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Southold Town Clerk
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TOWN OF SOUTHOLD
Town Code Chapter 205 "Public Entertainment and Special Events"
SPECIAL EVENT PERMIT INSTRUCTIONS AND APPLICATION FORM
Applications for a Special Event Permit are subject to an inter-departmental coordinated review by the
Southold Town Board,Town Attorney, Town Assessors,Land Preservation, Building, Planning, Zoning
Board of Appeals and Police Departments, and the Suffolk County Planning Commission.
Application fee: $150.00 per application. Up to six(6) multiple events of the same type, occurring over
a period of three months, may be permitted on one(1)application for a fee of$150.00. However, specific
details of each event must be included with this application.
All applications must be submitted at least 60 business days before the event. Applicants
are encouraged to submit applications as early as possible.
Any completed application that is not submitted 60 or more business days prior to the scheduled
event may be rejected or subject to a late processing fee of$250.00 by the Office of the Town Clerk,w
unless a waiver is obtained. Requesting an expedited review must be submitted in writing to the Ton
Clerk. The Town Clerk will forward all applications to the Special Events Committee for processing.
The Committee will obtain comments on all applications from relevant Town, County and/or State
agencies and will forward completed applications to the Town Board with a recommendation as to
whether to grant or deny the application.
The Town reserves the right to request additional information from an applicant to address issues related
to the health, safety, and welfare of the community.
When is a Permit Required?
All Special Events, per Southold Town Code Article I, Section 205-2 (Definitions) must obtain a permit.
Occasional events on private residential properties hosted by the owner thereof that are by invitation such
as family gatherings, weddings, graduations, parties or not-for-profit fundraisers do not require permits.
Any use of residential propeily for profit such as a venue for weddings or other events is prohibited.
This application is deemed complete once all the following requirements are submitted to the Town
Clerk Please indicate submission of the following by checkdng off the boxes and signing below.
IJ A completed application form signed by the owner and the event manager. Applications without
�j property owner's signature/apRroval will be rejected.
l� FEE: Is the application being submitted at least 60 days before the event [ ] Yes [V/1 No
❑ If Yes; Fee of$ hh has been submitted
lJ If No. Fee of$ Vb has been submitted
Updated 8/7/2018
I-1 The applicant/owner of the property where the special event is proposed to take place must provide a
certificate of insurance not less than 2 million dollars naming the Town of Southold as an additional
insured
A Parking/Event Plan: consisting of a survey, site plan and/or aerial view of the subject property that
includes the locations of on-site parking, sanitary facilities, and tents or other temporary structure(s).
�j (See application form for details)
L'J Events for three hundred (300) or more people require submission and approval of a traffic control
lLan acceptable to the Town of Southold AND a qualified traffic controller must be provided at the
�j event. (See application form for details) p l A-
LJ Signature of Property Owner on the applic�a"tion authorizing Code Enforcement Personnel of the Town
of Southold to enter the subject premises during the hours of the event to ensure compliance with any
and all special event permit conditions.
My signature below affirms that I have submitted all the information required above in connection
with my application.
--�caoa�
Dated Signature
Activities associated with outdoor public events are strictly prohibited from taking place on land
preserved through the sale of development rights to the Town of Southold, and can only take place on
land preserved through the sale of development rights to the County of Suffolk with a permit issued by
the Suffolk County Farmland Committee.
If food is to be served, it must be catered and prepared off-site by food vendors who hold a permit to
operate issued by the Suffolk County Bureau of Public Health Food Protection Unit.
Updated 8/7!2018
, S�F F0 Aj
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APPLICATION FOR A PERMIT TO HOLD A
SPECIAL EVENT
Please provide ALL of the information requested below. Incomplete applications WILL NOT be
reviewed.
Special Event Permit# Applicant(s) n l r,ame: Q
Date of Submission �. 2 107, Name of Event m oyel * ICE>�I)am W e f I/L GI
SCTM#'s 1000-Section I Obb—_I!j ODBlock- 01, 00 Lot(s) 006. 001
Dates of Each Event: I • �•
If Multiple Dates are requested, applicant must give all information for all dates.
Nature of Event: W C
(Please atta a detailed description of EACH event to this application)
Time Period (Hours) of Event: From 5• 00fM to I d ' 90 PM
Town Services requested: ( )Yes ()l No If yes,Describe Police Dept._Highway Dept.
Describe Services W
Maximum Number of Persons Attending At One Time: 110 Number of cars expected 115
Is a Tent or other temporary structure being used? [�] Yes [ ]No If yes provide size(s)
Will food be served? ] Yes [ ]No If yes provide number and name(s) of food vendors)
IS
Suffolk County pertnitN (s)
Will other vendors be on the premises during the event? [ ] Yes y]No Ifyes how many? Describe
Type of vendor(s) NO ve n do rs -
Property Owner(name/address): 01( itic ' "t yfn a ,
Contact Person and Contact Tel.#t it LY>�� U ,�h�au 3�• 4v. 0 �r � S t� N� ���0
e-mail address
Updated 8/7/2018
T v p
Event Location: Street-Hamlet Address: "I o u o Yt/l ath Ko a d/� � yn ��'� r ( ( 57
SCTMtt vvv
Will any services be requested [ ] Yes No. If Yes describe Police Highway Other:
Ll Mailing Address to Send Event Permit to: 0 2 6 a RgAd, ► 1 �h� I' /
Have any of the development rights been sold to the Town of Southold [ ] Yes Q� No and/or Suffolk
County Agricultural Program? [ ] Yes r4 No If yes to either or both also indicate on the
attached plan the boundaries of the reserved'ar_ea upon which the event will take place.
YOU MUST ATTACH A PARKING/EVENT PLAN TO THIS APPLICATION IF THE
EXPECTED ATTENDANCE IS 300 OR MORE PEOPLE YOU MUST ALSO ATTACH A
TRAFFIC CONTROL PLAN (see next pane)
A Parkinp_/Event Plan may be a survey, site plan and/or aerial view (for example Goole Earth) of
the subject property. INDICATE ON THE PLAN ALL of the following information:
A parking/event plan showing:
(1) The size of the property and its location in relation to abutting streets or highways.
(2) The size and location of any existing building(s) or structure(s)that will be in operation
during the course of the event and any proposed building, structure, or signs to be erected
temporarily for the event.
(3) The location of the stage or tents, if any.
(4) The designated areas of use for spectators, exhibitors,vendors, employees and
organizers.
(5) Location of all entries and exits.
(6) The location of all fire extinguishers and other fire safety equipment.
(7) The location of all temporary utilities to be installed for the event, if any.
(8) The layout of any parking area for automobiles and other vehicles and the means of
ingress and egress for such parking areas. The parking spaces must allow for 300 sq. ft.
per car.
(9) A traffic control plan for vehicles entering and leaving the site for the proposed event.
(10) Plan for the use of live outdoor music, loudspeakers and other sounds which will be used,
if any, and the type and location of speakers and other audio equipment.
(1 1) A description of emergency access and facilities related to the event.
(12) Provisions to dispose of any garbage,trash, rubbish or other refuse.
(13) Location and description of any additional lighting to be utilized in conjunction with the
event.
(14) Location of sanitary facilities on site.
Traffic Control Plan
Events for three hundred (300) or more people also require submission and approval of a traffic control
plan, acceptable to the Town of Southold, AND a qualified traffic controller must be provided. Please
attached a written description and/or notate on the parking event plan the following: 1) Who will be
conducting traffic, 2) Where they will be stationed on site, 3) How they will direct the entrance,
circulation, parking, and exiting of cars on site, and 4) Contact information for use by Southold Town
Police.
Updated 8/7/2018
0WNER'S SIGNATURE:
I am the Owner of the Property where this event is to be held and I agree to comply with the laws,
rules, regulations, conditions, and requirements of the Code of the Town of Southold, including but
not limited to the conditions listed below, as well as all other applicable agency rules and regulations
pertaining to the activities under this event. Furthermore, I hereby swear or affirrn that the
information contained herein and attachments hereto are true and correct to the best of my knowledge,
and agree to provide notice to the Town immediately should there be any material changes regarding
to this application. .
Furthermore, I hereby authorize Code Enforcement Personnel of the Town of Southold to enter the
property during the hours of the permitted special event to make any and all inspections necessary in
connection with this Special Event..-
Print name of Owner Signature of Owner
Print name of Authorized Person/Representative Signature of Authorized Person/Representative
PERMISSION IS HEREBY GRANTED SUBJECT TO THE FOLLOWING CONDITIONS:
1. By acceptance of this permit, applicant agrees to adequately supervise and direct all parking to be on
the premises or at another site, and to provide parking assistants and any additional traffic controls
necessary for this event. Parkin is strictly prohibited on ANY Town County or State Roads or Rights of
Way.
2. Traffic control at events for three hundred (300) or more people shall be provided by a qualified traffic
controller in accordance with the attached, approved traffic control plan.
3. One "on-premises" sign not larger than six (6) square feet in size may be displayed not longer than
thirty (30) days before this event, and removed immediately after the event. Directional parking signs
shall be adequately displayed.
4. Applicant indemnifies and holds harmless the Town of Southold from all claims, damages, expenses,
suits and losses including but not limited to attorney's fees arising from activities under this permit.
5. Tent proposals must receive permit approval from the Southold Town Building Inspector before
placement on the property and must meet all fire and safety codes.
6. This permit is valid only for the time, date, place and use specified above, and for the designated
event. Each additional day will require a separate permit application, fee, and related documents for
review, etc. at least 60 business days prior to the scheduled event.
7. Adequate temporary sanitary facilities must be provided by applicant for this event and applicant
agrees to remove the temporary facilities from the premises within 48 hours after the day of the event.
8. On-site food preparation is NOT permitted, although food may be catered subject to all Suffolk
County Department of Health regulations.
9. NO activities associated with this event including but not limited to parking ingress/egress/access,
tent(s) or temporary structures) or temporary sanitary facilities shall be conducted on Town of Southold
Purchase of Development Rights land.
Updated 8/7/2018
10. NO activities associated with this event including but not limited to parking ingress/egress/access,
tent(s) or temporary structures) or temporary sanitary facilities shall be conducted on Suffolk County
Purchase of Development Rights land without a permit issued by the Suffolk County Farmland
Committee.
11. Issuance of this permit does not authorize in any manner the occupancy of any building exceeding the
legal limitations under the fire code or other codes which would prohibit such increased occupancy.
12. Access shall be provided for emergency vehicles, to all public assembly areas, all buildings, all work
areas and any additional area where emergencies may occur. Two emergency-fire exits and exit paths
from the building(s) on the property, to a public way or remote safe area, shall remain open and
unobstructed at all times.
13. Owner assures full compliance with all fire, safety, building, and other Town laws.
14. Music, when outdoors, is required to stop at the time specified in the permit. Placement of the
speakers must be in a location that affords the greatest protection from noise intrusion upon adjacent
properties.
15. Owner will allow access to Code Enforcement Personnel of the Town of Southold during the
hours of the special event to make any and all inspections necessary in connection with this
Special Event.
16. ADDITIONAL CONDITIONS: ,
ANY VIOLATIONS IN CONNECTION WITH THE CONDITIONS LISTED HEREIN WILL
TERMINATE THIS PERMIT.
APPROVED Town of Southold
Resolution Number: Date Issued:
Updated 8/7/2018
HOLD HARMLESS AGREEMENT
The applicant of this Special Permit shall defend,
indemnify and hold harmless the Town of Southold, its officers, employees, and representatives
from and against any and all damages, liability,judgments, losses, and expenses, including but
not limited to attorney's fees, including damages arising from injuries or death of persons and
damage to property which arise from or are connected with the event or events authorized by
resolution of the Town Board of the Town of Southold, or caused by the negligent misconduct,
and/or omissions under this Agreement and that of applicant's agents, servants and/or employees.
If this Agreement is being executed in a representative capacity, the individual executing this
Agreement hereby represents that this action has been authorized.
Dated:
Signature:
Name: � `(`�PcrS �� k&RWf d Agent
i
On behalf of: ,1�2`� SL: � �t �'tv
(Name of Business Entity)
Dates of event(s):
Sworn to before me this
Day of lQ�J" , 20,,)_Q.
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® CERTIFICATE OF LIABILITY INSURANCE DATE(M
o2a
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLYAND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND ORALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on
this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT Paula Eglevsky
NAME:
Morley Agency Inc PHONE (631)283-3100 FAX 631 287-0081
AIC No Ext: A/C,No: ( )
32 Hampton Road E-MAIL paula@morleyagency.com
ADDRESS:
INSURER(S)AFFORDING COVERAGE NAIC#
Southampton NY 11968 INSURERA: Burlington Ins Co
INSURED
INSURER B
MGHE LLC INSURER C:
65 E 55th Street INSURER D:
31 St Floor INSURER E:
New York NY 10022 INSURER F:
COVERAGES CERTIFICATE NUMBER: 24-25 GULQR REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAYBE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR TYPE OF INSURANCE POLICY EFF POLICY EXP
LTR INSD WVD POLICY NUMBER MM/DDIYYYY MMIDDIYYYY LIMITS
X COMMERCIAL GENERALLIABILITY EACH OCCURRENCE $ 1,000,000
CLAIMS-MADE ❑X OCCUR DAMAGES R NTED 100,000
PREMISES Ea occurrence $
MED EXP(Any one person) $ Excluded
A 229BG09443-02 05/04/2024 05/04/2025 PERSONAL BADVINJURY $ 1,000,000
GEN'LAGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $ 2,000,000
POLICY PRO-
JECT LOC PRODUCTS-COMPlOPAGG $ 2,000,000
OTHER: $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
Ea accident
ANYAUTO BODILY INJURY(Per person) $
OWNED SCHEDULED BODILY INJURY(Per accident) $
AUTOS ONLY AUTOS
HIRED NON-OWNED PROPERTY DAMAGE $
AUTOS ONLY AUTOS ONLY Per accident
UMBRELLA LIAB OCCUR EACH OCCURRENCE S
EXCESS LIAB CLAIMS-MADE AGGREGATE S
DED RETENTION$ $
WORKERS COMPENSATION PER OTH-
AND EMPLOYERS'LIABILITY YIN STATUTE ER
ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ NIA E.L.EACH ACCIDENT $
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $
Liquor Liability Liquor Liability Each $1,000,000
A 229BG09443-02 05/04/2024 05/04/2025 Liquor Liability Aggregate $1.000,000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
Restaurant
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
Town of Southold ACCORDANCE WITH THE POLICY PROVISIONS.
53095 Main Road
AUTHORIZED REPRESENTATIVE
Southold NY 11971 4,
@ 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
r
I.., 0454
� MGHE LLC DIME
OPERATING ACCOUNT
PO BOX 333 50-666/214
ORIENT,NY 11957 8/20/2024
i
i
ORDER OF E Denis Noncarrow, Town Clerk $ **400.00
i Four Hundred, 00/100***************************************************************************************************
DOLLARS
Denis Noncarrow, Town Clerk PERATING Acco
Southold Town Hall
PO Box 1179 P�sF
l Southold, NY 1197.1. s,
MEMO _ AUTHORIZED SIGNATURE fCGq➢4�,�°p�
0
1110004 54113 1:0 2 140666 71: S000 2 289 S Slim
MGHE LLC
OPERATING ACCOUNT
Denis Noncarrow, Town Clerk 8/20/2024
Date Type Reference Original Amt. Balance Due Discount Payment
8/20/2024 Bill duryea event 400.00 400.00 400.00
Check Amount 400.00
BNB- MGHE LLC Op 400.00
Noncarrow, Denis
From: Noncarrow, Denis
Sent: Thursday, November 14, 2024 8:19 AM
To: gwood@alchemy-hospitality.com'
Subject: Southold
HI Gabriella
I hope all is good with you.we have a check at Town Hall that was given to us for an event for a special event permit that
you did not need.Would you like to pick up that check or we can mail it to you.
Let us know address if you would like it mailed.
Thank you
Denis Noncarrow
Southold Town Clerk.
Town of Southold, New York
www.southoldtownny.gov
denisn@southoldtownny.gov
631-765-1800
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