Fillable Amusement Device License and Operator Permit for Game (Town of Brookhaven)

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Amusement Device License and Operator Permit for Game (Town of Brookhaven)

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Amusement Device License Application
rev. 12/15
Donna Lent, Town Clerk
Lauren Thoden, Deputy Town Clerk
One Independence Hill, Farmingville, NY 11738
(631) 451-9101 FAX: 451-9264
1
Amusement Device License and Operator Permit
for Game Rooms and Accessory Game Rooms
Instruction Sheet
Application Check List
_____ Completed Application
_____ Copy of current Game Room Permit issued by the Zoning Board of
Appeals
_____ Application Fee (Game Room with more than three games: $50.00/
Accessory Game Room with no more than three games: $25.00)
After your application has been reviewed and approved by all required
departments, you will be notified by the Town Clerk’s Office. After initial
approval please submit the following:
_____ Two 1” x 1” photographs of the amusement device operator
_____ Fee of $50.00 for the Operator’s Permit
_____ Fee of $25.00 per amusement device
Should you have any questions concerning the permitting procedure
outlined above, please contact the Town Clerk’s Office at 451-9124.
If you have any questions concerning the Building Codes, please contact
the Building Department at 451-6333.
Amusement Device License Application
rev. 12/15
Donna Lent, Town Clerk
Lauren Thoden, Deputy Town Clerk
One Independence Hill, Farmingville, NY 11738
(631) 451-9101 FAX: 451-9264
2
Town of Brookhaven
Application for Amusement Device License
Pursuant to Chapter 34A of Town Code
1. Applicant Information Name: __________________________________
Address: __________________________________
__________________________________
Telephone: __________________________________
2. Operator Information Name: __________________________________
(if different from
applicant) Address: __________________________________
__________________________________
Telephone: __________________________________
3. Has operator ever been convicted of __________________________________
a crime? If yes, list dates and nature __________________________________
of offenses: __________________________________
4. Supplier Information Name: __________________________________
(if more than one, list all Address: __________________________________
suppliers on a separate sheet) __________________________________
Telephone: __________________________________
5. Name and Address of premises __________________________________
where devices are located: __________________________________
__________________________________
6. Number of devices on premises: __________________________________
7. Hours of operation: __________________________________
THE UNDERSIGNED AFFIRMS, UNDER PENALTIES OF PERJURY, THAT THE ABOVE
STATEMENTS ARE TRUE AND ACCURATE.
Sworn to before me on this ____
day of _____________ 20____
________________________________
Signature of Applicant
________________________________
Notary Public
For Official Use Only
License #:
Receipt #:
Date:
Amusement Device License Application
rev. 12/15
Donna Lent, Town Clerk
Lauren Thoden, Deputy Town Clerk
One Independence Hill, Farmingville, NY 11738
(631) 451-9101 FAX: 451-9264
3
________________________________________________________________________________
For Building Department Use Only
Zone:
_________________________________
Verification of Location:
_________________________________
Distance from Schools: within 500’ _________________________________
within 2500’
_________________________________
Certificate of Occupancy #
________________________________
Issued:
_________________________________
Certificate of Existing Use #
________________________________
Issued:
_________________________________
Certificate of Zoning Compliance #
________________________________
Issued:
_________________________________
Zoning Violations (list):
_________________________________
_________________________________
_________________________________
State Building Code Violations (list)
_________________________________
_________________________________
_________________________________
COMMENTS: ________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
By
_______________________________
Date
______________________________
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Amusement Device License and Operator Permit for Game (Town of Brookhaven)

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Completed 12 February 2021

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