Fillable Taxi Licensing Application PDF (Town of Brookhaven)

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Taxi Licensing Application PDF (Town of Brookhaven)

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  • 4 check-boxes
  • 232 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Town of Brookhaven

BROWSE TOWN OF BROOKHAVEN (NY) FORMS

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Town of Brookhaven
Department of Public Safety
One Independence Hill
Farmingville, NY 11738
(631) 451-6180
APPLICATION FOR TAXICAB BUSINESS LICENSE AND TAXICAB MEDALLION
FEE: $200.00 FOR BUSINESS OWNER'S LICENSE $125 PER TAXICAB DATE:
PERSONAL INFORMATION: (Please complete all information)
Name: Maiden Name: Home Telephone #:
Local Address:
City: State: Zip Code:
Legal Address: (if different)
Place of residence for past 5 years (if different from above) use back of application if necessary:
Date of Birth: Age: Place of Birth:
Height: Weight: Eye Color: Hair Color:
Are you a citizen of the United States? YES NO
If citizenship was obtained by naturalization, the date and place where obtained:
If you are not a citizen, proof of legal entry into the United States must be submitted with this application
BUSINESS INFORMATION: (Please complete all information)
Business Name: Business Telephone #:
Business Address:
City: State: Zip Code:
Place of business and/or employment for past 5 years: (if different from above)
Licenses Held: (include licenses in any occupation)
Date Held: Where was license issued?
Was license ever revoked or suspended? YES NO If yes, date and reason for revocation:
Business is a: Corporation Partnership LLC D/B/A
New York State Sales Tax ID # & Federal Employer ID #:
COPIES OF ALL FILED BUSINESS CERTIFICATES MUST BE SUBMITTED WITH THIS APPLICATION
CERTIFICATES OF INSURANCE FOR THE BUSINESS LISTED HEREIN MUST BE PROVIDED
The name, address, telephone number and title of the person designated to accept legal notices:
FROM PROPERTY TAX MAP:
District: Section: Block: Lot:
Street #: N/S/E/W of:
Distance (feet): N/S/E/W of:
Nearest Cross Street: Town Tax Item #:
Does premises have the following? CO CEU CZC ZBA outdoor storage permit
Number: Date Issued:
IF APPLICANT IS NOT PROPERTY OWNER, A COPY OF A CURRENT WRITTEN LEASE FROM PROPERTY
OWNER MUST BE SUBMITTED WITH THIS APPLICATION
FEE: $125.00 PER TAXICAB
OWNER' S NAME:
BUSINESS NAME:
CERTIFICATES OF INSURANCE FOR EACH VEHICLE LISTED HEREIN MUST BE PROVIDED
VEHICLE INFORMATION: Please provide copies of the current, valid title, New York State Registration and
Proof of New York State inspection certificate
Year: Make: Model: Color:
Seating Capacity: Plate #: VIN:
Registration #:
Fleet Number of Vehicle: (if applicable) Medallion #:
Name, Address and Telephone Number of Vehicle Owner: (If different from Business Owner)
Year: Make: Model: Color:
Seating Capacity: Plate #: VIN:
Registration #:
Fleet Number of Vehicle: (if applicable) Medallion #:
Name, Address and Telephone Number of Vehicle Owner: (If different from Business Owner)
Year: Make: Model: Color:
Seating Capacity: Plate #: VIN:
Registration #:
Fleet Number of Vehicle: (if applicable) Medallion #:
Name, Address and Telephone Number of Vehicle Owner: (If different from Business Owner)
Year: Make: Model: Color:
Seating Capacity: Plate #: VIN:
Registration #:
Fleet Number of Vehicle: (if applicable) Medallion #:
Name, Address and Telephone Number of Vehicle Owner: (If different from Business Owner)
Year: Make: Model: Color:
Seating Capacity: Plate #: VIN:
Registration #:
Fleet Number of Vehicle: (if applicable) Medallion #:
Name, Address and Telephone Number of Vehicle Owner: (If different from Business Owner)
Year: Make: Model: Color:
Seating Capacity: Plate #: VIN:
Registration #:
Fleet Number of Vehicle: (if applicable) Medallion #:
Name, Address and Telephone Number of Vehicle Owner: (If different from Business Owner)
Year: Make: Model: Color:
Seating Capacity: Plate #: VIN:
Registration #:
Fleet Number of Vehicle: (if applicable) Medallion #:
Name, Address and Telephone Number of Vehicle Owner: (If different from Business Owner)
Year: Make: Model: Color:
Seating Capacity: Plate #: VIN:
Registration #:
Fleet Number of Vehicle: (if applicable) Medallion #:
Name, Address and Telephone Number of Vehicle Owner: (If different from Business Owner)
Year: Make: Model: Color:
Seating Capacity: Plate #: VIN:
Registration #:
Fleet Number of Vehicle: (if applicable) Medallion #:
Name, Address and Telephone Number of Vehicle Owner: (If different from Business Owner)
Year: Make: Model: Color:
Seating Capacity: Plate #: VIN:
Registration #:
Fleet Number of Vehicle: (if applicable) Medallion #:
Name, Address and Telephone Number of Vehicle Owner: (If different from Business Owner)
Year: Make: Model: Color:
Seating Capacity: Plate #: VIN:
Registration #:
Fleet Number of Vehicle: (if applicable) Medallion #:
Name, Address and Telephone Number of Vehicle Owner: (If different from Business Owner)
Year: Make: Model: Color:
Seating Capacity: Plate #: VIN:
Registration #:
Fleet Number of Vehicle: (if applicable) Medallion #:
Name, Address and Telephone Number of Vehicle Owner: (If different from Business Owner)
Year: Make: Model: Color:
Seating Capacity: Plate #: VIN:
Registration #:
Fleet Number of Vehicle: (if applicable) Medallion #:
Name, Address and Telephone Number of Vehicle Owner: (If different from Business Owner)
Year: Make: Model: Color:
Seating Capacity: Plate #: VIN:
Registration #:
Fleet Number of Vehicle: (if applicable) Medallion #:
Name, Address and Telephone Number of Vehicle Owner: (If different from Business Owner)
Have you been convicted of a felony or misdemeanor in the last five (5) years? YES NO
If yes, state the original charge, the charge upon conviction and the sentence imposed, the date of conviction and the
court that imposed it, including the docket, index, indictment or file number in such court.
By initialing below, the undersigned agrees that he/she and his/her agents will take all training courses as may be
prescribed by the State of New York, County of Suffolk and Town of Brookhaven designed to educate and familiarize
them with customary safety standards and shall provide evidence of the satisfactory completion of such courses.
(INITIAL)
By initialing below, the undersigned agrees that he/she is responsible for ensuring that all vehicles possessing certificates
medallions
are outfitted with such equipment as may be prescribed , from time to time, by the State of New York, County of Suffolk,
and/or Town of Brookhaven.
(INITIAL)
I, THE UNDERSIGNED AFFIRM UNDER PENALTIES OF PERJURY THAT THE INFORMATION CONTAINED HEREIN
IS TRUE AND THAT THE TAXI IS EQUIPPED AS REQUIRED BY LAW. I FURTHER AFFIRM THAT THIS APPLICATION
IS ACCEPTED ON THE CONDITION THAT THE PROVISIONS AND REGULATIONS OF THE TOWN OF BROOKHAVEN
CODES AND THE REQUIREMENTS OF THE RESPECTIVE TOWN DEPARTMENTS SHALL BE COMPLIED WITH. IT
IS UNDERSTOOD THAT ANY VIOLATION OF THE CODES OF THE TOWN OF BROOKHAVEN MAY RESULT IN THE
IMMEDIATE REVOCATION OF THIS APPLICATION AND ITS ATTACHED LICENSES.
Date Signature of Applicant
Print Name of Applicant
Sworn to me before this ______________ day of _____________________________ 20_______.
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Taxi Licensing Application PDF (Town of Brookhaven)

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Completed 16 July 2020

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