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Special event November 2011 .04 r Ll 1/0 City of Atlantic Beach • 800 Seminole Road •Atlantic Beach,Florida 32233- �f 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 tem orary special events should be submitted to the City not less than thirty(30) days prior to the propo ed e ent. DATE �1 BUSINESS AND APPLICANT NAME: S L ,/ c MAILING ADDRESS: 12 T. �t Lfl br (2 l i (` C4- 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 property ow or atho ed agent. SIGNATURE . #1 PRINT NAME r, CONTACT INFORMATION OF PERSON SUB ITTING THIS REGISTRATION FORM (PLEASE PRINT) NAMEe-Z4 1 �� l _ MAILING ADDRESS ? �,_ S.4 r LLfij Sf( PHONEFAX G/l� Z � E-MAIL CC-)�Z _ Please provide all in ormati n s requested on the attached pages. 1. What type of alcohol will be served and how? eer? in? ther erved7 Outside? 2. Provide approved copy of any required Alcoholic Beverage Permits from the Division of Alcohol tz Beverages and Tobacco? (Additional permit required by DABT for any expansion of Licensed Premises.) 3. Identify the event sponsor and provide a propriate contact person in case of any emergency.y 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? Ir 5 6. Will there be outdoor music? Will there he amplified outdoor music?( t) What hours? tZ F, 7. Will there be a live band?,_ S Whit hours? 8. How many people are expected to attend this event? 4 (� 9. How will crowd control be managed if there is an overflow crowd? fi -�?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") ® C 1—�`t�- Sr CAK_-EW 1 l ! 11. How will parking be located and in aged? Include site plan showing parking areas to be used for this event. � r �Q�N�01�.S � l►z A-��:.� '�( L 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 approved by City of Atlantic Beach Polic Department. 13. How are they going to assure that'all people consuming alcohol are old e ough? rist ands. oor� ren? 14. Are any tents to be erected on the property? (Tent registration form required.) IF:7S J nrj� 2-D Ll- 15. t15. 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 z after the event, be addressed? \,J W1 LL_ 3t3 c -��►C��t c:4S�J C� -T� S OLk1-\P&Trd(_ 4.,YD --SAP 16. Will there be any extension of electricity into the parking areas, outdoor areas or any yards? 0&JE T�xM'5(cxJ e ow -fi � r V- 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. rAt,.}.1 .�� 1S t tAr4\J1Z0 A-iD Sty-PP C4 E�o 19. Are there going to be anyfiresor fireworks. V 20. Other than service animals, are there going to be any animals allowed as part of this special event? 2 21. Is this a first time event or a continuation of an annualevent? 3-5 ' t S G�.c 1`� L �w € �i�ftt-S C L.Llb3 Cif- �— TJ d`'E 22. Were they complaints or problems at prior events of this nature? N _ ot' 23. What additional signage will be used? (Such as for advertising, restrooms, alcohol consumption? (City Sign regulations apply.) t�'A 0 24. How will the event be promoted and advertised (such as through the use of fliers, TV, Radio, etc.) A .T7KrrFU\aC._ }' �' ;�S INJ _PLAN 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. It SIGNATURE �"" DATE PRINT NAME LP CIU EVENT APPROVED: V REQUEST DENIED: SIGNED: DATE: D partment of Pub isSaf id SIGNED: DATE: rr/8/ir Jim Hanson, ity Manager 3 FRONT TENT sta e ,_ 77 Deck CrI Pub 0 00 Back Deck Kitchen _ _ ��.tl 11111111111111 i 111111111111111 i l 1111111 rlllllllltllll�i�ii�ii����i t s INSTRUCTIONS FOR COMPLETING DBPR ABT—6029 DIVISION OF ALCOHOLIC BEVERAGES AND TOBACCO APPLICATION FOR EXTENSION OF LICENSED PREMISES OR AMENDED SKETCH OF LICENSED PREMISES Application begins on page 3 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. hftp://www.state.fl.us/dbpr/abt/contact/index.shtmi GENERAL REQUIREMENTS This application must be submitted for approval when changes are made to licensed premises. Please complete all information. Incomplete applications will be returned. All questions are applicable and must be answered fully and truthfully. You must provide an original and a copy of the application and duplicate copies of all supporting documentation. All signatures must be original. APPLICATION REQUIREMENTS Zoning Approval—Applies to Permanent or Temporary Extension of Premises Only Zoning approval is executed by the city or county zoning authority in which the business to be licensed is located. This application is to be taken to the Zoning Department(City or County)that governs the location of your business. Affidavit of Applicant Read and sign in the presence of a notary. The affidavit must be signed by the individual applicant, all partners of a general partnership, all general partners of a limited partnership, all managing members of a limited liability company, or one of the officers of a corporate applicant. Sketch of Premises Draw, in ink,a complete sketch of the premises,which includes all walls, doors, counters, sales areas, storage areas,etc. No architectural drawings are accepted. Amended Sketch of Premises Draw, in ink, a complete amended sketch of the premises,which includes all walls, doors, counters, sales areas, storage areas,etc. Changes may be made to the existing premises only; no additional rooms may be added. No architectural drawings are accepted. Note: The completion of Section 3-Zoning Approval does not apply to amended sketch premises. APPLICATION CHECKLIST Select the appropriate transaction below and comply with the corresponding application requirements. 1 S r TRAIusAcilo l I1PP LCATJON REQU19EMEN`tS Pay$100 fee for temporary extension of licensed premises only Extension of Licensed (make payment payable to the Department of Business and Professional Regulation) Premises ❑ Complete DBPR ABT-6029 Division of Alcoholic Beverages and Tobacco Application for Extension of Licensed Premises or Amended Sketch of Licensed Premises ❑ Complete DBPR ABT-6029 Division of Alcohofic Beverages and Amended Sketch Tobacco Application for Extension of Licensed Premises or Amended Sketch of Licensed Premises ❑ Section 3 of this ap2lication does not apply 2 DBPR ABT-6029-Division of Alcoholic Beverages and Tobacco Application for Extension of Licensed Premises or Amended Sketch of Licensed Premises Fl . ' �rf. •�c V STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION )OW. ally North Monroe Street 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 em 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. hftp://www.state.fl.us/dbr)r/abt/contact/index.shtmi SECTIOW.,1 -'CHECK TRANSAOTION'REQUESTED Tr nsaction Type: Temporary Extension ❑ Amended Sketch ❑ Permanent Extension SECTION 2;-"LICENSE.,'INFORMATjQN>' Full Name of Applicant Trade Name (D/B/A) SA-tAx AS A go\F Location Address(Street) 17+ n J�t �� f -%'`" es i\j . City nty St CouLC de x2-9 . Beverage Licnsemer eriType 2600! L3 -4 _eo FOR TEMPORARY EXTENSIOPYS Oft Y. Date(s)of Extension: Z �� P I Z C�3 l J SE TI 3 zQN�NQ�APPROAL' TO S1:GOMPi.ETD Bl/THE ZCiNiNG`AtTHO� �F.R�tIN�, C►UR BUSINESS LOCATION Is sec#fon`o " lies to a rmanet or#em ra' +az#enslon of"licensed promises Trade Name(D/B/A) 1- � ?LA, Are there outside areas which are contiguous to the premises which are to be part of the premises sought to be licensed?" 0 Yes ❑ No The above extension of the licensed premises as shown in the sketch ❑ does comply or❑ does not comply with zoning requirements for the sale of alcoholic beverages pursuant to this application. Signed: Title: Date: 3 SEC710N 5,- ;C1N=DESCPJPTIO t�M15 . `t E .GEwSED , - AS&T"AUTHORIZEDSIGIVAt I E`REQUIRED 7multi-story be drawn in ink and include all walls,doors, counters, sales areas, storage areas, cations and any other specific areas which are part of the premises sought to be licensed. din where the entire building is to be licensed must show each floor. Trade Name (D/B/A) PA Receipt Number Date of Receipt Extension Fee Date ] AB&T Authorized Signature ❑ Approved ❑ Disapproved 5 DIVISION OF ALCOHOLIC BEVERAGES AND TOBACCO LICENSING DISTRICTS DEBI PENDER, CHIEF, BUREAU OF LICENSING NORTH REGION CENTRAL REGION SOUTHERN REGION Damon Larry Tina Kachmar Carie Beckerman Regional Supervisor Regional Supervisor Regional Supervisor PENSACOLA-DIST.#1 ORLANDO-DIST.#5 MIAMI-DIST.#8 Donna Thompson,Sylvia Edge,Galt Daysl Tejera,Spring Davis, Bayou Corporate Office Ctr. Flynn,Mona Lewis-Felton Maria Delalloval 4900 Bayou Blvd. 400 West Robinson St. Augusta Building,Suite 100 Suite 210 Hurston Bldg.,Rm 709 8685 M.W.53rd Terrace Pensacola,FL 32503 North Tower Miami,FL 33166 Phone:(850)494-5970 Orlando,FL 32801 Phone:(305)470-6787 SC: 690-5970 Phone:(407)245-0785 SC: 429-0787 Fax:(850)484-5080 SC:690-5080 SC: 344-0785 Fax:(305)470-6756 SC:429-6756 Escambia,Okaloosa,Santa Rosa Fax:(407)317-7289 SC:344-7289 Dade Brevard,Flagler,Lake,Orange,Osceola, TALLAHASSEE-DIST.#2 Seminole,Volusia FT.LAUDERDALE-DIST.#9 Linda Smith Patricia Cohen,Desiree Cahill, 1940 N.Monroe Street TAMPA-DIST.#6 Yolanda Morales Tallahassee,FL 32399-1021 Paula Bouie,Theresa Espinosa,Sharon 5080 Coconut Creek Pkwy. Suite C Phone:(850)488-4271 Scott Margate,FL 33063-3942 SC: 2784271 Park Trammel Building Phone:(954)917-1350 Fax:(850)921-7800 SC:291-7800 1313 Tampa Street SC: 423-1350 Columbia,Dixie, Gadsden, Hamilton, Suite 909 Fax:(954)917-1357 SC:423-1357 Jefferson,Lafayette,Leon,Liberty, Tampa,FL 33602 Broward Madison.Suwannee,Taylor,Wakulla Phone:(813)-272-2610 SC: 512-0516 WEST PALM BEACH-DIST.#10 JACKSONVILLE-DIST.#3 Fax:(813)233-2896 Toni Sucese,Patricia Maxwell Quida Anderson,Lori Johns Hardee,Hernando,Highlands, 400 N.Congress Ave.#150 7960 Arlington Expressway Hillsborough,Pasco,Pinellas,Polk West Palm Beach,FL 33401 Suite 600 Phone:(561)682-0077 Jacksonville,FL 32211 FORT MYERS-DIST.#7 SC: 256-0077 Phone:(904)727-5552 Sally Castiano,Rhonda Bogatitus Fax:(561)681-6207 SC:256-6207 SC: 841-5552 4100 Center Point Drive Palm Beach Fax:(904)727.5562 SC:841-5562 Suite 101 Baker,Bradford,Duval,Nassau,St. Fort Myers,FL 33916 KEY WEST DIST.#17 Johns,Union Phone:(239)278-7195 Susan Lowe GAINESVILLE DIST.#11 SC: 729-7195 Key West Professional Ctr. Fax:(239)278-7061 SC:729.7061 1111 12th Street Myrna Williams 240 N.W.76`"Drive,Ste#B Charlotte,Collier,DeSoto,Glades, Suite 205 Hendry,Lee,Manatee,Sarasota Key West,FL 33040 Gainesville,FL 32607 Phone:(305)292-6755 Phone:(352)333-2515 SC: 464.6755 SC: 627-2515 Fax:(305)292-6864 SC:464-6864 Fax:(352)333-2514 SC:627-2514 Monroe Alachua,Citrus,Clay,Gilchrist,Levy, Marion,Putnam,Sumter CENTRAL OFFICE FORT PIERCE DIST.#18 1940 N.Monroe Street Margie Beltran PANAMA CITY DIST.#13 Tallahassee,FL 32399-1021 4984 S.25`"Street Gina Metcalf Lois Williams 98 34 FL 1 ,Fort Pierce 7948 Front Beach Road Central Office Licensing Supervisor phone:(ceFL 349 1 Panama City Beach,FL 32407 SC: 2403927 Phone:(850)236.3050 Fax:(772)595-1300 SC:240-1300 SC: 770-3050 Vickie Gordon (850)414.6487 Indian River,Martin, Fax:(850)236-3054 SC:7703054 Okeechobee,St.Lucie Bay,Calhoun,Franklin,Gulf,Holmes, Stephanie Gurley (850)414-6497 Jackson,Walton,Washington Mayse!Jackson (850)414-0484 Ronda Rosier (850)414-6490 Mary Wilson (850)414-6494 JACKSONVILLE DISTRICT RETAIL LICENSES & FEE INFORMATION License Fees—Baker and Union Counties Series Provisions Annual Fee 1APS Beer(Package Sales Only) $28.00 2APS Beer and Wine (Package Sales Only) $84.00 1COP Beer(Package and Consumption) $56.00 2COP Beer and Wine (Package and Consumption) $168.00 3DPS Beer, Wine and Spirits (Package Sales Only) $468.00 8COP Beer, Wine and Spirits (Package and Consumption) $624.00 11C Beer Wine and Spirits (Consumption Only) $400.00 License Fees—Duval, and St.Johns Counties Series Provisions Annual Fee 1APS Beer(Package Sales Only) $140.00 2APS Beer and Wine (Package Sales Only) $196.00 1 COP Beer(Package and Consumption) $280.00 2COP Beer and Wine (Package and Consumption) $392.00 3PS Beer, Wine and Spirits (Package Sales Only) $1,365.00 4COP Beer, Wine and Spirits (Package and Consumption) $1,820.00 11C Beer, Wine and Spirits (Consumption Only) $400.00 License Fees—Bradford County Series Provisions Annual Fee 1APS Beer(Package Sales Only) $56.00 2APS Beer and Wine (Package Sales Only) $112.00 1COP Beer(Package and Consumption) $112.00 2COP Beer and Wine (Package and Consumption) $224.00 3CPS Beer, Wine and Spirits(Package Sales Only) $643.50 7COP Beer, Wine and Spirits(Package and Consumption) $858.00 11C Beer, Wine and Spirits (Consumption Only) $400.00 License Fees—Nassau County Series Provisions Annual Fee 1APS Beer(Package Sales Only) $84.00 2APS Beer and Wine(Package Sales Only) $140.00 1COP Beer(Package and Consumption) $168.00 2COP Beer and Wine (Package and Consumption) $280.00 3BPS Beer, Wine and Spirits(Package Sales Only) $975.00 6COP Beer, Wine and Spirits(Package and Consumption) $1,300.00 11C Beer, Wine and Spirits(Consumption Only) $400.00 Temporary Fees All Transfers $100.00 (Alcoholic beverages only, no transfer allowed for tobacco) New KLD $1,000.00 New JDBW $312.50 New AMW $250.00 New DD $1,000.00 New ERB $1,000.00 New IMPR $125.00 New CMBP $125.00 New CWD $100.00 New TWD $25.00 Special Restaurant Licenses Baker, Bradford, Duval, St.Johns, and Union Counties: Licenses are issued pursuant to Florida Statute 561.20(2)(a)4 to establishments that maintain a bona fide restaurant having 2,500 square feet of floor space under permanent cover, seating for 150 patrons, and 51% of their gross revenue from the sale of food and non-alcoholic beverages. Duval County(The Landing and vicinity): Licenses are issued pursuant to HB 845, Special Act, to establishments that maintain a bona fide restaurant having 1,800 square feet of floor space under permanent cover, seating for 100 patrons, and 51%of their gross revenue from the sale of food and non-alcoholic beverages. Nassau County: Licenses are issued pursuant to SB 644, Special Act, to establishments that maintain a bona fide restaurant having 4,000 square feet of floor space under permanent cover, seating for 200 patrons, and 51%of their gross revenue from the sale of food and non-alcoholic beverages. Special Hotel Licenses Baker, Bradford, Duval, St.Johns, and Union Counties: Licenses are issued pursuant to Florida Statute 561.20(2)(a)1 to hotels, motels, and motor courts having not fewer than 100 guestrooms and deriving 51%of their gross revenue from the rental of rooms. Nassau: Licenses are issued pursuant to SB 644, Special Act,to hotels, motels, and motor courts having not fewer than 50 guestrooms and deriving 51%of their gross revenue from the rental of rooms. Club Licenses 1. Subordinate lodges or clubs of national fraternal or benevolent associations; 2. Golf clubs,tennis clubs, and beach or cabana clubs which are municipally or privately owned or leased; 3. Nonprofit corporations or clubs devoted to promoting community, municipal, or county development or any phase of community, municipal, or county development; 4. Clubs fostering and promoting the general welfare and prosperity of members of showmen and amusement enterprises; 5. Clubs assisting, promoting, and developing subordinate lodges or clubs of national fraternal or benevolent associations;and 6. Clubs promoting, developing,and maintaining cultural relations of people of the same nationality. DISTRICT DEPARTMENTS CONTACT INFORMATION Department of Revenue—Area Locations Baker, Bradford, Union Counties (904)758-0420 2651 West US 90 Lake City, FL 32055 Nassau, Duval Counties (904)359-6070 921 North Davis Street, Building A, Suite 250 v Phone Only— Lake Butler—City Hall Health Department— Locations (No Food Preparation) Baker Baker Co. Health Department (904)259-6261 657S. 6th Street MacClenny, FL 32063 Bradford Bradford County Health Department (904)964-7732 329 N. Church Street Starke, FL 32091 Duval Duval County Health Department (904)630-3260 900 University Blvd. N., Suite 300 Jacksonville, FL 32211 Nassau Nassau County Health Department (904)321-5765 30S. 4 th Street Fernandina Beach, FL 32034 St.Johns St. Johns County Health Department (904)825-5055 180 Marine Street St. Augustine, FL 32084 Union Union County Health Department (904)496-3211 Lake Butler— PHONE ONLY Health Department (For Food Service Establishments) Division of Hotels and Restaurants 7960 Arlington Expressway, Suite#610 (850)487-1395 Jacksonville, FL 32211-7467 Serving Baker, Bradford, Clay, Duval, Nassau, St. Johns, and Union Counties for the Northeast Florida Region.