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CIRCUS/CARNIVAL LICENSE APPLICATION

  1. CIRCUS / CARNIVAL LICENSE APPLICATION - CITY OF PLATTSBURGH

  2. MM-DD-YYYY

  3. Street #, Street Name, City, State, Zip Code

  4. (Area Code)XXX-XXXX

  5. PROPOSED EVENT DATE:

    Description:__________________________________________________________________________
    ____________________________________________________________________________________
    ____________________________________________________________________________________

    Date(s):_____________________________________________________________________________

    Location:____________________________________________________________________________

  6. IF APPLICABLE:

    Number of Animals:____________

    Rides:_______________________

    Games:______________________

    You may be subject to Approvals/Licenses/Inspections by New York State, as well as Clinton County Health Department. For animals, current health and inoculation certificates must be available.

  7. CERTIFICATION OF INSURANCE REQUIRED:


    Furnish on ACORD form 25 or comparable
    City of Plattsburgh named as additional insured
    Thirty (30) day written cancellation notice
    General Liability - Premises/Operations
    BI/PD $1,000,000 CSL/$2,000,000 Aggregate
    Worker's Compensation and Disability

  8. LICENSE FEE:


    Carnival $120.00/day

    Circus $375.00/day

  9. Re: Section 154, Code of City of Plattsburgh penalty for violation of code requirements: Fine up to $250 and/or 15 days imprisonment each day of violation constitutes separate offense.


    __________________________________________________________________________________
    Applicant Signature

  10. Name

  11. Street #, Street Name, City, State, Zip

  12. (Area Code) XXX-XXXX

  13. _____________________________________________________________________

  14. APPROVALS:

    Insurance: (Y) (N) _________________


    Police: (Y) (N):____________________
    (Initial/Date)

    Clerk (Y) (N)______________________

  15. Leave This Blank: