Public Assembly License Application

USE TYPEWRITER TO ANSWER ALL QUESTIONS
TWO COPIES OF FULLY DIMENSIONED FLOOR LAYOUT WITH SEATING ARRANGEMENT, IF ANY, MUST BE SUBMITTED WITH THIS APPLICATION.

I solemnly swear to the truth of the following statements:

(1) Name: Tel No.

INDIVIDUAL, PARTNERSHIP OR CORPORATE NAMES: ANSWER ITEM 12 ALSO

(2) Residence of Business Address:

(3) If applicant does not reside in the Inc. Village of East Rockaway, has Agency Designation Form been filed with this application: ☐ Yes ☐ No

(4) Trade Name, if any Filed (date): No. County:

(5) Name and address of owner or agent of building in which premises are located:

(6) Does the applicant occupy the said premises under a lease: ☐ Yes ☐ No
If yes, indicate:
Written or Oral Date of Lease Date of Expiration

(7) Is any license under the Alcoholic Beverage Control Law now in affect in the name of the applicant:
☐ Yes, please attach ☐ No

(8) Is an application for a license under the Alcoholic Beverage Control law now pending in the name of the applicant?
☐ Yes ☐ No If yes, give date of application:

(9) State the name and address of each person, firm or corporation other than the applicant, the partners of the applicant partnership, or the applicant corporation, its officers, directors or stockholders, who are entitled to a share of the income or profits or, or has an interest in, the business to be licensed. If none, so state.
Name Address Details of Interest

(10) Give the following information with respect to each concession. If none, so state
Name Address Nature and Terms of Concession

(11) If a corporate application, give date and place where corporation was organized:
Date: State:
If a foreign corporation, has a certificate of authority to do business in this State been obtained? ☐ Yes ☐ No
If yes, state: Date: Registration Number:
State the principal place of business

(12) INDIVIDUAL: Last name and residence.
PARTNERSHIP: List names and residences of all partners and percentage of interest.
CORPORATION: List names and residences of all officers, directors, and any other stockholders, and percentage of interest in said corporation.

(13) Has any Public Assembly License previously granted by the Inc. Village of East Rockaway has been suspended?
☐ Yes ☐ No If yes: License No. Date of Suspension: Date of Reinstatement:

(14) Are other licenses or permits required for operation (other than as described in No. 7, 8, 13)? ☐ Yes ☐ No
☐ License ☐ Permit Number:

(15) Type of use (Restaurant, Cabaret, Bowling Alley etc.)

(16) How long has this been in existence:

(17) Has a certificate of Occupancy been issued for the building: ☐ Yes ☐ No
If yes, No. Date

(18) Has applicant (if corporation its stockholders, if partnership all partners) ever been convicted of any crime, misdemeanor or violation of any Local Law of Municipal Ordinance? ☐ Yes ☐ No
If yes, state nature:
Court: Date of Conviction: Disposition:

In consideration of being granted the license herby applies for, it is agreed that the applicant will comply with the requirements of the Inc. Village of East Rockaway now in force or which may in the future be promulgated for places of public assembly, PENALTY FOR FALSIFICATION: Falsification of any statement made herein may be subject to revocation.

SIGNATURE OF APPLICANT:

Sworn to Before Me This
Day of , 20

NOTARY PUBLIC

FOR OFFICE USE ONLY

1. Classification of building (type of construction)
2. Maximum number of persons permitted: Patrons Employees Total
3. Has Agency Designation form been submitted where required?

SUPERINTENDANT RECOMMENDATIONS

Based on the Statements in the Application, Inspection Reports, Office Reports, and other relevant matter, it is recommended that a License be: ☐ Approved ☐ Denied

Date: , 20

Inspected By:

Applicant Notified: , 20

SUPERINTENDENT OF BUILDING

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Under Chapter 134 of the Code of the Inc. Village of East Rockaway, effective June 1, 1997, if you own a piece of public assembly you must be licensed to do business. The following requirements are necessary to obtain a license.

There are two classifications- Public Assembly or Public Assembly being used as a Cabaret or Dance Hall.

For the purposed of classification, the following definitions will serve as a guide line for classifying your establishment:

1. RESTAURANT or BAR - Any Place (except a catering establishment) in which food or drink is served to the public.
2. PLACE OF PUBLIC ASSEMBLY - Any place or space which is used for recreation, amusement, social, sports, religious, patriotic, civic, travel and similar purposes whether indoor or outdoor.
3. CABARET - Any place which provides in addition to food or drink, any form of live music or other amusement.
4. CATERING ESTABLISHMENT - Any place serving drink or food which is not generally open to the public and is designed for special function.
5. DANCE HALL - Any place in which dancing is carried on.

PUBLIC ASSEMBLY:

1. Application form entitled, "Public Assembly License Application" must be submitted along with the $150.00 application fee.
2. Two professional type complete dimensioned floor layout with seating arrangement must be submitted with an application.
3. Applicants for a license for any premise which served alcohol or permits alcohol to be consumed must supply a current New York State Liquor Authority license (Please attach to application).
4. Application may be submitted in person or by the mail to:
   East Rockaway Village Hall - Building Department
   P.O. Box 189
   East Rockaway, NY 11518-0189

PUBLIC ASSEMBLY USED FOR CABARET and/or DANCE HALL:

Applicants must complete a separate application for a Dance-Cabaret-Entertainment License if the place of public assembly is to be used for entertainment or dancing.

FEE SCHEDULE FOR ALL PLACES OF PUBLIC ASSEMBLY:

PUBLIC ASSEMBLY LICENSE- $150.00 per year.

CABARET/DANCING/PERFORMANCE LICENSE- $100.00 per year.

• Application must be completely answered and mailed together with a check to:
• East Rockaway Village Hall - Village Hall
• P.O. Box 189
• East Rockaway, NY 11518-0189