Permit 177 Sailfish approval for potato party 2011 j
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City of Atlantic Beach - 800 Seminole Road -Atlantic Beach,Florida t jEy
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.
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BUSINESS ANPAPPLICANT N Z�s 11 .4—
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MAILING ADDRESS:
ADDRESS AND LOCATION WHERE EVENT WILL TAKE PLACE (If different from mailing address.)
REQUESTED DATE(S)FOR TEMPORARY EVENT
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 pror
'_rtj owner or authorized agent.
SIGNATURE( PRINT NAME PhW6,6 CT('11A6AA",4A#-AJ
CONTACT 11WORMATION OF PERSON S!��ING THIS REGISTRATION FORM (PLEASE PRINT)
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NAME 86WI FC/—
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Please vi e all information as requested on the attached pages.
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1. What type of alcohol will be served and ho Beer lin Served insidet Outside?
2. Provide approved copy of any required Alcoholic Beverage Permits from the Division of Alcohol
Beverages and Tobacco? (Additional t ed by DABT for any expansion of Licensed Premises.)
3. Identify the event sponsor and provide a propnate contact rso in case any eyner ency.
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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? k
6. Will there be outdoor music?��ill there be amplified outdoor music? What hours?
7. Will there be a live band?Yr-,.0, What hours?
8. How many people are expected to attend this event? C4-f T/0-0 X1 m i:�TF- I-X
9. How will crowd control be managed if there is an overflow crowd? --3 at '�--cJ)Q 1 -7- P-
10. What specific special events are planned? (...such as bobbing for apples; ring tossQ�� g�booths; et
t-shirts; bikini contests; all male/female "review")
11. How will parking be located and managed? Include site plan showing parking areas to be us&d f4
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event. dqTX::S46i5/v-r- 'FAR-OeIA34i L-0--r-5,i &/, -Y'Ncx:�c
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 qerson on-
site if problems arise? (Must be approyed by City of Atlantic Beach Police Department.
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13. How are they going to assure that all people consuining alco�o`la(e old eno"'Igh? rrist band2-?A600r
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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? k IT VQ A ::,:)Q ro P t<
16. Will there be any extension of electricity into the parking areas, outdoor areas or any yards? Yd
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. -F P E V x 0 J-3 ff�
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18. Address how fire code requirements and access for emergen6y vehicle be monitored and maintained at all
times during the Special event. -�E>i:51- C U 0- ( V:,/-/ -C:9!f-T > A A)
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ig. paehere 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? ffo
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2 1. Is this a first time event or a(continuation of an annual event)
22. Were they complaints or problems at prior events of this nature? AIDIJ G-3-
23. What additional signage will be used7 (Such as for advertising, restrooms, alcohol consumption? (City
Sign regulations apply-) Fc'V All I -
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24. How.will the event be promoted and advertised(such as through the use o fl ie Radio, tc.)
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 stafYing this event.
SIGNAT
DATE
PRINT NAME �11Z A VW
EVENT APPROVED:
REQUEST DENIED:
SIGNED: DATE:—
Departnient of Public Saffty
SIGNED: �L:Z DATE:
Jim 117glon, City Manager
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