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CITY OF WEST CHICAGO
PUBLIC AFFAIRS COMMITTEE
AGENDA ITEM SUMMARY
ITEM TITLE:
AGENDA ITEM NUMBER: 4.0.
CF Cycle for Life
Special Event Permit Application
Cystic Fibrosis Foundation
FILE NUMBER:
COMMITTEE AGENDA DATE: June 3, 2024
COUNCIL AGENDA DATE:
sionature
APPROVED BY CITY ADMINISTRATOR:
Michael Guttman SIGNATURE
STAFF REVIEW: Tom Dabareiner
ITEM SUMMARY:
The Cystic Fibrosis Foundation is seeking approval for their CF Cycle for Life bike ride scheduled for
Saturday, September 28, 2024 from 8:00 a.m. — 2:00 p.m. with an estimate of 75 attendees. They will be
starting at Pollyanna in St Charles with routes utilizing the IL Prairie Path throughout DuPage County.
The estimated time that the riders will be in the West Chicago area is between 11:00 and 1:00pm.
The Special Event Permit Application 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 maps.
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
PERMIT NO.
——— ee
Special Event Permit Application
The Special Event Application must be submitted 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 and/or city personnel. The 90-day time period allows sufficient time to evaluate
the request and provide a recommendation to the City Council for its consideration. For
any late submittals (applications submitted less than 90 days prior to the event), a $50 late
fee must be paid with the application. Further, the applicant runs the risk of their Special
Event request being denied.
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
a 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
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)
a 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
a Raffle Registration Application — requires separate application
a Temporary Liquor License Application — requires separate application
o Temporary Food Service Permit (DuPage Co. Health Dept. 630-682-7979)
ASIII ICICI III IOI IOI ATI STII TTI ITO ITT AI IAS IOS ISI BSI OSI OS IOS OSA SSO OS SI SSO S SOARES ORAS SOSA SOS ISOS SOA SOSA
Received: 4y a ZA _ Fee Paid: $
Receipt # Check #
Event Acknowledgement Form returned by:
Police Dept. Fire Dist. PW Park Dist. CDD
a 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

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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 IML-RMA 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.
- Cystic Fibrosis Foundation
L, Meg Schneider _ representing
(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.
4 [@[24
signature (date)
CF Cycle for Li 9-28-2024
(name of event) (date of event)
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SECTION 1 — GENERAL INFORMATION
Name of Event: Cycle for Life
Type of Event:
O Parade ® Walk/Run/Bike O Carnivals O Fireworks O Festival
O Other 2 bike ride utilizing the Illinois Prairie Path requiring no street closures
Location of Event: llinois Prairie Path-Etgin Branch
Date(s) of Event: 9/28/2024 Hours of Event: 8:00AM to 2:00PM Est. Attendance: 75 Event
Website: Nttps://fightcf.cff. org/site/TR/Cycle/4S_Greater_lllinols_Chicago?fr_id=10128&pg=entry Purpose of
event:A fully supported bike ride benefiting the Cystic Fibrosis Foundation that is starting at Pollyanna
in St. Charles with routes utilizing the IL Prairie Path throughout DuPage Co.
Name of Sponsoring Organization(s): Cystic Fibrosis Foundation
Organization's Legal Status (i.e. NFP, Partnership, Corporation); Nonprofit Organization
Contact person from sponsoring organization: Naomi Ishihara
Organizer address; _200 N. LaSalle St., Suite 2300
City/State/Zip: Chicago, {L 60601 Phone: 312-236-4491
Cell Phone: E-mail: nishihara@cff.org
Emergency contact information (provide mobile numbers for on-site coordinators during event):
1" Contact: Naomi Ishihara Phone:
2"4 Contact: Phone:
Is this an annual event? KX] Yes O 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 or neighborhood parking complaints.
This is our second year riding on the Illinois Prairie Path, however, there have
been no problems or incidents that have occurred.
What, if anything, are you doing to rectify the problem(s)?
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.
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SECTION 3 —- PERMITS
Will your event include a carnival? oYes aNo
If yes, you must submit a Carnival Permit Application ninety (90) days prior to the event.
Please visit www.westchicago.org under Forms 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 for an application.
Will your event include a fireworks display? o Yes mNo
If yes, you must submit a Fireworks Permit Application thirty (30) days prior to the event.
Please visit www.westchicago.org under Forms for an application.
Are you holding a raffle at yourevent? o Yes % No
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 mNo
. 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?
QO Police O Fire District/ Paramedics © Public Works
Specify services: We are requesting no services from any of your departments unless the City of Chicago
requires we use their police department for any needed crossing guards.
Will you be utilizing any of the following services? No
O Water O Electric/Generator O Other
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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 (1 No _sIfyes, please indicate the property that you are requesting to use.
Bike route is situated along the IL Prairie Path, going through West Chicago
Would you like to request the closing of City streets? O Yes & No
If yes, please fill in the following information or submit a route map along with this application:
Street From To Dates Times
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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" : F —
Document (included with Special Event Permit apoli ee aw Page os
Application, pg.2) PP!
| 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
L sign in West Chicago's Special Events Policy)
*If this requirement is not met, the proposed event may be cancelled.
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SECTION 6 — WAIVER AND HOLD HARMLESS AGREEMENT
In consideration of the Cystic Fibrosis Foundation (name of organization) and its Members,
employees, volunteers or guests, being allow to participate in CF Cycle for Life , (the Activity) the
undersigned hereby recognizes, acknowledges and assumes any and all risk pertaining to
Cystic Fibrosis Foundation (name of organization) participation in the Activity.
To the fullest extent permitted by law, the Cystic Fibrosis Foundation (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
Cystic Fibrosis Foundation
officials, agents and employees, arising in consequence of (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
Cystic Fibrosis Foundation (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 CYStic Fibrosis Foundation (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 Cystic Fibrosis Foundation (name of organization).
Agreed this 4G day of AN 4 | , 20 2
Cystic Fibrosis Foundation
Name of Organization
Meg Schneider
ignature thorized Person
Executive Director
Title
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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 Iilinois Firearm Concealed Carry Act.
*All applications must be signed and notarized.
= ¥ , A |
Cystic Fibrosis Foundation f Nec Sh , eros Y Lo Ww
(Name of Organizatie Print Name of Signatory) (Date)
Notary Public - State of i(linols
My Commission Expires May 12, 2026
Signed and sworn to before me this lo day of April 20,244 .
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 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
AREA RAE TERRE RARE RR EEE ER ERENT REE ER ET ROR EERE ER ERE ER EET EEER ERE ERR EEE ERE ERE ERT ERATE ATER ERAN RERERE AETHER ERROR RENE
FOR OFFICE USE ONLY
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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:
© Approved Permit No. .
O Denied
Remarks:
Authorized Signature
Title Date
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