Today s Date SECTION 1 Application for (Please check one) SPECIAL PARK MOBILE FOOD DISPENSING PERMIT City of Hollywood Special Events and / or Parks $75 /6 month permit $125 / 1 year permit MOBILE FOOD DISPENSING PERMIT Public Right of Way, City of Hollywood property, Private Property $75 /6 month permit $125 / 1 year permit Owner / Operator Business /Food Truck Name Adddress City /State /Zip Code License Number /State Telephone with Area Code Email Address SPECIAL PARK MOBILE FOOD DISPENSING PERMIT: Please continue to Section 2, below MOBILE FOOD DISPENSING PERMIT: Please continue to Section 3, below SECTION 2 Event Name Event Date(s) Services Requested (please check) Electric Water Space Requested (please check) Tables (3, maximum) Chairs (4 each, maximum)
Please continue to SECTION 4, below. SECTION 3 LOCATION(S) / Route Requested (Within the City of Hollywood) Attach MAP and Copy of Menu Date(s) / Time(s) / Duration Number of Employees Location of Parking for Employees Please note: Requested routes and stop locations may be reviewed and approved by the City Engineer. Please continue to SECTION 4, below. SECTION 4 Documentation, as stated below must be submitted at time of application: $1M general liability, City of Hollywood stated as Additional Insured and Certificate Holder $100K automobile insurance, City of Hollywood stated as Additional Insured and Certificate Holder Indemnification Agreement (form provided by City of Hollywood) Proof of City of Hollywood Fire Marshal inspection (annually updated) SafeServ Food Service Certificate (National Restaurant Association) Mobile Kitchen Business and Professional Regulation License (issued from State of Florida) City of Hollywood Business Tax Receipt Map of locations and Site Plan Menu
PLEASE READ THE FOLLOWING STATEMENT AND SIGN BELOW: I affirm that all information that I have provided is true and correct. I further acknowledge that I will be subject to all penalties prescribed by law for providing any false information to the City. I understand that the requested permit, if approved, will be issued to the Mobile Food Dispensing operator subject to applicable fees payable to the City of Hollywood. I also understand that these conditions will be made part of the permit. Food Truck Owner / Operator (Print Name) Signature Date STATE OF FLORIDA ) COUNTY OF BROWARD ) The foregoing instrument was acknowledged before me this day of, 20 by and who is personally known to me; or produced the following identification. My Commission Expires: NOTARY PUBLIC State of Florida Submit this completed, notarized application, application fee and documents appearing in SECTION 4 to: City of Hollywood Department of Parks, Recreation and Cultural Arts SPECIAL EVENTS P. O. Box 229045, Hollywood, Florida 33022-9045 To submit in person: Department of Parks, Recreation and Cultural Arts 1405 S. 28th Avenue, Hollywood, FL 33020
INDEMNIFICATION AGREEMENT THIS INDEMNIFICATION AGREEMENT made and entered into this day of,20, among the City of Hollywood, Florida, a municipal corporation of the State of Florida ( City ), and the City of Hollywood, Florida, Community Redevelopment Agency ( CRA ) and ( Vendor ). I,, Vendor or Company Name individually and/or as the agent of the Vendor performing Service performed or Product being sold ( Services ) do hereby agree to indemnify and hold harmless the City, and CRA, their officers, agents, employees and contractors from and against any and all loss, damage, claim, demand, liability or expense by reason of any damage or injury to property or person which may be claimed to have arisen as a result of or in connection with the occupancy or use of said premises by Vendor performing Services. During the conduct of a at Name of Event on the date. Location of Event Such obligation to indemnify and hold harmless shall continue notwithstanding any negligence or comparative negligence on the part of the City and/or CRA relating to such loss or damage and shall include all costs, expenses and liabilities incurred by the City and/or CRA in connection with any such claim, suit action or cause of action, including the investigation thereof and the defense of any action or proceeding brought thereon and any order, judgment or decree which may be entered in any such action or proceeding or as a result thereof. These provisions shall survive the expiration or earlier termination of the use of premises. Nothing in this Agreement shall be construed to affect in any way the City nor the CRA s rights, privileges, and immunities as set forth in Florida Statutes section 768.28. Signature Title Print Name Daytime phone number Email Address (Please Print) Address City State Zipcode APPROVED AS TO FORM AND LEGALITY For the use and reliance of the City of Hollywood, Florida, and The City of Hollywood, Florida, Community Redevelopment Agency only. JEFFREY P. SHEFFEL, CITY ATTORNEY