COVID-19 Large Gathering Event Notification Form

This form is to be completed by the responsible party or parties, i.e.: Owner, Operator and/or Business hosting the event. This form is to be used for events with attendees exceeding the State's social gathering limit, currently 100 indoor and 200 outdoor. A separate form must be submitted for each event to the Chemung County Health Department at least five days in advance of the event. Failure to do so may result in the issuance of a notice of hearing, fines, and/or revocation of your permit to operate. Please note that submission of this form is not an approval of the event. By submitting the form you are attesting that you have completed an updated NY Forward Safety Plan specific to your facility and In-person/Catered Events, it is on file at your facility, and you are ensuring that all of the NYS required guidance will be followed and adhered to. If you have any questions or if there are any changes to this form between now and the time of the event, please contact us at 607-737-2019.

Event Name*

Date of Event*

Date

Start & End Time of Event*

Hour Minutes

AM/PM Option

Until

until

Hour Minutes

AM/PM Option

Event Duration (Including loading and unloading times)*

Facility Name*

Room or Area Name/Description/Indoor/Outdoor and Floor Plan:*

Floor Plan Upload (If Available)

Event Location?*

IndoorOutdoor

Room Listed Capacity (at 100%):*

Room Calculated Capacity (at 75%):*

Expected # of Attendees (must be the lesser of 150 persons or 75% of venue capacity)*

Venue Capacity (at 100%):*

Venue Calculated Capacity (at 75%):*

Expected # of Attendees (Effective April 2nd, 2021, must be the lesser of 500 persons or 75% of venue capacity)*

Event Location Additional Details:*

Event Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Location Contact Name*

First NameLast Name

Location Contact Phone Number*

Please enter a valid phone number.

Location Email*

example@example.com

Food Service Facilities, Caterers, and Event Venues must have their NY Forward Safety Plan completed, attached, and available for review.

Safety Plan Upload*

Primary Contact Name*

First NameLast Name

Primary Contact Phone Number*

Please enter a valid phone number.

Primary Contact Email*

example@example.com

Secondary Contact Name*

First NameLast Name

Secondary Contact Phone Number*

Please enter a valid phone number.

Secondary Contact Email*

example@example.com

•All guests must be required to sign in, and provide full name, date of birth, address, email and phone #'s.

•All Support Staff (Florist, Photographer, DJ, Musicians, etc.) must be required to sign in, and provide full name, date of birth, address, email and phone #'s.

•Table seating chart (if applicable) must be retained.

Who will maintain guest sign in (and table seating chart) for 28 days in the event contact tracing is required?

Name for Guest Sign In*

First NameLast Name

Phone Number for Guest Sign In*

Please enter a valid phone number.

Email for Guest Sign In*

example@example.com

Please provide contact information for the person(s) conducting the mandatory Health Screening of the employees, event staff and attendees prior to the event, and who will be reviewing/checking for proof of negative diagnostic test results for COVID-19 or proof of immunization against COVID-19 at this event.

Name for Health Screener*

First NameLast Name

Phone Number for Health Screener*

Please enter a valid phone number.

Email for Health Screener*

example@example.com

COVID Test/Immunization Screener Name*

First NameLast Name

COVID Test/Immunization Screener Phone Number*

Please enter a valid phone number.

COVID Test/Immunization Screener Email*

example@example.com

The information below is provided as a reminder of some of the requirements. Please refer to the NYS Forward Phase 3 "Interim Guidance For Food Services During the COVID-19 Public Health Emergency" for full explanation of requirements.
https://www.governor.ny.gov/sites/governor.ny.gov/files/atoms/files/Indoor_and_Outdoor_Food_Services_Detailed_Guidelines.pdf

COVID Testing for Attendees
To attend the event, guests must have and provide proof:
• negative PCR or NAATS COVID test 72 hours prior to event, OR
• negative FDA authorized antigen test within 6 hours of the event, OR
• completion of vaccine series at least 14 days prior to the event
Anyone unable to ptrovide such must be allowed to attend the Event

COVID Testing for Employees and Event Staff
Employees and event staff include anyone who may interact with attendees and other employees or event staff. Examples are venue staff, catering staff, bartenders, entertainers, photographers/videographers, security personnel, parking attendants, floral arrangers, etc

Employees and event staff must be tested, and test negative:
• through a diagnostic (PCR or NAATS COVID) prior to working their first event, AND
• be tested biweekly while continuing to work events, OR
• provide proof of completion of vaccine series at least 14 days prior to the event
Employees and Staff MUST NOT be allowed to work the event if they do not meet these requirements

Health Screening of Attendees, Employees and Event Staff
(Must be conducted prior to entry to Event or Workplace)
Immediately before entering the event, employees, event staff and event attendees must be screened for the following:
• COVID-19 symptoms, such as temperature above 100.4°F, cough, loss of taste and smell, shortness of breath, etc
• Recent positive COVID-19 test results (when previous 10 days)
• Recent contact with suspected or confirmed COVID-19 positive individuals (within previous 10 days)
• Compliance with NYS travel advisory
Anyone with the above MUST NOT be allowed to work or attend the event

Seating
• Limited to maximum 10 persons per table
• Where possible, attendees should be seated at a table or area with members of their same immediate party, household or family
• Tables must be spaced a minimum of 6 feet (from chair back to chair back)
• Guests may only remove face coverings when seated at a table

Food Service
• Sit Down Service - no additional restrictions
• Buffet - facility must have designated food workers at each station in order to serve food items to the guests, queue line signage and floor markings must encourage social distancing
• Bar Service - table service or guests must take beverages back to their table for consumption
• Table Size - no table may exceed 10 attendees

Music / Dancing
• Live music performers and other entertainers must be separated from attendees by either 12 feet of physical space or an appropriate physical barrier
• Dancing is allowed with the following conditions:
• Select attendees pre-designated to the responsible party or parties may participate in ceremonial dances with members of their immediate party/household or family
• Non-ceremonial dancing is allowed, but attendees must wear face coverings and may only dance with members of their same immediate party/household/family who are seated at their table and can only dance in clearly marked areas or zones that are assigned specifically to them and spaced, at least, six feet apart from any other dancing areas or zones, and any tables.

General Reminders
Please refer to the NYS Forward Phase 3 "Interim Guidance For Food Services During the COVID-19 Public Health Emergency" for full explanation of requirements. https://www.governor.ny.gov/sites/governor.ny.gov/files/atoms/files/Indoor_and_Outdoor_Food_Services_Detailed_Guidelines.pdf

• In the event of a COVID positive employee, event staff, vendor or attendee, responsible parties must cooperate with Chemung County Health Deoartment contact tracing staff to trace all affected contacts
• Employees and event staff must wear appropriate face coverings at all times
• Venue staff, event staff and/or responsible parties must ensure that attendees are not congregating , except when seated at their assigned table
• Venue staff, event staff and/or responsible parties must ensure that attendees properly wear face coverings when standing, and are only standing when necessary

Face Coverings: Responsible Parties must ensure that attendees, employees, and event staff wear acceptable face coverings at all times; provided, however, that attendees may remove their face coverings when seated at their assigned table to eat or drink

• Facilities must conduct regular cleaning and disinfecting, and more frequent cleaning and disinfecting of frequently touched surfaces-see NYSDOH "Interim Guidance For Cleaning and Disinfection of Public and Private Facilities for COVID-19" for detailed instructions
https://coronavirus.health.ny.gov/system/files/documents/2020/08/interim-guidance-public-and-private-facilities_0.pdf

Responsible Party
The responsible party submitting this form must affirm below that all applicable current NYS COVID-19 Executive Orders and Guidance will be followed.

Mandatory Sample Event Signage

Responsible Party Name*

First NameLast Name

Association with Event (organizer, facility operator, etc.)*

I am the responsible party, i.e.: Owner, Operator and or business, hosting the event listed. I have reviewed all applicable New York State interim guidance for In Person/Catered event activities and operations during the COVID-19 public health emergency and I affirm that I have read and understand my obligation to operate this event in accordance with such guidance. I understand that my event may be subject to inspection by the Chemung County Health Department and or other regulatory authorities to ensure compliance will all provisions of the NYSDOH Interim Guidance for Food Services During the Covid-19 Public Health Emergency and any and all applicable Codes, Rules, and Regulations.

I understand that by checking this box, it is the same as if I am physically signing this form.

Date*

Date

Responsible Party Email*

example@example.com

Responsible Party Phone Number*

Please enter a valid phone number.

Responsible Party Alternate Phone Number*

Please enter a valid phone number.

COVID-19 Large Gathering Event Notification Form

Event/Location Information

Event Organizers/Contacts/Responsible Parties