(tables, bandstand, demonstrations, etc.)
I hereby acknowledge that I will be responsible for the members of the group and in signing this form there is no insurance provided, and I, hereby, release the City of Summit, the Department of Community Programs, and any individual connected with the City, the Department of Community Programs from any and all law suits or other expenses that may arise from injury to or caused by each individual’s participation in this event.
Mark Ozoroski, Assistant Director
This agreement made this day
by and between
, a non-profit corporation of the State of New Jersey
or individual, having its address at
(the "applicant"), and the City of Summit Department of Community Programs, a municipal corporation of the State of New Jersey, having its place of business at:
100 Morris Avenue
Summit, NJ 07901
(the "Department of Community Programs").
1. Pursuant to Title 31 of the Revised Ordinance of the City, entitled "Establish Rules and Regulations for the Use of Public Property" (the "ordinance"), applicant has requested that it be permitted to use public property owned by the City, or one of its departments, and located at:
2. The ordinance sets fort as one of its requirements in connection with applicant's request to use the property that applicant enter into an agreement with the City in the form hereof.
Now, therefore, it is agreed by and between the applicant and the City of Summit Department of Community Programs as follows:
1. Following its use, applicant shall restore the property to the condition in which it existed prior to the use by applicant, including without limitation, the removal of debris, emptying of trash receptacles and correction of temporary changes to the property.
2. If requested by the Director, the applicant shall pay to the City of Summit Department of Community Programs for the cost of furnishing municipal labor, services, and material beyond those normally provided by the Department of Community Programs, and resulting from or caused by the applicant's user of the property, which shall include an administrative surcharge of 15% of such amount.
In witness whereof, applicant and the City of Summit Department of Community Programs have caused this agreement to be signed the day and year first above written.
Describe in detail
I sign this Hold Harmless as my voluntary act and by this act agree to hold you harmless and indemnify you from any claims, suits, or other actions arising from, caused by, or which are the alleged result of any act or omission of any organization, corporation, guest, invitee, licensee, visitor or other person present on the premises listed above in order to participate in, organize, assist, enjoy, supervise or in any other way further the activity to be held (as described above) on the dates listed above.
I state that the activity listed above will not include the consumption of alcoholic beverages but should any person described in paragraph 4 consume alcohol or allow or permit others to consume alcohol then I agree to be bound by the terms of paragraph 6 below.
I state that the activity listed above will include the consumption of alcoholic beverages and that because of such consumption; I have
the following additional duties to you related to the use of the site listed above:
a) that I am solely responsible for the dispensing and consumption of alcohol, including the prudent and responsible dispensing and consumption of alcohol by all persons involved in the activity described above, including but not limited to those persons described in paragraph 4 above;
b) To acknowledge by the signing of this Hold Harmless that you have no authority, control, or participation in the dispensation or consumption of alcohol on the site and date listed above and that I will take no step, action, or measure to convey the idea that you in any way have promoted, assisted, or participated in the dispensing and consumption of alcoholic beverages on the site and date listed above.
c) That I will not allow persons under the age of 21 to dispense or consume alcohol at the site during the activity to be held on your property.
d) To comply with all municipal ordinances relating to the consumption of alcoholic beverages, including but not limited to obtaining any necessary permits.
I also agree that where the municipal officer signing this Hold Harmless on your behalf feels I should provide to you a “Certificate of Insurance” and proof of “Special Events Insurance” that I shall provide same to that municipal officer as soon as practicable and not less than 5 business days before the date of the planned activity listed above. Said Insurance shall be written with a company maintaining a rating of at least “A-“, according to A.M. Bests. Said policy shall be in an amount of not less than one million dollars ($1,000,000) per occurrence. It is understood You will be listed as an additional insured on the policy and Certificate of Insurance.
I also agree that I am obligated to reimburse you for all reasonable attorney’s fees incurred by you to enforce the terms of this Hold Harmless or to defend yourself against any claim, suit, demand for subrogation, or other action which a court of competent jurisdiction later determines by final order or judgment should have been defended by me at my sole cost and expense pursuant to this Hold Harmless.
“I” or “me” shall mean the individual, organization, or corporation set forth below.
I hereby acknowledge that I have been requested to sign an agreement which states that I will be responsible to make the City of Summit whole from any claim, lawsuit, settlement, or judgment, including all attorneys’ fees, together with all costs, fees, and interest, that arises in or out of the use of municipal property by myself, my guests, invitees, licensees, visitors, or other person(s) present on the premises of the municipality in order to participate in, organize, assist, enjoy, supervise, or in any other way, further the activity to be held.
I have also indicated that I will not serve, or allow to be served, alcoholic beverages or that, if I do, in fact allow them to be consumed, then I will comply with Paragraphs 6(a), 6(b), 6(c) and 6(d) of the Hold Harmless Agreement which places the sole responsibility for any claim or lawsuit wholly upon me.
If a corporation, corporate acknowledgement is to be attached.
State of New Jersey, County of
I certify that on
personally came before me and this person acknowledged under oath, to my satisfaction, that:
this person is the
, the corporation named in the attached document;
this person is the attesting witness to the signing of this document by the proper corporate officer who is
of the corporation.
this document was signed and delivered by the corporation as its voluntary act duly authorized by a proper
resolution of its Board of Directors;
this person knows the proper seal of the corporation which was affixed to this document; and
this person signed this proof to attest to the truth of these facts.
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