Circus/Carnival License Application

City of Plattsburgh

Date:

Applicant:

Telephone Number:

Proposed Event Data:

Description:

Date/s:

Location:

If Applicable: 

        Number of Animals:

        Number of Rides: 

        Number of 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.

Certification of Insurance is Required:

        Furnish on ACCORD Form 25 or comparable;

        City of Plattsburgh named as additional insured;

        Thirty (30) day written cancellation notice;

        General liability - Premises/Operations:

                    BI/PD $500,00 CSL/ $1,000,000 Aggregate

        Workers Compensation and Disability.

LICENSE FEE

Carnival $100/day;  Circus $300/day

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

Applicant Signature

Contact:

                        Name                                Address                                Phone

===================================================================================

APPROVALS:

Insurance: (Y) (N)                    Police: (Y) (N)                    Clerk: (Y) (N)

Initial/Date: _______                Initial/Date: _______           Initial/Date: _______