Special Event Application
Revised 11/2019
1
Special Event Permit Application
Activity type (Please select all that apply):
____
Block Party ____ Demonstration ____ Other
____ Parade ____ Festival (please describe)
____ Film Production ____ Race/Walk __________________________
____ Carnival ____ Fair __________________________
Event Location Requested:
__
__ Rose Hill Park ____ Rixey-Moore Parking Lot ____ Hogan’s Alley
____ Other Public Space
Group Requesting Event
________________________________________
Da
te of Event _________________________________________
Rain Date, if any _________________________________________
Ti
me of Event _________________________________________
Organizer’s contact Information (Representative must be present at the event with approved permit
available for inspection)
Pr
imary Name __________________________________ Cell Phone ______________________
Address_________________________________ Work Phone ____________________
City ____________________________________ State/Zip _______________________
Email __________________________________ Home Phone ____________________
Secondary Name __________________________________ Cell Phone ______________________
Address_________________________________ Work Phone ____________________
City ____________________________________ State/Zip _______________________
Email __________________________________ Home Phone ____________________
FOR OFFICIAL USE ONLY
Organizational Status
___Non-Profit ___Commercial___Independent
Attachment Verification
___Maps ___ Insurance ___ ABC Permit
___Tent Permit ___VDH Permit
___ Road Closure Permits
_______________________
Date Application Received
Special Event Application
Revised 11/2019
2
D
escription of the Event (P
lease attach additional sheet if more space is needed)
Wil
l the activity require the blocking of any surrounding public streets, driveways or entrances?
Yes _____ No _____ If yes, please identify: ______________________________________________
Ev
ent Hours
Set-Up Time____________ Hours of Event _________________________ Clean-Up Time ____________
Ant
icipated Attendance
Participants ________ Spectators ________ Other ______________________________________
Na
me of Insurance Company: ____________________________________________________________
(Certificate of Insurance and additional insured endorsement providing $1 million in general liability
insurance required. May be increased or waived as deemed necessary as determined by the Town
Manager or their designee.) Please note that animals on site require additional insurance.
Will s
ound amplification devices be used? Yes _____ No _____
If Yes, length of time: _______________________________________________________________
Wil
l the event require use of any parking lots for staging areas? Yes _____ No _____
If Yes, please identify: __________________________________________________________________
Wil
l alcohol be served? Yes _____ No _____
If Yes, all state laws and local ordinances must be followed. The organizer must obtain a Virginia ABC
permit (http://www.abc.virginia.gov/
) and is responsible for all required permits.
Will
food be served? Yes _____ No _____
If Yes, the organizer may be required to obtain a permit from the Virginia Department of Health
(540/955-1033) and is responsible for all requisite permits.
Special Event Application
Revised 11/2019
3
Wi
ll any fees be charged in association with the event, admissi
on, etc.?
Yes _____ No _____ If yes, amount to be charged ___________________________________
If Yes and the special event is to occur in Rose Hill Park, please note that a Fundraising Permit is required
upon application for valid and duly-constituted non-profit organizations for the purpose of approved
charitable, educational, cultural, and/or community-oriented projects and activities. Commercial
activity is prohibited.
Will you have security on site? Yes _____ No _____
If Yes, please identify who will be on site ___________________________________________________
Will weapons or firearms be present? Yes _____ No _____
If Yes, please provide detail of activity _____________________________________________________
Will there be a parade? Yes _____ No ______ (If yes, please complete the following section)
VDOT and/or Town of Berryville Land Use Permit and fee are required.
Please identify parade route
Wi
ll there be vehicles in the parade? Yes ____ No ____ Number of vehicles anticipated______
What time will staging occur? _________________________________
Where will staging occur? ________________________________________
Will there be animals in the parade? Yes ____ No _____
If Yes, what type and how many? ___________
Wil
l you need assistance from Fire & Rescue? Yes_____ No _____
If Yes, please contact John H. Enders Fire & Rescue at 540/955-1110 at least ten (10) days prior
to the event.
Special Event Application
Revised 11/2019
4
Wi
ll you be using any of the f
ollowing? (Mark all that apply)
____ Tents ____ Tables _____ Portable Toilets
____ Live Radio ____ Signs _____ Electricity
____ Banners ____ Animals
Please note: Architectural Review Board review and approval and Zoning Permits may be required for
certain banners, signs and temporary structures. Permits from the Clarke County Building Department
may be required for temporary structures and tents.
___________________________________________________________________________________
Please supply a sketch of how the requested venue will be organized for the event below, or attach a
map with this application.
Special Event Application
Revised 11/2019
5
Hold Harmless Agreement
___________________________ (Legal name of business/organizer, exactly as it appear on Insurance
Endorsement), shall defend and hold harmless, the Town, its officers, employees, agents, and
representatives thereof, harmless from all suits, actions, claims of any kind, including attorney’s fees,
brought on account of any personal injuries, damages, or violation of rights sustained by any person or
property in consequence of any neglect on behalf of ____________________________ (Legal name of
business/organizer) while their personal property is situated on Town Property.
__________
__________________ (Legal name of business/organizer) shall further hold the Town
harmless for any claims or amounts arising from violation of any law, bylaw, ordinance, regulation or
decree.
Lega
l Name of Business/Organizer _______________________________________________
(As it appears above)
By (signature): _______________________________________________________________
Nam
e (printed): ______________________________________________________________
Title: ____
_________________________________________________________________
Add
ress: _______________________________________________________________
__________
_____________________________________________________
Date: _______________________________________________________________
++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
For Office Use Only
Permit
Approved_______ Denied _______
By: _____________________________________
Date: __________________
Permit #________________
click to sign
signature
click to edit
Special Event Application
Revised 11/2019
6
Special Event Permit # __________
Permission is hereby to __________________________________
(Name of Organization/ Organizer)
for the use of the facilities identified in the attached application on _____________________
(Date)
from _______________ to ______________________.
(Time)
This permit is issued with the understanding that ___________________________________
(Name of Organizer)
shall accept responsibility for adherence to the Town of Berryville Special Events and
Demonstrations Regulations, Ordinances of the Town of Berryville (Chapter 20- Parades and
Demonstrations), and Ordinances of the Town of Berryville (§ 13-36 Regulation of Use and
Conduct in Rose Hill Park) as well as to any special conditions which may be attached hereto.
Date ________________ Signed ______________________________________________
Town Manager
Process For Appeals of Permit Denial
An applicant that wishes to appeal the denial of a permit must submit a written request to the attention
of the Town Manager including a stateme
nt of the basis for the objection of the denial. The appeal will be
reviewed by the Town Manager with a decision rendered and notice provided to the applicant at least
three business days prior to the requested event date.
Applications that are denied after appeal to the Town Manager may be further appealed to the Berryville
Town Council. This appeal must be submitted in writing within five business after receiving notice of
appeal denial from the Town Manager.
granted
Special Event Application
Revised 11/2019
7
Special Fundraising Permit
Permission is further granted to the above-named Organization for a fundraising event
pursuant to the approved application for same dated _____________________________.
Date _________________ Signed ____________________________________________
Town Manager
Applied
$25.00 $25.00
$100.00 $100.00
$50.00 $50.00
$50.00
$50.00 $100.00
$100.00 $50.00
$150.00 $100.00
$500.00
$50.00
$100.00
$50.00
$300.00
Street Closure Fee
Gazebo Use Deposit
Gazebo Use Deposit
Street Closure Fee
Electricity Deposit
Public Space Rent
0 - 1,000 Attendees
Total Due
Special Events Deposit Worksheet
Application Fee
Fee Description
Cost
Application Fee
Events Charging Admission Fee
Events Free to Public
Fee Description
Cost
Applied
Public Works Deposit
Public Safety Deposit
Cleanup Deposit
Electricity Deposit
Public Works Deposit
Public Safety Deposit
Cleanup Deposit
Total Due
1,001 - 1,999 Attendees
2,000 - 2,999 Attendees
3,000 Attendees or Greater
0
0
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