Syracuse Amusement Device Operator Licenseq by PermitDocsPrivate


									FEE:    $100.00 ONE-YEAR                                                               LICENSE #

PAID:                                                                                  DATE ISSUED



The undersigned                                                                 , does hereby apply to the
License Commissioner of the City of Syracuse, State of New York, for a license to engage in the business of
amusement device operator, pursuant to the General Ordinances of the City of Syracuse.

                                                 PLEASE PRINT

Name of Applicant:                                                           Date of Birth:
Home Address:                                                                Home Phone:
Business Address:                                                            Business Phone:
Is the Applicant a Corporation?
If yes, list its principal officers with their respective places of residence, phone numbers and titles:

                                                                           Date of Birth:
                                                                           Date of Birth:
Is the applicant a Partnership, Association or Firm?
If yes, please list any partners with addresses and date of birth, or any assumed names.

Has the applicant or any member of the applicant (in case of a corporation or partnership) ever been convicted
of a felony or misdemeanor? YES       NO
If yes please state facts:

All devices or machines (which are to be placed in different location) must not be in violation of the provisions
of sections 225.00 et. seq. of the penal law of the state of New York and other sections relating to gambling

                                      INDEMNIFICATION STATEMENT

The applicant, upon issuance of a license, herein agrees to indemnify and save harmless the City of Syracuse, its
agents, officers and employees thereof from all claims, suits or actions of every name or description brought
against the City, its officers, employees or agents for or on account of bodily injuries, including death or
damages to property, received or sustained, or alleged to be sustained by any person or persons arising out of
the license issued herein.

             (SIGNATURE OF APPLICANT)                                          (DATE)

                 (PLEASE PRINT NAME)                                          (NOTARY)
I,                                                   affirm that all amusement devices to operated within the
City of Syracuse shall be the property of, and operated by, applicant and that none shall be owned or operated
by any other amusement operator either licensed or unlicensed d by the City of Syracuse.

I,                                                   hereby certify that the devices and machines for which this
application is made will not be placed in any location that is within 200 hundred feet of the lot line of a public
or private schools, church or playground.

I,                                                       understand that any license issued pursuant to this
application is subject to all the provision contained in pt. 0, article 5, ss. 37-73 adopted by the common council
May 2, 1988, and all ordinance of the city, pertaining to amusement device operators hereafter enacted.

I,                                                 affirm that none of the amusement devices placed, operated
or maintained at said amusement center are or will be “adult entertainment amusement devices” as that term is
defined in section 5-38 of said ordinance.

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