1.     Text Box: TOWN OF HAVERHILL JAMES R. MORRILL MUNICIPAL BUILDING USE OF GYMNASIUM POLICY AN APPLICATION FOR USE WILL BE FULLY COMPLETED AND APPROVED PRIOR TO ANY AUTHORIZED USAGE
OF THE GYMNASIUM.

2.     ANY USAGE INVOLVING CHILDREN WILL BE PROPERLY SUPERVISED BY APPLICANT/ORGANIZATION.

3.     THERE WILL BE NO ALCOHOL OR TOBACCO USE IN THE BUILDING OR ON THE PREMISES.

4.     A CUSTODIAN WILL BE ON DUTY BEFORE, DURING AND AFTER THE EVENT TO ALLOW FOR PROPER OPENING AND CLOSING OF THE PREMISES. CUSTODIAL SERVICES MAY BE CHARGED AT TWICE THE NORMAL CUSTODIAL HOURLY WAGE RATE.

APPLICATION FOR USE OF GYMNASIUM

AT MUNICIPAL BUILDING
 








I. APPLICANT INFORMATION

 

 

NAME:_____________________________________________________________________________________________________

 

ORGANIZATION:___________________________________________________________________________________________

 

MAILING ADDRESS:________________________________________________________________________________________

 

TELEPHONE NUMBER (S):___________________________________               ________________________________________

 

 

II. USE OF GYMNASIUM

 

PURPOSE:________________________________________________________________________________________________________________________
                       

                        ________________________________________________________________________________________________________________________
                       

                        ________________________________________________________________________________________________________________________

 

 

DATE (S):__________________________________

 

HOURS:___________________________________

 

NUMBER OF PARTICIPANTS/ATTENDEES:_____________________________________________________________________

 

CUSTODIAL PREPARATION NEEDED:                                      YES (  )             NO (  )

 

CUSTODIAL CLEANUP NEEDED:                                              YES (  )             NO (  )

 

CUSTODIAL SERVICES MAY BE CHARGED AT TWICE THE NORMAL WAGE RATE.

 

 

 

 

 

III. INSURANCE & INDEMNIFICATION

 

AS A CONDITION OF PERMISSION TO USE THE J. R. MORRILL MUNICIPAL BUILDING GYMNASIUM ON THE SPECIFIED DATES AND TIMES THE APPLICANT HEREBY AGREES TO RELEASE AND HOLD HARMLESS THE TOWN OF HAVERHILL, NH, ITS AGENTS AND EMPLOYEES, FROM ANY AND ALL LIABILITY, DAMAGES OR OTHER EXPENSES, INCLUDING ATTORNEY FEES, THAT MAY RESULT FROM THE USE OF THE PREMISES BY THE APPLICANT.

 

AS A CONDITION OF THIS AGREEMENT, THE APPLICANT HAS SECURED GENERAL LIABILITY INSURANCE TO COVER ITSELF AND TO PROPERLY INDEMNIFY THE TOWN OF HAVERHILL, NH FOR ANY AND ALL CLAIMS FOR DAMAGES OR EXPENSES, INCLUDING ATTORNEY FEES, THAT THE TOWN MAY INCUR AS A RESULT OF ANY DAMAGE OF LOSS SUFFERED BY ANY INDIVIDUAL OR ORGANIZATION AS A RESULT OF THE USE OF OCCUPANCY OF THE PREMISES BY THE APPLICANT.*

 

DATED THIS____________________DAY OF _________________________,20_______.

 

 

                                                                                                _______________________________________________

                                                                                                                   ORGANIZATION/APPLICANT

 

BY:______________________________________________

 

*AN ACORD CERTIFICATE OF INSURANCE WILL BE FILED WITH THE TOWN OF HAVERHILL AT THE TIME OF   
 APPLICATION FOR USE OF BUILDING DETAILING COVERAGE LIMITS, COMPANY NAME AND ADDRESS AND 
  SIGNED BY A COMPANY AGENT.

 

 

IV. FEES

 

USAGE FEE OF $50.00 (FIFTY) DOLLARS FOR NON-PROFIT AND SERVICE ORGANIZATIONS, $200.00 (TWO HUNDRED) DOLLARS FOR PRIVATE OR COMMERCIAL CONCERNS IS TO BE INCLUDED WITH SUBMISSION OF APPLICATION AND CERTIFICATE OF INSURANCE. IF WAIVER/ABATEMENT IS GRANTED APPROPRIATE REFUND OF USAGE FEE WILL BE MADE.

 

V. REQUEST FOR ABATEMENT/WAIVER

 

______REQUEST IS HEREBY MADE FOR WAIVER OF INSURANCE AND INDEMNIFICATION AGREEMENT
 REQUIREMENT (SECTION III) BY:

 

                                                                                                ________________________________________________
                                                                                                 APPLICANTŐS SIGNATURE

 

DETAILED REASONS FOR WAIVER REQUEST:

 

____________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________

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FOR TOWN OFFICIALS USE ONLY

 

APPLICATION APPROVED___________________________________         FEE_________________________________

 

INSURANCE & INDEMNIFICATION WAIVER APPROVED_______________________________________________________

 

COMMENTS________________________________________________________________________________________________

                      ________________________________________________________________________________________________

                    ________________________________________________________________________________________________