Fillable Donna Lent, Town Clerk (Town of Brookhaven)

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Donna Lent, Town Clerk (Town of Brookhaven)

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U.S.A. forms for Town of Brookhaven

BROWSE TOWN OF BROOKHAVEN (NY) FORMS

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Application for Wooden
Public Walks Permit
TC-18 rev. 8/19
Donna Lent, Town Clerk
Lauren Thoden, Deputy Town Clerk
One Independence Hill, Farmingville, NY 11738
(631) 451-9101 FAX: 451-9264
Page 1 of 4
Pursuant to Brookhaven Town Code Chapter 83, between April 1 and October 31 of each
year, only vehicles with a valid Business Use Permit or Special Use Permit may operate on
any wooden public walk within the Town of Brookhaven.
Business Use Permit: Only vehicles used for business purposes are eligible for business
use permit. Completed applications for a business use permit must be submitted with
copies of the following:
• Proof of business (e.g. Corporate Documentation, Business Certificate, Professional
License, etc.)
• Proof of ongoing work on Fire Island (e.g. Contracts/Quotes/Invoices evidencing
current and future work on Fire Island)
• Valid driver license(s) of vehicle operator(s)
• Valid vehicle registration (if applicable). The vehicle must be registered in the name
of the business.
• Insurance Certificate. The insurance policy must be issued to the business. Please
see additional insurance requirements below.
• If applying for multiple permits, the applicant must submit a notarized statement on
letterhead identifying the business need for each permit and the names of all vehicle
operators with copies of their driver licenses.
Special Use Permit: Only bona fide chartered homeowners’ associations operating
electrically powered golf or similar type carts used solely for the transport of persons with
special needs due to a disability are eligible for a special use permit. Completed
applications for special use permit must be submitted with copies of the following:
Valid driver license of vehicle operator
Valid vehicle registration (if applicable)
Insurance Certificate. The insurance policy must be issued to the association.
Please see additional insurance requirements below.
Notarized statement on letterhead from the homeowner’s association confirming the
sole use of the vehicle will be for the transport of persons with special needs due to
a disability.
Insurance Requirements: Insurance certificate showing one million dollars ($1,000,000)
combined single-limit bodily injury and property damage and five thousand dollars ($5,000)
medical-payment liability insurance for such vehicle showing Town of Brookhaven as
certificate holder. The certificate must include the vehicle identification number (VIN #). The
business or homeowners’ association making application must be listed as insured on the
certificate.
Fee: $100.00 Check or Money Order must be made payable to: Donna Lent, Brookhaven Town
Clerk
Application for Wooden
Public Walks Permit
TC-18 rev. 8/19
Donna Lent, Town Clerk
Lauren Thoden, Deputy Town Clerk
One Independence Hill, Farmingville, NY 11738
(631) 451-9101 FAX: 451-9264
Page 2 of 4
1. NAME OF APPLICANT (BUSINESS):
2. PHYSICAL ADDRESS:
3. MAILING ADDRESS:
4. EMAIL ADDRESS:
5. DAYTIME TELEPHONE NUMBER:
6. EVENING TELEPHONE NUMBER:
7. NAME OF AGENT:
8. NATURE OF BUSINESS:
VEHICLE INFORMATION
9. WEIGHT: (LIMIT - 1800 LBS)
10. WIDTH:
(NOT TO EXCEED 4 FEET OR 48 INCHES)
11. RUBBER WHEELS:
Yes No
12. MUFFLER:
Yes No
13. VEHICLE TYPE:
14. COLOR:
15. NUMBER OF WHEELS:
16. VEHICLE I.D #:
17. REGISTRATION OR PLATE NUMBER: (IF REGISTERED WITH NYS DMV)
18. EXPIRATION DATE:
Insurance: A certificate of insurance in the name of the business must be submitted with application.
See instructions on reverse for detailed insurance requirements.
19. NAME AND ADDRESS OF INSURER:
20. POLICY LIMITS:
21. EFFECTIVE DATE:
22. OPERATOR OF VEHICLE:
23. NYS DRIVER LICENSE NUMBER:
24. DO YOU HAVE ANY OTHER WOODEN PUBLIC WALKS PERMITS:
Yes No
IF YES, LIST THEM:
___________________________________________________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________________________________________________
For Office Use Only
Permit #:
Receipt #:
Application for Wooden
Public Walks Permit
TC-18 rev. 8/19
Donna Lent, Town Clerk
Lauren Thoden, Deputy Town Clerk
One Independence Hill, Farmingville, NY 11738
(631) 451-9101 FAX: 451-9264
Page 3 of 4
25. HAS ANY WOODEN PUBLIC WALKS PERMIT EVER ISSUED
TO YOU BEEN REVOKED FOR ANY REASON: Yes No
26. IF YES, BRIEFLY EXPLAIN:
SIGNATURE _______________________________
APPLICANT’S NAME _______________________________
TITLE _______________________________
Acknowledgement of Corporation
STATE OF )
COUNTY OF ) SS.:
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
I do hereby certify that all statements made by me in this application are true and correct to the
best of my knowledge, information and belief, further, I understand that in the event that I have
knowingly and willfully made any false statements, I will be liable for punishment in accordance
with all applicable laws and statutes.
Application for Wooden
Public Walks Permit
TC-18 rev. 8/19
Donna Lent, Town Clerk
Lauren Thoden, Deputy Town Clerk
One Independence Hill, Farmingville, NY 11738
(631) 451-9101 FAX: 451-9264
Page 4 of 4
SAFETY AFFIDAVIT FOR WOODEN WALKS PERMIT
Make_____________________________ VIN#____________________________
I, the undersigned, do swear, under penalty of perjury, that the cart, hand truck, wagon,
vehicle, bicycle, or conveyance of any kind has been maintained according to the
manufacturer’s recommendations. I further certify that the said vehicle’s safety features,
including but not limited to, its brakes and steering system are in proper working order.
______________________________________
Signature of applicant
Acknowledgement of Corporation
STATE OF )
COUNTY OF ) SS.:
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
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Donna Lent, Town Clerk (Town of Brookhaven)

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Completed 12 February 2021

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