Fillable GREAT SOUTH BEACH VEHICLE PERMIT APPLICATION Donna Lent, (Town of Brookhaven)

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GREAT SOUTH BEACH VEHICLE PERMIT APPLICATION Donna Lent, (Town of Brookhaven)

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Beach Buggy Permit Application
TC-07 rev. 1/21
Donna Lent, Town Clerk
Lauren Thoden, Deputy Town Clerk
One Independence Hill, Farmingville, NY 11738
(631) 451-9101 FAX: 451-9264
GREAT SOUTH BEACH VEHICLE PERMIT APPLICATION
A Town Clerk issued permit is required for motor vehicle use on the Great South Beach.
RESIDENTIAL USE: If the permit is for residential use, the applicant’s primary residency must
be on Fire Island. Completed applications must be submitted with copies of the following:
• Fire Island National Seashore Vehicle Permit
• Two consecutive utility bills dated within the last two months listing the applicant’s name
and Fire Island service address
• Valid driver license
• Valid vehicle registration in the name of the applicant
• Insurance certificate showing $250,000/500,000 for bodily injury coverage on a split limit
policy or $500,000 on a combined single limit policy on vehicle, showing the Town of
Brookhaven as an interested party. Vehicle VIN number or identification number must be
on certificate. The insurance policy must be issued to the resident applicant.
•
COMMERCIAL USE: If the permit is for commercial use, the application 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 of vehicle operator
• Valid vehicle registration in the name of the business
• Insurance certificate showing $250,000/500,000 for bodily injury coverage on a split limit
policy or $500,000 on a combined single limit policy on vehicle, showing the Town of
Brookhaven as certificate holder. Vehicle VIN number or identification number must be on
certificate. The insurance policy must be issued to the business.
If applying for multiple permits for commercial use, the applicant must also 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.
2021 FEE: $110.93 Check or Money Order must be made payable to: Donna Lent,
Brookhaven Town Clerk
Beach Buggy Permit Application
TC-07 rev.1/21
Donna Lent, Town Clerk
Lauren Thoden, Deputy Town Clerk
One Independence Hill, Farmingville, NY 11738
(631) 451-9101 FAX: 451-9264
OFFICE USE ONLY Permit #: Receipt #:
1. Name of Applicant:
First Name Last Name
2. Telephone Number:
3. Business Name (if applicable):
4. Residential Address:
Street
V
illage, Town or City State Zip
5. Business Address (if applicable):
Street
V
illage, Town or City State Zip
6. Mailing Address:
Street
V
illage, Town or City State Zip
7. Reason(s) Permit is Needed:
8. Intended Use of Permit:
9. Times of Intended Operation: 10. Location of Intended Operation on Beach:
11. Make and Model of Vehicle: 12. Year of Vehicle:
13. Vehicle Registration Number: 14. License Plate Number:
Pursuant to Brookhaven Town Code, vehicles must be equipped with a tow cable,
fire extinguisher, jack, jack board, shovel, tire gauge, first aid kit, spare tire and flashlight.
15. Vehicle Operator: Is the Vehicle Operator a duly licensed operator under the
laws of the State of New York?
Yes No
16. Has the town ever revoked a permit
that has been issued to you?
Yes No
If yes, why?
I certify that all information supplied is true and accurate and subject to a penalty for making a false statement in
violation of Section 210.45 of the Penal Law.
______________________________________ ______________________
Signature Date
Beach Buggy Permit Application
TC-07 rev. 1/21
Donna Lent, Town Clerk
Lauren Thoden, Deputy Town Clerk
One Independence Hill, Farmingville, NY 11738
(631) 451-9101 FAX: 451-9264
Release and Hold Harmless
The undersigned in being granted a Great South Beach Vehicle Permit (A/K/A Beach Buggy Permit) for
the use of a motor vehicle on Town property hereby agrees to assume all liability and all risk of loss and
shall be responsible for losses incurred by the Town or third parties while on or using Town property in
co
nnection with the permit issued.
The liability assumed will be a result of whether directly or indirectly caused or contributed to by the
undersigned, its invitees and guests.
The undersigned further hereby releases the Town of Brookhaven to the fullest extent permitted by law,
its officers, employees, servants, agents and non-remunerated volunteers from any liability for any
injuries sustained, or damages incurred and agrees to reimburse the Town for any damages arising out
of, or in connection with, whether directly or indirectly, the undersigned’s use of the Town property
pursuant to the issuance of said permit.
The undersigned hereby further agrees that it will indemnify and hold harmless the Town of Brookhaven,
its officers, employees, servants, agents and non-remunerated volunteers harmless from any liability or
claims that may result from the use of the Town property arising out of said permit. The undersigned’s
responsibility under this section shall not be limited to the required or available insurance coverage.
This indemnification shall survive termination or expiration of the permit.
_______________________________________
Applicant Signature
___________________________
Vehicle Make & Model
___________________________
Vehicle Identification Number
STATE OF NEW YORK )
) ss.:
COUNTY OF SUFFOLK )
On the_____ day of _____________in the year _______ 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/they executed the same in his/
her/their capacity(ies), and that by his/her/their 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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GREAT SOUTH BEACH VEHICLE PERMIT APPLICATION Donna Lent, (Town of Brookhaven)

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Completed 12 February 2021

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