Fillable Special Event Permit Application $100 Permit Fee (City of Cottage Grove)

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Special Event Permit Application $100 Permit Fee (City of Cottage Grove)

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The Special Event Permit Application $100 Permit Fee (City of Cottage Grove) form is 4 pages long and contains:

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  • 4 check-boxes
  • 46 other fields

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BROWSE CITY OF COTTAGE GROVE (MN) FORMS

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CITY OF COTTAGE GROVE
12800 Ravine Parkway
Cottage Grove, Minnesota 55016
www.cottage-grove.org 651-458-2800 Fax 651-458-2897 Equal Opportunity Employer
Special Event Permit Application
$100 Permit Fee
Re
turn To: City of Cottage Grove
ATTN: Business Licensing
12800 Ravine Parkway South
Cottage Grove, MN 55016
Th
is application must be filed with the City at least sixty (60) days in advance of the event. The City will
review the application to determine whether the event is exempt or will have to go through the
permitting process outlined in the City Code. If the event is exempt the permit fee will be refunded.
Attach additional sheets, maps, etc. if necessary. For runs, walks, races or parades a separate addendum
must be included with the special event application.
1. Ty
pe and description of the special event and a list of all activities to take place at the special event.
2.
Name of the sponsoring entity, contact person, address, email, and phone number.
3. Nam
e of property owner, if different from applicant.
4. Pr
oposed date(s) of the special event, together with the beginning and ending times for each date.
5. Pr
oposed location of the special event, including a site plan or diagram of the proposed area to be
used showing the location of any barricades, perimeter/security fencing, fire extinguishers, safety or
first aid stations, entertainment, stages, restrooms or portable toilets, parking areas, ingress and egress
routes, signs, special lighting, trash containers, and any other items related to the special event.
City of Cottage Grove
Special Event Permit Application
Page 2
6. A sign package including size, quantity, and location, and any large inflatable balloons, statues, or
structures.
7. Maximum estimated number of persons expected to attend at any one time and the estimated time
and date at which that will occur.
8. Number of event staff that will be provided for the event. Applicant must provide the contact
information, including cellphone number and e-mail address for the on site event staff coordinator,
manager or supervisor.
9. Public health plans, including supplying water to the site, solid waste collection and the number of
toilet facilities that will be available.
10. Fire prevention, emergency medical service plans, and severe weather plans.
11. Any security plans.
12. The admission fee, donation, or other consideration to be charged or requested for admission to the
special event.
13. Whether food or alcohol will be served or sold at the event.
City of Cottage Grove
Special Event Permit Application
Page 3
14. Whether camping or temporary overnight lodging will be included.
15. Whether any sound amplification or public address system will be used or if there will be any live
performances of any music or musical instruments.
16
. The name, address and contact information of any entity providing entertainment.
17
. A detailed description of all public rights of way and private streets for which the applicant requests
the city to restrict or alter normal parking, vehicular traffic or pedestrian traffic patterns, the nature of
such restrictions or alterations, and the basis.
18
. A detailed description of any shuttle service, including off site parking locations, shuttle routes, types
of vehicles that will be used for shuttling passengers, hours of operation and frequency of shuttle
service.
Minnesota Tax ID Number: Federal Employer Identification Number:
The MN Department of Revenue has requested that we provide MN Tax ID
and Federal Employer Identification Numbers to
them per Minnesota Statute 270C.72. Please enter your numbers above. If you are an individual applicant without a MN Tax ID
Number or Federal Employer Identification Number, please enter your Social Security Number or Individual Taxpayer
Identification Number here:
I affirm that I am authorized to execute this application on behalf of the applicant and that the statements
contained therein are true and correct to the best of my knowledge. If the special event requires special services
provided by the City of Cottage Grove, the applicant agrees to indemnify, defend and hold the City of Cottage
Grove, its officials, employees, and agents harmless from any claim that arises in whole or in part out of the special
event, except any claims arising solely out of the negligent acts or omissions of the City of Cottage Grove, its
officials, employees and agents. The applicant agrees to pay all fees and meet all City Code requirements.
Signature: ________________________ Title: ____________________ Date: _______________
I affirm that I am the property owner or authorized to execute this application on behalf of the property owner
and that the applicant has been given permission to conduct the Special Event at this location.
Signature: ________________________ Title: ____________________ Date: _______________
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Minnesota Department of Labor and Industry
Construction Codes and Licensing Division
Licensing and Certification Services
443 Lafayette Road North
St. Paul, MN 55155
Mailing Address:
PO Box 64217
St. Paul, MN 55164-0217
E-mail: dli.license@state.mn.us
Web Site: www.dli.mn.gov/ccld.asp
Directions: http://www.dli.mn.gov/Direct.asp
Phone: (651) 284-5034
Certificate of Compliance
Minnesota Workers’ Compensation Law
THIS FORM MUST BE COMPLETED AND SIGNED
BY ALL BUSINESS TYPES
PRINT IN INK or TYPE.
Minnesota Statutes, Section 176.182 requires every state and local licensing agency to withhold the issuance or renewal of a
license or permit to operate a business in Minnesota until the applicant presents acceptable evidence of compliance with the
workers' compensation insurance coverage requirement of Minnesota Statutes, Chapter 176. If the required information is not
provided or is falsely stated, it shall result in a $2,000 penalty assessed against the applicant by the commissioner of the
Department of Labor a
nd Indu
stry.
A valid workers’ compensation policy must be kept in effect at all times by employers as required by law.
CONTRACTOR’S LICENSE or REGISTRATION NO (if applicable) BUSINESS TELEPHONE NO. FAX TELEPHONE NO.
BUSINESS NAME (Use the person(s) name if business structure is sole proprietor or partnership (i.e., John Doe, or John Doe and Jane Doe), otherwise it is
the legal name of the business entity.)
DBA NAME
(Doing business as name / assumed name – if applicable
)
BUSINESS ADDRESS (must be physical street address, no PO boxes)
CITY
STATE
ZIP
COUNTY
YOUR LICENSE OR REGISTRATION WILL NOT BE ISSUED WITHOUT THE FOLLOWING
INFORMATION. You must complete number 1 or 2 below.
NUMBER 1 – Workers’ compensation insurance policy information
INSURANCE COMPANY NAME (not the insurance agent)
NAIC Number
POLICY NO.
EFFECTIVE DATE
EXPIRATION DATE
NUMBER 2 – Reason for exemption from workers’ compensation insurance
If you have questions regarding the need to obtain workers’ compensation coverage, including exemptions, contact
651.284.5032:
I have no employees. (See Minn. Stat. § 176.011, subd. 9 for the definition of an employee)
I am self-insured for workers’ compensation (include a copy of authorization to self-insure from the Minnesota Department
of Commerce).
I have employees but they are not covered by the workers’ compensation law. (See Minn. Stat. § 176.041 for a list of
excluded employees) Explain why your employees are not covered:
Other:
I certify that the information provided on this form is accurate and complete.
APPLICANT SIGNATURE (mandatory) TITLE DATE
NOTE: You must notify us if there is any change to your Workers’ Compensation Insurance Information or Employee Status Change by resubmitting this form.
This material can be made available in different forms, such as large print, Braille or on a tape. To request, call 1-800-342-5354 (DIAL-DLI) Voice or TDD (651)
297-4198.
CC0515 Work Comp Compliance (12/12)
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Special Event Permit Application $100 Permit Fee (City of Cottage Grove)

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Completed 12 February 2021

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