Public Safety & Welfare Committee
Regular MeetingVerona, WI · August 26, 2019
Minutes
CITY OF VERONA
PUBLIC SAFETY AND WELFARE COMMITTEE
AUGUST 26, 2019
VERONA CITY HALL
MINUTES
1. Call to order: Heather Reekie called the meeting to order at 6:00 p.m.
2. Roll Call: Heather Reekie and Katie Kohl were present. Also present: Police Chief Bernie
Coughlin, Sergeant Jesse Christensen, and City Clerk Ellen Clark.
3. Approval of Minutes: Motion by Kohl, seconded by Reekie, to approve the minutes from
the August 12, 2019 Public Safety and Welfare Committee meeting. Motion carried 2-0.
4. Public Comment: There was no public comment.
6:02 p.m. - Evan Touchett is now present.
5. Discussion and Possible Action Re: A Special Event Permit application from Simeon Alder
for the Madison 56ers Soccer Club Fall Invitational on Friday, September 6, 2019 - Sunday,
September 8, 2019 from 7 a.m. – 10 p.m. The Madison 56ers Soccer Club will be holding its
31st annual Fall Invitational at Reddan Soccer Park. Tents for merchandise sales and beer, as
well as four food carts, will be on the grounds. One police officer is scheduled to be
stationed on Cross Country Road from 9:30 a.m. – 3:30 p.m. Motion by Reekie, seconded by
Kohl, to recommend to the Common Council to approve a Special Event Permit for the
Madison 56ers Soccer Club Fall Invitational on Friday, September 6, 2019 - Sunday,
September 8, 2019 from 7 a.m. – 10 p.m. Motion carried 3-0.
6. Discussion and Possible Action Re: An Application for a Temporary Class “B” Beer License
from the Madison 56ers Soccer Club for the Fall Invitational on Saturday, September 6, 2019
- Sunday, September 8, 2019 at Reddan Soccer Park, 6874 Cross Country Road, from
4 p.m. – 9 p.m., Simeon Alder, Agent. The club will be getting the beer from the Grumpy
Troll Brewery, which has a wholesaler’s license. The beer tent area will be fenced, with one
in/out point. IDs will be checked by 56ers Club volunteers, and an officer is scheduled to be
on site from 4:00 p.m. – 9:00 p.m.
Touchett asked if there is any measurement of how often, and to what degree, officers have
had to step in at local events because of an alcohol related incident.
Christensen replied if there is reason to believe that the Police Department should have
more staff on hand, or for a longer period of time, they will make sure that happens. They
try to gauge the peak event times, and have more personnel available at that time. The
department counts on the organizations to police themselves, as well.
Coughlin stated it’s much easier today than it was several years ago. There doesn’t seem to
be as much drinking as there used to be. To date, there probably has not been a significant
incident at an event.
Motion by Reekie, seconded by Kohl, to recommend to the Common Council to approve a
Temporary Class “B” Beer License from Madison 56ers Soccer Club for the Fall Invitational
on Saturday, September 7, 2019 only, at Reddan Soccer Park, 6874 Cross Country Road,
from 4 p.m. – 9 p.m., Simeon Alder, Agent, contingent upon completion of a background
check of Club officers by the police department. Motion carried 3-0.
7. Discussion and Possible Action Re: A Special Event Permit application from Sandy Wolf for
the Opportunity 34 Foundation’s Ride for Opportunity on Saturday, September 14, 2019
from 7 a.m. – 5 p.m. This is a charity bike ride for the Opportunity 34 Foundation. The ride
will begin and end at Community Park. Foundation volunteers will be stationed throughout
the course, which will be marked with taped arrows. No police assistance is required for this
event. Motion by Reekie, seconded by Touchett, to recommend to the Common Council to
approve a Special Event Permit for the Opportunity 34 Foundation’s Ride for Opportunity
on Saturday, September 14, 2019 from 7 a.m. – 5 p.m. Motion carried 3-0.
8. Discussion and Possible Action Re: An Application for a Temporary Class “B” Beer License
from the Opportunity 34 Foundation for the Ride for Opportunity on Saturday,
September 14, 2019 at Community Park, 531 E. Verona Avenue, from 10 a.m. – 3 p.m.,
Sandy Wolf, Agent. The Foundation will be serving beer to event participants at the end of
the route at Community Park. The pavilion will be fenced, and alcohol service and
consumption will be restricted to that area. One officer will be scheduled from
12 p.m. – 3 p.m. Motion by Reekie, seconded by Kohl, to recommend to the Common
Council to approve a Temporary Class “B” Beer License from the Opportunity 34 Foundation
for the Ride for Opportunity on Saturday, September 14, 2019 at Community Park, 531 E.
Verona Avenue, from 10 a.m. – 3 p.m., Sandy Wolf, Agent. Motion carried 3-0.
9. Discussion and Possible Action Re: A Special Event Permit application from Lyndsay Andrea,
Sugar Creek PTO, for the Sugar Creek Fun Run on Saturday, September 28, 2019 from
6 a.m. – 11 a.m. This is the fifth year for this fundraising event for the Sugar Creek
Elementary School PTO. The course begins and ends at Sugar Creek Elementary School. Two
police department staff will be on hand for traffic control, which will be billed to the PTO.
The race starts at 9:00 a.m. An updated route was submitted due to the construction taking
place on West End Circle. This route is safer than the old route. Motion by Reekie, seconded
by Kohl, to approve a Special Event Permit for the Sugar Creek Fun Run on Saturday,
September 28, 2019 from 6 a.m. – 11 a.m., contingent upon the City receiving proof of
approval from the DNR for use of the Military Ridge Bike Trail. Motion carried 3-0.
10. Discussion and Possible Action Re: An application for a Special Event Permit from Emily
Peterson for the Arthritis Foundation of Wisconsin’s Jingle Bell Run on Saturday,
December 14, 2019, from 7:30 a.m. – 1:30 p.m. The event has two routes: a 5K run and a 1-
mile walk. Event coordinators will be on site from 6 a.m. – 2 p.m. The race starts at 10:00
a.m. Three officers will be assigned to the event. No Parking signs will be posted, and a
resident notification form will be mailed to residents along the route approximately 10 days
in advance of the event. Motion by Reekie, seconded by Kohl, to approve a Special Event
Permit for the Arthritis Foundation of Wisconsin’s Jingle Bell Run on Saturday, December
14, 2019, from 7:30 a.m. – 1:30 p.m. Motion carried 3-0.
1. Adjournment: Motion by Reekie, seconded by Touchett, to adjourn at 6:31 p.m. Motion
carried 3-0.
Ellen Clark, City Clerk
Agenda
City Of Verona
PUBLIC SAFETY AND WELFARE COMMITTEE
MONDAY, AUGUST 26, 2019 AT 6:00 P.M.
COUNCIL CHAMBERS
VERONA CITY CENTER
111 LINCOLN STREET, VERONA, WI 53593
AGENDA
1. Call to order
2. Roll Call
3. Approval of Minutes from the August 12, 2019 Public Safety and Welfare Committee meeting
4. Public Comment
5. Discussion and Possible Action Re: A Special Event Permit application from Simeon Alder for the
Madison 56ers Soccer Club Fall Invitational on Friday, September 6, 2019 - Sunday, September 8,
2019 from 7 a.m. – 10 p.m.
6. Discussion and Possible Action Re: An Application for a Temporary Class “B” Beer License from
Madison 56ers Soccer Club for the Fall Invitational on Friday, September 6, 2019 - Sunday,
September 8, 2019 from 4:00 p.m. – 9:00 p.m. at Reddan Soccer Park, 6874 Cross Country Road,
Simeon Alder, Agent
7. Discussion and Possible Action Re: A Special Event Permit application from Sandy Wolf for the
Opportunity 34 Foundation’s Ride for Opportunity on Saturday, September 14, 2019 from
7 a.m. – 5 p.m.
8. Discussion and Possible Action Re: An Application for a Temporary Class “B” Beer License from
the Opportunity 34 Foundation for the Ride for Opportunity on Saturday, September 14, 2019
from 10:00 a.m. – 3:00 p.m. at Community Park, 531 E. Verona Avenue, Sandy Wolf, Agent
9. Discussion and Possible Action Re: A Special Event Permit application from Lyndsay Andrea,
Sugar Creek PTO, for the Sugar Creek Fun Run on Saturday, September 28, 2019 from
6 a.m. – 11 a.m.
10. Discussion and Possible Action Re: An application for a Special Event Permit from Emily
Peterson for the Arthritis Foundation of Wisconsin’s Jingle Bell Run on Saturday, December 14,
2019, from 7:30 a.m. – 1:30 p.m.
11. Adjournment
Heather Reekie, Chairperson
POSTED: Verona City Hall
Verona Public Library
Miller & Sons Market
City Web Page at: www.ci.verona.wi.us
IF YOU NEED AN INTERPRETER, MATERIALS IN ALTERNATIVE FORMATS OR OTHER ACCOMODATION TO ACCESS
THE MEETING, PLEASE CONTACT THE CITY CLERK AT 608-845-6495 AT LEAST 48 HOURS PRECEDING THE MEETING.
EVERY REASONABLE EFFORT WILL BE MADE TO ACCOMMODATE YOUR REQUEST.
PUBLIC SAFETY & WELFARE COMMITTEE - 2019-08-26
1. Discussion and Possible Action Re: A Special Event Permit application from Simeon
Alder for the Madison 56ers Soccer Club Fall Invitational on Friday, September 6,
2019 - Sunday, September 8, 2019 from 7 a.m. – 10 p.m.
The Madison 56ers Soccer Club will hold its 31st annual Fall Invitational at Reddan
Soccer Park in Verona, Wisconsin. There will be two to three 10x10 tents for
merchandise sales and a beer tent. Four food carts will be on the grounds, as well.
One police officer will be stationed on Cross Country from 9:30am –3:30pm, which
will be billed to the 56er’s, and the last game is scheduled for 7:45 p.m. on Saturday.
Motion: To recommend to the Common Council to approve the Madison 56ers Soccer
Club Fall Invitational on Friday, September 6, 2019 - Sunday, September 8, 2019 from
7 a.m. – 10 p.m..
2. Discussion and Possible Action Re: An Application for a Temporary Class “B” Beer
License from Madison 56ers Soccer Club for the Fall Invitational on Friday,
September 6, 2019 - Sunday, September 8, 2019 at Reddan Soccer Park, 6874 Cross
Country Road, Simeon Alder, Agent
They will be getting the beer from Grumpy Troll who has a wholesaler’s license, and
will be selling the beer to the 56'ers and serving the alcohol. Service will be in plastic
cups, the area will be fenced with a single layer, one in/out point, ID’s checked by
56ers club volunteers, and an officer will be on site from 4:00 p.m. – 9:00 p.m.,
which the 56ers will be billed for.
Motion: To recommend to the Common Council to approve the Temporary Class “B”
Beer License for Madison 56ers Soccer Club Fall Invitational on Friday, September 6,
2019 - Sunday, September 8, 2019 from 4 p.m. – 9 p.m.
3. Discussion and Possible Action Re: A Special Event Permit application from Sandy
Wolf for the Opportunity 34 Foundation’s Ride for Opportunity on Saturday,
September 14, 2019 from 7 a.m. – 5 p.m.
The charity bike ride is at Verona’s Community Park. They do not require any police
assistance. Participants will follow the rules of the road. Staggered start time at
9:00 a.m. from Ice Arena to Enterprise Dr. They will have volunteers wear bright
color or vests at Enterprise Dr and throughout the course. DJ with speakers will be
at Community Park. Route will have taped arrows.
Motion: To recommend to the Common Council to approve the Opportunity 34
Foundation’s Ride for Opportunity on Saturday, September 14, 2019 from
7 a.m. – 5 p.m.
4. Discussion and Possible Action Re: An Application for a Temporary Class “B” Beer
License from the Opportunity 34 Foundation for the Ride for Opportunity on
Saturday, September 14, 2019 from 10:00 a.m. – 3:00 p.m. at Community Park, 531
E. Verona Avenue, Sandy Wolf, Agent
The event applicants would like to serve/give away beer at the conclusion of the
bike ride. It is recommended that the pavilion at Festival Park be fenced and that
alcohol service and consumption is restricted to this area. It is recommended that
one officer be present at the time the ride is scheduled to conclude, 12:00 p.m., and
remain present until at least 3:00 p.m.
Motion: To recommend to the Common Council to approve the Temporary Class “B”
Beer License for Opportunity 34 Foundation for the Ride for Opportunity on Saturday,
September 14, 2019 from 10 a.m. – 3 p.m.
5. Discussion and Possible Action Re: A Special Event Permit Application from
Lyndsay Andrea, Sugar Creek PTO, for the Sugar Creek Fun Run on Saturday,
September 28, 2019 from 6 a.m. – 11 a.m.
This is the fourth year for this fundraising event for the Sugar Creek Elementary
School PTO. The course begins and ends at Sugar Creek Elementary School. Two
police department staff will be on hand for traffic control which will be billed to the
PTO. Race starts at 9:00 a.m. A separate route was submitted later due to the
construction taking place on West End Cir.
Motion: To approve a special event permit for the Sugar Creek Fun Run on Saturday,
September 28, 2019 from 6 a.m. – 11 p.m. contingent upon the City receiving proof
of approval from the DNR for use of the Military Ridge Bike Trail
6. Discussion and Possible Action Re: An application for a Special Event Permit from
Emily Peterson for the Arthritis Foundation of Wisconsin’s Jingle Bell Run on
Saturday, December 14, 2019, from 7:30 a.m. – 1:30 p.m.
The Jingle Bell Run is a fundraiser for the Arthritis Foundation. This is the sixth year
for the event in Verona. The event has two routes: a 5K run and a 1-mile walk. Event
coordinators will be on site from 6 a.m. – 2 p.m. Race starts at 10:00 a.m. Three
officers will be assigned to the event. No Parking signs will be posted, and a resident
notification form will be mailed to residents along the route approximately 10 days
in advance of the event.
Motion: To approve a special event permit for the Arthritis Foundation of Wisconsin’s
Jingle Bell Run on Saturday, December 14, 2019, from 7:30 a.m. – 1:30 p.m.
CITY OF VERONA
PUBLIC SAFETY AND WELFARE COMMITTEE
AUGUST 12, 2019
VERONA CITY HALL
MINUTES
1. Call to order: Heather Reekie called the meeting to order at 6:00 p.m.
2. Roll Call: Heather Reekie, Katie Kohl and Evan Touchett were present. Also present: Police
Sergeant Jesse Christensen, and City Clerk Ellen Clark.
3. Approval of Minutes: Motion by Touchett, seconded by Kohl, to approve the minutes from
the July 8, 2019 Public Safety and Welfare Committee meeting. Motion carried 3-0.
4. Public Comment: There was no public comment.
5. Discussion and Possible Action Re: A Special Event Permit application from Ryan Richards
for the World Triathlon Corporation’s Ironman Triathlon on Sunday, September 8, 2019
from 7:30 a.m. – 4:30 p.m.
Christensen stated this is a solid event every year. This is the 18th year for the event. The
Ironman event brings several thousand participants and spectators to the City. All police
officers are assigned to this event to assist with traffic and road crossings. New construction
on CTH M between Whalen Road and Locust Street was a topic of concern regarding
bringing the bikes off of Whalen, up Main Street, and then onto Locust Street. Christensen
and Richards walked that area, and developed a route that they believe is the safest for all
involved. It will require the bikers to cross South Main Street diagonally from north to
south, then follow South Main Street on the south side to Locust Drive. There will be a hard
shut down on Locust Street to Bruce Street.
Touchett asked if there will be advance communication to the participants to let them know
that there are areas in this section of the route that may be harder to navigate.
Christensen replied a meeting will be held the evening before the event to communicate
any course changes for the year. Maps of the course will be available for participants, as
well. Costs for police department presence will be reimbursed by the applicant.
Motion by Touchett, seconded by Kohl, to approve a Special Event Permit application from
Ryan Richards for the World Triathlon Corporation’s Ironman Triathlon on Sunday,
September 8, 2019 from 7:30 a.m. – 4:30 p.m. Motion carried 3-0.
6. Discussion and Possible Action Re: A Special Event Permit application from Rita Mortenson,
Verona Area High School (VAHS), for the VAHS Homecoming Parade on Friday, October 4,
2019 from 4:00 p.m. – 5:15 p.m. The route and time for the parade have not changed from
last year. The parade begins at the K-Wing parking lot of the high school, travels south on
CTH M, west on Verona Avenue, and north on Westlawn Avenue back to the high school
parking lot.
Motion by Kohl, seconded by Touchett, to approve a Special Event Permit application from
Rita Mortenson, Verona Area High School (VAHS), for the VAHS Homecoming Parade on
Friday, October 4, 2018 from 4:00 p.m. – 5:15 p.m. Motion carried 3-0.
7. Adjournment: Motion by Reekie, seconded by Touchett, to adjourn at 6:18 p.m. Motion
carried 3-0.
Ellen Clark, City Clerk
APPLICANT INFORMATION
Name: sI H
First
eo t1 v.
M.I. last
Phone: '111- f )0 - S-8 70\
Address: l q I 'f MADI Sot-I W! 5"'.;111
Driver License#:
Email: tor.o,·��tlil(l.1td1°(((tor@ MA41.Sc)� ,b,t(S. or.5
s--
AGENCY/ORGANIZATION INFORMATION
Name: M ltD Is� t-1 ')6 ER! So (C �� I?> Phone: ( ,o �) 8'3 I'" 2
Address: I 5'"5" S � A-lAH � 12 D 1< � a uH wr 5""3 5'7 �
c
If this is a non-profit organization, please provide your EIN number for verification:
EVENT INFORMATION
fi1AJJI KD H ,i ERJ
Name of Event: f.4:U INV I IATI Ot:l A:I Type of event Yo IATH S-t>(C; Jl
Event date(s): �/ C - � /(1/2.0 14 - ID P r1
Event time(s): ] .+..,
Set up Start Time:�,/, ./ I 'I' .
l ] AJA. Tear Down End Time: � le�I J
('1 . lo PM
EVENT (ONTACTS
PLEASE LIST NAMES LOCATIONS AND CELL PHONE NUMBERS OF ON-SITE EVENT CONTACT PERSONS
I
NAME Driver License# LOCATION AT EVENT TIME ON-SITE CELL PHONE
as shown on ID (Ex: Race Start, Supply (Ex: 10 a.m. to
Tent etc.) 2p.m.)
itPPAtf F1rLO 7 A-"1 - IO t' r--1 ti 11-15'"1 - S-37'1
Sl'1S:11'f .P ALDER A If3 ' - ld''t7- 2.Z't?
_,.,,_ Hc>�SE
�A�tl .J w FI I \i"P,. "'',O•Qf 01 ��,
-,
,,-01 " ,, r,u�->7 r-, l..J j)
!t /;2
Date:.��� a=-+-<s...J.-_
CITY OF VERONA CR#:________
Account#: 100-44910
APPLICATION FOR A SPECIAL EVENT/NEIGHBORHOOD EVENT PERMIT
For Parades, Runs, Walks, Bicycle Events, Triathlons, Festivals, Neighborhood Events, etc.
•All required application materials must be submitted at least 45 days prior to the event. Failure to meet this requirement may
result In the denial of the application pursuant to Section 7-7-1{h) of the City of Verona Code of Ordinances*
Application Fee:
$150.00 + any additional fees
Non-Profit Organization: $50.00 + any additional fees
REQUIRED INFORMATION
Please include the following information/materials regarding the event with your application:
� A copy of the applicant's Driver's License
Route map and description and/or map of event layout
�
:� Certificate of Insurance - at least 30 days prior to event
APPLICANT INFORMATION
Phone: fnQ8--44-4-2CJ
.. }-0
Address: ,55-f �51:: la N.D \�A ) lA3r 53�)
Driver License#: DOB: 2 �2.LJ-t,'Z)
Email: ±swo\t.:SaJ �g:n"'�·L (O'()"\
AGENCY/ORGANIZATION .INFORMATION
Name: OpPad:uo:-ty 3<-1, 4Pun·wJ<ao f'fi
Phone:._...,.p{ �..........
_.;�
__;�
::..;..;;;.
;;_-_q )f.....:.
...;..:....i '7___
Address: 5 <Rb (a;J- V .:ew fd
If this is a non-profit organization, please provide your EIN number for verification: fu - 38 w13S4
EVENT INFORMATION
Name of Event: (<;di to( O�o;� Type of event___.fu ' '-'\\R
.._, .......__y , rJ.,,�----
.........,
Event date(s): J.p\.. I'-}, WI C( Eventtime(s):.___ /l
-------
�-'-A l'Y>
Set up Start Time: ___J :Affi
....._.....,_'-'-------- Tear Down End Time: :S ptn
(Appllcatlon Continues on Reverse)
Last updated
Date:._______
Initials:______
EVENT CONTACTS
PLEASE LIST NAMES, LOCATIONS AND CELL PHONE NUMBERS OF ON-SITE EVENT CONTACT PERSONS
NAME DOB LOCATION AT EVENT TIME ON-SITE CELL PHONE
as shown on ID (Ex: Race Start, Supply (Ex: 10 a.m. to
Tent etc.) 2p.m.)
8..-2J·l-
C- s-, ,�-
APPLICATION PROCEDURES
1. Application and all required materials shall be submitted to the City Clerk a minimum of 45
days prior to the event. (Section 7-7-l(h) of the City of Verona Code of Ordinances)
2. Upon verification of the application the City Clerk shall submit the application to the Police Chief for
further review.
3. The applicant will be contacted by the Police Department Staff to review event route and the
need for on- site police officers or City staff at the event.
4. The applicant is subject to a background check.
5. All police traffic control/city staff time incurred shall be billed to the applicant upon the completion
of the event.
6. The applicant may be required to attend a Public Safety and Welfare Committee meeting
and/ora Common Council meeting at which the event application will be reviewed for
approval.
7. Once the application is approved by the appropriate official(s) the permit will be issued.
APPLICANT SIGNATURE
PLEASE READ CAREFULLY BEFORE SIGNING
I understand the application and event requirements and agree to adhere to all applicable federal, state, and
municipal laws in addition to the requirements on the application. I agree to pay any invoices received from the
City of Verona for staff time at the event within 30 days of the invoice date. I understand that failure to adhere to
any application requirements or any federal, state or municipal laws involving the event will result in the denial of
the application or immediate termination of the event. The violation of federal, state or municipal laws will be
subject to applicable fines and penalties.
" ,.. J�-19
�l1
Applicant Signatur� Date
Once application ls approved, the permit will be issued to applicant via email.
A copy of the permit must be available at event for conformation.
Application for Temporary Class “B” / "Class B" Retailer’s License
See Additional Information on reverse side. Contact the municipal clerk if you have questions.
FEE $ 38.00 Application Date: 08/06/2019
Town Village ✔ City of VERONA County of DANE
The named organization applies for: (check appropriate box(es).)
✔ A Temporary Class "B" license to sell fermented malt beverages at picnics or similar gatherings under s. 125.26(6), Wis. Stats.
A Temporary "Class B" license to sell wine at picnics or similar gatherings under s. 125.51(10), Wis. Stats.
at the premises described below during a special event beginning 09/14/2019 and ending 09/14/2019 and agrees
to comply with all laws, resolutions, ordinances and regulations (state, federal or local) affecting the sale of fermented malt beverages
and/or wine if the license is granted.
1. Organization (check appropriate box) ✔ Bona fide Club Church Lodge/Society
Chamber of Commerce or similar Civic or Trade Organization
Veteran's Organization Fair Association
(a) Name OPORTUNITY 34 FOUNDATION
(b) Address 566 EAST VIEW RD, VERONA, WI 53593
(Street) ✔ City
Town Village
(c) Date organized 12/27/2017
(d) If corporation, give date of incorporation 12/29/2017
(e) If the named organization is not required to hold a Wisconsin seller's permit pursuant to s. 77.54 (7m), Wis. Stats., check this
box: ✔
(f) Names and addresses of all officers:
President KRISTIN KELLERMAN 566 EAST VIEW RD, VERONA, WI 53593
Vice President BRIAN KELLERMAN 566 EAST VIEW RD, VERONA, WI 53593
Secretary TIM CHATMAN 6573 WINDING WAY, DEFOREST, WI 53532
Treasurer KARIN VICTERSON 349 MEDINAH RD, OREGON, WI 53575
(g) Name and address of manager or person in charge of affair: SANDY WOLF 551 HARVEST LN
VERONA, WI 53593
2. Location of Premises Where Beer and/or Wine Will Be Sold, Served, Consumed, or Stored, and Areas Where Alcohol
Beverage Records Will be Stored:
(a) Street number 531 E VERONA AVE, VERONA, WI 53593
(b) Lot Block
(c) Do premises occupy all or part of building? COMMUNITY SHELTER WILL BE USED
(d) If part of building, describe fully all premises covered under this application, which floor or floors, or room or rooms, license is
to cover: A SMALL PORTION OF THE COMMUNITY SHELTER
3. Name of Event
(a) List name of the event RIDE FOR OPPERTUNITY
(b) Dates of event 09/14/2019
DECLARATION
The Officer(s) of the organization, individually and together, declare under penalties of law that the information provided in this applica-
tion is true and correct to the best of their knowledge and belief.
(Name of Organization)
Officer Officer
(Signature/date) (Signature/date)
Officer Officer
(Signature/date) (Signature/date)
Date Filed with Clerk Date Reported to Council or Board
Date Granted by Council License No.
AT-315 (R. 6-16) Wisconsin Department of Revenue
CITY OF VERONA
Account#: 100-44910
APPLICATION FOR A SPECIAL EVENT/NEIGHBORHOOD EVENT PERMIT
For Parades, Runs, Walks, Bicycle Events, Triathlons, Festivals, Neighborhood Events, etc.
*All required application materials must be submitted at least 45 days prior to the event. Failure to meet this requirement may
result in the denial of the application pursuant to Section 7-7-l(h) of the City of Verona Code of Ordinances*
Application Fee:
$150.00 + any additional fees
Non-Profit Organization: $50.00 + any additional fees
REQUIRED INFORMATION
Please include the following information/materials regarding the event with your application:
D A copy of the applicant's Driver's License
D Route map and description and/or map of event layout
D Certificate of Insurance - at least 30 days prior to event
APPLICANT INFORMATION
Name: \--'jYla&ly..,\ '{<.. \(,. -AndY-lt-C:, Phone: (oOS- "Z. \ 1-etoci·i
F� M.I. Last
Address: L\'2S \j\J-t:,S.tt I d '3,e t'o.x\<V'f°=j , '\feX"C1Y'\a... \Nl G3S4·�
Driver license#: . tD/to/BD
DOB:---'--------
AGENCY/ORGANIZATION INFORMATION
Name: S�ClX Cxee� t::Lc,\'Y)�Y <j &>nod PTO Phone:.___________
Address: tf·2.D 0h1..,0rc)J 9.:\rG.eJ:, \/exoY)CL�\cl\ S3SCj?
If this is a non-profit organization, please provide your EIN number for verification: 21 ... 1L\BB°IG3
EVENT INFORMATION
Name of Event: S�ax C'<ce\:'.. nm Qu.n Type of event � K run IY"CA. l K..
/-'-\°I_,_________
Event date(s):._O\...!.J/'--1-�....... Event time(s): Che c¥ iY\ Baro I l<'.4.c-e a.t q a..\'Y1
_________
Set up Start Time:._l.P'---·.O_O_a..-_m ....:.:..I �
Tear Down End Time:· I �=-------
�00 (:1. yY'I
(Application Continues on Reverse)
Last updated
Date: ______
Initials:______
MEMBER CERTIFICATE OF INSURANCE 8/21/19
Thank you for purchasing your insurance from AIM. This is your Member Certificate and should be kept with your permanent records.
Insured #: WI11371
NAMED INSURED MEMBER: Named Insured & Mailing Address PRODUCER NAME
Sugar Creek PTO Education Support Purchasing Group AIM Association Insurance
Attn: Josh Rodriguez or Current Officer c/o AIM Management, Inc.
420 Church St. P.O. Box 674051 PO Box 674051
Dallas TX, 75267-4051 Dallas TX, 75267-4051
Verona, WI 53593
Company / Coverage Policy # Effective Dates Deductible Limits of Insurance
Tudor Insurance Company / CPG1132808 4/26/19 - 4/26/20 $0 Each Occurrence $1,000,000
Commercial General Liability
General Aggregate $2,000,000
Products - COMP/OPS - Subject Included
to General Aggregate
Personal & Advertising Injury $1,000,000
Fire Damage (any one fire) $50,000
Tudor Insurance Company / CPG1132808 4/26/19 - 4/26/20 $0 Any One Person $25,000
Extended Medical Payments
Tudor Insurance Company / CPG1132809 4/26/19 - 4/26/20 $ 1,500 Aggregate $1,000,000
Professional Liability (Directors
& Officers Liability)
Retro-active Effective Date: 4/26/14
City of Verona is added as an Additional Insured to the General Liability policy only.
Event: Sugar Creek Fun Run
Date: 9/28/19 8AM - 1PM
Certificate Holder: This member certificate, together with the common policy conditions, coverage
part(s), coverage form(s), and endorsements, if any, complete the above numbered
City of Verona policy. Copies of the Master Policies are available upon request or may be printed at
111 Lincoln Street www.aim-companies.com
Verona, WI 53593
AUTHORIZED REPRESENTATIVE
Get email alerts for Verona
A daily email when new agendas and minutes are posted.