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2. CITY OF MIDDLETOWN COVID-19 EO 7MM TEMPORARY OUTDOOR DINING/RETAIL APPLICATION
4. BUSINESS INFORMATION
6. Company Name:*
8. Address
10. City
11. State
12. Zip Code
14. Phone Number
16. APPLICANT INFORMATION
18. Name
20. Company Name
22. Address
24. City
25. State
26. Zip Code
28. Phone Number
29. Email Address
31. EMERGENCY CONTACT INFORMATION
33. First Name
34. Last Name
36. Primary Number
37. Secondary Number
39. CHECKLIST (PLEASE SUBMIT THE FOLLOWING FOR A COMPLETE APPLICATION)
    Site Plan and Narrative must be attached to this application at the bottom of the form. Insurance Certificate can also be attached (only required if using public property)
41. Application Form Complete*

    1. Yes
43. Site Plan Complete*

    1. Yes

    Must show the following: • Outdoor Dining/Retail Area layout and dimensions • Location of tables with number of seats noted and all furniture. • Location of fencing/barriers • Building(s)/structures dimensions • Staff stations and pathways • Sidewalk dimensions • Entrances/Exits • All other features or obstructions (lamp posts, trees, etc.) • Property owner’s approval (if applicable) • Temporary heaters, sanitizing stations, lighting, signage and fire extinguisher locations
45. Brief Narrative Complete*

    1. Yes

    Narrative should include at a minimum the following: hours of operation, general description of outdoor activity area needed and if it will be on public property, public safety measures to protect customers as well as if alcohol will be served in the outdoor area.
47. Insurance Certificate Complete*

    1. Yes
    2. Not Applicable (not using public property)

    Please contact 860-638-4828 for insurance requirements
48. Property Owner Approval*

    1. Yes
    2. I am the Property Owner

    Please submit authorization by the Property Owner if you are not the owner of the parcel.
50. CERTIFICATIONS
52. I agree to conform to the provisions as specified under Executive Order 7MM, dated May 12, 2020*

    1. Yes
54. I agree to adhere to the City of Middletown Temporary Outdoor Dining/Retail Area Permit Policy*

    1. Yes
56. I agree to all Local, State and Federal laws not in conflict with Executive Order 7MM.*

    1. Yes
58. I certify that the above information and the information submitted with this application form are true and correct.*

    1. Yes
60. ELECTRONIC SIGNATURE
    Please type your name and enter the date below. This will constitute a legal signature.
62. First Name
63. Last Name
65. Date*
    Date
67. UPLOAD FILES
    Attach Site Plans, Narratives, Certificate of Insurance (if applicable) and Property Owner approval (if applicable)
69. Temporary Outdoor Dining/Retail Site Plan*
    Please attach a detailed site plan to this form. You will not be able to submit an application without a site plan.
71. Brief Narrative*
73. Certificate of Insurance (If Applicable)
74. Property Owner Permission Statement (If Applicable)
Leave This Blank:


76. 1. Receive an email copy of this form.
77. Email address

    This field is not part of the form submission.

78. Submit

* indicates a required field