Fillable Application for Parades, (Town of Brookhaven)

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Application for Parades, (Town of Brookhaven)

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BROWSE TOWN OF BROOKHAVEN (NY) FORMS

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Application for Parades,
Road Races or Similar Events
TC-20 rev. 2/20 Donna Lent, Town Clerk
Lauren Thoden, Deputy Town Clerk
One Independence Hill, Farmingville, NY 11738
(631) 451-9101 FAX: 451-9264
1 of 6
APPLICATION MUST BE FILED IN TRIPLICATE
Application is hereby made to the Town Clerk of the Town of Brookhaven for issuance of a permit as hereinafter
specified. In the event that this application is granted, we do hereby agree to comply with the Ordinance as adopted
by the Town of Brookhaven and to read as follows:
ARTICLE III - PARADES AND PROCESSIONS
§ 4-11.
Permit required, exceptions:
N
o person, firm, corporation or other entity shall organize, conduct or take part in any parade upon any town
highway, public street or any other public place in the Town of Brookhaven without a permit issued therefor by
the Town Clerk. Such permit shall not be required for any funeral procession for the actual burial of the dead and
processions to and from a place of worship in connection with a religious service there celebrated. The discharge
of firearms or fireworks and the making of other unreasonable noise during funeral processions are prohibited.
§ 4-12
. Permit application:
A
ll applications for permits issued pursuant to this Article shall be in writing, stating the purpose thereof, and shall
be signed by an officer of such organization. Such application shall be submitted to the Town Clerk at least fifteen
(15)
day
s prior to the date such parade is to be held.
§ 4-13
. Permit restrictions, revocation:
A
ny parade held pursuant to a permit issued by the Town Clerk shall only take place upon those highways
and parts of highways or public streets as shall be specified by the Town Clerk in the permit. The Town Clerk
may revoke such permit upon the recommendation of the Highway Department, Department of Traffic Safety,
Department of Public Safety of the Town of Brookhaven, the local Fire Department or the Suffolk County Police
Department.
§ 4-14
. Penalties for offenses:
A
ny person taking part in or causing to conduct a parade without permit issued therefor pursuant to this Article shall
be guilty of a misdemeanor punishable by a fine not to exceed five hundred dollars ($500.00) or by imprisonment
not to exceed ninety (90) days, or by both.
***APPLICATION MUST BE FILED IN TRIPLICATE***
ALL ROUTES MUST CONTAIN POINTS OF INGRESS AND EGRESS FOR RESIDENTIAL AREAS.
RESIDENTS ALONG THE ROUTE MUST BE NOTIFIED AT LEAST TWO WEEKS PRIOR TO THE EVENT.
A copy of the Waiver/Liability Release and Hold Harmless must be signed and notarized by the applicant
AND by any person, entity or organization coordinating, managing or operating the event.
P
lease feel free to contact the Town Clerk’s Office at 451-9124 if you need any assistance in completing this
application.
Application for Parades,
Road Races or Similar Events
TC-20 rev. 2/20
Donna Lent, Town Clerk
Lauren Thoden, Deputy Town Clerk
One Independence Hill, Farmingville, NY 11738 (631)
451-9
101 FAX: 451-9264
2 of 6
1. Date: 2. Exact Name of Organization: 3. By:
4. Name of Organization or Institution Applying for Permit:
5. Address of Said Organization: Number and Street, Town, State Zip
6. Is the organization a local religious, fraternal, educational, political, civic,
veterans, firefighters, non-profit or charitable organization?
Yes No
7. Set forth exact dates and time for said event for which permit is sought:
Date(s): ________________________________ Begin time: ___________________ End time: ___________________
8. Set forth name, address & phone numbers of Chairperson or Manager to be in control of the said event for which permit is sought:
Name
: ____________________________ Home Telephone: ___________________ Business Telephone: ___________________
Address:
__________________________________________________________________________________________________
9. Set forth detailed description of the entertainment features and each of the activities of such event for which permit is sought:
Number of bands
: _________ Number of marching units: _________ Number of floats: _________ Number of vehicles: _________
Total number of participants (approximate):
___________ Other: _____________________________________________________
Comments:
_______________________________________________________________________________________________
10. Set forth purpose for which permit is sought:
11. Will the equipment to be used for such event be solely in the ownership and
control of the applicant organization?
Yes No
12. If the answer to the preceding question is “No”, state the name(s) and address(es) of the owner(s) and lessor(s) of such
equipment and the arrangements under which such equipment is to be used (hired, leased, loaned):
13. Is there a school, library, church, hospital, firehouse, etc. that will be affected by the participants?
If yes, kindly notify the appropriate authority at the location
at least one month prior to the event. Yes No
14.Has your organization held this event in the past? Yes No If yes, when:
15. Set forth detailed description of the street or streets and in what area such event will take place:
Street(s)
: ____________________________________________ Area: ____________________________________________
“Form up” will be at (location):
_______________________________________________________________________________
Application for Parades,
Road Races or Similar Events
TC-20 rev. 2/20
Donna Lent, Town Clerk
Lauren Thoden, Deputy Town Clerk
One Independence Hill, Farmingville, NY 11738 (631)
451-9
101 FAX: 451-9264
3 of 6
N
W E
S
16. Describe the exact route event will follow from the starting place to the ending place, including streets and highways. All routes
must contain points of ingress and egress for residential roads. Complete diagram of the route the event will follow (see below):
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
____
______________________________________________________________________________________________________
__________________________________________________________________________________________________________
17. Does any part of this route enter an incorporated village? If yes, please list the streets that are within the village below.
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Please note you will need to obtain authorization from the Villa
ge for this portion of the route.
17. Set forth detailed statement of any noise-making devices to be operated or maintained:
__________________________________________________________________________________________________________
18. Include Certificate of Insurance showing your organization’s coverage of not less than one million dollars
($1,000,000.00). The Town of Brookhaven must be named on certificate.
19. What Fire Department(s) and Ambulance District(s) have jurisdiction over the area your parade will be marching in?
__________________________________ __________________________________ __________________________________
PARADE ROUTE DIAGRAM
Application for Parades,
Road Races or Similar Events
TC-20
rev. 2/20
Donna Lent, Town Clerk
Lauren Thoden, Deputy Town Clerk
One Independence Hill, Farmingville, NY 11738
(631) 451-9101 FAX: 451-9264
4 of 6
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.
_______________________________
By:
________________________________________________________________
DATE SIGNATURE
________________________________________________________________
NAME OF APPLICANT
________________________________________________________________
TITLE OF APPLICANT
________________________________________________________________
NAME OF ORGANIZATION
Application having been made for the permit as above set forth and subject to the terms
and expressed conditions and limitations contained therein, the above application for
permit is granted as requested for the operation of the event specified above. It is expressly
understood that this permit is issued subject to the provisions herein specified and may be
revoked or cancelled without notice.
_______________________________
By:
________________________________________________________________
DATE TOWN CLERK OF THE TOWN OF BROOKHAVEN
Application for Parades,
Road Races or Similar Events
TC-20 rev. 2/20 Donna Lent, Town Clerk
Lauren Thoden, Deputy Town Clerk
One Independence Hill, Farmingville, NY 11738
(631) 451-9101 FAX: 451-9264
5 of 6
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
Application for Parades,
Road Races or Similar Events
TC-20 rev. 2/20 Donna Lent, Town Clerk
Lauren Thoden, Deputy Town Clerk
One Independence Hill, Farmingville, NY 11738
(631) 451-9101 FAX: 451-9264
6 of 6
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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Application for Parades, (Town of Brookhaven)

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Completed 12 February 2021

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