DANCE HALL PERMIT APPLICATION

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1 Application # PZ - - DANCE HALL PERMIT APPLICATION Serving the Community Community Services Department Phone: (321) Planning and Zoning Division Fax: (321) Stone Street Web: Cocoa, Florida This form is divided into steps, which will help you prepare your application and provide supplemental items. A pre-application meeting with Staff is Recommended. For Office Use Only - Date Received Please TYPE or PRINT this application neatly. Stamp Only When Application is Fully Complete Type of Application: Adult Dance Hall Juvenile Dance Hall 1. Applicant Information: * NOTE: Applicant is the main point of contact. 2. Business Information: Company: Physical Address: Phone #: Fax #: Mobile #: Corporate Document #: Tax Identification #: Alcohol Beverage License # (if applicable): - Page 1 of 5 -

2 3. Partner, Officer, Stockholder Information: List the information of all partner(s), officer(s), and stockholder(s) directly connected with the business. If there are more than two, attach additional sheets. 4. Dance Hall Supervisor Information: 5. Property Owner Information: * If more than one owner, attach additional sheet with names and addresses. Company (if applicable): Name: - Page 2 of 5 -

3 6. Has any individual listed above ever had or been involved with a licensed Dance Hall operation that was suspended or revoked? Yes. If so, please explain. 7. Has any individual listed above been convicted, incarcerated or confined for a misdemeanor offense within the last two years or within the last five years for a felony offense for violation of the dance hall regulations of the City of Cocoa Code; or under Chapters 784 (Assault; Battery; Culpable Negligence), 787 (Kidnapping; False Imprisonment; Luring or Enticing a Child; Custody Offenses), 790 (Weapons and Firearms) 794 (Sexual Battery), 800 (Lewdness; Indecent Exposure), 812 (Theft, robbery and Related Crimes), 837 (Perjury), 856 (Drunkenness; Open House Parties; Loitering; Prowling; Desertion) 859, (Poisons; Adulterated Drugs), 870 (Affrays; Riots; Routs; Unlawful Assemblies), 874 (Street Terrorism Enforcement and Prevention), 877 (Miscellaneous Crimes), or 893 (Drug Abuse Prevention and Control) of the Florida Statutes or an offense under an analogous federal law, statute of a State other than Florida, or under an analogous ordinance of another county or city? Yes. If so, please provide all details including offense, dates, and places. 8. Does anyone listed above hold other licenses pursuant to the Dance Halls regulations of the City Cocoa Code? Yes. If so, please list all licenses. 9. Please submit the following items in order to complete the application: a. Application fee. Please make checks payable to the City of Cocoa and submit payment ONLY to the Community Services Department. b. Proof of ownership. A copy of the most recent recorded warranty deed is required. c. Letter of authorization or lease agreement. If the applicant is not the property owner, a notarized letter of authorization or agent affidavit or a copy of a lease agreement for the property is required. Each property owner must complete a separate authorization form or other suitable documentation to allow the agent to act upon his/her behalf. d. Corporate documents. If the applicant/owner is representing a company, articles of incorporation which show the applicant/owner is authorized to represent the company is required. A data record printout from the Florida Department of State, Division of Corporations website may also be provided (http://www.sunbiz.org/corpweb/inquiry/search.html). e. Partnership agreement. If applicable, provide a copy of the partnership agreement. f. Drivers licenses. Provide a copy of all drivers licenses for individuals listed in this application. g. Social security cards. Provide a copy of all Social Security cards for individuals listed in this application. h. Proof of Business Tax Receipt. A copy of the current City of Cocoa Business Tax Receipt for the business associated with the Dance Hall Permit. - Page 3 of 5 -

4 i. Floor plan. Provide an up-to-date floor plan which shall be accurate and drawn to scale, but need not be prepared by a licensed design professional, and which shall include the following: i. Dimensions of dancing areas, corridors, seating areas, and outdoor gathering areas; ii. A depiction of the number and placement of bar stools, tables and chairs or other seating; iii. A depiction of the location of restrooms, corridors, and all entryways and exits; iv. Such other information reasonably required by the city manager. j. Additional information (optional). Submit any information that may be helpful in understanding the request. This may include photos, sketches, or letters from adjoining property owners. 10. Signatures and tarization. I certify that I have read, understand and shall abide by all applicable criteria, standards, and conditions found in Chapter 14, Article II, of the City of Cocoa Code. Printed Name of Applicant tarized Signature of Applicant State of Florida, County of Brevard, subscribed and sworn to before me this day of, 20. who is personally known to me or produced: as identification. tary Public SEAL: My Commission Expires AREA BELOW FOR OFFICE USE ONLY Community Services: Fee of $ in cash or check (. ) payable to the City of Cocoa. Receipt Number: Application Fee received by: Approved by Community Services Director for compliance with Chapter 14, Article II. Dance Halls Denied by Community Services Director Concerns/Conditions: Police Department: Reviewed by Police Chief for compliance with City of Cocoa Dance Hall regulations. All persons listed on this permit application have been through standard background checks and all possible offenses listed in Section 7 above are noted below. Approved by Police Chief for compliance with Chapter 14, Article II. Dance Halls. - Page 4 of 5 -

5 Denied by Police Chief. Offenses noted: Fire Department: Approved by Fire Chief for compliance with Chapter 6, City of Cocoa Fire Prevention and Protection Code, relative to places of assembly, including but not limited to, maximum permitted occupancy load. Maximum permitted occupancy load is. Denied by Fire Chief. Offenses noted: City Manager: Approved by City Manager Denied by City Manager Concerns/Conditions: FINAL APPLICATION DETERMINATION: APPROVED DENIED - Page 5 of 5 -

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