1021 Atlantic Blvd # 967 St Patricks Day 2015 City of Atlantic Beach—Department of Recreation&Special Events
716 Ocean Blvd.—Atlantic Beach,Florida 32233-5445
l� Phone (904) 247-5828 - Fax (904) 247-5849 • http://www.coab.us
APPLICATION FOR SPECIAL EVENT IN CITY OF ATLANTIC BEACH
Please provide the following information in order to receive approval from the City of Atlantic Beach to
hold a special event at City of Atlantic Beach parks and beaches areas. Events are approved on a first
come, first serve basis, received one week(7) days prior to use of City facilities.
Name Responsible: PRINT
Or anization: t S
Street, City, Statefip ��1 �L
Daytime Phone Evening Phone TEmail
1p�f Z4
Name/Purpose of Event:
Location including park, parking, streets:
Date(s) of use: G{
Hours of use including set-up &clean up: 04 1 • 3o G.M
Give a description of event and activities: t GhR�c.�t-�J L
How many people do you expect to attend? u N-O t A S
Facility and area should be left in good and clean condition without damage. All City policies and
ordinances are to be followed. For fires, charcoal must be removed from the beach, the area picked-up,
and trash deposited in trash barrels or removed. If weather is inclement, events may be rescheduled up
to 30 days after submitted date of event upon notification of recreation office. No refunds on application
fee of$25.
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For office use
7Total;jApplication Usage/Event
Fee
25.00 Beach fire or fire usage (open flame) Nov. 1 to April 30 25.00/ night Group camping at Dutton island; primitive campsite ($25 for each
additional night.)
$ 25.00 Wedding or event on beach or in parks
$ 25.00 Use of pavilion, parks, courts, and playing fields
$ Special event in City of Atlantic Beach (business, photo shoot,
(51>5_1 0-C' 25.00 neigh)orhood party, church,festival, etc.
$ 7% SALES TAX (Fla.tax exemption accepted)
$ Paid Ck# 9`��� Receipt#
hr- '
Credit Cash
1
For large events, attach site/route map. „��
Yes Please answer the following:
Is additional equipment and/or ar endors planned for? (i.e. tents, chairs, tables,
bounce house, etc.) Describe: '76-4'. Cl.,o��� ��
(Certificate of Insurance may be needed for ame events)
Will public restroom need to be pen?
6A-A o
F-1
Is there music plan d r t1event?
Type of music iOt'�
Hours
❑ Will you be using signs, banners or decor ions? (All decorations and banners
JA
st be removed at end of event.) „`,.s,/S I.t� ,
f yes fora banner, have you filled out a banner application? Y/N Approved?
ElWil you be cooking at this event? If yes, by what medium?
F r sale?
Elill there be a fire or fireworks?
Where will people park? 150* "rG u f l*t
Are there any additional requests for city provided equipment or services?
If yes, pleasq list.
NO ALCOHOL MAY BE CONSUMED IN CITY PARKS OR ON CITY BEACHES.
The APPLICANT shall indemnify, defend, and hold harmless the City of Atlantic Beach, its officers, employees,
and agents from any and all losses, costs, expenses, claims, liabilities, actions, or damages, including bodily
injury and personal injury liability for injuries to any person or persons or damage to property arising at any
time during and/or arising out of, or in any way connected with APPLICANT'S use of CITY/PUBLIC property,
unless solely caused by the gross negligence of willful misconduct of the City, its officers, employees, or
agents.
By signing this application the APPLICANT has read and agrees to accept all responsibility outlined
and implied,to comply with the Ordinances and Codes of the City of Atlantic Beach,the Special Event
Guidelines and Policies, and a requirements sti lated for approval of this application.
Applicant Signature Date klS
(must be 18 years of age) � ,
Print Name L4,5 Y- Vu ( •� -�
Address if different from above:
Contact number if different from above:
Approved
Denied ��}�]/�
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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 r
BUSINESS AND APPLICANT NAME:
MAILING ADDRESS: r(L f 3235
ADDRESS ANDLOCATION WHERE.EVYf WILL TA F PLACE (If different from mailing address.)
11 �+�-(.Q_ �1
REQUESTED DATE(S)FOR TEMPORARY EVENTQrCA,.' t5N'r— �/' t
THE BELOW SIGNATURE ACKNOWLEDGES THAT THE PROPERTY OWNER AND/OR THE
CO'1IPANY 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 a ent.
SIGNATURE PRINT NA•bIE-0=!- CEL
CONTACT INFORNIATION OF PERSON SUBMITTING THIS REGISTRATION FORM (PLEASE PRINT)
NAME
MAILING ADDRESS G1
PHONE_�`-� Il-ef5FAX E-MAIL
Please provide all information as requested on the attached pages.
L What type of alcohol will be served and how? 0& Other? S 'ed inside`? utside?
2. Provide approved copy of any required Alcoholic Beverage Permits from the Division of Alcohol
Beverages and Tobacco? (Additional permit required by DART for any expansion of Licensed Premises.)
3. Identify the event sponsor and pAro �ideSzappropqqe contact person in case of an emergency.
��•.� Y
4.
Prvide a site plan`depicttng the 1 and location.of all activities,s,including parking and traffic flow
distribution points, any tents,fences,security check points,and location of planned events and activities.
5. Has the business consultedwithneighboring businesses to obtain their approvals?
b. Will there be outdo.) musics? Will there be amplified outdoor music? What hours?
7. Will there be a live band? What hours?
641s T ARL
8. flow many people are expected to attend this event?
9. flow will crowd control be managed if there is an overflow crowd?
t(:X r
10. What specific special events are planned? (...such as bobbing.for apples;ring toss;dunking oaths;wret
t-shirts; bikini contests;all. aletfemale'`review')
11.How will parking be locate and managed? Include site plan showing parking areas to be used for this
event. E.)I tAl' CILA- gl,.o y9
la
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 Police Department.
i3.How are they goiiYg to assure that all people consuming alcohol are old enough? Wrist bands? Door
men?
W'I-L6�— '9 cool-�— ��..C,ec.� ,c-c� /,�.—.`
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 greaseloiUrefuse. How will any extra trash collection and disposal needs,during and
after the event,be addressed?
NO N
16.Will there be any extension of electricity into a parking areas,outdoor areas or any yards?
k
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.
tS 144-
19. Are there going to be any fires or fireworks? l"J C>
20. Other than set-vice 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?
W &4 4&/-5
22. Were they complaints or�roblems at prioV events of this nature?
,►Jev_lc_�
23. What additional signage will be used? (Such as for advertising,restrooms,alcohol consumption?(City
Sign regulations apply.) to
24. Ilow will the event be promoted and aderti
by signature
(such as through the use of fliers,JAI,Radio, etc.)
25. Acknowledgea nature 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.
SIG1tiTATIJRE DATE i IJ
PRINT NAME
EVENT APPROVED:
REQUEST DENIED:
SIGNED:
]XVIE:
Jirtment of Public Safety A I
SIGNED: J''�= —...__ DATE:___
City Manager
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3
INSTRUCTIONS FOR COMPLETING
DIVISION OF ALCOHOLIC BIrVERAGES AfdD TOBACCO
LIGATION FOR EX'T'ENSION OR AMENDED SKETCH:OF LICENSED PREMISES
if you have any questions ee assts ance rn comp a rng MIS dpplIUM1071,PMNSU c e Division of
Alcoholic Beverages& Tobacco's(AB&T)local district office. Please submit your completed application
and required feels)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 web site at the link provided below:
httr)://www.mvflorida.com/dborlabt/district offices/licensing.html
GENERAL REQUIREMENTS
This application must be submitted for approval when changes are made to the licensed premises
whether the extension is permanent or temporary.
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 application and a copy of all supporting documentation. All signatures must
be original.
APPLICATION REQUIREMENTS
Applicants for Temporary Extension of Premises Permits must submit the application at least
seven(7)days prior to the first date of the event to insure the permit is issued by the event date.
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.
Health Approval—Applies to Permanent Extension of Premises Only
Health approval is required on all applications for consumption on the premises. Businesses that serve
food or are located on premises licensed by the Division of Hotels and Restaurants, must obtain approval
from that division. Businesses that do not serve food must contact the County Health Authority or the
Department of Health. Food service establishments located in grocery and convenience stores, bakeries
or delicatessens must contact the Department of Agriculture and Consumer Services.
Note: Health Approval is not required for a temporary extension of the licensed premises or amended
sketch of the licensed premises.
Affidavit of Applicant
Read and sign in the presence of a notary. The affidavit must be signed by the individual applicant, each
partner of a general partnership, a general partner of a general partnership of a limited partnership, a
managing member, manager,or officer of a limited liability company, each partner of a limited liability
partnership,or one of the officers of a corporate applicant.
Sketch of Premises
A complete sketch of the premises, drawn in ink or computer generated(letter size)which includes all
permanent walls, doors,windows, countcrs, labeling each room and area. Include any outside areas
where alcoholic beverages will be sold,consumed, or served. Due to the difficulty of scanning, no
blueprints are accepted.
Auth.61A-5.0017
Amended Sketch of Premises
A complete sketch of the premises, drawn in ink or computer generated(letter size)which includes all
permanent walls, doors,windows, counters, labeling each room and area. Changes may be made to
the interior of the existing premises only; no additional rooms may be added.
Note: Zoning Approval is not required for an amended sketch of premises.
APPLICATION CHECKLIST
Select the appropriate transaction below and comply with the corresponding application requirements.
TRANSACTION APPLICATION REQUIREMENTS
❑ Complete DBPR ABT-6029 Division of Alcoholic Beverages and
Extension of Licensed Tobacco Application for Extension or Amended Sketch of Licensed
Premises Premises
❑ Pay$100 fee for each temporary extension of licensed premises
1 requested (make check payable to the Division of Alcoholic s
Beverages and Tobacco) ;
❑ Complete DBPR ABT-6029 Division of Alcoholic Beverages and
Amended Sketch Tobacco Application for Extension or Amended Sketch of Licensed
Premises
Auth.61A-6-0017 2
DBPR ABT-6029—Division of Alcoholic Beverages and Tobacco
Application for Extension or Amended Sketch of Licensed Premises
STATE OF FLORIDA DBPR Form
DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION ABT-6029
Revised 02/2013
If you have any questions or need assistance in completing this application,please contact the Division of
Alcoholic Beverages& Tobacco's(AB&T)local district office. Please submit your completed application
and required fee(s)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&Ts web site at the link provided below:
htti)://www.myflorida,com/dbi)r/abt/district offices/licensing.htmi
SECTION 1;-CHECK TRANSACTION REt+'till"M0
Tvansaction Type:
Temporary Extension ❑ Amended Sketch
Permanent Extension
SECTION 2-LICENSE INFORMATION
Licensee(as listed al oholic evera a license)
Business Name(D/B/ )
Location Address(Street
CityA �C County Sde
ate Zip C z
Alcohta}ic Beverage ice Number Series S Type/Ct 1
Business Tllephone Number Email Address(Optional) Jn
irJ ext. S�'l ,�� l 6—ca�
FOR TEMPORA)?Y EXTENSIONS ONLY:
Date(s)of Extension:
ABT District Office Received t Date Stamp
Auth.61A-5.0017 1
SECTION 3-ZONING APPROVAL
FTOCOMPLETED BY THE ZONING AUTHORITY GOVERNING YOUR BUSINESS LOCATION
s section ont a ties to a ermanent or:tem ra extension of licensed remissStreet Address A� ch ,County Zip Code
�., �G CIV4 1 1 FL 72.2
Are there outside areas which are contiguous to the premises which are to be part of the premises sought
to be licensed?" ❑Yes ❑ No
❑ The PERMANENT extension of the licensed premises as shown in the sketch complies with zoning
requirements for the sale of alcoholic beverages pursuant to this application.
XThe TEMPORARY extension of the licensed premises as shown in the sketch complies with zoning
requirements for the sale of alcoholic beverages pursuant to this application.
Title:
Signed: �. mate: :2/.7
/S
This approval is valid until 3Z1
SECTION 4-HEALTH
TO BE COMPLETED BY THE DIVISION OF HOTELS AND RESTAURANTS
OR COUNTY HEALTH AUTHORITY
OR DEPARTMENT OF HEALTH
OR DEPARTMENT OF AGRICULTURE&CONSUMER SERVICES �
The above establishment complies with the requirements of the Florida Sanitary Code.
Signed Date
Title
Agency
This approval is valid until
Auth.61A-6.4017 2
SECTION 6-A1FFIDAVtT IF APPUCANT
NOTARIZATION REQUIRED
Business Name
`I,the undersigned individually, or if a registered legal entity 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❑ "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
APPLICANT SIGNATURE
The foregoing was( )Sworn to and Subscribed OR( )Acknowledged Before me this Day
of__,201 By who is( )personally
(print name(s)of person(s)making statement)
known to me OR( )who produced as identification.
Commission Expires:
Notary Public
Auth.61A-6.0017 3
ISECTION 6—DESCRIPTION OF PREMISES TO BE WCENSED
Business Name(D/B/A)
1 Yes ❑ No Is the proposed premises movable or able to be moved?
2. Yes 11No Is there any access through the premises to any area over which you do not
have dominion and control?
3. Yes ❑ No Are there more than 3 separate rooms or enclosures with permanent bars or
counters?
Is the business located within a Specialty Center? If yes,check the applicable statute:
4. Yes ❑ No [] 561.20(2)(b)1, F.S.or❑ 561.20(2)(b)2, F.S.
Neatly draw a floor plan of the premises in ink,including sidewalks and other outside areas which are contiguous to the
premises,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
the details of each floor.
cit
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Auth.61A-5.0017 4