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City of Atlantic Beach • 800 Seminole Road •Atlantic Beach,Florida 32233-5445
Phone (904)247-5800 • Fax (904)247-5845 • http://www.coab.us
REGISTRATION FORM
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 (�
BUSINESS AND APPLICANT NAME: �,(/` L{� (.S4
MAILING ADDRESS: Lsc —)-J"I (C- L OL6, t (c &k,d E22_ Z3
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ADDRESS AND LOCATION WHERE EVENT WIL�JAKE PLACE (If different from mailing address.)
REQUESTED DATE(S)FOR TEMPORARY EVENTI bL
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.
SIGNATURE PRINT NAME (-L
CONTACT INFORMATION OF PERSON SUBMITTING THIS REGISTRATION FORM (PLEASE PRINT)
NAME Lk-C C(Ai_-t-A
MAILING ADDRESS 26C:1, �-J A--CJ t ^jt�
PHONE FAX E-MAIL C.-Ae tCI-•(��,�SC
Please provide all information as requested on the attached pages. � t.0 A V ��
e
1. What type pf alcohol will tae served
aand�wer9 � O her? Served inside? . use
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2. Provide approved copy of any required Alcoholic Beverage Permits from the Division of Alcohol
Beverages and Tbacco? (Additional permit required by DABT for any expansion of Licensed Premises.)
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3. Identify the event sponsor and provide appropriate contact erson in case of any, emergency.
4. Provide a site plan depicting the layout and location of all activities, including arking and traffic flow
distribution points, any tents, fence , security heck points, and location of planned events and activities.
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5. Has the business consulted with neighboring businesses too tpin the*r approvals?
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6. Will there be outdoor music? Will there be amplified outdoor music? What hours?
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7. Will there be a live band? What hours?
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8. How many people are expected to attend this event?
1000 f�10t P_
9. Howw}ll crocontrol be managed if there is an overflow crowd?
10. What specific special events are planned? (...such as bobbing for apples; ring toss; dunking booths; wet
t-shirts; bikini contests; all male/fele "review")
11. How will parking be located and managed? Include site plan showing parking areas to be used for this
event.
63,A"K✓o -
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 prems arise? (Must be approved by City of Atlantic Beach Poli c Department
13. How are they going to assure that all people consuming alcohol are old enough? Wrist bands? Door
men? R tS � 4 G^CtA G (.W?il
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/oil/refuse. How will any extra trash collection and disposal needs, during and
after the event, be addressed? )\J r
16. Will there be any extension of electricity into the parkin areas, outdoor areas or any yards?
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17. Special temporary even`M cannot negatively impact traffic flows, particularly in any adjacent residential
areas, or close or block any public `trpeet 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?
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20. Other than service animals, are there going to be any animals allowed as part of this special event?
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21. Is this a fir-sAt�ime event or a continuation of an annual event?
22. Were the complaints or problems atirior events of this nature?
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23. What additional signage will be used? (Such as for advertising, restrooms, alcohol consumption? (City
Sign regulations apply.) S) �016S i --t- oCj- -, S
24. How will the event be promoted and advertised (such as through the use of fliers, TV, Radio, etc.)
Levent SS �G�,✓ A-,:J `'S
25. Acknowledge by signature below that this sp8cial 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 l C�`Q DATE 4)- ' C)
PRINT NAME
EVENT APPROVED:
REQUEST DENIED:
SIGNED: DATE:
Department of Public Safety
SIGNED: DATE:
Jim Hanson, City Manager
3
DBPR ABT-6029—Division of Alcoholic Beverages and Tobacco Application for Extension of
Licensed Premises or Amended Sketch of Licensed Premises
f� 1Fµ �4 STATE OF FLORIDA
DEPARTMENT OF BUSINESS AND PROFESSIONAL
DBPR
REGULATION
,fir 1940 North Monroe Street
�7`�;Lt(I� ' Tallahassee, FL 32399-0783
If you have any questions or need assistance in completing this application, please contact the
Department of Business and Professional Regulation or your local district office. Please submit your
completed application to your local district office. This application may be submitted by mail, through
appointment, or it can be dropped off. A District Office Address and Contact Information Sheet can be
found on AB&T's page of the DBPR web site at the link provided below.
http://www.state.fl.us/dbpr/abt/contact/index.shtml
SECTION 1 CHECK TRANSACTION REQUESTED
T nsaction Type:
Temporary Extension ❑ Amended Sketch
Permanent Extension
SECTION 2 LICENSEtNFORMAT10Nh:'
Full Name ofC H nt ���� �� K3 G
Trade Name (/JB/Av1) LA C t 14OL-0E
Location 1191T
(Street) �L G
* Code
City �l.--Ar--1-QC 9- County _ Sta Z19�
2-
Beverage �asIu b r '�`{ Series Type
f I-
Cont ct Person 1 s P on umbr-rr I13gr�e/Mobile P7hoone umbe
'�F(.�
FOR TEMPORARY EXTENSIONS ONLY:
Date(s) of Extension: v
SECTION 3-ZONING APPROVAL
Erlicensed?"
COMPLETED,BY THE ZONING AUTHORITY GOVERNING YOUR BUSINESS LOCATI(SN ;
is secton'onl applies to a ermanont or tem' ora extension of lconsed" remises
e(D/B/A)
utside areas which are contiguous to the premises which are to be part of the premises sought to
d?" �❑Yes ❑ No
extension of the licensed premises as shown in the sketch ❑does comply or❑does not comply
requirements for the sale of alcoholic beverages pursuant to this application.
Title: Date:
3
SECTION 5—DESCRIPTION OF PREMISES TO BE LICENSED
AB&T AUTHORIZED SIGNATURE REQUIRED
Sketches should be drawn in ink and include all walls,doors,counters,sales areas, storage areas,
restrooms, bar locations and any other specific areas which are part of the premises sought to be licensed.
A multi-stoy building where the entire building is to be licensed must show a ch floor.
Trade Name(D/B/A)
A
vV
Receipt Number Date of Receipt
Extension Fee Date
AB&T Authorized Signature ❑Approved ❑ Disapproved
5
SECTION 4-AFFIDAVIT OF AP.PLICAN7
NOTARIZATION REQUIRED
Trade Name(D/B/A)
"I, the undersigned individually, or if a corporation for itself, its officers and directors, hereby swear or affirm
that I am duly authorized to make the above and foregoing application and, as such, I hereby swear or affirm
that the attached sketch is a true and correct representation of the extended licensed premises and agree
that the place of business may be inspected and searched during business hours or at any time business is
being conducted on the premises without a search warrant by officers of the Division of Alcoholic Beverages
and Tobacco,the sheriff, his deputies, and police officers for the purposes of determining compliance with the
beverage and cigarette laws."
I swear under oath or affirmation under penalty of perjury as provided for in Sections 559.791, 562.45 and
837.06, Florida Statutes, that the foregoing information is true and correct."
If applying for a temporary extension, check the box to confirm the following statement:
❑ "I understand that the premises must be restored to its original form at the conclusion of the authorized
temporary event."
STATE OF
COUNTY OF
APPLICANT SIGNATURE
The foregoing was( ) Sworn to and Subscribed OR( )Acknowledged Before me this Day
of , 20 , By who is( )personally known
to me OR( )who produced as identification.
Commission Expires:
Notary Public
4
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