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 planned to have attendees over the New York State gathering limit (which is subject to change).  A separate form must be submitted for each event, (even if more than one is held on the same day) no less than 5 days prior to the event, to the Genesee or Orleans County Health Department.  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 submittal of this form is not an approval of the event.  By submitting the document 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 document between now and the time of the event, please contact the appropriate County Health Department.  For Genesee County, call 585-344-2580 ext. 5555 or e-mail: Health.Dept@co.genesee.ny.us.  For Orleans County, call 585-589-3278 or e-mail:  OCPublicHealth@orleanscountyny.gov.  Thank you.
Required fields are marked with an asterisk * and must be completed.

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* 1. Event Name:

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* 2. Date of Event

Date

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* 3. Start /End Time of Event (including loading and unloading times):

Time
Time

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* 4. Event Location / Facility Name:

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* 5. Caterer or Food Service Establishment Health Department Permit #:

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* 6. County of Event

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

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* 8. Room Listed Capacity (at 100%)

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* 9. Room Calculated (at 50%)

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* 10. Expected # of Attendees (must be the lesser of 150 persons or 50% of venue capacity)

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* 11. Expected # of Event Staff:

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* 12. Event Location Additional Details:

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* 13. Location Contact First Name:

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* 14. Location Contact Last Name:

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* 15. Location Contact Telephone:

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* 16. Location Contact E-mail:

***Food Service Facilities must have NY Forward Safety Plan completed and available for review***
Event Organizers/Contacts/Responsible Parties

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* 17. First Name of 1st Contact:

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* 18. Last Name of 1st Contact:

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* 19. Telephone for 1st Contact:

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* 20. E-mail for 1st Contact:

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* 21. First Name of 2nd Contact:

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* 22. Last Name of 2nd Contact:

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* 23. Telephone for 2nd Contact:

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* 24. E-mail for 2nd Contact:

***All guests must be required to sign in and provide full name, date of birth, address, e-mail, and phone numbers.

***All Support Staff (Florist, Photographer, DJ, Musicians, etc.) must be required to sign in, and provide full name, date of birth, address, e-mail, and phone numbers.

***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?

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* 25. First Name of Contact for Guest Sign-in:

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* 26. Last Name of Contact for Guest Sign-in:

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* 27. Telephone of Contact for Guest Sign-in:

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* 28. E-mail of Contact for Guest Sign-in:

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

Interim Guidance for Small and Medium Scale Performing Arts & Entertainment During the COVID-19 Public Health Emergency:  https://www.governor.ny.gov/sites/governor.ny.gov/files/atoms/files/Small_and_Medium_Performing_Arts_Detailed_Guidance.pdf
COVID TESTING FOR ATTENDEES:
  • To attend the event, guests must have:
    • negative PCR or NAATS COVID test 72 hours prior to event, OR
    • negative FDA authorized antigen test within 6 hours of the event, OR
    • proof of completion of vaccine series at least 14 days prior to the event.
  • COVID positive guests MUST NOT 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 completions of vaccine series at least 14 days prior to the event.
  • COVID positive employees and event staff MUST NOT be allowed to work the event.
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.
    • Recent contact with suspected or confirmed COVID-19 positive individuals.
    • Compliance with NYS travel advisory.
  • This screening may be done remotely (by phone, online form, etc.) or in person.
  • COVID symptom positive employees and event staff 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 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:
    • Ceremonial dances by selected attendees with members of their immediate party/household or family.
    • Non-ceremonial is allowed, but attendees must wear face coverings and may only dance with members of their same immediate party/household/family.
    • Dancing zones or areas must be clearly marked, and dancers must remain in their designated zone/area.
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 Genesee / Orleans County 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 properly wear face coverings when standing, and are only standing when necessary.
  • 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.
The responsible party submitting this form must affirm below that all applicable current NYS COVID-19 Executive Orders and Guidance will be followed.
Responsible Party:
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 Genesee / Orleans County Health Departments and/or other regulatory authorities to ensure compliance with all provisions of the NYSDOH Interim Guidance for Good Services During the COVID-19 Public Health Emergency and any and all applicable Codes, Rules, and Regulations. 

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* 29. Attestation:

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* 30. Responsible Party First Name:

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* 31. Responsible Party Last Name:

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* 32. Association with event (organizer, facility operator, etc.)

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* 33. Date:

Date

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* 34. E-mail Address:

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* 35. Telephone Number:

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* 36. Alternate Telephone:

For Genesee County questions, please e-mail:  Health.Dept@co.genesee.ny.us
For Orleans County questions, please e-mail: OCPublicHealth@orleanscountyny.gov

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