Essex County, New York
PO Box 338, Main Street · Bloomingdale, NY 12913 · 518-891-3189 · Fax: 518-891-6092


Today's Date:______________________________ Date(s) Requested:_______________________________

Facility Requested:


Name of Organization or Individual:

Time:__________ to _______________________ Person in charge: _____________________________________

Mailing Address:

Telephone: (Day) _____________________________ (Night) ___________________________________


Purpose of Use:

Total Participants Expected: _____ Adults: _____ Children: ______

Is material or equipment required from municipality? Yes No

If needed, state what types and for what purpose:

Is an admission fee charged? Yes No

If yes, what will proceeds be used for?


The undersigned is over 21 years of age and has read this form and attached regulations and agrees to comply with them. He/she agrees to be responsible to the municipality for the use and care of the facilities. He/she, on behalf of Name of Organization or Individual: ____________________________does hereby covenant and agree to defend, indemnify and hold harmless the Town of St. Armand from and against any and all liability, loss, damages, claims, or actions (including costs and attorney's fees) for bodily injury and/or property damage, to the extent permissible by law, arising out of or in connection with the actual or proposed use of the Town of St. Armand's property, facilities and/or services by Organization or Individual: ____________________________

Signature of Representative:


Telephone Number:

READ ATTACHED REQUIREMENTS AND RETURN APPLICATION TO: Town of St. Armand Supervisor - Town Hall: 1702 NYS Route 3, PO Box 338, Bloomingdale, NY 12913

The use of all town facilities shall be subject to the accompanying rules of use and approval of the town supervisor.
  • Organizations/lndividuals wishing to use municipal facilities shall first apply to the town supervisor on the prescribed form.
  • In the event of inclement weather, the town supervisor has the final authority on whether facilities are usable.
  • Alcohol shall not be brought onto municipal facilities at any time. Smoking is not permitted on the Youth Field or Veterans Memorial Park.
  • All posted rules must be adhered to.
  • Profanity, objectionable language, disorderly acts or illegal activities of any kind are absolutely prohibited, and those violating this prohibition will be ejected from the premises.
  • Any damage to municipal facilities shall be promptly repaired at the user's expense. No exceptions. If maintenance personnel are not available, make sure all doors are locked and lights are turned out when leaving.
  • Organizations using the facilities must clean-up afterwards.
  • Permits may be revoked at any time.
  • Any Organization/lndividual with youth under 18 years old attending, requires the presence of adequate adult supervision at all times.
  • Call 911 in case of Emergency.
  • When required, users must provide the following insurance prior to using facilities.
Commercial Users:

A. The user hereby agrees to effectuate the naming of the municipality as an unrestricted additional insured on the user's policy.

B. The policy naming the municipality as an additional insured shall:
  • be an insurance policy from an A.M. Best rated "secured" New York State licensed insurer;
  • contain a 30-day notice of cancellation;
  • state that the organization's coverage shall be primary coverage for the Municipality, its Board, employees and volunteers; and
  • additional insured status shall be provided with ISO endorsement CG 2026 or its equivalent.

C. The user agrees to indemnify the municipality for any applicable deductibles.

D. Enclose a copy of the endorsement providing additional insured status.

E. Required Insurance: Commercial General Liability Insurance - $1,000,000 per occurrence/ $2,000,000 aggregate.

F. User acknowledges that failure to obtain such insurance on behalf of the municipality constitutes a material breach of contract and subjects it to liability for damages, indemnification and all other legal remedies available to the municipality. The user is to provide the municipality with a certificate of insurance, evidencing the above requirements have been met. The failure of the municipality to object to the contents of the certificate or the absence of it shall not be deemed a waiver of any and all rights held by the municipality.


Required Insurance: Homeowners Insurance - Section Two - Liability: $100,000 limit of liability. Policy shall not exclude the off-premises activities of the insured.

In the event of an accident, please notify the town supervisor immediately.

Town of St Armand
PO Box 338, Main Street, Bloomingdale, NY 12913 · 518-891-3189 · Fax: 518-891-6092
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