SPECIAL EVENTS APPLICATION FORM

SPECIAL EVENTS APPLICATION FORM

FOR THE TOWN OF KENSINGTON

Event Name: ___________________________________________________________

Purpose of Event: _______________________________________________________

________________________________________________________________________

Organization/Sponsor Name:

________________________________

________________________________

Address: ________________________

________________________________________________________________________________________________

Phone: __________________________

E-mail: _________________________

Applicant/Contact Name:

________________________________

________________________________

Address: ________________________

________________________________________________________________________________________________

Phone: __________________________

E-mail: _________________________

Date of actual event: __________________ Time of actual event: _________________

Date of set-up: _______________________ Time of set-up: ______________________

Date of clean-up operations: ____________ Time of clean-up operations: ___________

Specific location of event: (Please attach site plan and/or map)_______________________________

________________________________________________________________________

1. List any roads that may need to be closed, including specific dates and times plus time of re-opening:

ROAD NAME	CLOSING DATE	CLOSING TIME	DATE OF RE-OPENING	TIME OF RE-OPENING

2. List projected number of person attending the event. Include the basis for projection:

________________________________________________________________________

3. Will any temporary structures be built? Yes No

If yes, describe in detail and include location:

________________________________________________________________________

4. Will any signs or pennants be hung? Yes No

If yes describe in detail and include location:

________________________________________________________________________

5. Will there be any entertainment or music? Yes No

If yes, describe performance, times and location:

________________________________________________________________________

6. Will additional utility services be used such as power and water beyond that which is available

in the area?

Yes No

Describe in detail specific utilities and location: (Any additional utilities must be provided by the applicant.)

________________________________________________________________________

7. Is a parade planned in connection with the event? Yes No

State details, time and anticipated crowd; attach a map of route:

__________________________________________________________________________

8. Are any street peddlers or vendors being planned? Yes No

Describe in detail:

__________________________________________________________________________

9. Are food sales planned? Yes No

Describe in detail: (Applicant should also contact the local health department for regulations governing food sales.)

___________________________________________________________________________

10. Describe in detail how do you plan to remove refuse and garbage: (Applicant must complete

clean-up supplement for special events.)

__________________________________________________________________________

11. Describe in detail how do you plan to provide security:

__________________________________________________________________________

12. Describe parking areas and available transportation modes to and from the event:

__________________________________________________________________________

13. Will existing bathroom facilities be adequate? Yes No

Describe plans to augment available sanitary facilities:

__________________________________________________________________________

14. Do you plan to sell beer, wine or alcohol for public consumption? Yes No

List any license presently held (section a.); provide evidence of liquor liability insurance.

a._________________________________________________________________________

_________________________________________________________________________

b. List beverages and vendors, plus locations and times of sale.

BEVERAGE	VENDOR	TIME OF SALE	LOCATION	LICENSE

15. Explain the proposed controls for the sale of alcohol beverages where minors may be present:

________________________________________________________________________

16. Do you plan to publicize the event? Yes No

If yes, attach publicity plans.

________________________________________________________________________

Additional information questions:

A-1. ________________________________________ Yes No

________________________________________________________________________

A-2. ________________________________________ Yes No

________________________________________________________________________

Approval of this application will reserve for the applicant the requested event date/place providing all requirements outlined in this policy are met. If the special event request is approved, the sponsor shall assume full responsibility for compliance with all conditions, fees, and charges and further agrees to pay any cost associated with damage to Kensington town property, lost barricades/signs, cleanup by Kensington town crews, or any other additional Kensington town expense caused by this event, over and above the security deposit.

Applicant’s Signature: _______________________________________________ Date: ____________

RETURN COMPLETED APPLICATION TO: BOARD OF SELECTMEN’S OFFICE

Approved Denied

Authorized Signature: _______________________________________________ Date: ____________

________________________________________________________________________

SPECIAL EVENTS LIABILITIES INFORMATION SHEET

Name of Event: ___________________________ Date(s) of Event: __________________

Entity: __________________________________ Event Coordinator: _________________

Starting time of Event: ______________________ Ending time of Event: _______________

Location of Event: _________________________ Estimated Attendance: _______________

Contacts

Event Sponsor/Promoter(s): ______________________________ Phone: _____________

_____________________________________________________ Phone: _____________

Facility Maintenance Contact: _____________________________ Phone: _____________

Fire Department Contact: __________________________________ Phone: _____________

Police Department/Security Contact: __________________________ Phone: _____________

Medical Response/Ambulance Contact: _______________________ Phone: _____________

Utility Company Contact(s): ________________________________ Phone: _____________

Parking & Traffic Control Contact: ___________________________ Phone: _____________

Designated Media Spokesperson: ____________________________ Phone: _____________

Local Health Department Contact: ____________________________ Phone: _____________

Any other pertinent department(s): ____________________________ Phone: _____________

______________________________________________________ Phone: _____________

Insurance Contacts

Property/Liability Insurer: __________________________________ Phone: _____________

Contact: _______________________________________________ Phone: _____________

Special Events Liabilities Coverage Insurer: _____________________ Phone: _____________

Contact: _______________________________________________ Phone: _____________

Workers’ Compensation Insurer: ____________________________ Phone: _____________

Contact: _______________________________________________ Phone: _____________

Claims Adjuster Company: ________________________________ Phone: _____________

Contact: __________________________________________________________________