===== PDF PAGE 13 =====
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CITY OF WEST CHICAGO
PUBLIC AFFAIRS COMMITTEE
AGENDA ITEM SUMMARY
ITEM TITLE:
AGENDA ITEM NUMBER: A.
Healthy West Chicago 5k & Fun Run
Special Event Permit Application
Healthy West Chicago
FILE NUMBER:
COMMITTEE AGENDA DATE: April 27, 2020
COUNCIL AGENDA DATE:
STAFF REVIEW: Tom Dabareiner SIGNATURE es
APPROVED BY CITY ADMINISTRATOR:
Michael Guttman SIGNATURE
ITEM SUMMARY:
Healthy West Chicago is seeking approval for a 5k and Fun Run scheduled for Saturday, August 22,
2020 from 6:30 a.m. — 11:00 a.m. with an estimate of 200 attendees. All proceeds from this event will be
used to support Healthy West Chicago programming and sustainability.
Set-up is scheduled to begin at 6:30 a.m. The 5k race begins at 8:30 a.m. and the 100 meter Fun
Run/Kiddie Dash begins at 9:30 a.m., or immediately after the last 5k participant crosses the finish line.
The event is expected to end at approximately 11:00 a.m.
Healthy West Chicago has requested use of the public walkway along Yale Street as well as National
Street east of Yale Street for the race route. Park District property at Reed Keppler Park and the ARC
Center have also been requested for use.
The Special Event Permit Application, which includes the requests of the City and Park District, has been
reviewed and approved by staff from the Police, Public Works, and Community Development
Departments as well as the Park District and Fire Protection District. The Special Event Permit
Application is attached, which includes the course map. Since some DuPage Trails will be used for the
race, a permit will be required and we are waiting on the confirmation that it is completed.
ACTIONS PROPOSED:
Recommend event for approval as proposed, contingent upon submittal and approval of required
insurance documentation.
COMMITTEE RECOMMENDATION:

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City of West Chicago
SPECIAL EVENT PERMIT APPLICATION
THIS FORM MUST BE COMPLETED IN FULL & SUBMITTED
90 DAYS PRIOR TO THE EVENT
wesi Chicace
PERMIT NO.
Special Event Permit Application
The Special Event Application is due to the City of West Chicago a minimum of ninety (90)
days prior to the event if it requires closure of public streets or use of public parking lots.
The 90-day time period allows sufficient time to evaluate the request and provide a
recommendation to the City Council for its consideration.
Note: Prior to review of the Special Events Permit Application, all applicants must
submit the Intent to Meet Insurance Requirements form (page 2).
Submittal Checklist
Dn
4, Completed and signed Special Event Application
a Intent to Meet Insurance Requirements
a Section 1 — General Information
a Section 2 — Narrative
a Section 3 — Permits
a Section 4 — Site Plan and/or Route Map
a Section 5 — Task List and Due Dates
a Section 6 — Hold Harmless Agreement
2. Completed and signed applications(s) for other permits(s) (See Section 3)
co Carnival Permit Application - $50 per employee
o Fireworks Permit Application -
$125 (Check made payable to the West Chicago Fire Protection District)
a Building Permit Application (temporary tents — see min. requirements) - $50
0 Raffle Registration Application — requires separate application
o Temporary Liquor License Application — requires separate application
co Temporary Food Service Permit (DuPage Co. Health Dept. 630-682-7979)
Je ESHER IOI od Eno HOES IOI SITES III ICI III IO TT TO TO TT TT To TOT TT I TOT TT TOT a A a
FOR OFFICE USE ONLY
Je ISI RINI ISIS IS IOS IIS ISIS IIE IBIS I RICCI TOI IT IOI TIT ATT T IST TI II TATA IA SITIOS ISSA IIT AA IS IIIT SISA II
Received: Fee Paid: $
Receipt # Check #.
Event Acknowledgement Form returned by:
Police Dept. Fire Dist. PW Park Dist.
co Background checks completed by Police Dept. Date
a DuPage Co. Health Department notified Date
a Certificate of Insurance received and approved Date
Page 1 of 8

===== PDF PAGE 15 =====
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*** INTENT TO MEET INSURANCE REQUIREMENTS ***
Must be returned prior to application review by City staff
Prior to the issuance of a Special Event Permit, all organizations must
present a certificate of insurance meeting the criteria listed below:
1. Required limits per IRMA are $1mil per occurrence and general aggregate no less than
$2mil for contractors/vendors.
2. ***PLEASE NOTE: Under the box labeled “Description of
operations/locations/vehicles/exclusions added by endorsement/special provisions”, the
following language must appear:
“The City of West Chicago, its officials, agents, employees, and volunteers is/are named
additionally insured. The additional insured is covered as respect to liability arising out of any
work or activities performed on behalf of (company involved) for (event) (date, times (if
applicable), location) No endorsements or additional forms modify or limit coverage provided
to additional insured, Coverage provided to additional insured is primary as it relates to
(event)”.
3. Vendors shall furnish the additional insured endorsement (consult insurance professional;
examples include but are not limited to forms CG 2010 or CG 2026) to support the certificate
of insurance. The endorsement shall also name “The City of West Chicago, its officials,
agents, employees, and volunteers” as primary and non-contributory.
4, If applicable, vendor shall furnish the City with evidence of Worker's Compensation
coverage with statutory limits.
5. The insurance provider will need to submit the Certificate of Insurance and supporting
endorsement form preferably via email to specialevents@westchicago.org or fax
(630-293-1257) to be considered an original document.
1, Carly Smitherman , representing Healthy West Chicago
(print name of authorized person) (organization)
have contacted the appropriate insurance provider and acknowledge that the above
insurance criteria can be met. | understand that the Special Event Permit Application
will not be reviewed until this document has been signed and returned to the City of
West Chicago.
Smitteman 4/1/2020
(signature) (date)
Healthy West Chicago 5K Fun Run with Kiddie Dash 8/22/2020
(name of event) (date of event)
Page 2 of 8

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Healthy West Chicago Sponsored Special Event
Healthy West Chicago Fun Run with Kiddie Dash
Special Event Proposal
Saturday August 22, 2020
Event Overview:
The Healthy West Chicago Fun Run with Kiddie Dash will be sponsored by Healthy
West Chicago, with the support of Race Time Inc. This event will take place on
Saturday August 22nd, 2020 with the race beginning at 8:30 a.m. This event will attract
participants from West Chicago and surrounding communities. The Fun Run will include
features such as a race t-shirt and awards by gender/age groups.
Race Time Inc. has offered to donate select race. The Healthy West Chicago's Program
Administrator will coordinate the Fun Run with Kiddie Dash activities with Race Time
Inc., Healthy West Chicago Volunteer Committee, and West Chicago Park District.
General Information:
Main Contact
Carly Smitherman
Healthy West Chicago Program Administrator
Phone: (630) 230-6370
Email: carlys@healthywestchicago.org
Proposed Course
USATF course Run to Remember.
Proposed map of racecourse submitted with permit application.
Course length: 3.1 miles.
Registration & Fee Structure
5K Run/Walk Adult (18 and older) $30.00
5K Run/Walk Student (17 and under) $10.00
Kiddie Dash: Free
Resident Discount: West Chicago residents will be offered a $5 discount.
All proceeds from the event will be used to continue with Healthy West Chicago
programing and sustainability.
Page 1 of 2

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Main Event Schedule
6:30 AM Staff & Volunteer Set-Up Begins
7:30 AM Registration Opens
8:00 AM Registration Closes
8:15 AM Group Stretch
8:30 AM 5K Walk/Run starts
9:30 AM 100 Meter Kiddie Dash on park property starts (approximate; after last 5k
participant crosses finish line)
10:00 AMAwards Announced/Distributed
10:20 AM Site Clean Up Begins
11:00 AM Site Clean Up Ends
Race Timing and 5k Course Organizer
Organizer: Race Time Finish Line Management & Timing Company
Website: http:/Awww.racetime. info
Contact: Julie Pearson
Email: racetime21@hotmail.com
Awards Participants Receive
5K Run: Awards will be distributed to one overall male and one overall female winner.
First, second, and third place medals will be distributed a male and female in each of
the following categories/age groups: 10 & under, 11 - 14, 15-19, 20 - 29, 30 - 39, 40 -
49, 50- 59, 60 & over.
Kiddie Dash: Finisher's ribbon
5k Walk/Run Participants Receive
Short sleeved 5k t-shirt
All Event Attendees Receive the Following
Water
Aid/water stations at Start/Finish and near mile markers 1 and 2 along the course
First-aid tent at turnaround on course
Official Chip time
Music and announcer at Start/Finish
Cancelation
Event will only be canceled in extreme weather.
City will be called the morning of the race to be notified.
Website & Registration Structure
Participants will register using Race Time Inc.'s online platform.
Participants can also register by submitting a completed "Healthy West Chicago Fun
Run Registration Form" to Race Time Inc. with cash or check payment.
Electronic signature of liability "Waiver & Release" will be required.
Volunteer sign-up option will also be available.
Page 2 of 2

===== PDF PAGE 18 =====
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===== PDF PAGE 19 =====
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Road Running Technical Council PRCA by
\ ale y USA Track & Field
usa. Measurement Certificate
TRACKE FIELD”
Name of the course Run to Remember" Distance 5 km
Location (state) Illinois (city) West Chicago
Type of course: road race (X] calibration] track [] Configuration: Out and Back
Type of surface: paved 23 % dirt % gravel 77% grass —%_~—track %
Elevation (meters above sea level) Start 234 Finish 234 Highest 240 _Lowest___228
Straight line distance between start & finish Same Point Drop 0 m/km Separation oO %
Measured by (name, address, phone & e-mail) Winston Rasmussen 33441 2nd Street
Warrenville, IL 60555 _ (630)393-4952__ W.Rasmussen@comcast.net
Race contact (name, address, phone & ¢-mail)_Robbi Peterson, West Chicago Police Dept, 325 Spencer ;
West Chicago, IL 60185 (630) - RPeterson@West Chicago.org
Measuring Methods: _ bicycle steel tape [] _ electronic distance meter []
Number of measurements of entire course: 2 __ Date(s) when course measured: April 14, 2015
Race date: April 19, 2015 Course certification effective date: April 15, 2015
Certification code: 1L15011WR
Notice to Race Director: Use this Certification Code
Be It Officially Noted That
Based on examination of data provided by the above named measurer, the course described above and
in the map attached is hereby certified as reasonably accurate in measurement according to the stan-
dards adopted by the Road Running Technical Council. If aay changes are made to the course, this ccr-
tification becomes void, and the course must then be recertified,
Verification of Course — In the event a National Open Record is set on this course, or at the discretion
of USA Track & Field, a verification remeasurement may be required to be performed by a member of
the Road Running Technical Council, Tf such a remeasurement shows the course to be short, then all
pending records will be rejected and the course certification will be cancelled.
This certification expires on December 31 in the year | 2025
AS NATIONALLY CERTIFIED BY:
LSE 4 Date: April 15, 2015
Winston C Rasmussen ~ USATF/RRTC Certifier
3844] 2nd Street, Warrenville, IL 60555 (630)393-4952 | W.Rasmussen@comcast.net

===== PDF PAGE 20 =====
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Run to Remember
5 kilometers
West Chicago, Illinois
USATF Certification # 1L15011WR
Effective April 15, 2015 — Dec 31, 2025 NORTH
Map Not to Scale
START: Mag nail, center of road, 58’ W of edge of gate post on N side of road (See detail)
1 MILE: North edgo of gravel path, 147' W of 2" electrical tower W of RR tracks
Turnaround; Center of path, even with stop sign (21'6" E of center of round storm drain on Industrial Drive
2MILE: South edge of gravel path, 23’6” E of center of culvert
3MILE: West edge of gravel path, 44'6" S of S end of parking fot
Finish: Same as the start
Measured by Winston Rasmussen April 14, 2015 (w.rasmussen@comcast.net)
BLNVd.
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===== PDF PAGE 21 =====
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[ ARC Center
EMCEE-Electrical outlet required for mic and speaker set up.
PP-Porta potty
Skate Park-Parking for volunteers and staff
Request for closure of Wiggly Field from 6AM-11AM due to runner foot traffic along road to Wiggly Field.
Request for Park District to close ARC Center Parking lot entrance briefly for beginning of race when walkers/runners are passing by.
Event organizer will ensure cones/barricades are set up in time for 8:30AM race start and then removed as soon as the last participant passes the
entrance (ETA 8:45-50AM)

===== PDF PAGE 22 =====
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SECTION 1 — GENERAL INFORMATION
Name of Event: Healthy West Chicago 5K Fun Run with Kiddie Dash
Type of Event:
O Parade @ Walk/Run/Bike © Carnivals © Fireworks O Festival
0 Other
Location of Event: Reed-Keppler Park, 129 W. National St, West Chicago
Date(s) of Event; 8/22/2020 Hours of Event: 8:30amto 11:30amest, Attendance: 200
Event Website: http://www. raceroster.com/29234
Purpose of event; community engagement
Name of Sponsoring Organization(s): Healthy West Chicago
Organization's Legal Status (i.e. NFP, Partnership, Corporation): NFP
Contact person from sponsoring organization: Carly Smitherman
Organizer address: 132 Main Street
City/State/Zip: West Chicago, IL 60185 Phone: 630-230-6370
Cell Phone: 630-230-6370 E-mail: catlys@healthywestchicago.org
Emergency contact information (provide mobile numbers for on-site coordinators during event):
1" Contact; Sara Phalen Phone: 815-751-0551
2"5 Contact; Adela Gonzalez Phone: 630-965-0279
Is this an annual event? @ Yes O No If Yes, provide next year’s event date: 8/21/2021
If the event is a recurring event, please state any problems and/or incidents that have occurred in past
years, such as noise or neighborhood parking complaints.
N/A
What, if anything, are you doing to rectify the problem(s)?
N/A
SECTION 2 — NARRATIVE
On a separate sheet, provide a detailed description of the overall event. The narrative will serve as
the special event proposal to City Council.
Page 3 of 8

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SECTION 3 — PERMITS
Will your event include a carnival? o Yes mNo
if yes, you must submit a Carnival Permit Application ninety (90) days prior to the event.
Please visit www.westchicago.org under Forms or contact the City of West Chicago at (630)
293-2200 ext. 135 for an application.
Does your event include the use of a temporary tent in excess of 400 sq. ft. in area with side curtains
or 700 sq. ft. in area without side curtains? o Yes #No
If yes, you must submit a Building Permit Application thirty (30) days prior to the event.
Please visit www.westchicago.org under Forms or contact the City of West Chicago at (630)
293-2200 ext. 137 for an application.
Will your event include a fireworks display? o Yes @No
If yes, you must submit a Fireworks Permit Application thirty (30) days prior to the event.
Please visit www.westchicago.org under Forms or contact the City of West Chicago at (630)
293-2200 ext. 135 for an application.
Are you holding a raffle at your event? oYes aNo
if yes, you must submit a Raffle Registration Application fourteen (14) days prior to the
event. Not all applicants will qualify for a license. Please visit www.westchicago.org under
Forms or contact the City of West Chicago at (630) 293-2200 ext.170 for an application.
Will you be applying for a Temporary Liquor License? «Yes mNo
If yes, you must submit a Temporary Liquor License Application thirty (30) days prior to the
event. To qualify for a Class D license, the applicant must be a local organization or group
providing beer and/or wine at a picnic, carnival or similar function. A Class D license shall be
authorized on a day-to-day basis but not for more than seven (7) consecutive days. Please
contact the City of West Chicago at (630) 293-2200 ext. 170 for an application.
Will you be serving food at your event? o Yes a@No
If yes, you may be required to submit a Temporary Food Service Permit Application thirty
(30) days prior to the event. Please contact the DuPage County Health Department at (630)
682-7979 or visit http:/www.dupagehealth. org/temporary-food-service for additional
information.
Are you requesting services from these departments?
OC Police O Fire District / Paramedics © Public Works
Specify services; NO
Will you be utilizing any of the following services?
C Water O Electric/Generator © Other NO
Page 4 of 8

===== PDF PAGE 24 =====
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SECTION 4— SITE PLAN AND/OR ROUTE MAP
Please attach a separate sheet to illustrate the layout for your event.
If applicable, the following must be included:
Location of garbage receptacles (G) Location and number of barricades (B)
Location of toilets (T) Location of fire lane (FL)
Location of hand washing sinks (HWS) Location of fire extinguishers (FE)
Location of retail vendors (RV) Public entrances and exits (PE)
Location of food vendors (FV) Location of "No Firearms" signage (NF)
Location of first aid (FA) Location of sound stages and amplified sound (S)
Location of residential streets surrounding event
Are you requesting the use of any City-owned property, i.e. City streets, parking lots, or sidewalks?
@ Yes O No _ If yes, please indicate the property that you are requesting to use.
Reed-Keppler Park and associated parking lots as permitted by Park District.
Only Turtle Splash parking lot will be use for participant parking. Rolling closure at Yale St. and National St.
Would you like to request the closing of City streets? fA Yes O No
If yes, please fill in the following information or submit a route map along with this application:
Street From To Dates Times
Park District Wiggly Field and Zone 250 parking lots 8/22/2020 6AM-11AM
Yale St. Use of public walkway along Yale St. 8/22/2020 8:30-8:50AM
National St. National St. east of Yale St. for race route, 8/22/2020 _8:30-8:50AM
Page 5 of 8

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SECTION 5 — PLANNING WORKSHEET AND REQUIRED TASK DUE DATES*
Use this form to determine the date each of these tasks needs to be completed. For tasks that do not apply,
please mark “N/A” in the Due Date column, If the Due Date falls on a weekend or holiday, the Due Date
becomes the next normal business day. However, this does not affect the other Due Dates, as they are only
dependent on the date of the special event.
Note: This section must be completed by event organizer prior to notary signature.
Date of Special Event:
Tasks to be completed Days Due
(All items due to City unless noted) Before Event Due Date
Submit "Intent to Meet Insurance Requirements” Pri . hcowe’
; i ‘ d rior to Prior to application
Document (included with Special Event Permit ; ‘ H
Application, pg.2) application review review
Submit Special Event Permit Application 90 days
Submit Carnival Permit Application 90 days
Submit Fireworks Permit Application 30 days
Submit Temporary Liquor License Application 30 days
Submit Building (Temporary Tent) Permit
a 30 days
Application
Submit Temporary Food Service Permit
Application(s) 30 days
(DuPage County Health Dept. — 630-682-7979)
Submit Original Certificate of Insurance* 21 days*
Submit Raffle Registration Application 14 days
Notify residents/businesses of special event 14 days
Post “No Firearms” signs at all public entrances
(See IL State Police requirements for standardized N/A Day of Event
sign in West Chicago's Special Events Policy)
“If this requirement is not met, the proposed event may be cancelled.
Page 6 of 8

===== PDF PAGE 26 =====
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SECTION 6 — WAIVER AND HOLD HARMLESS AGREEMENT
In consideration of the Healthy West Chicago (name of organization) and its Members,
employees, volunteers or guests, being allow to participate in HWC 5K Fun Run , (the Activity) the
undersigned hereby recognizes, acknowledges and assumes any and all risk pertaining to
Healthy West Chicago (name of organization) participation in the Activity.
To the fullest extent permitted by law, the Healthy West Chicago (name of organization)
hereby agrees to defend, indemnify and hold harmless the City of West Chicago, its officials, agents and
employees, against all injuries, deaths, loss, damages, claims, suits, liabilities, judgments, cost and
expenses (including attorneys fees), which may in anywise accrue against the City of West Chicago, its
officials, agents and employees, arising in consequence of Healthy West Chicago __(name of
organization) participation in the Activity, or which may in anywise result therefore, except that arising out
of the sole legal cause of the City of West Chicago, its agents or employees. The
Healthy West Chicago (name of organization) shall, at its own expense, appear, defend and
pay all charges of attorneys and all costs and other expenses arising therefore or incurred in connections
therewith, and, if any judgment shall be rendered against the City of West Chicago, its officials, agents
and employees, in any such action, the Healthy West Chicago (name of organization) at
its own expense, satisfy and discharge the same.
The invalidity or unenforceability of any of the provisions hereof shall not affect the validity or
enforceability of the remainder of this Agreement.
The undersigned represents it has full authority to execute this Waiver and Hold Harmless Agreement on
behalf of the Healthy West Chicago (name of organization).
Agreed this | day of April , 20.20
Healthy West Chicago
Name of Organization
Carly Smitherman
Print Name of Authorized Person
Omatarmanr
Signatdte of Authorized Person
Program Administrator
Title
Page 7 of &

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The Organization and the authorized signatory below agree to inform the City of West Chicago of any
changes in the application at least thirty (30) days prior to the event. Please note: Final approval of
this event is pending satisfactory completion of Certificate of Insurance requirements.
Signatory agrees to abide by all requirements of the Special Events Policy, including
compliance with the State of Illinois Firearm Concealed Carry Act.
*All applications must be signed and notarized.
Healthy West Chicago Carly Smitherman 4/2 / 2?
(Name of Organization (Print Name of Signatory) (Date)
OFFICIAL SEAL
AMY SUE ANDERSON
NOTARY PUBLIC - STATE OF ILLINOIS
MY COMMISSION EXPIRES:12/10/20 ee Public)
ue! day of hort 20.22,
After submitting all forms, your application will be reviewed by City staff. All departments that will be
involved in providing services or permits for the event will be notified. Please do not assume that all
aspects of the event will be approved. You may be asked to make some changes to your plan
based on the availability of services or scheduling of other events.
Signed and sworn to before me this
The City of West Chicago reserves the right to cancel any event at any time for reasons deemed
necessary by the City Council and/or City Administrator.
Deliver all completed items to:
City of West Chicago
Attn: Community Development — Special Events
475 Main Street
West Chicago, IL 60185
ROTI ROR I TOI SII SIC SI ORCI CI IRCA TOI ROR IIR II I III IR I IIHR TIC OI SIESTA TR ToT TETRIS TORO TOI I TI ROI TT ICTR TOTO TI BOOT FOI IO TO I IRR TI TOR TORT ION Ae
FOR OFFICE USE ONLY
Jet SIERO SI IOI DROI IOI ISO OIG III IOI ITI I TOSI IIIS OT IO JOIST TI TIT IT TA TOT TT ITT IIA TIA TITS AIT AT TOO AT SO SOS SAOSIN AA
Based on the information which has been submitted and contingent upon approval of any necessary inspections
the day of the event, the request for a permit has been:
O Approved Permit No. .
O Denied
Remarks:
Authorized Signature
Title Date
Page 8 of 8