TOB191–Special Events Permit Application

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63 River Road
Belville, NC 28451

(910) 371-2456 Telephone
(910) 371-2474 Fax


    1. Special Event Name:

    2. Contact Information:

    3. Brief Description of Event:

    4. Application Authorization:

    Attach a written communication from the organization or organizations in whose name the event will be advertised which authorizes you, the applicant, to apply for the special events permit on its or their behalf.

    5. Event Principals:

    Please list names, addresses, and telephone numbers of all the principals involved in any way in the proposed event. Include professional event organizers, event promoters, financial underwriters, commercial sponsors, charitable agencies for whose benefit the event is being produced, the organization or organizations in whose name the event is being advertised, and all others administratively, financially, and organizationally involved as principals in the production of the proposed special event. Make additional copies of this section as needed to include all of the principals involved in the special event.

    6. Requested Event Components:

    7. Insurance:

    Attach to this application either an insurance policy or a certificate of insurance including the policy number, amount and the provision that the Town is included as an additional insured. (Please note that insurance requirements depend upon the risk level of the event. Also, if your event can be classified as First Amendment expressive activity, insurance requirements can be waived by the Town Council under certain circumstances.)

    8. Sanitation:

    Attach your “Plan for Clean/up Material Preservation.” Include number, type and location of trash containers to be provided for the event. Indicate who and how many will be responsible for emptying and cleaning up around containers during the event. Indicate who and how many will be responsible for cleaning up the event area after the event. Describe the number, type and location of portable toilets to be provided for the event area after the event. Describe the number, type and location of portable toilets to be provided for the event (or permanent toilets to be used for the event). Include any other plan you have for ensuring post-event cleanliness and material preservation of city facilities, equipment, premises and streets.

    9. Location Map:

    Check off below items that apply to your event. Indicate these items on attached maps. Use, where necessary, a to-scale drawing.
    _____ If a route is involved, the beginning area, the route (indicate directions with arrows), and the finish area
    _____ If a route is involved, the places where buses, trolleys, or trains need to be considered
    _____ If a relay is involved, indicate hand-off points
    _____ Entertainment or stage locations (grandstand operators should provide you with a to-scale drawing)
    _____ Alcoholic beverage concession area
    _____ Non-alcoholic concession areas
    _____ Food concession areas
    _____ General merchandise concession areas
    _____ Portable toilet facilities (indicate number)
    _____ First-aid facilities
    _____ Event participant and/or spectator parking areas
    _____ Event organizer’s command post
    _____ Fireworks or pyrotechnics site
    _____ Vehicle fuel-handling site
    _____ Cooking areas
    _____ Tables, enclosures, etc.
    _____ Temporary or permanent structures constructed for the event
    _____ Site of electrical wiring to be installed for the event
    _____ Trash containers (indicate number): ________
    _____ Other. Please describe:_____

    10.Availability of Food, Beverages and/or Entertainment:

    If yes, attach to the application a copy of your permit from the State Alcoholic Beverage Control Board. Alcohol may not be served without a permit.

    If yes, you may need to have a health permit from the County Department of Health Services. Attach a copy of your health permit to this application.

    11.Security and Safety Procedures:

    Attach to this application a copy of your building permit or permits if you are installing any electrical wiring on a temporary or permanent basis and/or if you are building any temporary of permanent structures such as bleachers, scaffolding, a grandstand, reviewing stands, stages or platforms.Attach a copy of your fire department permit or permits to this application if you will use parade floats; an open flame; fireworks or pyrotechnics; vehicle fuel; cooking facilities; enclosures (and tables within those enclosures); tents, air-supported structures, canopies, or any other fabric shelters.Give name, address and telephone numbers of the agency or agencies which will provide first-aid staff and equipment. Attach additional sheets if necessary.

    Indicate medical services that will be provided for the event:

    12.Vendors or Concessionaires:

    13. Mitigation of the Impact on Others:

    14.Town Services/Equipment:

    15.Optional Information:

    Age 15 years & under

    16 to 25 years

    26 to 45 years

    46 years & older

    63 River Road
    Belville, NC 28451
    Monday–Friday: 8:00AM–4:30PM
    Saturday & Sunday: Closed
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