OFFICE OF THE TOWN CLERK
KATE MURRAY
Town Clerk
One Washington Street Hempstead, NY 11550
Tel: (516) 812-3025 email: licensing@tohmail.org
SPECIAL EVENTS
Name of sponsor organization: Email:
Address:
Person in charge of event:
Address:
Location where event will be conducted:
Type of special event:
Hours of operation:
1) Certificate of Insurance - naming the Town of Hempstead additional insured
Bodily Injury - $ 400,000 - One person
Bodily Injury - $ 1,000,000 - One accident
Property Damage - $ 100,000 - One accident
2) Written approval from Nassau County Department of Health
3) Town building permit (When required)
4) Cash bond of $ 500.00 (When required)
5) Written permission of property owner
6) Board of Zoning Appeals (When required)
7) Are tents being used for Public Assembly ?
7a) Will Mechanical rides be operated ?
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THE FOLLOWING MUST BE PRESENTED WITH THIS APPLICATION
Dates of operation: / / Through / /
Received
Phone #
20
Phone #
Office Use Only
APP. #
FEE PAID
DATE
LICENSE #
ISSUED
*YES NO
*YES NO
Sworn to before me this
Day of 20
NOTARY PUBLIC
Signature of Applicant
TOWN CLERK
Rev. 1/20
( * If yes to 7 or 7A, a Building Department permit is required )
Office Use Only
DONALD X. CLAVIN JR.
Supervisor
