Fillable Special Event Permit Application (City of Worcester)

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Special Event Permit Application (City of Worcester)

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  • 136 check-boxes
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1
Special Event Permit Application
Please fill out all information. Incomplete applications will be returned.
•
To aid you in the completion of your application, refer to the Special Events Planning Guidebook.
Each part of the application has a corresponding section in the guidebook.
•
A Deposit is required towards the Police Department to obtain a Special Events permit (A deposit
of 50% of the total cost or one must obtain a bond for the full amount of the anticipated cost of
the police detail)
•
The City of Worcester requires that the applicant submit proof of occurrence basis liability
insurance with minimum coverage limits in the following amounts:
o Commercial General Liability $1,000,000 per occurrence/$2,000,000 aggregate;
and
If alcohol will be sold or served, Liquor Liability $1,000,000 per occurrence/$2,000,000
aggregate; and Additional coverage may be required.
•
No permit may be requested less than 90 days prior to the requested date of event, unless the
event qualifies as an expressive event of a time sensitive nature (see page 12)
•
Permit must be complete and signed with all approvals 14 days prior to event date
•
After staff review of application, all additional permit fees must be submitted to obtain approval
of application. Fee schedule for all permits can be found on page 31 of the Special Events
Guidebook
SPONSORING ORGANIZATION
Select type of organization:
�
Commercial (for profit)
�
Non-Profit with 501(c)(3) exemption
�
Non-Profit
Please attach to this application a copy of your IRS 501(C)(3) tax exemption letter providing proof and certifying your current tax
exempt, non-profit status. (REQUIRED)
Org
ani
za
tion:
E
ve
nt
C
oo
r
dinato
r
:
A
dd
res
s
:
Cit
y,
Sta
te,
Zip
:
B
usin
e
ss
P
hon
e:
( ) Da
yt
i
me
P
hon
e:
( )
Even
in
g
P
hon
e:
( ) F
A
X
#:
( )
Email
A
dd
re
ss
Con
t
a
ct
Per
son(s)
"
on si
te":
Ce
ll
:
2
(Note: This person must be in attendance for the duration of the event and be immediately available to City
Officials at all times)
Please list any professional event organizer or event service provider hired by your organization that is
authorized to work on your behalf to produce this event.
REQUIRED: Please attach a letter or contract that authorizes this person to work on behalf of the applicant
organization.
Pr
o
fes
sional
E
ven
t
Org
ani
zer
Na
me:
A
dd
res
s
:
Ci
ty,
S
t
a
te,
Zip Cod
e
B
usin
es
s
P
hon
e:
( ) _Da
yt
i
me
P
hon
e:
( _)
Even
in
g
P
hon
e:
( ) F
AX
#
:
( _)
Email
A
dd
re
ss
:
EVENT SUMMMARY
E
ve
nt
T
itl
e
:
E
ven
t
D
ate(s):
Event hours from: am/pm to: _am/pm
(if applicable)
Event
da
y
2:
Event hours from: am/pm to: _am/pm
(if applicable) E
ve
n
t
da
y
3:
Event hours from: am/pm to: _am/pm
Lo
c
a
t
ion(s)
:
S
pec
i
fy
property type:
�
Public Park
�
Street Block
�
Multiple Streets
�
Private
�
O
t
h
er:
N
u
m
b
er
of
P
a
rt
i
c
ipan
t
s
:
N
um
ber
of S
pecta
to
r
s
:
T
otal
Anti
c
ipa
te
d
Attendan
ce
:
The number of attendees at your proposed event will determine what type of Proof of Liability Insurance
you will need. See page 6 in the guidebook.
Type of Event: (Please check any and all that apply)
�
Concert
�
Festival
�
Carnival
�
Block Party
�
Farmers Market/Fair
�
Parades /Procession
�
Fine Arts Exhibits
�
Run/Walk
�
Rental of Public Building or Facility
�
Picnic
�
Circus
�
Other – Please describe
Set-up/Assembly/Construction:
Da
te:
/ /
Start Time: am/pm
3
Breakdown
Da
te:
/ /
Completion Time: am/pm
(Please describe the scope of your setup/assembly work/breakdown (specific details). Use additional pages
if necessary.)
EVENT PLAN- TEMPORARY STRUCTURES
Will your event have any of the following?
Fencing
Tents larger than 10x10
Staging
Signs, banners, decorations
Special Lighting
EVENT PLAN- VENDORS AND CONCESSIONS
Are you requiring admission fees / donations to enter your event?
Yes / if yes, cost of admission: No
What kind of barriers will be used to close off the area?
W
ill
th
ere
b
e ven
din
g? Food
Bever
a
ge
G
oods Se
rv
ic
e
s To
t
al V
en
do
r
s
:
Will food be sold, served, or given away? Yes No
Will items or services be sold at the event? Yes, if YES, please describe: No
PLEASE NOTE: The sale of manufactured/mass-produced goods will require a Hawkers and Peddlers Permit
approved by the Worcester Police Department and the Commonwealth of Massachusetts (508) 799-8606
4
Will the event involve the sale or use of alcoholic beverages? Yes No
Lo
c
a
t
ion
:
Do you have a letter of permission to have alcohol on the premises from the owner of the location where
event will be?
Yes, if yes, please attach the letter to this application No
Do you have Copy of Server Training Certificate for each person who will be serving alcohol?
Yes, if yes, please attach the copy (ies) to this application No
Please describe the security plan to ensure the safe sale and distribution of alcohol at the event:
Please contact the Worcester Fire Department (508) 799-1822 for the following:
Will the event include open flames, cooking/propane, pyrotechnics/fireworks/flame effects, fire
performers or cannon firing? Yes No
I
f
yes,
pl
ea
s
e
d
escr
ib
e:
EVENT PLAN- ENTERTAINMENT AND ACTIVITES
Entertainment:
Are there any musical entertainment features related to your event? Yes No
What type of live Entertainment will be featured at your event?
Dance
Jugglers
DJs
Bands
Other
Please describe:
5
Nu
mber
o
f
Sta
ges
:
N
umber
o
f
Bands:
Sound Amplification: Start Time: am/pm - Finish Time: am/pm
Sound Checks prior to event: Start Time: am/pm - Finish Time: am/pm
Please describe the sound equipment that will be used for your event:
Name of Sound/Production Co
m
pan
y
A
dd
res
s
Ci
ty,
S
t
a
te,
Zip Cod
e
P
ho
ne
#
:
Cell
P
hon
e
fo
r
Da
y
of
Event:
Any Body Art and/or Temporary Tattoos? Yes No
Any Petting Zoos, Exhibition of Animals, Hayrides? Yes No
If yes, you must submit and file a Permit to Exhibit, Raise, or Keep Animals or Birds with the Worcester
Police Department. Please contact WPD at (508) 799-8606.
Please state whether as part of the entertainment any person will be permitted to appear on the premises
or depicted in any motion picture or television screen, in any manner or attire so as to expose to public
view any portion of the pubic area, anus, or genitals, or any stimulation thereof, of whether any female
person will be permitted to appear on the premises in any manner or attire as to expose to the public view
any portion of the breast below the top of the areola, or any simulation thereof. Yes No
Electrical Services:
Will your event require Electrical services/Generators? Yes No
I
f
yes,
pl
ea
s
e
p
r
o
v
id
e
na
me
of
ven
do
r:
EVENT OPERATION- SANITATION AND WASTE MANAGEMENT
Sanitation:
Portable and/or Permanent Toilet Facilities:
Delivery Date: / / Time: am/pm
Pick-up Date: / / Time: am/pm
N
umb
er
of
P
o
rta
bl
e
Toil
et
s
:
N
umb
er
of
ADA
Acce
ssible Toil
et
s
:
Permanent Toilet Facilities: Name of Portable Toilet Vendor: _
If you have a plan for using permanent toilet facilities please list the location of these facilities below:
6
Describe your plan for clean up and removal of waste and garbage during and after the event:
Clean-up Da
te:
/ / Time: am/pm
PLEASE 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. The City does
not provide cleaning or street sweeping services.
EVENT OPERATION- SAFETY AND SECURITY
Medical Services:
The City of Worcester requires a first aid station with medically certified personnel having a minimum of
current First Aid and completes CPR certifications at any event with an attendance of over 5,000 people.
Event planners must provide either a contracted emergency vehicle or equivalent. This station/vehicle
must be centrally located and clearly marked. Please indicate what arrangements you have made for
providing First Aid Staffing and Equipment and provide a copy of your contract with this application.
#
Am
bulan
ce(
s) Ho
w
p
r
o
v
id
e
d?
Co
m
pan
y’
s
P
ubli
c
Ut
ili
t
i
e
s Li
cen
s
e
#
Em
ergency
Med
i
c
al T
ec
hni
c
ian(s) Ho
w
p
r
o
v
id
ed
?
Security:
This area requires approval of the Worcester Police Dept.
Security must be provided by applicant in coordination with the Worcester Police Department. Please
contact the Off-Duty Assignment division at (508) 799-8685. If your event takes place in a public park, the
Parks Department must also approve your plan for security
Have you contacted the Worcester Police Department to handle security arrangements for this event?
Yes No
If yes, please list, Police Detail Contact Name:
B
usin
es
s
P
hon
e
Please describe the approved procedures set forth by the Worcester Police Department for both Crowd
Control and Security:
7
EVENT OPERATION– PARKING AND STREET CLOSINGS
St
r e et C
l
o
s
i
n
g s
This area requires approval of the Traffic Engineering Department and the Police Department.
Will your event use, close or block any of the following?
City Streets City Sidewalks City Parking Lots and/or Street Meters City Rights of Way
List any street(s), sidewalks, parking lots, or rights of way requiring closure as a result of this event.
Street Name Day of Week Date Time of Closing Time of Re-Opening
If re-routing traffic, please work with the Worcester Police Department and attach alternate traffic route to
this application.
Does this event involve a moving route of any kind along streets, sidewalks or highways? Yes No
If YES, attach a detailed site map showing all streets impacted by the event.
Have you contacted the Worcester Police Department for a Parade Permit? Yes No
If YES, attach a copy of your Parade Permit
Parking Plan/ Shuttle Plan/ Mitigation of Impact:
Please provide a detailed description of your PARKING and SHUTTLE plans:
Please describe your plan for Handicapped Parking:
8
Please describe your plans to notify all residents, businesses and churches impacted by the event:
Location(s)/Staging Area(s) on private property:
Please list all event locations on private property.
PLEASE NOTE: Events located on private property in a manner that varies from its current land use,
requires a Special Event Permit.
EVENT OPERATION– ADA COMPLIANCE
This checklist is intended to serve as a planning guide and may not be inclusive of all City, State and
Federal access requirements. You may attach more detailed information if necessary.
Yes No
□
□
Will there be a Clear Path of Travel throughout your event venue?
P
l
ea
s
e
D
escr
ib
e
□ □ Have you developed a Disabled Parking and/or Transportation Plan (including
the use of public transportation or shuttle services for your event?
P
l
ea
s
e
D
escr
ib
e
□
□
Will a minimum of 10% of portable restrooms at your event be accessible?
P
l
ea
s
e
D
e
s
cr
ib
e
□ □
W
ill all food
,
b
everage
s and
ve
ndin
g
are
as b
e
acce
ssible?
P
l
e
as
e
D
e
s
c
rib
e
□
□
Will all signage be provided in highly contrasting colors and placed so pedestrian
flo
w
w
ill no
t
obs
tr
u
ct
i
t
s
v
isibili
ty
?
P
l
ea
s
e
D
escr
ib
e
9
□ □ If telephones are provided, will at least one telephone at each phone bank have
a
v
olu
me
c
on
tro
l and is a h
e
arin
g
aid
c
o
m
p
at
ible?
P
leas
e
D
e
s
c
rib
e
□ □ If an information center is provided at your event will customer services
re
p
re
s
e
n
tat
iv
e
s b
e
av
ailable
t
o assis
t
disabled individuals?
P
leas
e
D
e
s
c
rib
e
IN CASE OF EMERGENCY:
Yes
No
□
□
Do you have an alert/notification plan in the event of an emergency accessible to
all?
P
l
e
as
e
D
escr
ib
e
□ □ Do you have an evacuation plan accounting for those with service animals,
mobilit
y
impair
me
n
t
s
,
v
ision o
r
h
ear
in
g
loss?
P
l
e
as
e
D
escr
ib
e
TRANSPORTATION (28 CFR PART 36.4)
Yes
No
□
□
Do you have an alert/notification plan in the event of an emergency accessible to
all?
P
l
e
as
e
D
escr
ib
e
□ □ Do you have passenger loading zones with access aisles at least 5ft wide and
20
f
t
lon
g,
adjac
e
n
t
and parall
e
l
t
o
t
h
e
ve
hicle pull up sp
ace
?
P
leas
e
D
e
s
c
rib
e
□ □ If Valet parking, have you provided a passenger loading zone on an accessible
r
ou
te
t
o
t
h
e
e
n
tr
an
ce?
P
l
ea
s
e
D
escr
ib
e
SERVICE ANIMALS
Yes No
□ □ Do you have plan to brief your staff or volunteers on Service Animal Etiquette?
P
l
ea
s
e
D
escr
ib
e
10
Yes No
□ □ Do you have plan for designating a relief area for the Service Animals?
P
l
ea
s
e
D
escr
ib
e
MARKETING AND COMMUNITY OUTREACH
How do you plan to publicize this event? Please list all television, radio, print, and web advertising &
sponsorship.
PLEASE NOTE: In order for the City to access event information for marketing purposes you must post event
information on SocialWeb (www.socialweb.net).
Written materials in alternative formats should be made available for people with disabilities. Such
accessible formats include braille, large print, and closed-captioning.
DIAGRAM COMPONENTS
Please attach a diagram showing the overall layout and set-up locations for the following items listed below
Food Concession and/or Food Preparation Area(s).
First Aid Facilities and Ambulance Locations.
Fencing, Barriers and/or Barricades.
Admissions Gate(s)
Generator Locations and/or Source of Electricity.
Canopies or Tent Locations
N
u
m
b
er
of Canopi
es
o
r
T
ent
s
Siz
e
(s) of Canopies o
r
T
e
n
t
s
Booths, Exhibits, Displays or Enclosures.
Platforms, Stages, Grandstands or Related Structures.
Vehicles and/or Trailers.
Portable Toilets
Trash Containers and Dumpsters.
N
u
m
b
er
of T
r
ash Cans
:
Du
m
ps
ter
s
w
/
c
o
ver
s
:
Gas Tanks, i.e. helium, propane, etc.
Generator
Other Related Event Components not covered above.
Please
d
escr
ib
e:
11
Please return application and all attachments
to:
Che Anderson
City of Worcester – Office of the City
(
508)
799-1175/ Fax: (508)
799
-
1208
sp
ec
iale
ve
n
t
s@
w
o
rce
s
terma.g
o
v
12
An “expressive event of a time-sensitive nature” is a spontaneously-planned event in response to a recent
occurrence, including but not limited to rallies, protests or vigils addressing current political, religious or
social issues, when the organizers could not have reasonably anticipated their need for such event in
advance of the permitting timeline established by the City’s Special Events regulations. The City provides
an expedited permitting process to facilitate this type of event.
Date of Application:_______________ Date of Event:________________
APPLICANT INFORMATION:
Applicant Name:___________________________________________________________
Applicant Address:_________________________________________________________
Telephone Number:________________________________ Fax:_____________________
Alternate Telephone (if any):_________________________
Email:___________________________________________
Other Responsible Parties:
Name:___________________________________________________________
Address:_________________________________________________________
Telephone Number:________________________________ Fax:_____________________
Alternate Telephone (if any):_________________________
Email:___________________________________________
ORGANIZATION INFORMATION:
Complete this section if there is an organization or entity sponsoring the Event:
Sponsoring Organization Name:___________________________________________________________
Sponsoring Organization Address:_________________________________________________________
Sponsoring Organization Contact Person:___________________________________________________
Telephone Number:________________________________ Fax:_____________________
Alternate Telephone (if any):_________________________
Email:___________________________________________
EVENT INFORMATION:
Type of Event:
Picket Religious Ceremony Rally Assembly/Public
Demonstration
March Petition/Signatures Parade/Procession Flier Distribution
Other (please explain):__________________________________________
Parade, Procession, March/Walk:
Requested Location: street sidewalk other:___________________________
Assembly Location (address):_______________________________________
Dispersal Location (address):_______________________________________
Route: (please provide a written description of the proposed route, including street names, number of
lanes, direction, etc.) __________________________________________________________________
____________________________________________________________________________________
Stationary Assembly:
Requested Location: street sidewalk park other: _________________
____________________________________________________________________________________
Address/Description: __________________________________________________________________
Event Purpose:________________________________________________________________________
Expressive Events Of A Time Sensitive Nature
13
Da
te,
Ti
me
and Exp
ecte
d Du
r
a
t
ion of
Event:
A
pproxi
m
a
te
Ex
pecte
d
Atte
ndan
ce:
Please indicate any equipment owned by the Applicant or Event Sponsor that are expected to be used:
Is this a spontaneous event which has been planned in response to a specific occurrence?
P
l
ea
s
e
p
r
o
v
id
e
a b
r
i
e
f s
t
a
teme
n
t
ex
plainin
g
w
h
y
us
e
of
t
his fo
r
u
m
is n
eces
sa
ry
fo
r
t
h
e
Eve
n
t:
Will this activity be free and open to the public? YES NO
Will donations be accepted? YES NO
Will there be sound amplification? YES NO
I
f
yes,
pl
ea
s
e
d
escr
ib
e:
The City of Worcester requires that the Event Organizer provide a certificate of insurance evidencing
coverage in the amount of $1,000,000 per occurrence/$2,000,000 aggregate and the applicable
endorsement prior to the Event; said certificate shall list the City of Worcester as additional insured, and
the City Manager, City of Worcester, 455 Main Street, Worcester, MA 01608 shall be listed as Certificate
Holder.
If obtaining the required coverage for your event imposes an undue financial burden or is impracticable
du
e
t
o o
t
h
er
c
i
rc
u
m
s
t
an
ces,
pl
ea
s
e
ex
plain
:
Applicant and Event Sponsor will be liable for any loss, damage or injury to persons or property resulting
from the Event. Applicant and Event Sponsor must obey all existing laws, ordinances and regulations
applicable to the Event, including but not limited to those pertaining to trespass, obstructing the right of
way, noise, disorderly conduct, and regulations concerning emergency medical services at special events.
When your permit is issues, applicant and/or a representative of the sp
onsoring organization shall carry the
permit throughout the event and be prepared to present it at the request of any public officials.
Submission of this application confirms receipt and understanding of the applicable event permitting
requirements of the City of Worcester. By signing below, Applicant and/or Event Sponsor indicate
understanding and agreement with said policies and requirements. Further, Applicant and/or Event
Sponsor hereby certify compliance with all existing laws, ordinances and regulations.
Signature Title/Organization (if applicable)
Print Name Date
Print Form
14
PAYMENT RECORD
(excludes Fire and Police detail)
To
t
al
Perm
i
t
F
ee:
Amo
un
t
$:
C
heck
#
:
Ch
eck
Da
te:
De
posi
t
#
:
Insurance Documentation* Required Date Received Staff Initials
Liability Insurance
ye
s
Alcohol Liability
*The City requires a policy endorsement which indemnifies and holds harmless the City of Worcester. The undersigned
applicant shall be listed as a named insured. The City shall be named as an additional insured, and the City Manager, City of
Worcester, 455 Main Street, Room 306, Worcester, MA 01608 shall be identified as Certificate Holder. The applicant shall
require its insurance company(ies) to notify the Certificate Holder of any reduction or cancellation of the insurance at least
thirty (30) days prior to the effective da
te of such reduction or cancellation. The applicant shall furnish certificates of
insurance of the types and amounts required, in a form satisfactory to the city, prior to the issuance of a Special Event
permit.
The following signatures are required for approval of your event:
Signature Date
Police Department
Parks Department
T
raf
fic & En
g
in
ee
rin
g
Lic
e
ns
e
Commission
De
pa
rtme
nt of
P
ublic
W
o
rk
s
Fire Department
E
merge
n
cy
Se
rv
ic
e
s
15
Cit
y
M
an
ager
A
ugustus
’
Offi
ce
Official Use ONLY: Please fill out this area
Name of Event:
Date Filed:
Date of Event: _ Date Approved:
Event Location:
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Special Event Permit Application (City of Worcester)

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Completed 10 February 2021

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