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Permit 1013 Atlantic Boulevard~yf 1%U~J jj ~ 3 sl S) ~'' . "~~ ~ ' }r'j~}~~ City of Atlantic Beach 800 Seminole Road • Atlantic Beach, Florida 32233-5~ Phone (904) 247-5800 Fax (904) 247-5845 http://www.coab.us ~j REGISTRATION FORM l FOR APPROVAL OF TEMPORARY SPECIAL EVENTS All information requested on this form must be fully addressed in order to receive approval from the City of Atlantic Beach to hold any special event by any commercial entity, non-profit, charitable, or for profit organization on private property, which involves activities exceeding normal day-to-day use of property or business operations, the use of outdoor tents, service or cooking facilities, or any expansion of the business area to an outdoor area or any parking area. Use of tents requires an additional tent registration form. In no case shall any such temporary special event extend to utilize any public property, street, sidewalk or right-of--ways. Requests to receive approval for temporary special events should be submitted to the City not less than thirty (30) days prior to the proposed event. DATE l~ I s I o~ BUSINESS ANDtAPPLICANT NAME: L i ~CX (~ 1'._. C. ~C~,i--1(1~Q~'1 ~'~-I ii Cyr--~-+cfa ~/o ~ MAILING ADDRESS: ~ l~ ~ ~ ~ ~ 1 ~ ~V ~ (`_~,~J'~1G IO~ ~t-~ ADDRESS AND LOCATION WHERE EVENT WILL TAKE PLACE (If different from mailing address.) RE VESTED DATES FOR TEMPORARY EVENT ~~ ~~"~ ~ ~ S-~' ~'J ~ i ~ ~ ~) ~~ C~ THE BELOW SIGNATURE ACKNOWLEDGES THAT THE PROPERTY OWNER AND/OR THE COMPANY CONDUCTING SUCH TEMPORARY EVENT ASSUMES ALL LIABILITY AND RESPONSIBILITY FOR SUCH EVENT. I HEREBY CERTIFY THAT ALL INFORMATION PROVIDED IS CORRECT. Signature of property owner or authorized agent. SIGNATUR~ ~ PRINT NAME '-~'~ , 1~-~- CONTACT INFORMATION OF PERSON SUBMITTING THIS REGISTRATION FORM (PLEASE PRIN1) NAME MAILI] PHONE ~,pZ - "l ~I C~~ FAX ~ ~ /V' ~ V,~J ~ U E-MAIL ~~ Please provide all information as requested on the attached pages. 1. What type of alcohol will be served and how? Beer? Wine? Other? Served inside? Outside? 2. Provide approved copy of any required Alcoholic Beverage Permits from the Division of Alcohol Beverages and Tobacco? (Additional permit required by DABT for any expansion of Licensed Premises.) 3. Identify the event sponsor and provide appropriate contact person in case of any emergency. 4. Provide a site plan depicting the layout and location of all activities, including parking and traffic flow distribution points, any tents, fences, security check points, and location of planned events and activities. 5. Has the business consulted with neighboring businesses to obtain their approvals? 7 ~ S 6. Will there be outdoor music? Will there be amplified outdoor music? What hours? ~ (~•~ ~ ~ PC'iM M~ 1~ 2 : ~ ~ ~'~ 7. Will there be a live band? What hours? ~ f e S , I IRS ~~cl~• ~1 p m _ ~ 1 ~ 3 c~ ~, 8. How many people are expected to attend this event? 2 J •~ ~~~~ 9. How will crowd control be managed if there is an overflow crowd? Y~ ~ 10. What specific special events are planned? (...such as bobbing for apples; ring toss; dunking booths; wet t-shirts; bikini contests; all male/female "review") `--} (,~~ ~~~p~ ~ ry~ -- -}~ ~j 1~2. S 11. How will parking be located and managed? Include site plan showing parking areas to be used for this event. 12. How will security needs be provided; particularly with respect to prohibiting minors from being served. (See following question.) Will off duty police or private security be used? Who is the contact person on- site if problems arise? (Must be a proved by City of Atlantic Beach Police Department. 17'f~2iY14~1'1 rl~ 14~~5 1,•J~~ -S~}'I~.l1~S 1rv~, ~1 V~G~ U,~~fD 2U~~P.~L G~C~ . 13. How are they going to assure that all people consuming alcohol are old enough? Wnst bands? Door men? 1N ~ W' ~ 1 1~ lJls 1 ~ W ~~ J~ hCi'i°~f.f' G~ ~la,~ (71 ert-1-~~ S{'_C,w +~ 14. Are any tents to be erected on the property? (Tent registration form required.) 15. Will there be any outdoor heating or cooking? If so, address how any by-products and refuse will be handled, including grease/oiUrefuse. How will any extra trash collection and disposal needs, during and after the event, be addressed? W ~ h(l ~'~ ~ ~0~~{ ~ ~UPYI~{{'ii2.. -tYZLb1~1 ~~,t-r CQJ~rI/l,~ 16. Will there be any extension of electricity into the parking areas, outdoor areas or any yards? I~ 17; Special temporary events cannot negatively impact traffic flows, particularly in any adjacent residential areas, or close or block any public street or right-of--way Please address. 18. Address how fire code requirements and access for emergency vehicle be monitored and maintained at all times during the Special event. 19. Are there going to be any fires or fireworks? 20.Other than service animals, are there going to be any animals allowed as part of this special event? n ~ 2 21. Is this a fist time event or a continuation of an annual event? ~\(.~ 22. Were they complaints or problems at prior events of this nature? 23. What additional signage will be used? (Such as for advertising, restrooms, alcohol consumption? (City Sign regulations apply.) r~Sk (1'a7~ d~'1 S ~C~•~ ~ ~j(~p~2 ~ r 1 L 1 ~ (~.~i~, ~ x ~ ~"-~ ICl'10e~ o~ 24. How will the event be promoted and advertised (such as through the use of fliers, TV, Radio, etc.) ~~ 1%12. A ~ C.~t ~ ~1 ~-2if~"~'~Q,~ , 25. Acknowledge by signature below that this special event will comply with all City of Atlantic Beach laws and ordinances and that the event will be conducted and managed as represented within this application. Such acknowledgement extends to all those organizing, planning and staffing this event. SIGNATURE DATE ~ PRINT NAME ~\C~~' V~I ~ -E' eiYl ~ C~-~._ r~~2~~~ EVENT APPROVED: REQUEST DENIED: SIGNED: Department of Public Safety :~ ~ r~-, !~i'~2,,u..4-~ ~S• f-~~IJi= 10~~.-7 (~6j ~~. SIGNED: DATE: ~0~30%` __ Jim Han n, City Manager 3 V '~' Y . i ~:, ~Z~ ~ n ~ ~ ~. ~~ ~~ -'t' ~ ~ .~1~? _--- ©~ O ~~ ~ ~' ti 4 ~, ~ ~ 1 `~ ~ o a ~ 4 ~~ ~ ~ ~~ 4 ~ s ~~ ~ 4 ©` G9 C? ~~ ® ca ~ ~~ o ~ ~~ ,~ a~ ~ oW~ ~o ~~ ° ~ ~' ~ p~ ~ z G~~~S ~ b 1~ ~ ~ h' Z ~Z ~ ~~~ ------- z ~ ~.F. h~ ~1 HP Fax,Series ~ Rhin paper Fax/Dopier Fax History Report for Oct 3~ ~~b 11:59am I~st a Bate x Time Ty.~ identification ~ t n ~ ~~ Oct 30 I I:SSam Sent 82466034 1:53 4 OK Result: OK -black and white fax