Fillable Amusement/Event Application Lauren Thoden, Deputy Town Clerk All (Town of Brookhaven)

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Amusement/Event Application Lauren Thoden, Deputy Town Clerk All (Town of Brookhaven)

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Amusement/Event Application
TC-06 rev. 2/20Donna Lent, Town Clerk
Lauren Thoden, Deputy Town Clerk
One Independence Hill, Farmingville, NY 11738
(631) 451-9101 FAX: 451-9264
Page 1 of 7
All amusements are prohibited in Brookhaven Town except those conducted under the sole
management and for the profit of local religious, fraternal, political, educational, veterans, fire
department, civic, non-profit, or charitable organizations when authorized by a permit issued by
the Town Clerk.
Amusement Time Limits: No more than fourteen (14) days duration.
Permissible Event Hours: Sunday through Thursday - 9:00 AM - 10:30 PM
Friday and Saturday - 9:00 AM - 11:30 PM
Any tents, rides, structures, electrical wiring and equipment shall be in place and operational for
purposes of inspection by Town and State Officials no later than 12 PM (Noon) of the last
Town/State business day prior to the scheduled opening the following day. There is an additional
fee for inspections that do not occur during normal business hours.
Application Requirements:
1. ALL PERMIT APPLICATIONS MUST BE SUBMITTED WITH ALL REQUIRED
DOCUMENTS AT LEAST FIFTEEN (15) DAYS PRIOR TO THE COMMENCEMENT OF
SUCH AMUSEMENT.
Any event application that involves an audience capacity or attendees in excess of 1,000
persons must be submitted with all required documents at least sixty (60) days prior to the
commencement of such event. All rodeo applications must be submitted at least 60 days
prior to the event date.
Pursuant to Part 18 of the New York State Sanitary Code, any public function with an
estimated peak attendance of 5,000 or more requires a New York State Permit for a Public
Gathering. Please call Suffolk County Health Services at (631) 853-3130 for a permit
application.
2. Completed application must be submitted in TR
IPLICATE with $100 non-refundable fee.
3. Fill out all spaces in Amusement Application. Carnival operators are to be listed under
“Names and Addresses of Individual Operators/Exhibitors/Vendors” on page 2.
4. If you will be serving food, you must contact the Suffolk County Health Department at (631)
852-5997 for Health Department requirements.
5. Application must be submitted with all required documents (see list on next page).
Amusement/Event Application
TC-06 rev. 2/20
Donna Lent, Town Clerk
Lauren Thoden, Deputy Town Clerk
One Independence Hill, Farmingville, NY 11738
(631) 451-9101 FAX: 451-9264
Page 2 of 7
Required Documents (must accompany completed application):
A. LIABILITY INSURANCE CERTIFICATE – Certificate shall include the Town of Brookhaven
as additional insured and shall not be cancelled without fifteen (15) days prior notice of
cancellation to the Town Clerk.
Public liability insurance is required in limits of not less than one million dollars ($1,000,000)
combined single limit for both bodily injury to or death of any one (1) or more persons and for
damage to or destruction of property. Additional insurance coverage may be requested if
deemed necessary.
**Circus applications require proof of general liability insurance in an aggregate amount of no
less than two million dollars ($2,000,000) and an excess liability insurance policy of ten
million dollars ($10,000,000), covering the period that Members of the Circus will be on site
including the setup and dismantling of the show. In addition, you must submit a certificate of
insurance for commercial auto liability in the amount of one million dollars ($1,000,000) and
proof of New York State Workers Compensation and New York State Disability Insurance.
Please note certificates must include the Town of Brookhaven as additional insured
and shall not be cancelled without fifteen (15) days prior notice of cancellation to the Town
Clerk.
B. CERTIFIED CHECK/SURETY BOND (FOR ADVANCE TICKET SALES ONLY) – Surety for
refund $5,000 (In the event that one or more performances of amusement are cancelled or
that ticket holders are refused admission on account of limited seating or capacity limitations
imposed).
C. LETTER FROM APPLICANT ORGANIZATION – On letterhead stating that the organization
will be responsible for clean up of the amusement site and naming the operator of
amusement rides and booths, if applicable.
D. LETTER OF PERMISSION FROM PROPERTY OWNER – If amusement site is owned by
the applicant organization, please state so in above letter.
E. VALID REGISTRATION FROM SECRETARY OF STATE (FOR PROFESSIONAL
FUNDRAISER OR COMMERCIAL CO-VENTURER ONLY) - see Item 31 on page 4.
F. INCORPORATION PAPERS – Submit copy of applicant organization’s legal Incorporation
papers.
G. WAIVER/LIABILITY RELEASE AND HOLD HARMLESS AGREEMENT – A copy of this
agreement must be signed and notarized by the applicant AND by any person, entity or
organization coordinating, managing or operating the event. Entities and organizations
owning and/or operating rides must complete and return this agreement.
Please feel free to contact the Town Clerk’s office at 451-7093 or 451-9120 if you need any
assistance in completing this application.
Amusement/Event Application
TC-06 rev. 2/20Donna Lent, Town Clerk
Lauren Thoden, Deputy Town Clerk
One Independence Hill, Farmingville, NY 11738
(631) 451-9101 FAX: 451-9264
Page 3 of 7
Please check appropriate Amusement/Event.
Carnival _____ Circus _____ Outdoor _____ Show _____ Fair _____ Other _____
1. NAME OF NON-PROFIT ORGANIZATION 2. DATE ORGANZATION WAS FORMED:
3. ADDRESS OF ORGANIZATION: NUMBER AND STREET TOWN STATE ZIP
4.VALID REGISTRATION NUMBER FROM SECRETARY OF STATE: 5. NAME OF ORGANIZATION’S REPRESENTATIVE AND POSITION:
6. ADDRESS OF REPRESENTATIVE: NUMBER AND STREET TOWN STATE ZIP
7. HOME TELEPHONE NUMBER: 8. BUSINESS TELEPHONE NUMBER: 9. DATE OF BIRTH: 10. SOCIAL SECURITY NUMBER:
11. HAVE YOU BEEN CONVICTED OF A FELONY? IF YES, EXPLAIN:
12. PURPOSE OF AMUSEMENT/EVENT AND DISPOSITION OF PROCEEDS:
13. LOCATION OF AMUSEMENT/EVENT :
SUFFOLK COUNTY TAX MAP NUMBER (SECTION BLOCK LOT):
14. FULL DESCRIPTION OF AMUSEMENT/EVENT ACTIVITY:
15. ANTICIPATED NUMBER OF ATTENDEES: 16. DATES AND HOURS OF AMUSEMENT/EVENT:
17. HAVE YOU HELD THIS EVENT IN THE PAST? IF YES, PROVIDE DATES:
18. WILL ALCOHOLIC BEVERAGES BE SERVED? IF YES, WHAT KIND? 19. STATE LIQUOR AUTHORITY PERMIT #: 20. WILL FOOD BE SERVED?
*ALL DRINKS, ALCOHOLIC AND NON-ALCOHOLIC BEVERAGES MUST BE DISPENSED IN PAPER CUPS ONLY*
21. WILL THERE BE LIVE ENTERTAINMENT? IF YES, WHAT TYPE? 22. WILL THERE BE FIREWORKS? IF YES WHEN? 23. WILL THERE BE CARNIVAL RIDES?
24. WILL THERE BE CRAFT SALES? 25. WILL ANY LIVE ANIMALS BE USED? IF YES, EXPLAIN: 26. WILL THERE BE GAMES OF CHANCE?
27. WILL ANY ROADS BE CLOSED TO VEHICULAR TRAFFIC? IF YES, LIST.
28.
NAMES & ADDRESSES OF INDIVIDUAL OPERATORS/EXHIBITORS/VENDORS
*IF MORE SPACE IS NEEDED, PLEASE LIST ON ADDITIONAL SHEET OF PAPER.
NAME
ADDRESS
DATE OF BIRTH
SOCIAL SECURITY #
Receipt #: ________________
Amusement/Event Application
TC-06 rev. 2/20
Page 4 of 7
}SS:
Donna Lent, Town Clerk
Lauren Thoden, Deputy Town Clerk
One Independence Hill, Farmingville, NY 11738
(631) 451-9101 FAX: 451-9264
51-9
29.
RIDES
*IF MORE SPACE IS NEEDED, PLEASE LIST ON ADDITIONAL SHEET OF PAPER.
NAME OF RIDE
NAME OF OWNER OF
RIDE
ADDRESS OF OWNER OF RIDE
Amusement rides must be set-up and ready for inspection by 12 PM (Noon) the last business day before the opening day of the
event. Failure to comply may result in a denial of the Amusement Permit.
30. Does any person or firm other than the charitable organization making this application conduct, promote, underwrite or
sponsor the event and/or have control over the disposition of proceeds? Yes No
(If charitable organization receives a flat fee or only a percentage of the proceeds from the carnival operator, the answer to the
above question
is
yes.)
31. If yes, please provide name and address of person or firm that has control over the distribution of the proceeds. (Please refer to item E, in the
instructions
,
requiring
Professional Fundraisers or Commercial Co
-
Venturer to provide
proof of registration with
the Secretary of State).
NAME: ADDRESS:
STATE OF NEW YORK
COUNTY OF SUFFOLK
I, _____________________________________, being duly sworn deposes and says that I am the above named
applicant and that I make this application to obtain a permit to conduct the amusement/event described herein as
required by the Code of the Town of Brookhaven, regulating conduct of persons therein, defining offenses and
providing penalties for violation thereof. I have personal knowledge that the matters stated in the within application
and its attachments herein contained are true. I make this application under penalty of perjury and swear to the truth
herein. Any representations and/or statement in this application that are found to be materially inaccurate may result
in denial of permit or revocation of permit.
_______________________
____________________________________
Date Applicant Signature
Sw
orn to before me this ______day of _________________, ___________.
____________________________________
Notary Public
Amusement/Event Application
TC-06 rev. 2/20Donna Lent, Town Clerk
Lauren Thoden, Deputy Town Clerk
One Independence Hill, Farmingville, NY 11738
(631) 451-9101 FAX: 451-9264
Page 5 of 7
SITE PLAN OF PROPOSED AMUSEMENT/EVENT ACTIVITY
Please supply the following:
1. Realistic description, with accurate footage and setbacks, of where the amusements and on-site parking will be
located.
2. Location of generators, indicating distance from closest residences.
3. Nearest cross street to the proposed site.
4. The location of all areas to be designated as entrances and exits to the proposed site.
5. An original survey of the property.
6. Minimum 50’ setback required off all public roadways.
7. If applicable, attach notarized statement of from true property owner stating nature, extent and duration of event/
amusement and granting permission to operate event/amusement on premises.
8. Attach separate list of number & types of displays, shows, exhibits, booths, pavilions, contest & rides (license
subject to revocation pending inspection of rides by NYS Department of Labor representative).
9. Attach a notarized letter from applicant to restore and clean site to prior condition.
N
OFFICIAL USE ONLY
This permit is approved subject to the Provisions of Chapter 4 of the Brookhaven Town Code, entitled “Amusements”, and any other
conditions so noted in the enclosed letter.
DATE: SIGNATURE, TOWN CLERK OF THE TOWN OF BROOKHAVEN:
Amusement/Event Application
TC-06 rev. 2/20
Donna Lent, Town Clerk
Lauren Thoden, Deputy Town Clerk
One Independence Hill, Farmingville, NY 11738
(631) 451-9101 FAX: 451-9264
Page 6 of 7
WAIVER/LIABILITY RELEASE AND HOLD HARMLESS
(Name)_______________________________,(address)_______________________________,
New York, hereby assumes all liability and all risks in the performance of the (Name of Event)
_________________________________ at (Location)______________________________
and undertakes complete responsibility for all acts undertaken by the undersigned in connection
with the event on the Town of Brookhaven premises/property located at
(Location)___________________________ New York, during the period, commencing on or
about (Date)__________________ through__________________.
The undersigned, its agents, servants, employees, invitees, volunteers and successors and
assigns further agree to save harmless and forever indemnify the Town of Brookhaven, its
officers, agents, servants, and employees, enumerated volunteers, from any and all liabilities,
damages, claims, expenses, suits, arbitrations, judgments and/or executions plus attorney’s fees
and the costs of investigation for any bodily injury, personal injury, wrongful death and property
damage arising out of or in any way connected to the event herein.
The undersigned, its agents, servants, employees, invitees, volunteers and successors and
assigns further agree that it will indemnify and hold harmless the Town of Brookhaven, it’s
officers, employees, agents and non-remunerated volunteers from any claims made by any
person for any loss, damage or injury resulting from or arising out of any acts or omissions of the
undersigned or any other persons acting on behalf of the undersigned, with regard to or in
Amusement/Event Application
TC-06 rev. 2/20
Donna Lent, Town Clerk
Lauren Thoden, Deputy Town Clerk
One Independence Hill, Farmingville, NY 11738
(631) 451-9101 FAX: 451-9264
Page 7 of 7
connection with the event. The undersigned’s responsibility under this section shall not be
limited to the required or available insurance coverage.
Dated:______________________ Signed:_____________________________
Print Name:__________________________
Acknowledgement of Corporation
STATE OF NEW YORK)
SS.:
COUNTY OF SUFFOLK)
On the ____________ day of _________________ in the year 20___ before me personally
came _____________________________ to me known, who, being by me duly sworn, did
depose and say that he/she/they reside(s) in
___________________________________________ (if the place of residence is in a city,
include the street and street number, if any, thereof); that he/she/they is (are) the
__________________________ (president or other officer or director or attorney in fact duly
appointed) of the (name of corporation), the corporation described in and which executed the
above instrument; and that he/she/they signed his/her/their name(s) thereto by authority of the
board of directors of said corporation.
______________________________
Notary Public
Acknowledgement of Individual
STATE OF NEW YORK)
SS.:
COUNTY OF SUFFOLK)
On the _____ day of _______________ in the year 20___ before me, the undersigned, a Notary
Public in and for said State, personally appeared__________________________, personally
known to me or proved to me on the basis of satisfactory evidence to be the individual(s) whose
name(s) is (are) subscribed to the within instrument and acknowledged to me that he/she
executed the same in his/her capacity, and that by his/her signature(s) on the instrument, the
individual(s), or the person upon behalf of which the individual(s) acted, executed the instrument.
_______________________________________
Notary Public
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AmusementEvent Application Lauren Thoden, Deputy Town Clerk All (Town of Brookhaven)

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Completed 12 February 2021

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