbers: Email Address:

Type of Event:

Facility/Location Requested:

If a one -time event: Date: Hours: from to

(If a re-occurring event, attach a detailed schedule of events)

Attendance: Is the event

Public

Private

Will money be received?*

(Number of persons estimated) (From ticket sales, entrance fee, gift/donation/solicitation, etc.)

If Entertainment or a Performance will be provided, please describe:

*If money is being received, you may also be required to complete an entertainment license application.

NOTE: THE PUBLIC IS NOT COVERED UNDER THE TOWN OF MILTON’S INSURANCE POLICY

If you would like to reserve and/or rent a Municipal Facility, these are your insurance options:

You may provide proof of insurance for your event or activity with a Certificate of Insurance Coverage. The

Certificate must name the Town of Milton as an additional insured and show coverage in the amount of combined

minimum single limit coverage of $300,000 per occurrence and $300,000 in the aggregate. This Certificate shall

remain in force from the date and time of the beginning of the event until the date and time of the end of the

event. Adding the Town of Milton as an additional insured to your homeowners policy may be of no additional

cost to you; OR

You may purchase insurance from Entertainment Brokers International offered through Vermont League of Cities and

Towns (VLCT PACIF) and is not related to PACIF or the Town of Milton in any way. Information is attached;

The Applicant(s) agrees to indemnify and hold the Town of Milton, its officers, agents, and employees harmless from any

loss or liability which may result from claims of injury to persons or property from any cause arising out of or during the

use of the Town’s Facility by the Applicant, the Applicant’s guests, agents, or employees.

You must select one option: As authorized representative of this application, I have chosen option: 1 2 3

If option 1 or 2 is chosen, attach your Certificate of Insurance Coverage with this Application.

Print Name:

Signature:

Date:

Page 1 of 4

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signature

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• Only the authorized representative may cancel the event (48 hours’ notice is required) and no refund or

any portion thereof will be made.

• Only scheduled league games will be reserved and scheduled games take priority over practices. Fields are

reserved on a first come first serve basis.

• It is the responsibility of League officials to inform all teams and coaches of the Town of Milton's Policies.

• Permission to use Town facilities can only be obtained by completing this form. Applications are considered on a

first come first served basis.

• Any services and/or requirements of the Town will be at the expense of the applicant. Town staff will provide an

estimate of costs to the applicant prior to the event and payment will be expected to in advance of the event.

• The applicant agrees to abide by and conduct its event in accordance with all park rules, laws, regulations and

ordinances, including those related to alcohol, smoking and noise. Alcohol is not permitted on Town property.

Applicant shall not allow or engage in any illegal activity.

• Any damage to the Town's property will be the sole liability of the responsible person signing this agreement

and/or their agent/heirs/executors.

• The Town, its officers, agents and employees shall have the right to enter the event to confirm the applicant's

conformance to this application and if a breach is determined, the Town shall have the right to immediately

terminate this application and use of the Town facility prior to the conclusion of the event without refund.

**Please note, if ENTERTAINMENT will be provided at the event and a fee is charged (like ticket sales or cover charge),

the applicant must also apply for an Entertainment License. Final approval of an Entertainment License is dependent on

Selectboard approval.

The applicant will be notified as soon as possible of the action taken with regard to approval or rejection of this application.

As the authorized representative of this application, I fully understand the requirements as noted herein and further

understand that it is my responsibility to read these documents and be cognizant of their content. I fully understand that the

services and/or requirements the Town indicates on page 4 will be at my expense. I agree to the estimated amounts indicated

and understand that I am expected to provide payment in advance of the event. Failure to pay in advance will result in

cancellation of the event. The Town of Milton reserves the right to cancel the event if necessary in the best interest of the Town.

Print Name:

Signature:

Date:

Page 2 of 4

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Liability Hold Harmless Agreement

Inconsideration of the agreement of the Town of Milton to engage my company and

me to perform certain services for the Municipality,___________________________

(company or individual name) and I agree, and for my heirs, executors and

administrators agree to indemnify, defend and hold forever harmless the Town of

Milton its officers, agents and employees from and against any and all claims,

demands, liabilities, actions, judgments, settlements, damages, costs and expenses

- including attorneys fees and disbursements - for injury to or death of any person

including myself, or damage to property arising out of or resulting from any material,

product, equipment, vehicle or service supplied by the company or by me, or the

agents, servants or employees of either, or from any action or failure to act on the

part of myself or the company, or the agents, servants or employees of either, while

performing services for, at the behest of, under contract with or on the of the Town of

Milton.

Printed Name

Signature and Date

Printed Name of Witness

Witness Signature and Date

Page 3 of 4

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THIS PAGE FOR OFFICE USE ONLY

Recreation: Event request reviewed by: Date: Approved: Denied: (see below)

If applicable, the location of the event has been tentatively reserved until this application is approved or denied by the Town Manager.

Comments/Conditions/Fees:

Approved: Denied: (see below)

Date:

Facilities: Event request reviewed by: Date:

Comments/Conditions:

Risk Management: The necessary documents are on file. Signed:

Comments/Conditions:

Police Needed: Crowd Control: Yes No Traffic Control: Yes _No

Signed: Date:

Comments/Conditions/Fees:

Fire needed: Yes _No Signed: Date:

Comments/Conditions:

Rescue needed: Yes No Signed: Date:

Comments/Conditions:

Health/Zoning: Yes No Signed: Date:

Comments/Conditions/Fees:

Town Manager Approval (if required)

Recreational Facility Use Fee $ Other applicable fee(s) $

Entertainment License Fee $ Other applicable fee(s) $

Fee Amount Received $ Verified by: Date:

Approved by: Town Manager Date:

If Selectboard approval sought:

Date Selectboard scheduled to consider:

Date Selectboard took action and action taken:

Page 4 of 4

Please enjoy your experience while using Town fields/facilities and clean the area prior to your departure!

Please Note: Park Road parking limitations will be considered when making a reservation ● Additional services may be required

such as but not limited to: trash removal, port

-o-let

rental, police, fire and/or rescue services. Town Staff will secure these services,

if required, on behalf of the applicant, at the applicant’s expense. A deposit may be required, and deposit/refund is

made at the discretion of Town Staff. If entertainment is provided at an event, an Entertainment Permit

must be obtained in advance from the Milton Selectboard.

Please adhere to the following Park Rules:

Use of Town facilities/fields is at your own risk ● Children are to be supervised at all times ● Speed limit is 15

MPH. Motorized vehicles are restricted to roads/parking areas ● Glass containers prohibited ● Pet owners are

required to pick up after pets ● Alcoholic beverages, smoking, illegal drugs, firearms, weapons and illegal

activity is prohibited. Report any illegal activity or damage of property to the Police Department ●

Rollerblades, skateboards and bikes are prohibited from Tennis Courts ● Fires, camping and/or fireworks

require a permit/permission from the Town ● Playground areas cannot be reserved for any functions ●

Fees only refundable if event cancelled by Town of Milton and unable to reschedule

App

roved Milton Selectboard 10/4/2010

Pavilion

(Tennis Court)

● Milton Outdoor Performance Center

(Park Road)

(Concessions in the Park for Profit: Private vendors must request an agreement with the Town Manager)

Milton Residents: Up to 4 hours: 20 people: $10 ● 21 – 40 people: $25 ● 41 – 75 people: $50 ● 20 – 75 people 4+ hours: $75

Milton Town/School, Milton Church, Milton Non‐Profit functions/sponsored events: No Charge

Non‐Resident, Non‐Resident Non‐Profit, For‐Profit Organization/Business: Up to 4 hours: $100 4+ hours: $175

Horseshoe Pits ● Tennis Courts ● Volleyball Court ● Skating Rink/Basketball Court

Milton Residents, Milton Town/School and Milton Non‐Profit: No Charge

Non‐Residents, For‐Profit/Others:

Basketball/Tennis/Volleyball Courts – Tournaments/Other: $50/court/day Clinics/Lessons: $5/court/hour

Horseshoe Pits: With the exception of Regular Season League Play, the pits may be used by Town residents at no charge.

Other users – contact Town Staff. Please be considerate and cover the pits after use. Horseshoe Tournaments: $50/event

Field Usage Fees

(Note: Milton Youth Leagues’ regular season games –

exempt when Milton teams play)

Field Set Up:

Prep, Line and/or Layout field(s): $25 per task (in addition to fees noted below)

Softball/Baseball: Milton Residents:

Soccer/Football/Lacrosse: Milton Residents:

$30 per field per event Non‐Residents: $60 per field per event

Tournaments/Jamborees/Camps – Refer to fees above (Note: Milton Youth Leagues not exempt)

The Town of Milton Buildings and Grounds Department reserve the right to declare any field or court unplayable

at any time if conditions are unsafe or continued play would damage the facility or field.

● ● ● ● ● ● ● ●

Exclusive use of all Municipal Park fields/facilities for an event; use

of fields/facilities for other than what it is intended;

request to use the Field House, water and/or electricity, will be reviewed with the cost set,

if applicable, by the Recreation Coordinator, with the approval of the Town Manager.

●

Town of Milton Field and Facility Use Fee Schedule ●

43 Bombardier Road, Milton, VT 05468 ● 802-893-4922 ● miltonvt.gov/recreation

Fill Online, Printable, Fillable, Blank Form 140 (Town of Milton, Vermont) Form

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Fillable Form 140 (Town of Milton, Vermont)

Fill Online, Printable, Fillable, Blank Form 140 (Town of Milton, Vermont) Form

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