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Dominick Pangallo MAYOR Trish O’Brien Superintendent CITY OF SALEM, MASSACHUSETTS PARK, RECREATION & COMMUNITY SERVICE 401 Bridge Street, Salem MA 01970 Tel. (978) 744-0924 [EMAIL REDACTED] Road Bike/Race/Walk/Parade Application PLEASE SUBMIT PAYMENT OF $200 WITH THIS PERMIT TO THE CITY OF SALEM PARK, & RECREATION DEPARTMENT NO LATER THAN 45 DAYS PRIOR TO THE EVENT. ANY FOR PROFIT EVENTS WILL REQUIRE AN ADDITIONAL 5% FROM THE REGISTRATION FEES Please fill out application completely and legibly We, the undersigned, respectfully apply for permission to host a road race/walk in the City of Salem as follows: Applicant’s Organization Name: Name of Race/Walk/Parade: Contact E-Mail Address: City/State/Zip: Organization Tax Status (please include Tax ID Number): What Charities Will This Race/Walk Be Benefiting? Approximately How Much of the Race/Walk/Parade Proceeds Will Be Donated to Each Charity(s) Day of Race/Walk Contact Information: Name: Contact Date of Event: Estimated Number of Participants: Time of Event: Estimated Finish Time of Event: Start Location: Finish Location: Distance of Event: PLEASE SUBMIT PAYMENT OF $200 WITH THIS PERMIT APPLICATION TO THE CITY OF SALEM PARK, RECREATION AND COMMUNITY SERVICES DEPARTMENT NO LATER THAN 60 DAYS PRIOR TO THE EVENT. Registered Non-Profit Fee $150 ANY FOR PROFIT EVENTS WILL REQUIRE AN ADDITIONAL 5% FROM THE REGISTRATION FEES POST EVENT. ---PAGE BREAK--- Has This Event Been Held Before? Yes No All Races/Walks/Parades Are Required to Recycle and Remove Trash. Onsite EMT/Ambulance Service (Required): initial Please Attach a Map of Route With the Following Items: 1. Race/Walk Course 2. Direction of Runners Through the Race/Walk course 3. Starting and Finishing Points 4. Meeting Points For Racers Before and After the Race/Walk 5. Last year’s race financials Certificate of Insurance Attached? Yes A certificate of insurance for general liability naming the City of Salem as primary additional insured for amount not less than $1,000,000 combined single limit for injury or death or property damages (including loss of use) in any one occurrence, and $1,000,000 general aggregate coverage. (The City of Salem reserves the right to increase coverage minimum if event presents extraordinary risk). RELEASE & INDEMNITY AGREEMENT APPLICANT’S SIGNATURE The undersigned Sponsor, by signature below, shall defend, indemnify, and hold the City of Salem, its officers, agents and employees, harmless against all liability, loss, or expenses, including attorney’s fees, and against all claims, actions or judgments based upon or arising out of damage or injury (including death) to persons or property caused by any act or omission of an act sustained in any way in connections with the performance of this event or by conditions created thereby, or based upon violation of any statute, ordinance or regulation. This contractual indemnity provision does not abrogate common law or statutory liability and indemnification to the City of Salem, but is in addition to such common law or statutory provisions. Applicant’s signature Name of applicant A copy of this permit will be sent to the applicant upon approval. Please call Park, Recreation & Community Services if you have any questions. [PHONE REDACTED] CITY USE ONLY Payment Received: Date Permit Issued: Date Permit Mailed to Applicant: Approved By: Director (Or Designee) of Salem Park, Recreation & Community Services Salem Police Department Effective date of form: 2/8/12 Revised date of form: 1/1/18