Special event for 12/3/11 i�.1T1
t`y v 9 1
�y_ c32 G' it
City of Atlantic Beach 800 Seminole Road •Atlantic Beach,Florida 32233-�4'
� I
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 propoed e ent.
DATE � '
BUSINESS AND APPLICANT NAME: ? r' P �6
MAILING ADDRESS: 1:7 T c =�4 ,zt
ADDRESS AND LOCATION WHERE EVENT WILL TAKE PLACE (If different from mailing address.)
REQUESTED DATE(S) FOR TEMPORARY EVENT Z- -S +'
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 propertyow ora tho ed agent.
-nq��JAJ
SIGNATURE ti PRINT NAME
CONTACT INFORMATION OF PERSON SUTTING THIS REGISTRATION FORM (PLEASE PRINT)
NAME �ci. +�
MAILING ADDRESS s41 L.fl` l( �. 7-L_ i
G l( C�TFAx r/y��� 2 f� L " E-MAIL j r CKP, �-T
PHONE 1[:%��CC� V ��
�i—
Please provide all information as requested on the attached pages.
1. What type of alcohol will be served and how eer? Wine? Ether efved insi e 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 plannedeventsand activities.
5. Has the business consulted with neighboring businesses to obtain their approvals?
k 111
6. Will there be outdoor music? Will there be amplified outdoor music?(JL) What hours? 12 1,7
7. Will there be a live band?WS What hours? 2 -
8.
—8. How many people are expected to attend this event? VS-0
9. How will crowd control be managed if there is an overflow crowd?
10. What specific special events are planned? (...such as bobbing for a Ales; ring toss; dunking booths; wet
t-shirts; bikini contests; all male/female "review") �C wv c:. I e� ,r_ 5 C {
I (
11. How will parking be located and nh�i:L
naged? Include site plan showing parkingareas to be used for this
event. `�Ps v c.2 S TT, L
vim_ DCS►c`= Fc� -i�c�� lL �
12. How will security needs He 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 thaLll people consum(ng alcohol are old e ough? rist lands. `
hien?
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, durinand
after the event, be addressed? W` -� r '- -, `{'� ` L` S
16. Will there be any extension of electricity into the parking areas, outdoor areas or any yards?
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.
WrE - W 1 L1._ n j e%T_ L.c c-�c (21C'1+-c T c:r=
18. Address how fire code requirements and access for emergency vehicle be monitored and maintained at all
times during the Special event. f-iA-C-{{ �� r t S !�% u`v�) SL`►'(� W 1�' �
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? �--�
2
21. Is this a first time event or a continuation of an annual,event?
C.to-C t r
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.) w , 1 01
24. How will the event be prom-mooted and advertised (s-u..�c-h, as through the use of fliers, TV, Radio, etc.)
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.
1
SIGNATURE " ^ DATE 9
PRINT NAME
EVENT APPROVED:
REQUEST DENIED:
SIGNED: DATE:
Department of Public Safety
SIGNED: DATE:
Jim Hanson, City Manager
3
FRONT TENT
stage
Deck
Pub
l
i
Back Deck
1---- _ r __
_
_
_
Kitchen
_
_
_
_
_
�®dt�lllliilllltl��ol,i'�ea��'i1�i1111�t,r��if�l�lonui�� i�i�Eass��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.
http://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
TRANSACTION APPLICATION REQUIREMENTS
Pay$100 fee for temporary extension of licensed premises only
Extension of Licensed (make payment payable to the Department of Business and
Premises Professional Regulation)
❑ 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 Alcoholic Beverages and
Amended Sketch Tobacco Application for Extension of Licensed Premises or
Amended Sketch of Licensed Premises
❑ Section 3 of this application 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
STATE OF FLORIDA
R* JL VDEPARTMENT OF BUSINESS AND PROFESSIONAL' hl:Here,.
REGULATION
1940 North Monroe Street
KI&NOW. 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.
hfp://www.state.fl.us/dbr)r/abt/contactfindex.shtml
-SECTION1 -CHECK TRANSACTIONREQUESTED
Tr nsaction Type:
Temporary Extension 13 Amended Sketch
❑ Permanent Extension
SECTION 2''-LICENSE INFORMATION
Full Name of Applicant
Trade Name (D/B/A)
Location Address(Street) i i5�
%>Z.►v �.
City County St C_ de
C -,--�3
BeverageLicense Number 3 Series !��� Type
� G
FOR TEMPORARY EXTENSIONS ON Y:
Date(s)of Extension: 23
Z 0 J1
SECTION-3-ZONING APPROVAL
TO HE COMPLETED BY,THE ZONING AUTHORITY GOVERNING.YOUR BUSINESS LOCATION
ffhIs section onN iappiles to a permanent or temporary extension of licensed remises
Trade Name(D/B/A) � T�I.--
Are
Are there outside areas which are contiguous to the premises which are to be part of the premises sought to
be licensed?" 4 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
SECTION;5—:DESCRIPTION OF PREMISES TO BE LICENSED
AB&T AUTHORIZEDSIGNATURE 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-story building where the entire building is to be licensed must show each floor.
Trade Name(D/B/A) � rS .n y�J`.�
r
Receipt Number Date of Receipt
Extension Fee Date
AB&T Authorized Signature U Approved U 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,Gail Daysi 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 N.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: 429-6787
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
TALLAHASSEE-DIST.#2 Brevard,Flagler,Lake,Orange,Osceola,
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: 278-4271 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: 512-3516 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
SC: 729-7195 Key West Professional Ctr.
GAINESVILLE DIST.#11 Fax:(239)278-7061 SC:729-7061 1111 12th Street
Myrna Williams Charlotte,Collier,DeSoto,Glades, Suite 205
240 N.W.76'x'Drive,Ste#B 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
PANAMA CITY DIST.#13 Tallahassee,FL 32399-1021 Margie 25"
BelSn
Gina Metcalf Lois Williams Fort S.rc Street
Central Office Licensing Supervisor Fort Pierce, 46FIL 34981
7948 Front Beach Road g P Phone:(772)468-3927
Panama City Beach,FL 32407 SC: 240-3927
Phone:(850)236.3050 Fax:(772)595-1300 SC:240-1300
SC: 770-3050 Vickie Gordon (850)414.6487
Fax:(850)236-3054 SC:770-3054 Indian River,Martin,
Bay,Calhoun,Franklin,Gulf,Holmes,
Stephanie Gurley (850)414-6497 Okeechobee,St.Lucie
Jackson,Walton,Washington
Maysel Jackson (850)414-6484
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
1COP 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) $22.4.00
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
Phone Only—Lake Butler—City Hal
Health Department— Locations (No Food Preparation)
Baker
Baker Co. Health Department (904)259-6261
657S. 6 th 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 Ih 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.