Loading...
HomeMy WebLinkAboutItem 6 2013 liquor app and COI Minnesota Department of Public Safety Alcohol and Gambling Enforcement Division ' M(D C: 444 Cedar Street, Suite 222,St. Paul, MN 55101 651-201-7500 Fax 651-297-5259 TTY 651-282-6555 APPLICATION AND PERMIT FOR A 1 DAY Alcohol&Gambling Enforcement TO 4 DAY TEMPORARY ON-SALE LIQUOR LICENSE Name of organization Date organized Tax exempt number Lake Elmo Jaycees October 1970 1072528 Address City State Zip Code PO Box 198 ILake Elmo Minnesota 55042 Name of person making application Business phone Home phone Heather Noyes 651-438-5504 612-801-6145 Date(s)of event Type of organization August 8th-11th,2013 ❑ Club ❑X Charitable ❑ Religious ❑ Other non-profit Organization officer's name City State Zip X ! South St.Paul Minnesota 55075 Add New Officer Location where permit will be used. If an outdoor area,describe. Lions Park,Lake Elmo,MN. Concession stand area. If the applicant will contract for intoxicating liquor service give the name and address of the liquor license providing the service. If the applicant will carry liquor liability insurance please provide the carrier's name and amount of coverage. Insurance By Design,LLC. 14041 Burnhaven Drive.Suite 100.Burnsville,MN 55337(certificate of insurance attahced) APPROVAL APPLICATION MUST BE APPROVED BY CITY OR COUNTY BEFORE SUBMITTING TO ALCOHOL AND GAMBLING ENFORCEMENT City/County Date Approved City Fee Amount Permit Date Date Fee Paid Signature City Clerk or County Official Approved Director Alcohol and Gambling Enforcement NOTE:Submit this form to the city or county 30 days prior to event. Forward application signed by city and/or county to the address above. If the application is approved the Alcohol and Gambling Enforcement Division will return this application to be used as the permit for the event. Page 1 of 1 ACOROI DATE(MM/DDNYY`f) C" CERTIFICATE OF LIABILITY INSURANCE 6/13/2013 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 DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Julie Quiring NAME: Insurance By Design, LLC PHONE(A/C No Fxtl- (952)808-7002 FAX No:(952)808-7004 14041 Burnhaven Drive -MAIL qnsurance ADDRESS: g ulie @idesi n.net Suite 100 INSURERS AFFORDING COVERAGE NAIC# Burnsville MN 55337 INSURERA:First Specialty Insurance Corp INSURED INSURER B: Minnesota Jaycees, Inc INSURERC: Affiliated Local Chapters INSURERD: 2101 West Highway 13 INSURERE: Burnsville MN 55337 INSURERF: COVERAGES CERTIFICATE NUMBER:CL1292001089 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDLISUBRITYPE OF INSURANCE INSR WVD POLICY NUMBER POLICY EFF MMIDDY EXP LIMITS LTR GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE To X COMMERCIAL GENERAL LIABILITY PRE M SES(E.occu RENTED $ 50,000 A CLAIMS-MADE � OCCUR IRE200023500 9/22/2012 9/22/2013 MED EXP(Any one person) $ 5,000 X $2,500 Deductible PERSONAL&ADV INJURY $ 1,000,000 X I Excl Athletic Part GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY PRO X LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident 1 L $ UMBRELLA LIAB FOCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY ER Y 1 N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ A Liquor Liability IRE200023500 9/22/2012 9/22/2013 Each Common Cause $1,000,000 Annual Aggregate $1,0 0 0,0 0 0 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Provides evidence of insurance for the Lake Elmo Jaycees as respects the Huff N Puff event to be held 8/8/13 to 8/11/13. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Lake Elmo ACCORDANCE WITH THE POLICY PROVISIONS. 3800 Laverne Ave N Lake Elmo, MN 55042 AUTHORIZED REPRESENTATIVE LuAnn Paulet/LBP ACORD 25(2010105) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025 rgmnn.,i nt Tha ArOPr)namo nnri Innn mra ranicfarcri mmrlrc of Arnpn