Form Sh-80 - Application For Amusement Device, Viewing Stand Or Tent Operating Permit - New York State Department Of Labor
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1
2New York State Department of Labor
Division of Safety and Health
License and Certification Unit
Harriman State Office Campus
Building 12, Room 161A
Albany, NY 12240
(518) 457-2735
Application for Amusement Device, Viewing Stand or Tent Operating Permit
For all permit applications, new and renewal, complete: numbers 1 through 6b, and sign number 9. In addition:
•
If your application is for a viewing stand or tent permit renewal, also complete number 7
•
If your application is for an amusement device permit, also complete number 8
Return the signed form to the address above. See page 2 for more information and required documentation.
If you received this form preprinted, it is for your convenience to renew your permit. You must return it 10 days prior to the
permit issue date:________________.
If you do not want to renew your permit, check the appropriate box:
I no longer own the amusement devise, viewing stand or tent
I do not need to renew my permit at this time because the amusement devise, viewing stand or tent is not in use
Then return the signed form to the address above. (You do not need to complete numbers 1 through 8.)
1. This application is for (check one):
6 b. If ‘Yes,’ describe any changes or modifications
since the last inspection in NYS, or any other
An amusement device
A viewing stand
A tent
comments relevant to your application:
2. The permit type needed is a (check one):
_
_
New permit
Renewal
_
3. Legal name and mailing address of operator:
_
Name:
________________________________________
_
______________________________________________
_
_
Street:
________________________________________
_
City:
__________________________________________
_
State:
_____
Zip:
_____________
_
Doing Business As (DBA) (if
any):___________________
_
______________________________________________
_
Phone:
(______)_____________________
_
Federal Employer Identification Number (FEIN):
_______________________
7. For viewing stand or tent permit renewal only:
4. Manufacturer information:
State registration number:
___________________
Name:
________________________________________
8. For amusement devices only:
______________________________________________
Type of device:
______________________________
Street:
________________________________________
Name device is known by (example: Roller Coaster –
City:
__________________________________________
Wild Mouse”):
_______________________________
State:
_____
Zip:
_____________
Identification number:
_____________________
Phone:
(______)_____________________
Device classification:
Adult
Kiddie
Model number, if any:
_______________
Maximum speed:
__________
(not applicable for zip
Capacity, number of persons:
___________
lines or rock walls)
5. Is the amusement device or viewing stand or tent
Capacity,
weight:________
permanently installed?
Yes
No
_________________________________
9. Signature:
6 a. Has the amusement device, viewing stand or tent
________________
Date:
been rebuilt or modified since the last inspection?
________________________________
Print name:
Yes
No
______________________________________
Title:
SH 80 (05/16)
Page 1 of 2
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