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2. Pursuant to the provisions of Wyoming County Local Law Number 2 of 2015, this Public Assembly Permit is submitted no less than 90-days prior to the public assembly. No permits shall be granted unless the applicant complies with all requirements of this Application.
6. Applicant Type
   -- Select One --Corporate ApplicantIndividual ApplicantPartnership / Organization Group
8. Section I - Identification
   Names of individual, corporations, partnerships or other organized groups, addresses, names of directors and officers.
10. First Name
11. Last Name
13. Date of Birth
    Date of Birth
15. Address
17. City
18. State
19. Zip Code
21. First Name
22. Last Name
24. Date of Birth
    Date of Birth
26. Address
28. City
29. State
30. Zip Code
34. Section II - Financing
    List of all names and addresses of person, corporations, partnerships or other entities to provide financing for the event.
36. Type
    -- Select One --CorporationOther EntityPartnershipPerson
37. If other entity, please describe
39. First Name
40. Last Name
42. Address
44. City
45. State
46. Zip Code
48. First Name
49. Last Name
51. Address
53. City
54. State
55. Zip Code
59. Section III - Event Location
    Name and address of the recorded property owner where the event will occur. Upload a notarized letter of permission from the owner to use such property if applicant is not the property owner.
61. First Name
62. Last Name
64. Address
66. City
67. State
68. Zip Code
70. First Name
71. Last Name
73. Address
75. City
76. State
77. Zip Code
79. Upload notarized letter of permission
83. Section IV - Dates and Hours
    Proposed dates and hours of the event.
85. Date and Time
    Date and Time Start Date

    Date and Time Start Time

    —

    Date and Time End Date

    Date and Time End Time
87. Date and Time
    Date and Time Start Date

    Date and Time Start Time

    —

    Date and Time End Date

    Date and Time End Time
89. Date and Time
    Date and Time Start Date

    Date and Time Start Time

    —

    Date and Time End Date

    Date and Time End Time
93. Section V - Number of Persons & Fees
    Expected maximum number of persons intended to use the property at any one time during the event.
95. Expected Maximum Number of Persons

    1. 0 to 4999 Persons - No Permit / No Fee
    2. 5000 to 9999 Persons - Permit Required
    3. 10,000 - 24,999 Persons to Permit and Fee Required
    4. Over 25,000 Persons to Permit and Fee Required
97. 0 to 4999 Persons to No Permit / No Fee
    - A promoter must comply with all regulations as required by County or State Health Departments. In addition, the promoter must contact the Wyoming County Sheriff and Office of Emergency Services to ensure safety issues are adequately addressed.
99. 5000 to 9999 Persons - Permit Required
    - A non-refundable application fee of $200.
    - A promoter will be required to meet the necessary requirements of the permit application and provide Proof of Insurance.
101. 10,000 - 24,999 Persons - Permit & Fee Required
     - A non-refundable application fee of $400.
     - A promoter will be required to meet the necessary requirements of the Permit Application and provide Proof of Insurance.
103. Over 25,000 Persons - Permit & Fee Required
     - A non-refundable application fee of $600.
     - A promoter will be required to meet the necessary requirements of the Permit Application and provide Proof of Insurance and Cash Bond Surety.
105. Late Charge
     In the event the Application is not filed within 90 days of the date of the event, a late fee, in addition to the Application Fee and in an amount equal to 4 times thereof, shall be assessed. Upon a showing of good cause, at the discretion of the Chairman, said Late Charge may be reduced or waived.
109. Section VI - Parking
     The number of automobiles expected to use the property at one time as well as a plan for the provisions for parking such vehicle.
111. A. Number of automobiles expected to use property and plan for provision of parking said vehicles.
113. B. Plan for provisions of parking said vehicles.
115. Upload Parking Plan
119. Section VII - Purpose of Function
     Include the nature of the activities and admission fees to be charged, if any.
121. Nature of Activities
122. Fee charged?

     1. Yes
     2. No
123. If yes, amount
125. Nature of Activities
126. Fee charged?

     1. Yes
     2. No
127. If yes, amount
129. Nature of Activities
130. Fee charged?

     1. Yes
     2. No
131. If yes, amount
133. Upload Copy of Lease / Contract(s)
134. Was a copy sent to to Wyomning County Health Department?

     1. Yes
     2. No
138. Section VIII - Concessionaries, Services or Facilities
     List names and addresses of all persons providing contract, lease or other arrangements for the event together with such contracts, leases or other arrangements. Information called for in this paragraph shall be supplied no later than 7 days prior to the event and submitted to theWyoming County Health Department (WCHD).
140. First Name
141. Last Name
143. Address
145. City
146. State
147. Zip Code
149. First Name
150. Last Name
152. Address
154. City
155. State
156. Zip Code
158. Upload copy of Lease / Contract(s)
159. Was a copy sent to to Wyomning County Health Department?

     1. Yes
     2. No
161. Uploaded copy of Lease / Contract(s)
162. Was a copy sent to to Wyomning County Health Department?

     1. Yes
     2. No
166. Section IX - Diagrams or Similar Graphic Documents
168. Upload a diagram of the size and location of any existing or proposed building, structure or other facilities to be used for the purpose of the assembly.
170. Upload a diagram of the placement of the proposed distribution system for water, including supply, storage, treatment and distribution sites, if required by local or state health codes.
172. Upload a diagram of the facilities for the preparation, storage, sale, and distribution of food, if required, by local and state health codes.
174. Upload a diagram of the location of and access to any parking areas and the means that will be used to monitor and control this local traffic flow.
176. Upload a diagram of all services and other roads serving the public assembly area, food services, toilet facilities and entertainment and performance area.
180. Section X ~ Health Department
182. Upload a completed Wyoming County Health Department Attachment/Checklist. All aspects of the camping area must meet the New York State Sanitary Code, Subpart 7-3 (Campgrounds), requirements.
186. Section XI ~ Security / Public Safety
188. Upload a detailed plan and statement fully describing any private security personnel who will be engaged by the applicant to serve on or about the site.
190. Upload a detailed plan and statement providing for fire protection, specifying the location of fire lanes, water supply and equipment or apparatus to be available for such purposes is necessary. This will include a statement from the Officer in Charge of the Fire Department providing this service that arrangements will be made to adequately protect the residents of their district while they are committed to this event.
192. Upload a detailed plan and statement specifying the all facilities must be made available to Emergency Medical Services at the public assembly. This will include location of crews, ambulances that will be available at the location, preparations to bring additional ambulances to the scene if needed, name and address of the doctor that will be in attendance, if any. This will include a statement from the Officer in Charge of the Emergency Medical Services Agency that arrangements will be made to adequately protect the residents of their district while they are committed to this event. All Emergency Medical Service Agencies involved will hold a valid Certificate of Need that would allow them to provide service within Wyoming County and transport to and receive Medical Control from Wyoming County Community Hospital.
194. Upload all permit approvals from Wyoming County Code Enforcement Officer as required under Chapter 24 of the New York State Fire Code and Title 19 NYCRR including, but not limited to, tents; canopies; membrane structures; stages; platforms and pyrotechnics.
198. Section XII - Advertising
200. A. The applicant will specify in all advertising and promotional endeavors the limitation on the number of tickets to be sold or otherwise issued as specified in the permit.

     1. Yes
     2. No
     3. Not Applicable
202. B. The applicant also agrees that all tickets will be numbered, and that no other means will be used to grant admission to the site.

     1. Yes
     2. No
     3. Not Applicable
204. Upload a plan or map of methods of entering the area, number and location of ticket booths and entrances, and provision for keeping persons without tickets from the area.
208. Section XIII - Notification to County
     The information required of an applicant for a permit under this Application is for the sole purpose of providing notification to the County of Wyoming and to any other municipal subdivision impacted by the permitted event of the arrangements made by the sponsor or promoter for financing, sanitation, security, parking and the other information required in this Application so as to inform the County of Wyoming regarding the character and nature of the permitted event. Issuance of a permit under this Application does not constitute the County of Wyoming’s assumption of responsibility for maintaining the services for which information is required as part of the Application.
212. Section XIV - Insurance and Bond Requirements
     For events involving more than 5,000 persons but less than 7,500 persons, no permit shall be issued unless the applicant can furnish to the Chairman of the Board of the Wyoming County Board of Supervisors a Certificate of Insurance showing evidence of insurance coverage as follows and a copy of the policy endorsement showing the County of Wyoming and the Town or Village in which the event is held, named as an additional insured.
214. Bodily Injury and Property Damage Combined
     - Each Occurrence $1,000,000
     - Aggregate $2,000,000
     - The Certificate of Insurance shall provide no less than 30 days notice of cancellation or non-renewal of the insurance coverage.
     - All Insurance and Bonds shall be written with an Insurance Carrier licensed by the State of New York Insurance Department to conduct business in the State of New York and have an A.M. Best Company rating of A or better.
     - The County of Wyoming and Town and/or Village in which the event is to be held shall be named as an Additional Insured on a primary and noncontributory basis on all policies.
     - Waiver of Subrogation is required on all policies.
     - All Certificates of Insurance must be signed by a licensed agent or authorized representative of the insurance carrier. A broker signature is not acceptable.
216. For Events Involving 7,500 or More Persons
     For events involving 7,500 or more persons, the limits of insurance shall be established by the Chairman of the Board of the Wyoming County Board of Supervisors and shall not exceed the following limits. No permit shall be issued unless the applicant can furnish to the Chairman of the Board of the Wyoming County Board of Supervisors a Certificate of Insurance showing evidence of insurance coverage as follows and a copy of the policy endorsement showing the County of Wyoming and the Town or Village in which the event is held, named as an additional insured.
218. Bodily Injury & Property Damage Combined
     - Each Occurrence $5,000,000
     - Aggregate $10,000,000
     - The Certificate of Insurance shall provide no less than 30 days’ notice of cancellation or non-renewal of the insurance coverage.
     - All Insurance and Bonds shall be written with an Insurance Carrier licensed by the State of New York Insurance Department to conduct business in the State of New York and have an A.M. Best Company rating of A or better.
     - The County of Wyoming and Town and/or Village in which the event is to be held shall be named as an Additional Insured on a primary and noncontributory basis on all policies.
     - Waiver of Subrogation is required on all policies.
     - All Certificates of Insurance must be signed by a licensed agent or authorized representative of the insurance carrier. A broker signature is not acceptable.
     - For events involving 7,500 or more persons, no permit shall be issued unless the applicant shall deposit with the Chairman of the Board of the Wyoming County Board of Supervisors cash or good surety company bond in a sum not less than $10,000. The Chairman of the Board of the Wyoming County Board of Supervisors may reasonably require and condition that all requirements of an issued permit be fully performed by the applicant, that no damage will be done to any public or private property and that the applicant will not permit any litter, debris or other refuse.
     - Provided further that should the licensed event necessitate the employment of additional county or town personnel and equipment, such added expense shall be recoverable from the principal and/or its surety. The deposit or its balance is to be returned when the Chairman of the Board of the Wyoming County Board of Supervisors has determined that no such damage has been done and that the County did not incur such additional expense due to a said event or that the cost of the above has been paid by the applicant.
220. Upload insurance documentation
224. Section XV - Release of Claims and Agreement to Indemnify and Hold Harmless
     To the extent permitted by law, the applicant agrees to defend, indemnify and hold harmless the County of Wyoming, its officers, directors, agents and employees from and against any and all claims, suits, liens, judgments, damages, losses and expenses including reasonable legal fees and costs arising in whole or in part and in any manner from acts, omissions, breach or default, in connection with the performance of the stated event, by the applicant, its officers, directors, agents, employees and subcontractors.
226. Certification of Applicant
     All information provided in the above application is hereby true and correct and all statements contained herein are true to the best of my knowledge and belief. I further certify that the event will be performed in the manner set forth in this application and in the plans and specifications filed herewith.
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