Fillable Outdoors Assemblage Application Requirements (Town of Brookhaven)

Fill Online, Printable, Fillable, Blank Outdoors Assemblage Application Requirements (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.

Outdoors Assemblage Application Requirements (Town of Brookhaven)

On average this form takes 6 minutes to complete

The Outdoors Assemblage Application Requirements (Town of Brookhaven) form is 4 pages long and contains:

  • 0 signatures
  • 0 check-boxes
  • 24 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
 
Outdoors Assemblage Permit Application
TC- 08 rev. 2/20
Donna Lent, Town Clerk
Lauren Thoden, Deputy Town Clerk
One Independence Hill, Farmingville, NY 11738
(631) 451-9101 FAX: 451-9264
Page 1 of 4
Outdoors Assemblage Application Requirements
1. Fill out all spaces in Assemblage Permit
2. Completed application should be submitted at least (15) days prior to the assemblage.
3. REQUIREMENTS TO BE MET BY THE APPLICANT BEFORE PERMIT WILL BE
ISSUED:
A. Liability Insurance Certificate – Certificate shall include the Town of Brookhaven as
additional insured and shall not be cancelled without (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. A sketch and or map drawn to scale indicating the premises and location of proposed
outdoor assemblage and the location of the sanitary facilities.
C. Notarized letter from the applicant stating that they will be responsible for the clean up of
the site after assemblage.
D. Letter of permission from property owner – if the applicant owns assemblage site, 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 Licensing Division at 451-7093 if you need any assistance in completing
this application.
Outdoors Assemblage Permit Application
TC- 08 rev. 2/20
Donna Lent, Town Clerk
Lauren Thoden, Deputy Town Clerk
One Independence Hill, Farmingville, NY 11738
(631) 451-9101 FAX: 451-9264
Name of applicant requesting permit: _______________________________________________________
Set forth purpose for which permit is sought: _________________________________________________
Address of premises: ____________________________________________________________________
_____________________________________________________________________________________
Name and address of owner of premises: ____________________________________________________
_____________________________________________________________________________________
If owner is not applicant, attach notarized statement from true property owner stating nature, extent and
duration of event and granting permission to operate event on premises.
Set forth name, address, and phone number of person in control of assemblage:
Name: ________________________________________ Phone #: ______________________________
Address: _____________________________________________________________________________
Exact dates and times of said permit:
Dates: _________________ Time: _____________ Estimated # of attendees at assemblage: __________
Set forth detailed description of the activities of such event for which permit is sought:
_____________________________________________________________________________________
_____________________________________________________________________________________
I hereby declare to the best of my knowledge that the information contained in this application is true.
Date: Signature of person in charge of assemblage:
OFFICIAL USE ONLY
This permit is approved subject to the Provisions of Chapter 4 of the Brookhaven Town Code, entitled
“Assemblage”, and any other conditions so noted in the enclosed letter.
Date: Signature, Brookhaven Town Clerk:
Page 2 of 4
Outdoors Assemblage Permit Application
TC- 08 rev. 2/20
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
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
Outdoors Assemblage Permit Application
TC- 08 rev. 2/20
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
behalf of the undersigned, with regard to or in 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
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

Outdoors Assemblage Application Requirements (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