3 facilities usage & rental 3 - facilities usage & rental · 3 – facilities usage &...

3 – FACILITIES USAGE & RENTAL

Risk Management and Insurance Manual – March 2018 3.1

3 - FACILITIES USAGE & RENTAL

301 Overview

This policy pertains to all Diocesan property. There are certain requirements whenever parish, school or agency property is used (with or without charge) by any non-parish, school, agency or non-affiliated individuals. Use of the property is considered to be “by others” whenever the activity is “non-sponsored” by a Diocesan parish school or agency.

The following section outlines the requirements for facility usage and rental and the required procedures to follow for its use.

302 “Sponsored” Vs. “Non-Sponsored”

It is first necessary to determine whether an activity or group utilizing parish, school, or agency facilities is a “sponsored” or “non-sponsored” activity or group.

303 “Sponsored” Activities

If an activity is a sponsored activity, it will usually be covered under the Diocesan insurance program.

Compliance with state law, local ordinance, and diocesan Rules and Regulations is required if alcohol is served. Also refer to the following discussion in this section entitled “If Alcohol Is Served.”

Sponsored Activities Include meetings or events that are hosted by a parish, school or agency, that are directly related to ministry outreach. Sponsored activities also include events when all of the following conditions are met:

The activity is consistent with the mission of the organization.

The activity is under the direct control of the parish, school or agency.

The individuals running the program are accountable to the pastor, principal, agencydirector or their designee, for all aspects of the activity.

The financial aspects of the activity are directly handled by: (1) the parish office forparishes and parish schools, or (2) the Diocesan Finance Office for MACS, CatholicCharities and all other agencies. This covers:

o The depositing, accounting and reporting of all revenue from the activity.o The payment, accounting and reporting of all obligations for services rendered

and goods and materials received.

The activity is open to members of the parish, school or agency.

If ANY of the above conditions are not met then the activity is “non-sponsored,” meaning that the facility user needs to provide insurance which both the parish, school, agency, and the Bishop of Charlotte as an Additional Insured.



Some examples of non-sponsored activities are wedding receptions; birthday and anniversary parties; family and class reunions; exercise classes; non-parish ministry based recreational sports activities, book clubs, seminars, bridge groups, awards banquets; and, in some cases, parish fundraisers.

Events grounded in the liturgy of the Catholic Church such as wedding ceremonies, funeral masses, and baptisms are considered to be “sponsored” and do not require Special Events Coverage. Baptism, confirmation, and funeral receptions following the ceremony or Mass can be considered sponsored if they are open to all parishioners (not subject to invitation) and no alcohol will be served.

Please contact the Diocesan Properties & Risk Management Office if you require any assistance with differentiating between a sponsored and non-sponsored activity.

304 “Non-Sponsored” Activities

If it is determined that the facilities usage is a non-sponsored activity, the following apply:

There is to be a written agreement, specifying the terms of use of Diocesan property.

Whenever children or vulnerable adults are involved, the individuals or entity usingDiocesan property are to review the Diocesan Sexual Misconduct Policy and sign anacknowledgement indicating compliance with the policy.

All promotional materials are to clearly state the individuals or entity sponsoring theevent. All materials are to be reviewed by the pastor, principal or agency director beforebeing distributed.

There are THREE OPTIONS regarding liability insurance:

1. The organization or individual using parish/school/agency facilities can provide theirown insurance to be accompanied by the Facility Usage / Indemnity Agreement (Form3.C). Agreements require $1,000,000 in general liability coverage. The general liabilitycoverage must name both the parish/school/agency and the Bishop of Charlotte as an Additional Insured. (See additional requirements below if alcohol is served.)

2. As an alternative to providing their own insurance, individuals or organizations holdinga single event such as wedding receptions, birthday parties, etc., can utilize theApplication for Special Events Coverage (Form 3.A). (Refer to the following additionalrequirements if alcohol is going to be served.)

3. For other unique or miscellaneous circumstances where 1) or 2) above are notapplicable, an Adult Hold Harmless / Indemnity Agreement (Form 3.D) must be signedby individuals, or the Facility Usage / Indemnity Agreement (Form 3.C) for groups.

305 Special Event Insurance Coverage

305.1 What It Is

Special Event Insurance is general liability insurance coverage available to an individual or organization to comply with the insurance requirements necessary for using parish/school/agency facilities for a non-sponsored, one-time event. This coverage is not necessary if the event is sponsored, or if the individual or organization is able to provide evidence of their own liability insurance in an amount of at least $1,000,000. Coverage is available after acceptance of a completed application by the insurance company.



305.2 Submission Requirements & Procedures

If you plan on using a Diocesan-owned facility or premises for a non-sponsored event, then the following procedures must be followed:

Fill out the Application for Special Events Coverage (Form 3.A), available in Spanishonline.

Mail the completed application along with a check for the application fee to:

Catholic Diocese of Charlotte Properties & Risk Management Department Attn: Risk Manager 1123 South Church St. Charlotte, NC 28203

Please note that the application and fee should be received no later than 15 days in advance of the actual event to allow for review and approval by Catholic Mutual Group. This review is necessary in order to meet the insurance requirements and to be able to make any changes to an improperly submitted application.

Upon successful review and approval, you will be notified within 7-10 business days ifyour application has been approved and coverage is in place for your event.

306 If Alcohol Is Served

Diocesan facilities, including schools, are often utilized as the place where special events are held and may include the selling, serving, or furnishing of alcoholic beverages. Most often, these events are sponsored by the parishes or schools as a means of raising funds for general support or for particular fund-raising drives. There are also events that are purely social in nature wherein parishioners or supporters gather to promote goodwill. Whatever the nature of the event, in all instances where alcoholic beverages are available, locations need to develop and implement responsible practices and procedures designed to reduce incidences of wrongful intoxication. In addition to any obligations imposed by law, we have a moral obligation to provide the highest degree of protection possible to all people who are, or will be, on the property of parishes or institutions of the Diocese.

At events where alcohol (beer, wine, or liquor) is being served there is “social host liability” imposed on those who give, sell, or furnish alcohol to someone who later is alleged to have caused injury or death. Although the predominant trend has been to preclude social host liability, state legislatures and the courts have held “hosts” of private parties, weddings, and other social events liable. Generally, the imposition of liability has involved cases of serving intoxicating beverages to minors.

Each location that intends to have an event that includes the selling, serving, or furnishing of alcoholic beverages needs to give early forethought and planning on how they will specifically address the issue of liquor liability. With the introduction of beer, wine, or liquor into any event, significant liability exposure exists.



306.1 Required ABC Permits

When alcohol is to be “served” or “sold” at an event, there are two possible “One-Time Permits” available from the North Carolina ABC board that may be required for your event. They are the “Application for Limited Special Occasion Permit” (Form 3.F) and the “Special One-Time Permit Application for Sale of Alcoholic Beverages” (Form 3.G). We have included samples of these forms for your reference only. Both forms are available on the North Carolina ABC board’s website at the following link, http://abc.nc.gov/Permit/SpecialPermits. The following is a brief overview of these two permit requirements.

Application for Limited Special Occasion Permit (Form 3.F)

An “Application for Limited Special Occasion Permit” authorizes the permittee to bring fortified wine and spirituous liquor onto the premises, (with the permission of the owner of that property) and to SERVE those alcoholic beverages free of charge to the permittee’s guests at a reception, wedding, party or other special occasion being held there. There can be no charge to attend the function, any money collected constitutes an illegal sale of alcohol, and violators will be subject to criminal prosecution.

** Please note that an “Application for Limited Special Occasion Permit”

is NOT required if ONLY BEER AND WINE ARE SERVED.

Special One-Time Permit Application for Sale of Alcoholic Beverages (Form 3.G)

North Carolina Law prohibits the sale of alcoholic beverages without a license to do so. Therefore if you or any outside group plans to sell any alcoholic beverage, then a “Special One-Time Permit Application for Sale of Alcoholic Beverages” will be required. This permit authorizes the permittee to SELL beer, wine, fortified wines, and spirituous liquors at a single fund-raiser or a special event. Please note that the admission charge to an event should be the same for all attending without regard to whether or not they consume any alcoholic beverages.

The “Special One-Time Permit Application for the Sale of Alcoholic Beverages” obtained from the ABC Board requires a letter from the owner of the property granting permission for any group who wishes to sell alcoholic beverages on their property. It also requires proof of tax exempt status under subsection 501( c ) 3., both of these can be obtained from the Diocesan Legal Department. Please note that the process of obtaining a liquor license can take up to 4-6 weeks.

306.2 Procedures

If a group is allowed to serve or sell alcohol at an event, the following is required from the applicant: Contact the Diocesan Legal Office at (704) 370-3346 to obtain the required Lease Agreement and Letter of Tax Exempt Status signed by the Bishop needed to obtain the required Permits. You will need to provide contact information for the applicant, type of event,

http://abc.nc.gov/Permit/SpecialPermits



date, and location. Please note the entire process can take several weeks. Apply for your permit at least 4-6 weeks before your event.

306.3 Alcohol at Non-Diocesan Sponsored Events

If an outside group SERVES fortified wine or spirituous liquor at No Cost at aNON diocesan sponsored event then in addition to obtaining the required “LimitedSpecial Occasion Permit” (Form 3.F), they shall fill out and submit the Application forSpecial Events Coverage (Form 3.A) to the Properties Department indicating Liquorwill be served. At time of submission, a check must accompany the application for$100 to cover the cost of insurance for the Special Event application. Checks shouldbe made out to the “Diocese of Charlotte” and submitted AT LEAST 15 days prior tothe event. This will cover the event where liquor is being served under the CatholicMutual umbrella. Please note: A Liquor permit is not required if only beer andwine are being served.

If an outside group SELLS any alcohol (beer, wine, or liquor) or alcohol is included in the cost of the ticket at a NON diocesan sponsored event then in addition to obtaining the required “Special One-Time Permit Application for Sale of Alcoholic Beverages” (Form 3.G), they shall fill out and submit to the Properties Department the Application for Special Events Coverage (Form 3.A) and the K&K Liquor liability Application (Form 3.E) indicating alcohol will be sold. (Please note that if the outside group is able to provide evidence of acceptable host liquor liability insurance coverage, then the K&K Liquor Liability Application will not be required). Form 3.A and a check for $100, made payable to the "Diocese of Charlotte", should be sent to the Diocesan Properties Department to cover the cost of insurance for the Special Event application. The K&K Liquor Liability Application should be sent directly to Catholic Mutual Group. Please note each application from K&K is evaluated and coverage cost is “quoted” depending upon the size of the event. Typically the cost of coverage is about $75. Catholic Mutual Group will bill the event holder for the K&K coverage. All insurance forms should be submitted AT LEAST 15 days prior to the event. This will cover the event where alcohol is being served under the Catholic Mutual umbrella.

306.4 Alcohol at Diocesan Sponsored Events

If a Parish, School or Diocesan agency schedules a diocesan sponsored event where100% of the proceeds from a fund raiser goes to support the church, school, oragency then alcohol may be served or sold with no additional Catholic Mutualinsurance coverage required. However please note the Parish, School orDiocesan agency is still required to follow the procedures in 306.2 above inorder to obtain the required ABC Permits as outlined above.

Please refer back to the definition of which activities and / or groups are considered“Sponsored”. As a point of clarification, it is noted that groups such as Civicorganizations, Boy Scouts of America, or the Knights of Columbus are not consideredsponsored as they have their own charter and handle their own separate finances.

Please feel free to contact the Diocesan Properties & Risk Management Department at [email protected] for further information if you are unsure whether an event requires a special permit to serve alcoholic beverages.

mailto:[email protected]



307 Use of Non-Diocesan Owned Facilities or Premises

If you plan on using non-Diocesan owned facilities or premises for a “sponsored” parish function, please provide a copy of any related contract or agreement, along with a full description of the proposed activity to the Diocesan Properties & Risk Management Office at least 30 days in advance for review and approval. Most sponsored activities will be covered under the Diocesan insurance policy. This review, however, is necessary in order to meet the insurance agreements and to make changes in adverse agreements. Once approved by Catholic Mutual Group, contact Stacy Ebeling at 800-228-6108 -Ext. 2332 to request an official Certificate of Insurance to provide to the facility owner.

308 Adult Hold Harmless / Indemnity

Ideally, individuals utilizing parish/school/agency premises for activities that are neither sponsored nor affiliated is to provide a Certificate of Insurance naming both the parish/school/agency, the Diocese, and the Bishop of Charlotte as an Additional Insured. Refer to Sample COI (Form 8.E) for an example of appropriate proof of Liability Insurance.

However, in certain instances when groups or individuals do not have insurance, the Adult Hold Harmless / Indemnity Agreement (Form 3.D) can be used. This Release Form has NOT been designed to be a replacement for insurance, but has been developed only for certain situations. Specifically, it must be utilized for the following situations that are often encountered:

Adult Athletic Participation – ALL adults who use or rent the parish/school/agency gymfor non-sponsored basketball, volleyball, or like activity must sign the Release Form. Itis not adequate to have one representative of a sports group sign an agreement. Eachindividual must sign a Release Form for the contracts to be valid. Please note that anew form does not have to be obtained for each usage of the gym if the gym is beingutilized on a seasonal basis. Instead, the parish/school/agency may obtain one signedRelease Form per individual, per season.

Craft Fairs – Considering that a parish/school/agency craft fair usually involves a largenumber of craft vendors, it is impossible to obtain a Certificate of Insurance from eachvendor. Instead, the Release Form should be distributed with the craft vendors’registration material for the vendor to sign. A craft vendor who does not sign theRelease Form should not be allowed to participate in your parish/school/agency craftfair.

Other Small Groups – In rare instances, the Release Form can be used for very smallgroups that do not have liability insurance. Similar to the adult athletic participation, inthese cases a Release Form must be obtained from each individual of each group whoutilizes parish/school/agency facilities. When dealing with large groups, it is not feasibleto have each group member sign a Release Form. Considering this, large groups mustsign the Facility Usage / Indemnity Agreement (Form 3.C) which requires insurance.

The Adult Hold Harmless / Indemnity Agreement (Form 3.D) is a legal contract between your parish/school/agency and the individual who signs the form. The Release Form will effectively bar the signer of the agreement from successfully pursuing a claim against theparish/school/agency. Please note that the Release Form is only valid when the signer is at least 18 years old. You should not alter it in any way, since an alteration could result in nullifying its legality. Original copies of signed Release Forms should be kept in your files for 10 years. Injuries and accidents are often not promptly reported, necessitating the need for original copies to be maintained.

Name of Parish or Institution: Date of Event:

ZIP Code:

Time of Event: From _____________ To ______________

Is this an overnight event?Yes No

Approx. Number of Participants:

Is Food Being Served?Lessee (Additional Insured) Contact Person: Yes No

Is Liquor Being Served?Yes No

ZIP Code:

To receive approval notification please print e mail(s):

Events which exceed 3 days in dura on (charge TBD)

Political Rallies

SE_3P(8/14)

Lessee (Additional Insured) Information:

Street (Physical) Address (NO P.O. BOXES):

City/State:

Phone No.:

Events where a fee or admission is charged, unless all proceeds goto charity

MAKE CHECK PAYABLE TO: CATHOLIC DIOCESE OF CHARLOTTE

RETURN WITH FORM TO:CATHOLIC DIOCESE OF CHARLOTTEPROPERTIES & RISK MANAGEMENT OFFICE1123 SOUTH CHURCH STCHARLOTTE, NC 28203-4003

Events that exceed 1,000 in a endance (charge TBD)

Amusement rides, including mechanically operated devices,trampolines, & rebounding devices

IN THE EVENT OF A CLAIM, PLEASE CONTACT C.M.G. AGENCY CLAIMS DEPT: 800-228-6108

To Note: If liquor liability coverage is NOT purchased and an alcohol relatedclaim results, the claim will be excluded if it is determined thata liquor liability policy should have been purchased. (See Risk ManualChapter 3 for Alcohol Related Policies)

City/State:

Telephone:

(Please Print E mail(s) Clearly)

[email protected]

Name of Sponsoring Organization or Individual Requesting Coverage

(Please Print Lessee Name(s) or Organization)

Name:

NOTE: CATHOLIC MUTUALMUST RECEIVE APPLICATION AT LEAST 15 DAYS PRIOR TO EVENT. DO NOT SUBMIT APPLICATIONS MORE THAN 6 MONTHS IN ADVANCE.

DIOCESE OF CHARLOTTE 0727APPLICATION FOR SPECIAL EVENTS COVERAGE

TO AVOID DELAY OR DENIAL OF COVERAGE, PLEASE ENSURE THATEVERY FIELD IS COMPLETED.

Coverage Limit: $1,000,000 Combined Single Limit Bodily Injury and Host Liquor Liability, $500,000 Property Damage Liability.Includes $100,000 for Defense Costs for Sexual Misconduct, excluding overnight events(see below for purchase options).

Coverage provided is per event (not per claim). Submission of application does not bind coverage all events are subject to approval.

Type of Special Event (Example: wedding reception, anniv. party, etc.If it's a FUNDRAISER, be specific about what is occurring):

Cost of Coverage: $100 Per Event (Overnight Stays $125)

Coverage underwritten by Nationwide Mutual Insurance Company; Policy No. on file with C.M.G. Agency, Inc.

Events organized or operated by professional promoters/performers

In atable Amusement Device (Must be pre approved, picturerequired. Minimum charge of $100 per inflatable applies;each device is underwritten; charge is determined by size andpotential risk.)

Organized sporting events, including tournaments & camps (somesporting activities are allowed and must be preapproved).

If liquor is to be sold (or cost included in ticket price) and/or a license or permitis required in order for you to serve or furnish alcohol, you must obtainLIQUOR LIABILITY coverage by separate application.Does this event require the additional coverage? Yes .NoIf being SOLD fill out the "K&K Liquor Liability Application" for coverage)

COVERAGE DOES NOT APPLY TO CERTAIN EVENTS,SUCH AS, BUT NOT LIMITED TO:

Coverage does not automatically apply for overnight events, however,you have the option to purchase this coverage by separate application.Additional charge may apply.Do you want to apply for this coverage? ______ Yes ______ No

ADDITIONAL CHARGES WILL APPLY FOR:

DEFENSE COSTS FOR SEXUAL MISCONDUCTFOR OVERNIGHT EVENTS $100,000 LIMIT

Rap/Hip Hop/Alternative music (non religious bands)Events involving recreational vehiclesEvents involving pool or lake activitiesEvents involving 'BYOB' (Bring your own bottle)Fireworks & fireworks displays

Any carnival event

Street Address:

Risk Management and Insuance Manual - March 2018

Risk Management and Insurance Manual – March 2018 Form 3.B

INSTRUCTIONS TO THE FACILITY USAGE / INDEMNITY AGREEMENT

The Facility Usage / Indemnity Agreement must be used when non-sponsored or affiliated groups use parish/school/agency facilities on a short-term basis such as one day or a week.

The following groups are examples of non-sponsored or affiliated groups that should sign the Facility Usage / Indemnity Agreement:

Girl Scouts, Knights of Columbus, American Legion or other similar organizations that use parish facilities for meetings or fundraisers.

AAU sport teams or non-parish sponsored sport classes/clinics.

Parishioner and non-parishioner families that rent or use school facilities for wedding receptions, family reunions, anniversary parties or other similar activities. (In lieu of signing the Facility Usage / Indemnity Agreement, a parishioner or non-parishioner family would be eligible to purchase “special event” liability coverage through your parish via Catholic Mutual Group.) Please note that funeral luncheons are parish-sponsored events.

Any other organization, municipality or county organization that uses parish facilities for a meeting or function that is not school sponsored.

The Facility Usage / Indemnity Agreement requires the facility user to provide a Certificate of Insurance documenting general liability coverage in the amount of $1,000,000 per occurrence. This Certificate of Insurance must name your entity, the Diocese, the Bishop of Charlotte, and parish as an Additional Insured. It is not adequate to obtain a Certificate of Insurance, which names the entity as a “certificate holder.”

It is often asked what criteria an organization must meet to be sponsored or affiliated. In the event of an insurance claim involving a potential non-sponsored activity, the following questions would be asked to further determine if a group was sponsored and eligible for insurance coverage:

Did the school have full control over the group or function?

Did all costs or fees associated with the function flow through parish/school/agencyaccounts?

Was the function or group open to all members, students, and parents?

Was the purpose of the function or group to facilitate learning, raise revenue for theparish/school/agency or provide a social service on behalf of the parish/school/agency?

Was the teacher or leader of the group a school volunteer or employee?

In general, a group, which does not meet the definition of an affiliated organization or is unable to answer the above five questions in the affirmative would not be sponsored. Accordingly, that group must sign the Facility Usage / Indemnity Agreement and supply the parish with the necessary insurance documentation.

Risk Management and Insurance Manual – March 2018 Form 3.C REVISED

FACILITY USAGE / INDEMNITY AGREEMENT

(Return Completed Form to Location)

LOCATION: _______________________________________________________________

FACILITY USER/ ORGANIZATION: _____________________________________________

DATE(S) OF FACILITY USAGE: ________________________________________________

TYPE OF FACILITY USAGE: __________________________________________________

The above named FACILITY USER agrees to defend, protect, indemnify and hold harmless the above named LOCATION, the Roman Catholic Diocese of Charlotte, and the Bishop of the Diocese of Charlotte (“LOCATION”) against any and all claims arising out of the FACILITY USER’s use or occupancy of the above named LOCATION.

1. FACILITY USER agrees to provide a Certificate of Insurance (COI) to the LOCATION, which providesevidence of general liability coverage of not less than one million dollars ($1,000,000) per occurrence.FACILITY USER also agrees to have the BISHOP OF CHARLOTTE, the ROMAN CATHOLICDIOCESE OF CHARLOTTE and LOCATION (“hereafter collectively referred to as “DIOCESE”)named as an “Additional Insured” on its general liability policy for the DATE(S) OF FACILITY USAGEin relationship to the TYPE OF FACILITY USAGE for claims which arise out of FACILITY USER’Suse of the premises, without limitation. FACILITY USER also agrees to ensure that its liabilityinsurance policy will be primary in the event of a covered claim or cause of action againstLOCATION.

2. If FACILITY USER fails to comply with paragraph (one) above, then the above named FACILITYUSER must submit an Application for Special Events Coverage (See Form 3.A) and purchase therequired one-time event insurance coverage through Catholic Mutual Group.

3. The FACILITY USER hereby acknowledges and affirmatively states that they have received allnecessary, required and appropriate permits, licenses, verifications, approvals from any and allgovernmental agencies allowing them to lawfully engage in their intended use. They furtheracknowledges and affirmatively state that they shall not permit anything that is unlawful to occur onthe premises during the term of their tenancy.

4. The FACILITY USER agrees to protect, defend, hold harmless and fully indemnify the DIOCESE fromany claim or cause of action whatsoever arising out of or related to their usage of the above facilityduring the above identified DATE(S) OF FACILITY USAGE that is brought against the DIOCESE bythe above named FACILITY USER or its employees, agents, partners, family members, students,customers, function attendees, guests, invitees, organizational members, associates and/or any otherindividual(s) and/or entity(ies), even if such claim arises from the alleged negligence of the DIOCESE,its employees, agents or assigns, or the negligence of any other individual or organization. Thisparagraph does not relieve FACILITY USER’s responsibility to comply with the above paragraphs.

If any sentence or paragraph of this agreement is held invalid, it is agreed that the balance thereof, should continue in full legal force and effect. The undersigned hereby affirmatively states that they are authorized to sign this document on behalf of the FACILITY USER/ORGANIZATION and have full authority to bind said FACILITY USER/ORGANIZATION in all matters referred to herein.

SIGNED BY: ___________________________________DATE:_____________________

NAME (Please print): ________________________________________________________

Risk Management and Insurance Manual - March 2018 Form 3.D

ADULT HOLD HARMLESS / INDEMNITY AGREEMENT

(Return Completed Form to Parish/School/Agency)

NAME: ______________________________________________________________________

ACTIVITY: ___________________________________________________________________

DATE AND LOCATION: _________________________________________________________

PARISH/SCHOOL/AGENCY: ____________________________________________________

I wish to participate in the activity described above, and as a condition of my being allowed to do so, I, hereby, release and discharge the Diocese of Charlotte, its constituent organizations, including but not limited to said Parish/School/Agency and their officers, agents, and employees, from any and all rights and/or claims I may have or hereafter acquire, for personal injuries, property damage or other, that I may suffer as a result of my participation in the activity described above, whether or not such injuries or damage are caused by the negligence (active or passive), of any of the entities or individuals named or described above.

I, hereby, warrant and represent that I am physically fit and capable of taking part in such activity. I make this warranty and representation on the basis of advice given me by a duly licensed medical doctor within the last six months, and I know of no change in my medical condition since receiving such advice that would affect the opinion of said medical doctor.

I agree to abide by the rules and regulations governing the above described activity and to obey any instructions given by the person or persons having supervision and control over the activity.

Photo Release

I, and on behalf of my family, heirs, and assigns, hereby grant to the Parish/School/Agency and/or The Roman Catholic Diocese of Charlotte herein referred to collectively as the “Diocese”, permission to record on photography film and/or video, whether digital or otherwise, pictures, images and/or reproductions of my participation and/or my families participation in this activity. I agree that any or all of the material photographed may be used, in any form, as part of any future publications, brochure, social media, internet or other printed materials that the Diocese deems to be an appropriate use, and further that such use shall be without payment of fees, royalties, special credit or other compensation. I agree to indemnify and hold harmless the Diocese, its agents, representatives and assigns from any and all claims regarding the use of said material. Furthermore, I hereby waive any and all claims that I may have, or hereafter acquire, regarding the use of said material by the Diocese, its agents, representatives and assigns. This release shall not expire unless revoked by me in writing.

In the event that I should require medical treatment and I am not able to communicate my desires to attending physicians or other medical personnel, I give permission for the necessary emergency treatment to be administered.

I warrant and represent that I am eighteen years of age, or over, and upon request will produce satisfactory proof of such fact.

Name: _________________________ Signature: ____________________________ Date: __________

(Print)

NOTE: Where an employee of the Diocese is participating in such an activity the following paragraph should be included:

”My participation in this activity will be conducted on my own time and not on my time as an employee of_________________________________. Further, this participation on my part is for my own personal benefit, is voluntary on my part, and is not as a result of any suggestion or direction of my said employer or anyone acting on its behalf. I am fully aware that any injury I may incur as a result of such participation will not be considered as a work-incurred injury, or one arising out of or in the course and scope of my employment.

LIQUOR LIABILITY INSURANCE FORMK&K

INSURANCE An affiliate of SLE Worldwide, Inc.

1712 Magnavox Way P.O. Box 2338Fort Wayne, Indiana 46801(800) 553-8368 Fax (260) 459-5624www.kandkinsurance.comCA #0334819

1. Named Insured as it is to appear on policy:

Address:

City: State: Zip:

Contact: E-mail Address:

Telephone Number: ( ) Fax Number: ( )

2. Name Liquor License is in:

3. Liquor License Number: Class of License:

4. Opening and closing hours of event(s) (for each event):

5. Opening and closing hours of alcoholic beverage sales (for each event, must contain a minium 1/2 hour buffer:

6. Has applicants’ alcohol beverage license ever been revoked or suspended? Yes NoIf yes, please explain:

7. Has applicant incurred claims for liquor liability during the last three years? Yes NoIf yes, please explain:

8. Has any insuror cancelled or non-renewed coverage during the last three years? Yes NoIf yes, please explain:

9. Has applicant ever been fined by alcoholic beverage control or other governmental regulator? Yes NoIf yes, please explain:

10.Type of alcohol beverages sold: What proof:

11. Annual Gross Sales:

Event Alcoholic Beverage Sales Food Sales

$ $

$ $

$ $

$ $

12. Are patrons allowed to carry alcoholic beverages onto the premises? Yes NoIf yes, what type:

13.Do you maintain security personnel at event entry check points? Yes NoIf yes, what type:Do they exercise the right of search and seizure of contraband iteams Yes NoIf yes, how do they notify the public of this?:

14.Are the alcohol sales and consumption contained by fencing within one fixed siteor are booths/stands located throughout the event site (at each event)? Yes No

15.If site is completely enclosed, are minors allowed to enter? Yes No

16. Are the servers professional (two years bartending experience or more) Yes NoAre the servers non-professional (no bartending experience) Yes NoExplain:

17. Do the servers receive any type of alcohol awareness training? Yes NoExplain:

Form 3.E

Jcollins

Text Box

18. At what location are I.D.’s checked?

19. Are rules and regulations clearly displayed for patrons’ viewing? Yes NoExplain:

20. In what size container is the alcoholic beverage served at each event? Cup ______ oz. Pitcher Other:

21. Is there a limit placed on the quantity of alcoholic beverages purchased at one time? Yes No(We require maximum of two per person per trip) Explain:

22. Is there any type of designated driver program in effect? Yes NoExplain:

23. Is there any other underlying Liquor Liability coverage being provide? Yes NoIf yes, explain and attach a copy of the certificate of insurance:

24. Limits of Liquor Liability purchased? Yes NoIf yes, what is the additional limit?

Comments:

I understand that K&K Insurance Group, Inc., or the insuring company, shall be permitted but not obligated to inspect a proposedinsureds or an insureds property and operations for underwriting purposes at any time. Neither the right to make an underwritinginspection nor the making thereof nor any report thereon shall constitute an undertaking , on behalf of or for the benefit of any insured,or others, to determine or warrant that such property or operations are safe or healthful, or in compliance with any standards, rules orregulations. Underwriting inspections when conducted are for the sole purpose of determining and/or improving the insurability of cer-tain property and operations and not safety. I also understand that an insured is solely responsible for the safety of its facilities andoperations and shall not rely upon any underwriting inspections to determine the safety of its facilities or operations and shall not dimin-ish or forego its own safety practices and procedures.

I understand that this Information Form will be relied upon by the insurance company in determining whether to provide a quotation forinsurance coverage. I hereby warrant, represent and confirm that I have read all of the questions and answers on the Information Formand that, to the best of my knowledge, all information provided in this form is complete, true and correct.

I also understand that this is not an application for insurance and that no insurance is or will be in effect unless and until the insurancecompany, or K&K as its agent, provides a quotation offering to provide insurance coverage and the insurance company, or K&K as itsagent, receives written notice that the terms and conditions contained in the insurance quotation provided are accepted.

Signature: Date:

Arkansas, Florida, Kentucky, New Jersey, New York andPennsylvania Any person who knowingly provides false information in an applicationfor insurance with the intent to defraud an insurance company or anotherperson, or who conceals any information concerning a material fact forthe purpose of misleading, commits a fraudulent act, which is a crime.

ColoradoIt is unlawful to knowingly provide false, incomplete, or misleading factsor information to an insurance company for the purpose of defrauding orattempting to defraud the company. Penalties may include imprison-ment, fines, denial of insurance, and civil damages. Any insurance com-pany or agent of an insurance company who knowingly provides false,incomplete or misleading facts or information to a policyholder orclaimant for the purpose of defrauding or attempting to defraud the poli-cyholder or claimant with regard to a settlement or award payable frominsurance proceeds shall be reported to the Colorado division of insur-ance within the department of regulatory agencies.

OhioAny person who, with intent to defraud or knowing that he is facilitating afraud against an insurer, submits an application or files a claim contain-ing a false or deceptive statement is guilty of insurance fraud.

UtahAny person is guilty of workers’ compensation insurance fraud if that per-son intentionally, knowingly, or recklessly devises any scheme or artificeto obtain workers’ compensation insurance coverage, disability compen-sation, medical benefits, goods, professional services, fees for profes-sional services, or anything of value under this chapter or Chapter 3,Utah Occupational Disease Act, by means of false or fraudulent pretens-es, representations, promises, or material omissions and communicatesor causes a communication with another in furtherance of the scheme orartifice.

OklahomaAny person who knowingly, and with intent to injure, defraud or deceiveany insurer, makes any claim for the proceeds of an insurance policycontaining any false, incomplete or misleading information is guilty of afelony.

California Any person who knowingly makes an application for motor vehicle insur-ance coverage containing any statement that the applicant resides or isdomiciled in this state when, in fact, that applicant resides or is domiciledin a state other than this state, is subject to criminal and civil penalties.

FE-68 (3/00)Form 3.E (2)

AMOUNT FEE PAID: APPROVED DATE: REJECTED RECEIVED BY: BY: TEMP. #: DATE:

APPLICATION FOR LIMITED SPECIAL OCCASION PERMIT

Check One: Individual PartnershipLimited Partnership Limited Liability Company

County: Date:

Individual's Full Name:

Date of Birth: Social Security # ____________ (last four digits only)

If representing corporation, give corporation name:

Trade Name of Location where event held:

Location of event:City State Zip Code

Special Event:Date Date

Note: A Limited Special Occasion permit allows the host of a function to furnish liquorand fortified wine to invited guests, free of charge. Guests are not permitted to bring theirown liquor. There can be no charge to attend the function. Any money collected constitutesan illegal sale of alcohol, and violators will be subject to criminal prosecution.

I have read and agree. Initial here: Type of Event:

IF PERMIT IS TO BE MAILED BY COMMISSION, GIVE NAME AND MAILING ADDRESS:NAME:MAILING ADDRESS:

where the applicant resides.

NORTH CAROLINAALCOHOLIC BEVERAGE CONTROL COMMISSION

Location: 400 EAST TRYON ROAD RALEIGH NC 27610

(919)779-0700

C. Fee is $50.00 submitted by certified check, cashier's check or money order made payable to the NC ABC.D. Submit a copy of the lease/rental agreement or complete "Lease Information Box" on the back of this form.

MAIL TO ADDRESS ON BACK OF FORM

(Do Not Write Above This Line)

A. Complete the application by printing in ink.B. Application must be notarized.

I hereby make application for a Limited Special Occasion permit which authorizes me to transport, possess, and serve fortified

E. Submit a certified copy of the applicant's Criminal Record. Can be obtained from the Clerk of Court in the county

Time Event Begins

F. The completed application must be submitted 14 days prior to the event occurance.

Street/Route

Time Event Ends

wine and spirituous liquor to my guests at a reception, party, or other special occasion. The event will be held on thepremises of a business with the permission of the owner of the property.

Corporation

(in which event takes place)

First (no abbreviations) Middle Last

SAMPLE

Form 3.F

Street/Route City State Zip Code

Day

My commission expires:

As owner/lessee of the premises, I have no objection to: _____________________________LSO Applicant

receiving a Limited Special Occasion Permit for use on said premises on the

date of Day Month Year

Owner/Lessee Signature Telephone #

( )

MAIL THIS APPLICATION TO:

- I understand that failure to abide by the ABC laws may result in the immediate revocation of my

Month Year

Signature of Applicant_________________________________________________

Sworn to and subscribed before me this the

privilege to possess or serve alcohol.

- I am not the owner or possessor of the premises applied for.

offense within the past two years.- I have not been convicted of a felony within the past three years, and if convicted of a felony before then, I have had my citizenship restored.

- I am not less than 21 years of age.

- The information on this application is correct to the best of my knowledge.

NC ABC COMMISSION4307 MAIL SERVICE CENTER RALEIGH NC 27699-4307

NC ABC COMMISSION400 EAST TRYON ROADRALEIGH NC 27610

Signature of notary or other person qualified by law to administer oaths

If sending by U.S. Postal

Service (regular mail):

If sending by U.S. Postal Service

EXPRESS MAIL or by FEDEX/UPS:

Business Telephone # Date

Lease Information

- I have the written permission of the owner of the property to serve alcoholic beverages.

I CERTIFY UNDER OATH OR AFFIRMATION THAT:

- I have not had an alcoholic beverage permit revoked within the past three years.

- I have not been convicted of a misdemeanor controlled substance offense or alcoholic beverage

Daytime Telephone #: ( ) Fax #: ( ) email address

Home Telephone #: ( ) Business Telephone #: ( )

APPLICANT INFORMATION

Resident Address:

Form 3.F (2)

Application for Limited Special Occasion Permit Rev. 10/15

SAMPLE

AMOUNT FEE PAID: APPROVED DATE: REJECTED RECEIVED BY: BY: TEMP. #: DATE:

SPECIAL ONE-TIME PERMIT APPLICATION

Application Instructions:

E. The permittee shall notify local law enforcement and have the notification signed by law enforcement. (On back of form.)

I (We) are a : Nonprofit or Political Organization, requesting authorization to Sell or Serveat a ticketed event the following:

Malt beverages Spirituous LiquorWine Permit brownbagging

The following documents are required:

NAME OF ORGANIZATION OR CANDIDATE:

LOCATION: Where event or transaction will take place

Name of Building: (if applicable)

Address:

COUNTY: ______________________ If event is being held inside the city limits, indicate city: ( In which event is to be held)

MAILING ADDRESS FOR PERMIT:

DATE(s) OF EVENT:

TIME OF EVENT: Beginning

abc.nc.gov

(Do Not Write Above This Line)

NORTH CAROLINAALCOHOLIC BEVERAGE CONTROL COMMISSION

Location: 400 EAST TRYON ROAD RALEIGH NC 27610

(919)779-0700

FOR SALE OF ALCOHOLIC BEVERAGES

A. Complete this application in its entirety. (Please print.)B. Applicant's signature must be notarized.

F. The completed application must be submitted 14 days prior to event occurrence.

made payable to the North Carolina Alcoholic Beverage Control Commission.

C. The fee for a Special One-Time permit is $50.00.D. The fee must be submitted by certified check, cashier's check, or money order, and

subsection of Section 501(c) of the Internal Revenue Code or is exempt under similarprovisions of Chapter 105 of the North Carolina General Statutes.

I hereby make application to the North Carolina Alcoholic Beverage Control Commission for a Special One-Time permit allowing the sale or service of alcoholic beverages at the event described below:

Estimated Attendance

Please check applicable box(es):

5. Certified copy of criminal record check must be submitted for individual applying for a special one-time permit.

Ending

6. A political party as defined in NC General Statute 163-96(a)(1) or (2) or a campaign organizationwhich has properly filed and has had a person certified as a candidate . Statute 163-1.

1. Lease or rental agreement between nonprofit organization and owner of the premises.2. Diagram of the actual premises showing all entrances, exits, bar areas, and where consumption

and/or sale will take place.3. Documentation to show that the organization is exempt from taxation under the appropriate

4. Purpose of fund-raiser and recipient of funds raised.SAMPLE

Form 3.G

Email: ___________________________________________________________________________________________(please print clearly)

NOTIFICATION TO LOCAL LAW ENFORCEMENT:

( )

Comments

I CERTIFY UNDER OATH OR AFFIRMATION THAT:- I am not less than 21 years of age.- I have not been convicted of a misdemeanor controlled substance offense or alcoholic beverage offense within the past two years.- I have not been convicted of a felony within the past three years, and if convicted of a felony before then, I have had my citizenship restored.- I have not had an alcoholic beverage permit revoked within the past three years. - All of the information supplied by me in this application is complete and accurate.- I understand that ABC law prohibits any type of gambling activities or equipment upon my licensed premises (even if not for profit).- I, or my agent, will personally supervise the sale of alcoholic beverages and abide by all ABC laws. - I understand that failure to abide by the ABC laws may result in the immediate revocation of my privilege to sell/serve alcohol.

Sworn to and subscribed before me this theDay

My commission expires:Signature of Notary

MAIL THIS APPLICATION TO:If sending by U.S. Postal Service If sending by U.S. Postal Service

(regular mail): EXPRESS MAIL or by FEDEX/UPS:

NC ABC COMMISSION NC ABC COMMISSIONATTN: PERMIT & PRODUCT COMPLIANCE ATTN: PERMIT & PRODUCT COMPLIANCE4307 MAIL SERVICE CENTER 400 EAST TRYON ROADRALEIGH, NC 27699-4307 RALEIGH, NC 27610

Month Year

Signature of Applicant

It is a Crime to make a false statement to obtain an ABC Permit

Middle

Date of Birth

FAX #

To be completed by an officer of the Sheriff's Office, if event is held in the County, orcompleted by an officer of the Police Department, if event is held in the City.

Home Telephone #

Telephone #Department of Officer

( ) ( ) ( ) Business Telephone #

Signature of OfficerName of Officer

First (no abbreviations)

Applicant's Home Address

Last

City State Zip Code

PERSONAL INFORMATION OF INDIVIDUAL REPRESENTING THE ORGANIZATION OR CANDIDATE:

Special One Time Permit Application for Sale of Alcoholic Beverages Rev 3/2015

SAMPLE

Form 3.G (2)

3 facilities usage & rental 3 - facilities usage & rental · 3 – facilities usage &...

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