Fillable PUBLIC GATHERING PERMIT APPLICATION (Town of Simsbury)

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PUBLIC GATHERING PERMIT APPLICATION (Town of Simsbury)

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Town of Simsbury
933 HOPMEADOW STREET SIMSBURY, CONNECTICUT 06070
Page 1 of 6
PUBLIC GATHERING PERMIT APPLICATION
A Public Gathering Permit (PGP) is required when a proposal is made for a gathering of a number of people
on Town property which may cause questions or raise concerns regarding traffic circulation and access issues
involving local or state roadways, public safety, or issues regarding a required Special Exception permit from
the Zoning Commission.
Application should be completed in full, including original signatures, before submitting to the Zoning
Enforcement Officer at the Simsbury Town Offices, Planning & Zoning Department, 933 Hopmeadow
Street, Simsbury, Connecticut 06070. Please include 6 copies of your completed application IN
ADDITION TO the original when you submit it. Applications must be received in office at least
6
WEEKS prior to the date of the proposed event. The Board of Selectmen has the final authority to approve
or deny public gathering permit applications. The Town reserves the right to cancel an event that does not
obtain complete approval, as specified herein.
Organization’s Name:________________________________________________________________
Applicant’s Name:
Mailing Address:
Phone: Email:
Event Location:
Exact Date(s) of proposed Public Gathering: (MUST include all required “set up” and “tear down”
time, as well as the actual dates of the Public Gathering.)
Exact Time(s)/Date Begin:____________________________ End:___________________________
Number of people expected to be present for the event (incl. staff, volunteers, attendees):________
• The Town of Simsbury reserves the right to limit the number of attendees. The maximum number of permitted attendees
will be determined after consultation with the Town of Simsbury.
A Certificate of Insurance made out to the Applicant AND Town of Simsbury, evidencing coverage
of $1,000,000 in force for the duration of the event, must be submitted with this application. This
Certificate of Insurance must include a hold harmless agreement for the Town.
TOWN OF SIMSBURY USE ONLY:
Fee Received: YES
NO
N/A
Insurance Received: YES
NO
N/A
Request Approved: YES
NO
MORE INFO: ___________________
Signature: ____________________________________________________ Date: __________________
Page 2 of 6
EVENT INFO
Description of Event: _______________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Please indicate whether you will be bringing:
Additional trash and recycling receptacles: YES
NO
NUMBER: ________
• You are responsible for proper collection and removal of all waste generated by your event.
Portable toilets: YES
NO
NUMBER: ________
• If yes, please show locations on attached site plan.
Tent: YES
NO
SIZE: _____________
OPEN SIDES
ENCLOSED
• Tents must be in compliance with State of Connecticut tent regulations. The Town of Simsbury’s Building Official or Fire
Marshal can advise on tent requirements.
Lighting and/or sound equipment: YES
NO
• If yes, please attach a list of the equipment you plan to use along with a stage plot with locations for the equipment.
• Lighting must meet the requirements of the Town of Simsbury Fire Marshal.
Does your event require electrical access? YES
NO
• If so, a plan for electrical access will need to be reviewed with the Town of Simsbury Building Official or Fire Marshal.
Will food be sold or given away at your event? YES
NO
• If food is to be served, whether prepared on- or off-site, you must obtain a Temporary Food Permit from the Farmington
Valley Health District (www.fvhd.org).
Will alcohol be served at your event? YES
NO
• If alcohol is to be served, you must obtain all pertinent State permits and abide by all Town and State laws and
regulations. An additional list of policies applies if alcohol is to be served.
Will road closure(s) be necessary? YES
NO
• Details of proposed traffic circulation and closings must be presented to the Chief of Police prior to his signing of the PGP
application. If State roads are proposed for closing, a permit from the CT DOT may be necessary.
Page 3 of 6
PLANNING & ZONING DEPARTMENT
933 HOPMEADOW STREET, SIMSBURY, CT 06070 860-658-3245
Alcohol
• Does your event require a Special Exception? YES
NO
• Has the Zoning Commission approved a S.E.? YES
NO
• Have you obtained a State of CT liquor license? YES
NO
Signage
• Will your event require temporary signs? YES
NO
o No signage may be erected without written permission granted from the Zoning Enforcement Officer
• Has your organization secured permits for such? YES
NO
Attachments:
Site Map
• The site plan/map of the proposed Public Gathering should be to-scale and show exactly:
Layout of the Event (tents, booths/vendors, rides, aisles, etc.)
Location of Lighting
Parking Layout
FARMINGTON VALLEY HEALTH DISTRICT
www.fvhd.org
95 RIVER ROAD, CANTON, CT 06019 860-352-2333
If food will be prepared or dispensed at your event, you must obtain a Temporary Food Permit from Farmington Valley Health
District.
Has a Temporary Food Permit been secured? YES
NO
http://www.fvhd.org/food-protection1.html
BUILDING DEPARTMENT
933 HOPMEADOW STREET, SIMSBURY, CT 06070 860-658-3234
Tent: YES
NO
CAPACITY: ________
OPEN SIDES
ENCLOSED
SQUARE FOOTAGE: _____________________
• Tents may require a Building Permit, depending on square footage, capacity, enclosure (or not), and if there will be heat
and/or electrical. You should contact the Building Official to determine if a permit will be necessary.
Does your event require electrical access? YES
NO
• Will you be utilizing portable generators? YES
NO
FIRE MARSHAL
871 HOPMEADOW STREET, SIMSBURY, CT 06070 860-658-1973
Page 4 of 6
DEPARTMENT OF PUBLIC WORKS (DPW)
66 TOWN FOREST ROAD, SIMSBURY, CT 06070 860-658-3222
Will barricades/signage be required:
• For the day of the event? YES
NO
• In advance? DATES: ___________________________
Are DPW trucks required for use as barricades? YES
NO
QUANTITY: ________
• The fee schedule below is for one (1) Truck and one (1) staff member.
• All fees will begin when Public Works Trucks leave the DPW Campus.
• Each Truck will be filled with sand and operated by a single staff member.
• The number and positioning of the Trucks shall be determined by the Simsbury Police Department.
• The fees for using DPW trucks as barricades are as follows:
o $250 for first four (4) hours
o $50/hour for each additional hour during regular hours
o $75/hour for each additional hour on Federal holidays and Sundays
TOTAL FEE DUE: $250 + (__________hours x $50/$75) = $________________________
Fee is payable by check made out to the Town of Simsbury
Please note:
• No markings on the roadways or custom signage is allowed.
• Traffic cones shall not be provided by DPW.
POLICE DEPARTMENT
933 HOPMEADOW STREET, SIMSBURY, CT 06070 860-658-3100
Is this event a concert and/or festival? YES
NO
If yes, please list recent prior venues that have hosted this concert/festival:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Will on-site private security be provided? YES
NO
NUMBER: ______
Will on-site emergency medical services be provided? YES
NO
NUMBER: ______
• Where will they be located? ____________________________________________________________
____________________________________________________________________________________
Page 5 of 6
SIMSBURY VOLUNTEER AMBULANCE ASSOCIATION
64 WEST STREET, SIMSBURY, CT 06070 860-658-7213
Will there be any athletic competitions or other activity/activities that could increase the likelihood
of injury or illness? YES
NO
Will the attendance be equal to or greater than 5000? YES
NO
NUMBER: ______
Attendance will be:
STAGGERED OVER COURSE OF EVENT
AT A SPECIFIC TIME
TIME: _______
CULTURE, PARKS & RECREATION
100 OLD FARMS ROAD, SIMSBURY, CT 06070 860-658-3836
Are you serving food? YES
NO
• If so, trash recycling barrels are required at Permittee’s expense
Will you require any special field lining or set up? YES
NO
Do you intend to use “staked” tents on athletic fields? YES
NO
Will athletic field lighting be necessary? YES
NO
Have you provided a parking plan on your site map? YES
NO
Portable toilets must be provided at the rate of 1 toilet per 50 patrons, at the Permittee’s expense.
• ATTENDANCE: _____________ / 50 = _________ PORTABLE TOILETS REQUIRED
Public Gathering Permit
Required Declaration
I declare that the information provided on this application is true and correct to the best of my
knowledge and belief. I understand that if the information I have provided is a misrepresentation
of the actual event, or that the actual event digresses in a manner from the approved permit, that
the permit will be revoked.
Applicant’s Name (Printed): ___________________________________________________
Applicant’s Signature: ___________________________________________________
Date Signed: ___________________________________________________
Page 6 of 6
REQUIRED SIGN OFFS
(in order required)
And Rec.
Commission
(As may be
required by
Works
FVHD
Enforcement
Officer
Selectmen
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PUBLIC GATHERING PERMIT APPLICATION (Town of Simsbury)

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Completed 16 July 2020

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