Fillable Donna Lent, Town Clerk (Town of Brookhaven)

Fill Online, Printable, Fillable, Blank Donna Lent, Town Clerk (Town of Brookhaven) Form

Use Fill to complete blank online TOWN OF BROOKHAVEN (NY) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Donna Lent, Town Clerk (Town of Brookhaven)

On average this form takes 10 minutes to complete

The Donna Lent, Town Clerk (Town of Brookhaven) form is 6 pages long and contains:

  • 0 signatures
  • 0 check-boxes
  • 38 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Town of Brookhaven

BROWSE TOWN OF BROOKHAVEN (NY) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Drive-In Movie Theater Amusement Application
TC-06 rev. 06/20
Donna Lent, Town Clerk
Lauren Thoden, Deputy Town Clerk
One Independence Hill, Farmingville, NY 11738
(631) 451-9101 FAX: 451-9264
Page 1 of 6
The Town of Brookhaven authorizes the use of outdoor areas on private parcels of existing
businesses as drive-in movie theaters subject to the conditions listed in the attached Town of
Brookhaven Declaration of Emergency signed on June 8, 2020.
Drive-In Movie Theater Amusement Permits are authorized until November 1, 2020.
Permissible Event Hours: from sunset with the last movie commencing at 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.
EVENTS MUST COMPLY WITH ALL REGULATIONS LISTED IN THE ATTACHED
DECLARATION OF EMERGENCY. IT IS THE APPLICANT’S RESPONSIBILITY TO REVIEW
THE DECLARATION OF EMERGENCY IN ITS ENTIRETY.
ALCOHOL SALES ARE STRICTLY PROHIBITED.
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.
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 TRIPLICATE.
3. Fill out all spaces in Amusement Application.
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).
Drive-In Movie Theater Amusement Application
TC-06 rev. 06/20
Donna Lent, Town Clerk
Lauren Thoden, Deputy Town Clerk
One Independence Hill, Farmingville, NY 11738
(631) 451-9101 FAX: 451-9264
Page 2 of 6
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.
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 BUSINESS – On letterhead stating that the business will be
responsible for clean-up of the amusement site in accordance with Chapter 49, Property
Maintenance, code of the Town of Brookhaven.
D. LETTER OF PERMISSION FROM PROPERTY OWNER – If amusement site is owned by
the applicant business, please state so in above letter.
E. 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.
Please feel free to contact the Town Clerk’s office at 631-451-7093 or 631-451-9120 if you need
any assistance in completing this application.
Drive-In Movie Theater Amusement Application
TC-06 rev. 0620
Donna Lent, Town Clerk
Lauren Thoden, Deputy Town Clerk
One Independence Hill, Farmingville, NY 11738
(631) 451-9101 FAX: 451-9264
Page 3 of 6
}
SS:
1. NAME OF BUSINESS
2. DATE BUSINESS WAS FORMED:
3. BUS. ADDRESS: NUMBER AND STREET TOWN STATE ZIP
4. NAME OF BUS. REPRESENTATIVE MANAGING EVENT AND POSITION:
5. REP. ADDRESS: NUMBER AND STREET TOWN STATE ZIP
6. HOME TELEPHONE NUMBER:
7. BUSINESS TELEPHONE NUMBER:
8. DATE OF BIRTH:
9. SOCIAL SECURITY NUMBER:
10. HAVE YOU BEEN CONVICTED OF A FELONY? IF YES, EXPLAIN:
11. PURPOSE OF AMUSEMENT/EVENT AND DISPOSITION OF PROCEEDS:
12. LOCATION OF AMUSEMENT/EVENT (MUST BE THE SAME AS BUSINESS LOCATION):
SUFFOLK COUNTY TAX MAP NUMBER (SECTION BLOCK LOT):
13. FULL DESCRIPTION OF AMUSEMENT/EVENT ACTIVITY:
14. ANTICIPATED NUMBER OF ATTENDEES:
16. HAVE YOU HELD THIS EVENT IN THE PAST? IF YES, PROVIDE DATES:
17. WILL FOOD BE SERVED?
18.
NAMES & ADDRESSES OF INDIVIDUAL OPERATORS/VENDORS
*IF MORE SPACE IS NEEDED, PLEASE LIST ON ADDITIONAL SHEET OF PAPER.
NAME
ADDRESS
DATE OF BIRTH
SOCIAL SECURITY #
9
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.
Sworn to before me this ______ __ __________________________________
day of ______________, _______. Applicant Signature
_______
_____________________________ _______________________
Notary Public Date
Receipt #: ________________
Drive-In Movie Theater Amusement Application
TC-06 rev. 0620
Donna Lent, Town Clerk
Lauren Thoden, Deputy Town Clerk
One Independence Hill, Farmingville, NY 11738
(631) 451-9101 FAX: 451-9264
Page 4 of 6
SITE PLAN OF PROPOSED AMUSEMENT/EVENT ACTIVITY
P
lease 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.
I
f 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 food service and restroom locations.
9.
A
ttach 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:
Drive-In Movie Theater Amusement Application
TC-06 rev. 0620
Donna Lent, Town Clerk
Lauren Thoden, Deputy Town Clerk
One Independence Hill, Farmingville, NY 11738
(631) 451-9101 FAX: 451-9264
Page 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
Drive-In Movie Theater Amusement Application
TC-06 rev. 0620
Donna Lent, Town Clerk
Lauren Thoden, Deputy Town Clerk
One Independence Hill, Farmingville, NY 11738
(631) 451-9101 FAX: 451-9264
Page 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 202__ 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
TOWN OF BROOKHAVEN
STA TE OF NEW YORK
COUNTY OF SUFFOLK
,..,
..
-.,
.-j
.-.-
-.--.
----
.....
.,
DECLARATION OF ST ATE
OF
EMERGENCY
I, Edward
P.
Romaine, Supervisor
of
the Town
of
Brookhaven, pursuant to Article 2-
B Section 24
of
the New York State Executive law, hereby certify as follows:
WHEREAS, on January 30, 2020, the World Health Organization designated the novel
coronavirus, COVID-19, outbreak as a Public Health Emergency
of
International Concern;
WHEREAS, on January
31
, 2020, United States Health and Human Services Secretary
Alex
M.
Azar
Il
declared a public health emergency for the entire United States to aid the
nation's healthcare community in responding to COVID-19;
WHEREAS, cases
of
transmission
of
COVID-19 have been documented in the Town
of
Brookhaven and more are expected to continue; and
WHEREAS, the Town
of
Brookhaven is addressing the threat that COVID-19 poses to the
health and welfare
of
its residents and visitors.
WHEREAS, the State
ofNew
York by Executive Order No. 202 dated March 7, 2020, has
addressed the transmission
of
the cases
of
COVID-19.
1.
The Executive Order dated June 30, 2020, extended and/or amended on July
10,
2020, July
17
, 2020, July
21
, 2020, July
31
, 2020, August
5,
2020, August
17
, 2020
and August 25, 2020, and September 2, 2020, is hereby extended and provision 3r is
modified as follows:
3r. Any building permit, Fire Prevention new permission or new Installation permit,
issued by the Town
of
Brookhaven between March 1 and May
15
, 2020, which
expires within
12
months
of
issuance shall hereby be valid for
18
months from the
date
of
issuance. All open building permits existing between March 1, 2020 and
May 27, 2020, shall automatically be extended
by
75
days from the date
of
expiration. However, this shall not apply to any building permits that are for
construction not paused
by
COVID-19 Executive Order, including but not limited
to affordable housing and energy construction.
2.
The Executive Order regarding outdoor eateries dated June 11, 2020, extended and/or
amended on July
10
, 2020, July
17
, 2020, July
21
, 2020, July 31, 2020, August 5,
2020, August 17, 2020, August
25
, 2020, and September 2, 2020, is hereby extended.
3.
The Executive Order regarding drive-in establishments dated June
11
, 2020, extended
and/or amended on July 10, 2020, July
17
, 2020, July
21
, 2020, July 31, 2020, August
5, 2020, August
17
, 2020, August 25, 2020, and September 2, 2020, is hereby
extended until December
31
, 2020, and provisions 7 and 8 are modified as follows:
7.
Only one (1) food truck or mobile concession is permitted for each drive-in
movie event, which is located in a specifically designated and approved area,
provided that all queue lines have floor markings at a distance
of
six (6) feet
apart in order to ensure that individuals maintain a six (6) foot distance. No
amusement/carnival rides or games shall be permitted for any events.
8.
Attendees shall remain within their vehicles at all times except to utilize the
restrooms or make a purchase from the one
(1) food truck/mobile concession
situated in the designated and approved area. No outdoor seating
is
permitted
for viewing purposes.
.
#~
~
~-~
Edward
P.
Romaine, Supervisor
Town Attorney Town
of
Brookhaven
TOWN
OF
BROOKHAVEN
STATE
OF
NEW
YORK
COUNTY
OF
SUFFOLK
OCT
?7
'20
AM10:10
REC
TO
BCLRK
DECLARATION
OF
STATE
OF
EMERGENCY
I,
Edward
P.
Romaine, Supervisor
of
the
Town
of
Brookhaven, pursuant
to
Article
2-B
Section 24
of
the
New York State Executive law, hereby
certify
as
follows
:
WHEREAS,
on January 30, 2020,
the
World Health Organization designated
the
novel
coronavirus, COVID-19, outbreak
as
a Public Health Emergency
of
International Concern;
WHEREAS,
on January 31, 2020, United States Health and Human Services Secretary
Alex M. Azar
II
declared a public health emergency
for
the
entire United States
to
aid
the
nation's healthcare
community
in responding
to
COVID-19;
WHEREAS,
cases
of
transmission
of
COVID-19 have been
documented
in
the
Town
of
Brookhaven and
more
are expected
to
continue; and
WHEREAS
,
the
Town
of
Brookhaven
is
addressing
the
threat
that
COVID-19 poses
to
the
health and welfare
of
its residents and visitors.
WHEREAS,
the
State
of
New York by Executive Order No. 202 dated March
7,
2020,
has
addressed
the
transmission
of
the
cases
of
COVID-19.
WHEREAS,
the
Town
of
Brookhaven
is
desirous
of
assisting existing businesses in
the
Town
of
Brookhaven which have been authorized
to
re-open and seek
to
utilize existing
outdoor
areas
for
drive-in movie theaters, provided social distancing and cleansing/disinfecting
measures are
in
place.
Pursuant
to
the
powers vested
in
me by Executive Law §24, I hereby declare a State
of
Emergency. This State
of
Emergency
has
been declared because
there
is
a reasonable
apprehension
of
transmission
of
COVID-19
cases
in
the
Town
of
Brookhaven.
From
the
date
of
this Executive Order until December 31, 2020,
the
Town Board
of
the
Town
of
Brookhaven hereby authorizes and permits
the
use
of
outdoor
areas on private parcels
of
existing businesses
in
the
Town
of
Brookhaven
as
drive in movie theaters subject
to
the
following:
1. The Host/Applicant submit
an
Amusement/Event Application
for
Drive-In
Movie Theater
to
the
Brookhaven Town Clerk at least fifteen (15) days prior
to
the
commencement
of
utilizing a parcel
as
a drive-in movie
theater
.
2. All areas designated
for
drive-in movie
theater
use
must be situated at least
one thousand (1000) feet from any residential
property
li
nes
in
the
Town
of
Brookhaven.
3. The permissible event hours shall
be
daily, including weekends, commencing
from
sunset
with
the
last movie commencing at 11:30 p.m.
4.
At all times, all employees and guests shall strictly adhere
to
social distancing
guidelines and occupancy restrictions imposed by
the
Governor
of
the State
of
New
York, including
but
not
limited
to
maintaining a distance
of
six
(6)
feet
from
other
individuals
and/or
wearing a face mask
or
cloth face covering
that
covers
your
nose and
mouth
when
six
(6) feet
of
social distancing cannot
be
maintained.
5. The
Host/
Applicant
is
responsible
for
implementing all necessary
cleansing/disinfecting procedures
for
any on-site restroom facilities.
6.
The
Host/
Applicant
is
responsible
for
the designation
of
appropriate parki
ng
stalls which are at least
six
(6)
feet apart in
order
to
adhere
to
social distance
guidelines imposed by the Governor
of
the State
of
New York.
7. Food trucks and mobile concessions in specifically designated and approved
areas are
permitted
provided
that
all queue lines have
floor
markings at a
distance
of
six
(6)
feet apart
in
order
to
ensure
that
individuals maintain a
distance
of
six
(6)
foot
distance.
8.
The sale
of
alcohol
Is
strictly prohibited.
9.
Attendees shall remain
within
their
vehicles at all times except
to
ut
ilize the
restrooms
or
make purchases
from
food
trucks/mobile
concessions.
No
outdoor
seating
is
permitted
for
viewing purposes.
10. Nothing herein shall
be
deemed
to
supersede, alter
or
amend the
requirements
for
all preliminary approvals by Town
of
Brookhaven Division
of
Fire Prevention, Town
of
Brookhaven Division
of
Public Safety and Suffolk
County Police Department.
11. No fee shall
be
charged
for
drive-
in
movie
theater
applications.
12. The
Host/
Applicant
is
permitted
one
(1)
advertisement sign per street
frontage
not
to
exceed
thirty-two
(32) square feet in area and
sha
ll not
be
placed
in
the
Town's right
of
w
ay
or
in
a lo
ca
ti
on t
ha
t
wi
ll obstruct
or
impair
vi
sion or
traffic
in
an
y manner
or
create a hazard
or
disturbance
to
the health
and welfare
of
t he publ
ic
13. The
Host/
Applicant
is
responsible
for
maintaining
the
events/parcels free
of
trash and
other
debris and provide trash receptacles in accordance
with
Chapter 49, Property Maintenance, code
of
the
Town
of
Brookhaven.
14. All paved areas, including
but
not
limited
to
parking spaces, must conform
with
Chapter 49, Property Maintenance, code
of
the
Town
of
Brookhaven, in
order
to
afford safe passage
for
pedestrian and
motor
vehicle
traffic
in
order
to
prevent hazards
to
public health, safety and welfare.
15. Outside loudspeakers,
if
utilized, must comply
with
all provisions set
forth
in
Brookhaven Town Code Chapter
50.
16. The Host/Applicant must submit a public liability insurance certificate
of
limits
not
less
than one million ($1,000,000) dollars naming
the
Town
of
Brookhaven
as
an
additional insured, which shall
not
be cancelled
without
fifteen (15) days notice
to
the Town Clerk.
17. Any approval
to
utilize a site
as
a drive-in movie
theater
shall
not
negate or
permit
any violation which may exist on
the
subject premises at
the
time
of
approval
of
such accommodation.
18. The
following
sections
of
the Brookhaven Town Code are hereby temporarily
suspended
or
modified, from
the
date
of
this Executive
order
through
December 31, 2020:
a. Town Code Section 57A-
9(C)
is
suspended
to
the
extent
that
applicants/hosts need
not
submit
an
application
to
the
Division
of
Building
for
temporary
sign
permit(s).
b.
Town Code Section 4-3
is
suspended
to
the
extent
that
drive-in movie
theater
amusements
for
profit
are
permitted
.
c.
Town Code Section 4-4
is
hereby suspended
to
the
extent
that
drive-
in movie
theater
permit
applications
for
events involving attendees in
excess
of
1,000 persons need only apply 15 days
prior
to
commencement
of
such event.
d. Town Code Section 4-7
is
hereby suspended
to
the
extent
that
drive-
in movie
theater
events are permitted
to
operate daily, including
weekends,
from
sunset
with
the last movie commencing at 11:30
p.m.
DATED:
October
26,
2020
~Pk
Edward P. Romaine, Supervisor
Town
of
Brookhaven
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Donna Lent, Town Clerk (Town of Brookhaven)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 12 February 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document