===== PDF PAGE 19 =====
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CITY OF WEST CHICAGO
PUBLIC AFFAIRS COMMITTEE
AGENDA ITEM SUMMARY
ITEM TITLE:
AGENDA ITEM NUMBER: HB.
WGTK Back to School Event
WeGo Together for Kids and District 33 FILE NUMBER:
COMMITTEE AGENDA DATE: July 26, 2021
COUNCIL AGENDA DATE:
SIGNATURE__ >
APPROVED BY CITY ADMINISTRATOR:
Michael Guttman SIGNATURE
STAFF REVIEW: Tom Dabareiner
ITEM SUMMARY:
WeGo Together for Kids and District 33 are seeking approval for its annual Back to School Event
scheduled for August 18, 2021 from 4:30 p.m. — 6:00 p.m.
The event organizer has requested the use of City streets for the event, and the support of Police &
Public Works.
The Special Event Permit Application, which includes the requests of the City, has been reviewed and
approved by staff from the Police, Public Works, and Community Development Departments as well as
the West Chicago Fire Protection District. The Special Event Permit Application is attached, which
includes the proposed road closures.
ACTIONS PROPOSED:
Recommend event for approval. Approval is also contingent upon submittal and approval of required
insurance documentation.
COMMITTEE RECOMMENDATION:

===== PDF PAGE 20 =====
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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
Wit Cluckco,
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
1. Completed and signed Special Event Application
o Intent to Meet Insurance Requirements
0 Section 1 — General Information
a Section 2 — Narrative
a Section 3 — Permits
0 Section 4 - Site Plan and/or Route Map
0 Section 5 — Task List and Due Dates
0 Section 6 — Hold Harmless Agreement
2. Completed and signed applications(s) for other permits(s) (See Section 3)
6 Carnival Permit Application - $50 per employee
a 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
a Temporary Liquor License Application — requires separate application
a Temporary Food Service Permit (DuPage Co. Health Dept. 630-682-7979)
ialahahahehahahahalehedahabthadatalehhelehaieheloielalebsleheheleistsiatehlelsieietetedeisleiaiebioieiieiiuieihisiieiiddd dia oabiinik cee GORE CAGE TCC CET C COT
FOR OFFICE USE ONLY
THIS IAI UII IIR IIIA IE IIIa ATTICA IGS SIO ITE IIS TIE IAA IIA EAT SURES IA tei et
Received: Fee Paid: $
Receipt # Check #.
Event Acknowledgement Form returned by:
Police Dept. Fire Dist. PW Park Dist.
o Background checks completed by Police Dept. Date
a DuPage Co. Health Department notified Date
a Certificate of Insurance received and approved Date E e E 1 W (F
Page 1 of 8
JUL 8 2021
B Yo |

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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 Raver Apo stoi , representing Waste nicago Sh33
(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.
Arse Opostole T-1/20a
(sigthature) date)
WGTK Bask tr Sobol Punt _8leelaoay
(name of event) (date of event)
Page 2 of 8

===== PDF PAGE 22 =====
[Extraction: OCR (rendered-page OCR)]
DATE (MMIDDIYYYY)
—
ACORD® CERTIFICATE OF LIABILITY INSURANCE eon
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 have ADDITIONAL INSURED provisions or 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 Same" Tyler MacKenzie 1
Arthur J. Gallagher Risk Management Services, Inc. SHONE x FAX
2850 Golf Road xt): 630-694-5165 (AIC, No): 630-285-4062
Rolling Meadows IL 60008 ADDRESS: tyler_mackenzie@ajg.com _
INSURER(S) AFFORDING COVERAGE NAIC#
INSURER A; Collective Liability Insurance Cooperative
INSURED oy INSURER B :
West Chicago Elementary School District #33
312 E, Forest Avenue INSURER C :
West Chicago, IL 60185 INSURER D:
INSURER E : _
INSURER F :
COVERAGES CERTIFICATE NUMBER: 1634018569 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 [ADDL|SUBR| POLICY EFF POLICY EXP
LTR. TYPE OF INSURANCE linsD |wyp POLICY NUMBER IMM/DDIYYYY) | (MM/DD/YYYY) LIMITS
A | X | COMMERCIAL GENERAL LIABILITY Y CLICCGL2021 71112021 7412022 EACH OCCURRENCE $1,000,000
DAMAGE TO RENTED
ctams-mave | X | occur PREMISES (Ea occurrence) __| $500,000 _
MED EXP (Any one person) $s Excluded
X | Per district Ag PERSONAL & ADV INJURY __| $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $3,000,000
POLICY 5B Loc PRODUCTS - COMPIOP AGG | SIncluded _
OTHER: s
AUTOMOBILE LIABILITY GOMBINED SINGLELIMIT T's
ANY AUTO BODILY INJURY (Per person) |
OWNED SCHEDULED es
Sure ONLY Soros BODILY INJURY (Per accident)| §
HIRED NON-OWNED PROPERTY DAMAGE 3
AUTOS ONLY AUTOS ONLY Per accident)
s
UMBRELLA LIAB occuR EACH OCCURRENCE s
EXCESS LIAB CLAIMS-MADE AGGREGATE s
DED RETENTIONS $
WORKERS COMPENSATION PER QTH-
AND EMPLOYERS' LIABILITY YIN STATUTE ae Y
ANYPROPRIETORIPARTNER/EXECUTIVE E.L. EACH ACCIDENT $
OFFICER/MEMBEREXCLUDED? L] NIA
(Mandatory in NH) E.L. DISEASE - EA EMPLOYEE| §
if yes, describe under
DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT | §
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required)
*Collective Liability Insurance Cooperative Reinsurer - Great American Insurance Company (NAIC #16691)
Additional Insured status provided herein afforded by CLIC CG2028 0413, CLIC CG2012 0413, CLIC CG2013 0413, CLIC CG2026 0413, CLIC CG2015 0413
and/or CA CLIC 0715 when applicable.
RE: Event: The WEGO Together for Kids 6th Annual Back to School Event | Event Date: August 18th | at Leman Middle School
City of West Chicago is shown as additional insured solely as respects the General Liability coverage evidenced herein regarding the use of facilities by the
Named Insured during the policy period.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
City of West Chicago
475 Main Street
West Chicago, IL 60185
AUTHORIZED REPRESENTATI'
Cp Hhe: BoM tn
© 1988-2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
L
ACORD 25 (2016/03)

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SECTION 1 —- GENERAL INFORMATION
Name of Event: Wi bo Tage th 2 v for kids Lp? [hy Wi ial Ba ay ] D <) theo | Event
Type of Event:
O Parade O Walk/Run/Bike O Carnivals O Fireworks O Festival
WW Other
Location of Event: WL
Date(s) of Event: R18} 4 | Hours of Event: 4: ot, lg Of) Est. Attendance:
Event Website:
Purpose of event:
Name of Sponsoring Organization(s):
Organization's Legal Status (i.e. NFP, Partnership, Corporation):
Contact person from sponsoring organization: \g7_A F 2. Af
Organizer address: 3JA &. “err ust &
, T _ _
City/State/Zip: A Pte Phone:_/y, 3p), AGA-bWOOO
Cell Phone: 630/43) } -ARSD E-mail: fran Kovic hi 2 WowLap 43 Oa
Emergency contact information (provide mobile numbers for on-site coordinators during event):
1 Contact: orate flix kon. Phone:
2" Contact: fo Va, isl i Phone:
Is this an annual event? nt Yes OO No If Yes, provide next year's event date:
If the event is a recurring event, please state any problems and/or incidents that have occurred in past
years, such as noise of neighborhood parking A ed
San amen in Adan when Peta. at
Apo ba at h A
What, if anything, are you doing to rectify the problem(s )?
FRDAV AL oe
at di peal act
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.
oP.
Z
Page 3 of 8

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Al
weago Together for Kids
Connecting our Commurnity...Strengthening our Families
6" Annual Back to School Event
Every year, WeGo Together for Kids hosts a back to school event to kick off the school year and
offer school supplies to District 33 students. In a typical year, this event includes partner tables
sharing resources and activities and food. However, in response to COVID-19, this year’s event
will use a drive-thru model at Leman Middle School to mitigate gatherings of groups. Each car
will share how many students they are picking up for, and volunteers will load the trunk of the
car with the appropriate number of backpacks. Families will be allowed to pick up for other
students that are unable to attend the event itself. Our goal is to support 600 students with
school supplies, however this is based on donation intake. In 2020, we provided school supplies
to 500 District 33 students.

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oliet St
Batts
‘abeth’ Stuns
Start of Line
Traffic Flow Pattern
Traffic Control Device

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SECTION 3 —- PERMITS
Will your event include a carnival? 0 Yes dXNo
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 IXNo
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. 131 for an application.
Will your event include a fireworks display? 0 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? o Yes }xNo
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? o Yes No
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 yfNo
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?
Hf Police 0 Fire District / Paramedics ( Public Works
Specify services: i ft)
Will you be utilizing any of the following services?
O Water OC Electric/Generator © Other
Page 4 of 8

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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 ONo If yes, please indicate the property that you are requesting to use.
7 |
Would you like to request the closing of City streets? AX Yes ONo
If yes, please fill in the following information or submit a route map along with this application:
Street From To Dates Times
8/18) 4) Parl
Alisla\ 1A- lp: 30
ide Lk
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: & | 1% | 2p 2)
Tasks to be completed Days Due
(All items due to City unless noted) Before Event Due Date
Submit “Intent to Meet Insurance Requirements” Pri : +t:
: f , , rior to Prior to application
Document (included with Special Event Permit application review review
Application, pg.2) .
Submit Special Event Permit Application 90 days SI 3{2)
Submit Carnival Permit Application 90 days mn OK
Submit Fireworks Permit Application 30 days nr] Ge
Submit Temporary Liquor License Application 30 days wn) f—-
Submit Building (Temporary Tent) Permit '
. 30 days
Application —
Submit Temporary Food Service Permit
Application(s) 30 days J On
(DuPage County Health Dept. — 630-682-7979)
Submit Original Certificate of Insurance* 21 days* WA x] 2)
Submit Raffle Registration Application 14 days un) RH
Notify residents/businesses of special event 14 days g / i] a )
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

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SECTION 6 —- WAIVER AND HOLD HARMLESS AGREEMENT
. D CATAL 43
In consideration of the i 2 (name of y bp and its Members,
employees, volunteers or guests, being allow to participate in |, , (the Activity) the
undersigned hereby recognizes, acknowledges and assumes any and all risk pertaining to
’ —_ (name of organization) participation in the Activity.
To the fullest extent permitted by law, the yy) Ad KAA ad a 33 (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 _Distracd 33 (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
Distrrad 33 (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 A f 23 (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 Dd LAL a 33 (name of organization).
Agreed this 7 __dayof “paley, 2028}
+ ; . . 4 * )
i) ptt CAL Aehoop deatice
Name of Organizatior
Page 7 of 8

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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.
West Chips o Sh43 Koren Apostole t[1[202.1
(Name of Organizatio (Print Namé of Signatory) (Date)
(Authorized Sfgnatory) 1 |
of
“(Notary P
Signed and sworn to before me this 7 day of july , 20 2| .
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.
The City of West Chicago reserves the right to cancel any event at any time for reasons deemed
necessary by the City Councg and/or City Administrator.
OFFICIAL SEAL
ALYSON ROBBINS
NOTARY PUBLIC, STATE OF ILLINOIS
MY COMMISSION EXPIRES 05/29/2024 8
Deliver all completed items to:
City of West Chicago
n: Community Development — Special Events
475 Main Street
West Chicago, IL 60185
enn ern Cent eee cent Seng eeeeteeee Lec eeee eter ccc eee tented eee serew ett tttennt ttt vedtettttaeett eter reel teeennnnent
FOR OFFICE USE ONLY
EIS ITO TIO III III II IIT TEC TOTO TIAA TIT TII ACT I TTA IIIA TACT ARI TTA IATA ITI IIIT IIA TT IAS ASIA SA A
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:
OA ved Permit No.
Ppro ‘ml O Denied
Remarks:
Authorized Signature
Title Date
Page 8 of 8