Suffolk County Department of Parks, Recreation & Conservation
Mail Application to: P.O. Box 144, West Sayville, NY 11796
Phone: 631-854-4949
NAME OF EVENT: ____________________________ TYPE OF EVENT: ___________________________
(Group or scout camping, picnic, walk/hike, etc.)
Is this a Fundraiser? YES ____ NO ____ If yes: DO NOT continue to fill out this permit. A fundraiser
application/contract is required in lieu of this form.
Please note
: Fundraiser applications are time-sensitive as they
require Legislative approval. (Typically, 90 to 120 days lead time is required.)
PARK REQUESTED: ________________________________________________________________
Arrival Date: ________________ Arrival Time: ____________ A.M./P.M.
Departure Date: ______________ Departure Time: _________ A.M./P.M. (Parks Close at Dusk)
Name of Group/Organization ___________________________________________________________________________
Address ___________________________________________________________________ Zip Code ________________
Applicant Name _____________________________ Primary Phone # _______________ Alternate # ________________
Address ___________________________________________________________________________________________
Town __________________________________________________________ State ________ Zip __________________
Email _____________________________________________________________________________________________
Estimated # Attending _________ # Cars/Vans ______ # Buses ______ Camping Clubs: Total # of Families ________
Is event open to the general public? YES ____ NO ____
If event is open to public
food/beverages are being provided, a
be filed. Non-compliance with Health Services regulations may result in
event being shut down.
Will Food/Beverages be provided? YES ____ NO ____
Is event being catered? YES ____ NO ____ Name of Caterer _________________________________________
Will alcoholic beverages be provided or sold? YES____ NO_____
(If YES: File a Hold Harmless Agreement. Must be signed/notarized and returned with application.)
Will there be any tents? YES___ NO___ If yes: How many?_______ Size of each ____________________________
Suffolk County Fire Marshall inspection may be required. Contact Permit Dept. at 631-854-4949 for information.
Will there be any vendors? YES ___ NO___
List all _________________________________________________________________________________________
Names of vendors (amusement/entertainment, etc.) at event must be listed above. Attach separate sheet if necessary.
Vendor(s) chosen must provide a certificate of insurance naming SUFFOLK COUNTY as an additional insured in the
amount of $2,000,000 per occurrence Comprehensive General Liability. There will be a $25/per vendor fee
Incomplete applications will not be processed. Once completed application is submitted to the West
Sayville Administration Office, it will be reviewed and processed. You will be contacted for payment and for any
additional information that may be needed. You will receive a copy of this application once it has been approved
and processed.
SPECIAL REQUESTS/COMMENTS: ________________________________________________________
Applicant Signature_________________________________________ Date ________________________________
Office Use Only
PARK APPROVED _____________________________ DATE(S) APPROVED_________________________
AREA ASSIGNED _______________________________________________________________________
Payment Amount $ ___________ Cash___ MO___ Credit___ Check _________ Receipt #_____________
SPECIAL INSTRUCTIONS _____________________________________________________________________
PARKS DEPARTMENT APPROVAL _____________________________ HH ID#: ______________________
Alcohol Permit Approved _______ (Staff Initials)
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