575 Dorset Street South Burlington, VT 05403 tel 802.846.4106 fax 802.846.4101 www.sburl.com
Permit Number ______-__________
(office use only)
APPLICATION FOR PEDDLER’S PERMIT
1) APPLICANT
a. Home Address: ___________________________________________ Phone: ____________
___________________________________________
b. Business Address: ___________________________________________ Phone: ____________
___________________________________________
2) NAME OF EMPLOYEES (no more than two (2): ________________________________________
___________________________________________________________________________________
3) APPLICANT’S EMPLOYER/SPONSOR: _____________________________________________
a. Employer’s/sponsor’s address: _______________________________________________________
_______________________________________________________
b. Employer’s/sponsor’s phone: __________________
4) REQUESTED DATE FOR START OF PERMIT _______________________________________
5) REQUESTED DATE FOR END OF PERMIT__________________________________________
6) IF PEDDLING FROM A FIXED LOCATION, PROVIDE ADDRESS:
___________________________________________________________________________________
7) PROVIDE A DESCRIPTION OF THE GOODS TO BE PEDDLED:
____________________________________________________________________________________
____________________________________________________________________________________
8) DESCRIBE THE MANNER to be used in offering goods for sale, and in the case of fresh produce,
whether such items are the produce of lands owned or rented by the applicant or his/her sponsor:
2 Peddlers Permit Form. Rev. 5-2011
____________________________________________________________________________________
____________________________________________________________________________________
9) IF A MOTOR VEHICLE OR TRAILER is to be used, provide a description of same together with
license number, registration number or other identification:
____________________________________________________________________________________
____________________________________________________________________________________
10) HAS THE APPLICANT / SPONSOR been convicted of any crime or municipal ordinance
violation? Yes No
(a) If yes, include a description of the offense and the penalty assessed:
_________________________________________________________________________________
_________________________________________________________________________________
11) PROVIDE IDENTIFICATION OF ANY LIABILITY INSURANCE POLICIES, including a
statement of policy limits, available to cover any injury or damage resulting from the applicant’s
activities in South Burlington:
____________________________________________________________________________________
12) This application must be accompanied by a photograph of the applicant and each employee (if any)
taken within sixty days of the date the application is filed. The picture(s) shall be 2 inches by 2 inches,
clearly depicting head and shoulders. By signing this application, the applicant attests that the above
information is true to the best of his/her knowledge, and that applicant has read the City of South
Burlington Ordinance to Regulate Peddling and agree to comply with its terms.
13) Applicant Signature:________________________________________
Print Name: _____________________________________________Date: ____________________
14) Property Owner Signature (if fixed location):____________________________________________
Print Name: ____________________________________________Date: _____________________
_______
_
____________________________________________________________________________
Do not write below this line
DATE OF SUBMISSION:_____________________
Approved Denied
_
_______________________________________________________
Administrative Officer Date
3 Peddlers Permit Form. Rev. 5-2011
Certificate of Appointment of Registered Agent
To: The City Manager of South Burlington, Vermont
Pursuant to section 2D of the City of South Burlington Ordinance to Regulate Peddling,
_________________________________ hereinafter referred to as “Applicant”, does hereby
nominate and appoint the City Clerk of the City of South Burlington as Applicant’s true and lawful
agent with full power and authority to acknowledge service of notice or process for or on behalf of
Applicant, in respect to any matters connected with or arising out of business transacted under the
above said Ordinance.
Applicant expressly consents and agrees that service of any notice or process may be made upon the
City Clerk when so made shall be taken and held to be valid as if personally served upon Applicant
according to the law of this or any other state.
Applicant waives all claim or right of error by reason of such acknowledgement of service or manner
of service.
Applicant directs that any notice or process served on the City Clerk should be sent to the address
stated below and said address shall be Applicant’s last known address until such time as a new
certificate is delivered by Applicant to City Manager.
Address: _________________________________________________________________________
_________________________________________________________________________
Dated at South Burlington, this ________ day of ____________________, ________
Applicant’s Signature: ______________________________________________________________
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