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HomeMy WebLinkAboutPeconic Land Trust 2019-4 f , Southold Town Board - Letter Board Meeting of March 12, 2019 RESOLUTION 2019-233 Item# 5.17 yJdE ADOPTED DOC ID: 15008 THIS IS TO CERTIFY THAT THE FOLLOWING RESOLUTION NO. 2019-233 WAS ADOPTED AT THE REGULAR MEETING OF THE SOUTHOLD TOWN BOARD ON MARCH 12, 2019: RESOLVED that the Town Board of the Town of Southold hereby grants permission to Peconic Land Trust to hold a Special Event at the Agricultural Center at Charnews Farm- 3005 Youngs Avenue Southold,New York as applied for in Application 2019-4 for one (1) event: Peconinic 2019 from 12:00 PM to 4:00 PM on June 1, 2019 provided they adhere to all conditions on the application and permit and to the Town of Southold Policy for Special Events. Elizabeth A.Neville Southold Town Clerk RESULT: ADOPTED [UNANIMOUS] MOVER: Jill Doherty, Councilwoman SECONDER:William P. Ruland, Councilman AYES: Dinizio Jr, Ruland, Doherty, Ghosio, Evans, Russell Generated March 13, 2019 Page 28 RECEIVED MAR - 1 2019 Southold Town Mork SPE- -C-1-. A--L- EVENT ,20-1-9 _ 4 ; APPLICATION FOR A PERMIT TO HOLD A SPECIAL EVENT Please provide ALL of the information requested below.Incomplete applications WILL NOT be reviewed. Special Event Permit# Applicant(s)name: P�C C.ON�G L / TZ" "1 (g3 Su g019 PGCDAJ I A/ i G aOl Date of Submission���n�'�� of Event SCTM#'s 1000-Section �0 3 Block- ( Lot(s) Dates of Each Event: JU/V C 11-210(q If Multiple Dates are requested,applicant must give all information for all dates. Nature of Event: (Please attach a detailed description of EACH event to this application) Time Period(Hours)of Event: From I Q /4 DOW to Town Services, requested: ( )Yes (40 If yes,Describe Police Dept. Highway Dept. Describe Services N Cr( App U1 C.148 LC Maximum Number of Persons Attending At One Time: 20 Number of cars expected Q 5 1 � Is a Tent or other t mpora structure bein used? 1/1Yes [ ]No Ij yes vide sirze(s) (l yo loo s ao � o , nil Ic a Ili 4 c � Will food be served?[V/1 Yes [ ]No If yes provide number and name(s)of food vendor(s) ArLL— r^0�� Updated 8/7/2018 W(Ll- '$6 PK PA'R0 DrF- S f tf +-- f3ROuC7+r(_ Ole SRC- (PACgA&etb SNAGV.S T: RoAA 0. 3�'�a WHOUC- S� cw3 • �1V��Zl���� - -W 43 f• ,-a�- • & To AAAI RAIT I S OF UVC C L VC Suffolk County permit#(s) A 'r( I o�Her vendo'fsVon the p mise 1IRthe event?[ v6es [ ]No If yes how many?�"S Describe ^_ Type of vendor(s) U 1 b�J �d' W lC b Ll r� _T�CvG PROGA �It�� CT 01- 2J3.-3,q5 b 'rusf / q� �!Property Owner(name/address): PECoNIG LAAtb SO� WJ Contact Person and Contact Te #B12 (b & 1� 0. AAC E — AAk"d/�Zl e-mail address 0J– the--Z— ® f CONIC. RUST. o` )f- 13 Event Location: Street-Hamlet Address: A(rR(C V LTU R rL C Gl4MR AT CH40a4 rl'A 300S yQVNGS N'V GNVC SCTM# IDo� "�o�� � ' p�J.3 �O�S. �{ FA-R/K SotrtHoUb / Ny Itgq-1 Mailing Address to Send Event Permit to: PJG'COA/(G (,AN**D* -rR%)'Tr I !�- . P t-COVIMC p o. go� 1 :V+6 / 30m-(4AA-M/Y , 14\1 l I q � q 2a q Have any of the development rights been sold t/the Town of Southold [ Yes [ ]No and/or Suffolk County Agricultural Program? [ ]Yes [ J�/ No If yes to either or both,also indicate on the attached 121an the boundaries of the reserved area Won which the event will take place. YOU MUST ATTACH A PARKING/EVENT PLAN TO THIS APPLICATION IF THE EXPECTED ATTENDANCE IS 300 OR MORE PEOPLE,YOU MUST ALSO ATTACH A TRAFFIC CONTROL PLAN(see next pagel A Parking/Event Plan may be a survey, site Plan and/or aerial view (for example Google Earth) of the subject property.INDICATE ON THE PLAN ALL of the following information: A parking/event plan showing: (1) The size of the property and its location in relation to abutting streets or highways. (2) The size and location of any existing building(s)or structure(s)that will be in operation during the course of the event and any proposed building,structure,or signs to be erected temporarily for the event. (3) The location of the stage or tents,if any. (4) The designated areas of use for spectators,exhibitors,vendors,employees and organizers. (5) Location of all entries and exits. (6) The location of all fire extinguishers and other fire safety equipment. (7) The location of all temporary utilities to be installed for the event,if any. (8) The layout of any parking area for automobiles and other vehicles and the means of ingress and egress for such parking areas. The parking spaces must allow for 300 sq.ft. per car. (9) A traffic control plan for vehicles entering and leaving the site for the proposed event. (10) Plan for the use of live outdoor music,loudspeakers and other sounds which will be used, if any,and the type and location of speakers and other audio equipment. (11) A description of emergency access and facilities related to the event. (12) Provisions to dispose of any garbage,trash,rubbish or other refuse. (13) Location and description of any additional lighting to be utilized in conjunction with the event. Updated 8/7/2018 (14) 'Location of sanitary facilities on site. Traffic Control Plan Events for three hundred(300)or more people also require submission and approval of a traffic control plan, acceptable to the Town of Southold,AND a qualified traffic controller must be provided. Please attached a written description and/or notate on the parking event plan the following: 1)Who will be conducting traffic,2)Where they will be stationed on site , 3)How they will direct the entrance, circulation,parking, and exiting of cars on site, and 4)Contact information for use by Southold Town Police. OWNER'S SIGNATURE: I am the Owner of the Property where this event is to be held and I agree to comply with the laws, rules, regulations, conditions,and requirements of the Code of the Town of Southold, including but not limited to the conditions listed below, as well as all other applicable agency rules and regulations pertaining to the activities under this event. Furthermore,I hereby swear or affirm that the information contained herein and attachments hereto are true and correct to the best of my knowledge, and agree to provide notice to the Town immediately should there be any material changes regarding to this application.. Furthermore,I hereby authorize Code Enforcement Personnel of the Town of Southold to enter the property during the hours of the permitted special event to make any and all inspections necessary in connection with this Special Event. inn c, L&I j 16 rti Print name of Owner Signature of Owner V��e D� �Sc�(oda Print name of Authorized Person/Representative Si afore f Authorized Person/Representative PERMISSION IS HEREBY GRANTED,SUBJECT TO THE FOLLOWING CONDITIONS: 1. By acceptance of this permit, applicant agrees to adequately supervise and direct all parking to be on the premises or at another site, and to provide parking assistants and any addifional traffic controls necessary for this event. Parking is strictly,prohibited on ANY Town. County or State Roads or Rights of Way. 2. Traffic control at events for three hundred(300)or more people shall be provided by a qualified traffic controller in accordance with the attached,approved traffic control plan. 3. One "on-premises" sign not larger than six (6) square feet in size may be displayed not longer than thirty (30) days before this event, and removed immediately after the event. Directional parking signs shall be adequately displayed. 4. Applicant indemnifies and holds harmless the Town of Southold from all claims, damages, expenses, suits and losses including but not limited to attorney's fees arising from activities under this permit. 5. Tent proposals must receive permit approval from the Southold Town Building Inspector before placement on the property and must meet all fire and safety codes: 6. This permit is valid only for the time, date, place and use specified above, and for the designated event. Each additional day will require a separate permit application, fee, and related documents for review, etc. at least 60 business days prior to the scheduled event. 7. Adequate temporary sanitary facilities must be provided by applicant for this event and applicant agrees to remove the temporary facilities from the premises within 48 hours after the day of the event. Updated 8/7/2018 8. On-site food preparation is NOT permitted, although food may be catered subject to all,Suffolk County Department of Health regulations. 'g;,�j!O �elivitie+3`tf4Rb^.inttY-� �;^L1+'-t'lli,a��,.,j�il�,ja$'`�Lii#t not.:li�j�es�,ta"narkin¢.:ma�,•e a n�acss. '' (�i�ctias 1 rt�ent I�'�"gW_ land: 10. �cti�'t,p- e��ociated t•3itli l,ia eti"Ant in 1 in r but Aot limited to pad&g ing ss/eg access, irUY �� a of beyt�nmerit. 1 iota land VitTlbut a'fiehYiit_i"lled_by -the Suffd k County Fannibnil 11.Issuance of this permit does not authorize in any manner the occupancy of any building exceeding the legal limitations under the fire code or other codes which would prohibit such increased occupancy. 12. Access shall be provided for emergency vehicles,to all public assembly, areas,all buildings, all work fire exits krkd edit paths areas and any adt#tti9nal area�-,64re:t ntergeticies may occur. Two eines ettQ�! p fxQm the buildings) on•the npr6p v a,pub]ic way or remote Uf'e,arta; shall rawa open and k unobstructed at all times. k 13. Owner assures full compliance with all fire,safety,building,and other Town laws. , 14. Music,when outdoors,is required to stop at the'time specified in the permit.Placement of the speakers must be in a location that affords the greatest protection from noise intrusion upon adjacent properties., ' 15. Owner will allow access to Code Enforcement Personnel of the, of Southold during the hours of the special,event to make any and all inspections necessary in connection with this Special Even ' 16. ADDITIONAL CONDITIONS: ANY VIOLATIONS IN CONNECTION_WITH THE CONDITIONS LISTED HEREIN WILL TERMINATE THIS PERMIT. APPROVED Town bf Southbfd Y.` Resolution Number: 2Q19-7,33 Date Issued: �ebbruery 26, 2019 4 Updated 8n12018 i Town of Southold Special Event Permit Description of Event: Peconinic is a celebratory picnic to honor Trust supporters. Attendees are invited to experience the land that has been protected through our collective conservation work, and are also invited to participate in educational programming. Supporters from both the north and south forks are invited every year, including our partners at the Towh of Southold, to enjoy delicious lunch selections, good music, and informative programming designed to educate and connect guests to our conservation work and rich agricultural and maritime history. PECONIC LAND TRUST t Emergency and Security Plan Attachment#11 Title of Event:Peconinic 2019 Date(s) of Event:June 1,2019 Event Description:A thank you picnic for our supporters. Location: The Agricultural Center at Charnews Farm, Southold,NY On scene person in charge of event: Name:Yvette DeBow-Salsedo,Vice—President,phone: 646.284.8028 Bridget Micieli-Martinez, Event&Design Coordinator,phone: 631.312.6224 Email Address:YDebowPeconicLandTrust.org/BMartinez@PeconicLandTrust.org Medical Emergencies Procedure All medical emergencies will be reported to Police, EMS or event personnel as soon as possible either in person or via phone. Event personnel,when notified,will call directly to 911 and report the incident/problem. Responding emergency vehicles will be granted access to the site through 3005 Youngs Avenue Southold,NY, or depending on the location of the emergency, or a location determined by Police or EMS. The onsite person in charge or event coordinator will make sure an area is open to allow emergency personnel,vehicles and equipment to access the event grounds whenever emergency assistance is needed and this access shall be maintained throughout the event.The nearest hospital for receiving patients is Eastern Long Island Hospital which is located at 201 Manor Place, Greenport. Police Emergencies For all police emergencies 911 will be called immediately. All Emergency vehicles will be granted access to the site through 3005 Youngs Avenue,Southold NY. Police enforcement will be provided by the Southold Police Department. Fire Emergencies For all fire emergencies, 911 will be called.All Emergency vehicles will be granted access to the site through 3005 Youngs Avenue, Southold,NY. Onsite personnel will assist with evacuation to the parking field located to the north west area from the event site or if this area is unsuitable to an area designated by the fire personnel or police.Vehicles should not be moved during an emergency response.It is recognized that exiting traffic would inhibit and/or place arriving emergency responders and exiting individuals in peril. Portable fire extinguishers are located in each tent.Additional Firefighting equipment in the nature of water hookup is located on event site next to the dining tent. Lost Child Procedure: Police and onsite event personnel will be notified.In the event a lost child is found he/she should remain at the location he/she is found at unless the location is unsafe or impractical or until it is determined that it is impractical to remain at the location.The child,if able, will be asked to provide parent/guardian information. Audio equipment is available onsite and an announcement of the situation may be made at the decision of on scene police personnel. The child will remain under the supervision of police personnel or their designee(Peconic Land Trust Staff Member Kathy Kennedy) who will ensure the child is comfortable and safe until his/her parent/guardian arrives. Parental identification shall'be verified prior to release of the child. Weather Emergency: In the event of any weather emergency the police, event coordinator or onsite event personnel may decide to halt the event for the safety of participants and the public.At no time will the decision to halt an event due to a weather related event by the police be overridden by others. Coordination for the safety of participants and spectators will be accomplished by the event coordinator utilizing PA system, all volunteers and Peconic Land Trust Staff to inform attendees of situations and of next steps. During the entire evacuation/relocation process the local Southampton Police department will be apprised of its progress and status. If and when the weather emergency has passed, a decision will be made by police personnel and the event coordinator as when to allow the event to resume. Communication Plan: All onsite event personnel, event coordinator, EMS,fire and police personnel must have a means of communication during the event. This will be accomplished by cell phone communication and face to face. Personnel Vice President-Yvette Debow 646-284-8028 Event Coordinator: Bridget Micieli-Martinez,631-312-6224 Volunteer Coordinator: Kathy Kennedy 631-278-6183 Emergency Numbers: Police Emergency 911 Town of Southold Police Department 631-765-2600 Southold Fire Department 631-765-3385 Southold Ambulance 631-324-4477 Eastern Long Island Hospital 631-477-1000 OSHA 631-334-3344 New York State Police 631-728-3000 Poison Control 800-222-1221 Plan for Disposal of Garbage,Trash, Rubbish and Sanitary Waste and Sewage: Attachment#12 At the event site there will be a dumpster from Emile Norsic and Sons which will be in place during the day of set-up, 05/31/19) through the day of clean-up. On the day of clean-up (06/03//19) the dumpster will be removed. There will be trash/rubbish bins available for general waste in the main and distribution tent and both bar tents. All trash/rubbish bins will be emptied into the dumpster. I At the event site there will be a three single unit restroom facilities with and one handicapped single unit restroom facility provided by Island Portables. An outdoor sink with handwashing capabilities will be set up near the event site. 4,4 .*Ik ' �q [� 4 • A, '• e :w x em D • � O 3 _a a . . I w y r r r � �M .� Peconic Land Trust 296 Hampton Road/PO Box 1776 The Agricultural Center - Charnews Event SCTM#: p/o 1000-63-1-25.4 631- -3195 Town own of Southold,by:Jessie Marcus;2019 Feb 26 , NY Parkin www.PeconicLandTrust.org Source:Esri,DigitalGlobe,GeoEye,Earthstar Geographies,ONES/Airbus DS,USDA,USGS,AeroGRID,IGN,and the GIS User Community,Suffolk County Real Property Tax Service Agency N ' O S Restricted �f Area Dumpster CJS a --Generator Speaker Stage Speaker 20'X 40' Kit en 40'x80' Dining Tent Regi ratio � • 16'X 16' �16'X 16' F e Extinguls s 20'x20' Raffle/P gra ing T Barn House he Restroo P E C O N I C LAND TRUST Agricultural Center at Charnews Farm 296 Hampton Road I PO Box 1776 3005 Youngs Avenue I Southold,NY 1 11971 Peconinic 2019 Event Site Diagram Southampton,NY 11969 vww PcconlcLandTrust orb Town of Southold June 1st,2019 631 283 3195 � ® DATE(MMIDDIYYYY) A CO CERTIFICATE OF LIABILITY INSURANCE 01/17/2019 THIS CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Carol Losquadro NAME' Roy H Reeve Agency,Inc PHONE (631)298-4700 FAX (631)298-3850 (AIC, C o Ext• AIC No PO Box 54 E-MAIL closquadro@royreeve.com ADDRESS* 13400 Main Road INSURER(S)AFFORDING COVERAGE NAIC# Mattltuck NY 11952 INSURERA. Federal Ins Co 20281 INSURED INSURER B: Peconic Land Trust Inc INSURER C• PO BOX 1776 INSURER D: INSURER E: Southampton NY 11969 INSURER F COVERAGES CERTIFICATE NUMBER: CL1911709715 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED NOTWITHSTANDINGANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS EXP TR TYPE OF INSURANCE A gp D POLICY NUMBER POLICY EFF MM POLICY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 CLAIMS-MADE OCCUR PREM SES Ea occu D nce $ 1,000,000 MED EXP(Any oneperson) $ 10,000 A Y 35816018 02/27/2019 02/27/2020 PERSONAL BADVINJURY $ 2,000,000 GEN'LAGGREGATE LIMITAPPLIES PER GENERAL AGGREGATE $ 2,000,000 POLICY PRO ❑ LOC PRODUCTS-COMP/OP AGG $ 2,000,000 JECT OTHER Employee Benefits $ 1,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 A EXCESS LIAB CLAIMS-MADE 93647953 02/27/2019 02/27/2020 AGGREGATE $ 5,000,000 DED I X RETENTION$ 10,000 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PkOPRIETOR/PARTNER/EXECUTIVE E L EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED,) NIA (Mandatory in NH) E L DISEASE-EA EMPLOYEE $ If yes,descnbe under DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Peconlnic June 1 2019 Certificate holder Is named as additional insured by written contract policy form 80-02-2000 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town Of Southold ACCORDANCE WITH THE POLICY PROVISIONS. Town Clerk's Office AUTHORIZED REPRESENTATIVE 53095 Route 25 PO Box 1179 Southold NY 11971 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD ADDITIONAL COVERAGES Ref# Description Coverage Code Form No. Edition Date Liquor Liability LIQUR Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium 2,000,000 Ref# Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 TDeductible Amount Deductible Type Premium Ref# Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref# Description Coverage Code Form No.77dition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref# Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref# Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref# Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref# Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 TDeductible Amount Deductible Type Premium Ref# Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref# Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 TDeductible Amount Deductible Type Premium Ref# Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium �OFADTLCV Copyright 2001,AMS Services,Inc. PECONIC LAND TRUST 1 Bridget Q.Micieli-Martinez Events&Design Coordinator 296 HAMPTON ROAD I P O BOX 1776 1 SOUTHAMPTON,NY 11969 TEL 631.283 3195 EXT:13 1 CELL.631312 6224 I BMartinez@PecorucLandTrust org I www PeconicLandTrust org x Neville, Elizabeth From: Born, Sabrina Sent: Friday, March 01, 2019 2:44 PM To: Neville, Elizabeth; Noncarrow, Denis; Norklun, Stacey; Silleck, Mary Subject: Special Event#4-Peconic Land Trust Attachments: Special Event#4-Peconic_20190301144049.pdf Good Afternoon, Please see the attached Special Event application from Peconic Land Trust. Thank you, Deputy Town Clerk Southold Town Clerk's Office 53095 Route 25 P.O.Box 1179 Southold,NY 11971 Ph: 631-765-1800 ext. 1226 Fax: 631-765-6145 L 1 RECEIVED ® MAR - 1 2019 Southold Town Clerk TOWN OF SOUTHOLD Town Code Chapter 205 "Public Entertainment and Special Events" SPECIAL EVENT PERMIT INSTRUCTIONS AND APPLICATION FORM Applications for a Special Event Permit are subject to an inter-departmental coordinated review by the Southold Town Board,Town Attorney,Town Assessors,Land Preservation,Building,Planning,Zoning Board of Appeals and Police Departments,and the Suffolk County Planning Commission. Application fee: $150.00 per application. Up to six (6)multiple events of the same type, occurring over a period of three months,may be permitted on one(1)application for a fee of$150.00. However, specific details of each event must be included with this application. All applications must be submitted at least 60 business days before the event. Applicants are encouraged to submit applications as early as possible. Any completed application that is not submitted 60 or more business days prior to the scheduled event may be rejected or subject to a late processing fee of$250.00 by the Office of the Town Clerk, unless a waiver is obtained. Requesting an expedited review must be submitted in writing to the Town Clerk. The Town Clerk will forward all applications to the Special Events Committee for processing. The Committee will obtain comments on all applications from relevant Town, County and/or State agencies and will forward completed applications to the Town Board with a recommendation as to whether to grant or deny the application. The Town reserves the right to request additional information from an applicant to address issues related to the health,safety, and welfare of the community. When is a Permit Required? All Special Events,per Southold Town Code Article I, Section 205-2(Definitions)must obtain a permit. Occasional events on private residential properties hosted by the owner thereof that are by invitation such as family gatherings, weddings, graduations, parties or not-for-profit fundraisers do not require permits. Any use of residential propea for profit,such as a venue for weddings or other events is prohibited. This application is deemed complete once all the following requirements are submitted to the Town Clerk: Please indicate submission of the following by checking off the boxes and signing below. A completed application form signed by the owner and the event manager. Applications without roperty owner's signature/approval will be rejected. u FEE: Is the application being submitted at least 60 days before the event[./) Yes [ ]No If Yes,Fee of$ 1 50 has been submitted ❑ If No,Fee of$ has been submitted Updated 8/7/2018 [�(The applicant/owner of the property where the special event is proposed to take place must provide a certificate of insurance not less than 2 million dollars naming the Town of Southold as an additional insure YA Parking/Event Plan: consisting of a survey, site plan and/or aerial view of the subject property that includes the locations of on-site parking, sanitary facilities, and tents or other temporary structure(s). (See application form for details) Events for three hundred (300) or more people require submission and approval of a traffic control I� an acceptable to the Town of Southold AND a qualified traffic controller must be provided at the event. (See application form for details) Signature of Property Owner on the application authorizing Code Enforcement Personnel of the Town of Southold to enter the subject premises during the hours of the event to ensure compliance with any and all special event permit conditions. My signature below affirms that I have submitted all the information required above in connection with'my application. oa• off-- a01RU', - Dated Signature �^ 1 Activities associated with outdoor public events are strictly prohibited from taking place on land preserved through the sale of development rights to the Town of Southold, and can only take place on land preserved through the sale of development rights to the County of Suffolk with a permit issued by the Suffolk County Farmland Committee. If food is to be served, it must be catered and prepared off-site by food vendors who hold a permit to operate issued by the Suffolk County Bureau of Public Health Food Protection Unit. Updated 8/7/2018 RECEIVED u 1 2019 f MAR Southold Town Clerk TOWN OF SOUTHOLD Twyn Code Cbapter 20Jie Ent e inni d Swecial, E ! SPECIAL EVENT PERMIT INSTRUCTIONS AND APPLICATION FORM Applications for a Special Event Permit are subject to an inter-departmental coordinated review by the Southold Town Board, Town Attorney,Town Assessors,Land Preservation,Building, Planning,Zoning Board of Appeals and Police Departments, and the Suffolk County Planning Commission. Application fee: $150.00 per application. Up to six (6) multiple events of the same type, occurring over a period of three months,may be permitted on one(1) application for a fee of$150.00. However, specific details of each event must be included with this application. All .a Ii i ass mustsubmitted at least 60 siness days before tht-gyent. A ' ntS Arg encouraged submit aDDlications as early as.J1055ible. AnyC0111DIetedlie d t i n tsubm60 Qr itted, morg busingsri the l d rsi,ng fee f 111c TowA l is-qb1ainf Requesting an expedited review must be submitted in writing to the Town Clerk. The Town Clerk will forward all applications to the Special Events Committee for processing. The Committee will obtain comments on all applications from relevant Town, County and/or State agencies and will forward completed applications to the Town Board with a recommendation as to whether to grant or deny the application. The Town reserves the right to request additional information from an applicant to address issues related to the health, safety, and welfare of the community. Whgn is a1ermit RequirW2 All Special Events,per Southold Town Code Article I, Section 205-2(Definitions)must obtain a permit. Occasional events on private residential properties hosted by the owner thereof that are by invitation such as family gatherings, weddings, graduations, parties or not-for-profit fundraisers do not require permits. Any Use of resi i8l DI-ODC11V for nrofit, such ., a venue fr w�dd n Mor oth I cYclits is Prohibited. This `c;ation is deemed gpmoletee all t in iren ar-e fitted_tQAhe To ffn Qrk. Please judicatesubn i n of"th win. loin lae znd bg A completed application form signed by the owner and the event manager. Applications without Froperty owner's signature/approval will be rejected. EE: Is the application being g submitted at least 60 days before the event[. Yes [ ] No If Yes,Fee of$ 5o has been submitted 11 If No,Fee of$ has been submitted Updated 8/7/2018 IVThe applicant/owner of the property where the special event is proposed to take place must provide a certiflegag: f in r :, not less than 2 million dollars naming the o eiS Lth l as an a �tional insure E�rTarlCtn61/Evt nt Pan: consisting of a survey, site plan and/or aerial view of the subject property that includes the locations of on-site parking, sanitary facilities, and tents or other temporary structure(s). (See application form for details) 11 Events for three hundred (300) or more people require submission and approval of a trafficDrai;rl plan acceptable acceptable to the Town of Southold AND a qualified traffic controller must be provided at the event. (See application form for details) Signature of Property Owner on the application authorizing Code Enforcement Personnel of the Town of Southold to enter the subject premises during the hours of the event to ensure compliance with any and all special event permit conditions. My signature below affirms that I have submitted all the information required above in connection with my application. ® ► /� Dated Signature Activities associated with outdoor public events are strictly prohibited from taking place on land preserved through the sale of development rights to the Town of Southold, and can only take place on land preserved through the sale of development rights to the County of Suffolk with a permit issued by the Suffolk County Farmland Committee. If food is to be served, it must be catered and prepared off-site by food vendors who hold a permit to operate issued by the Suffolk County Bureau of Public Health Food Protection Unit Updated 8/7/2018 RECEIVED 1AAB - 1 2019 Southold Town C r APPLICATION FOR A PERMITT L A SPECIAL EVENT Please provide ALL of We information requested below. Incomplete applications WILL NOT he reviewed Special Event Permit#._ Applicant(s)name: Dateof Submission of Event G ' _ SCT #'s 1000-Section Block- Lot(s) Dates of Each Event: 1 If Multiple Dates are requested, applicant must give all information for all dates, Nature of Event: IT (Please attach a detailed description of EACH event to this application) Time Period(Hours)of Event: From to Town Services requested: ( )Yes ( No If yes,Describe Police Dept. Highway Dept. Describe Services .. -'.�" CAB LC Maximum Number of Persons Attending At One Time. Number of cars expected Is a Tent or other teniporalt st�r1:1 tr.�.e being,used'? ��] Yes [�]No Ijyes )vides e(s) kao/ 15 IV Will food be served?[V/]Yes [ ]No It ycs provide nttsnber and nanie(s)of food vendor(s)k� ---r Updated 8/7/2018 �'�.' isi ,-P 1)C rr- 3 Y LC I C.._ Suffolk County permit#(s;)_ Will oilier vendo' se�on the pmiseS dulirg the event? [ Yes [ ]No If yes how many?��S Describe Type of vendor(s) _ . Property Owner(name/address): Contact Person and Contact Tel# _ � . . .e-mail address qq l l k Event Location: Street-Hamlet Address: Mailing Address to Send Event Permit to: Pec o n c- LAN'D TRV% C/ ! . P C-COVW C, solq !!;el. .. l have any of the development rights been sold t the Town of Southold [Yes [ ]NoITand/or Suffolk 'ottnty Agricultural Program? [ ] Yi [' o If�c.rtltet or l)ot11„also indicate on the attached plan (he .oun . r eofthereserved axq upon which the °versa will take l� ace.. APrACW�0 MA-PS Y U M.UST ATTACH A PARKING/EVPL1 A,1. EXPECTED ATTENDANCE TS t1t1(11T M4C1° E PELT T ! AT"I"Al ti1I A TRAFFIC ar may be a survey. site lan and/or aerial v" (for example "oop-le Earth) of the subiet.t rnpert . INDICATE QN TETE PLAN ALL of the,following infor mt Oopnm.. A parking/event plan showing: (1) The size of the property and its location in relation to abutting streets or highways. (2) The size and location of any existing building(s)or structure(s)that will be in operation during the course of the event and any proposed building, structure,or signs to be erected temporarily for the event. (3) The location of the stage or tents,if any. (4) The designated areas of use for spectators, exhibitors,vendors, employees and organizers. (5) Location of all entries and exits. (6) The location of all fire extinguishers and other fire safety equipment. (7) The location of all temporary utilities to be installed for the event,if any. (8) The layout of any parking area for automobiles and other vehicles and the means of ingress and egress for such parking areas. The parking spaces must allow for 300 sq.ft. per car. (9) A traffic control plan for vehicles entering and leaving the site for the proposed event. (10) Plan for the use of live outdoor music,loudspeakers and other sounds which will be used, if any,and the type and location of speakers and other audio equipment. (11) A description of emergency access and facilities related to the event. (12) Provisions to dispose of any garbage,trash,rubbish or other refuse. (13) Location and description of any additional lighting to be utilized in conjunction with the event. Updated 8/7/2018 (14) Location of sanitary facilities on site. rattic Cent rol Plan Events for three hundred(300)or more people also require submission and approval of a traffic control plan,acceptable to the Town of Southold,AND ., _.-Mliflied.traffic controllerrll,Ust be'.[Mided. Please attached a written description and/or notate on the parking event plan the following: 1)Who will be conducting traffic,2)Where they will be stationed on site,3)How they will direct the entrance, circulation,parking,and exiting of cars on site, and 4)Contact information for use by Southold Town Police. I am the Owner of the Property where this event is to be held and I agree to comply with the laws, rules, regulations, conditions, and requirements of the Code of the Town of Southold,including but not limited to the conditions listed below, as well as all other applicable agency rules and regulations pertaining to the activities under this event. Furthermore,I hereby swear or affirm that the information contained herein and attachments hereto are true and correct to the best of my knowledge, and agree to provide notice to the Town immediately should there be any material changes regarding to this application. . Furthermore,I hereby authorize Code Enforcement Personnel of the Town of Southold to enter the property during the hours of the permitted special event to make any and all inspections necessary in connection with this Special Event. Print name of Owner Signature of Owner 0 Print name of Authorized Person/Representative Signature hod'Author i7c-d"per soii/Repiesentative PERMI; 15 HE " ;1 ANTTED, LL8j_1�4 T"1"O'I HE I+OLLOW G—CO I'l ITIQN : 1. By acceptance of this permit, applicant agrees to adequately supervise and direct all parking to be on the premises or at anothcr site, and to provide parking assistants and any additional traffic controls necessary for this event. Parking is strictly tt i.,,°1 ars ANS' Tower f;°l t "t' Roads r j htso Way. 2. Traffic control at events for three hundred(300)or more people shall be provided by a qualified traffic controller in accordance with the attached, approved traffic control plan. 3. One "on-premises" sign not larger than six (6) square feet in size may be displayed not longer than thirty (30) days before this event, and removed immediately after the event. Directional parking signs shall be adequately displayed. 4. Applicant indemnifies and holds harmless the Town of Southold from all claims, damages, expenses, suits and losses including but not limited to attorney's fees arising from activities under this permit. 5. Tent proposals must receive permit approval from the Southold Town Building Inspector before placement on the property and must meet all fire and safety codes. 6. This permit is valid only for the time, date, place and use specified above, and for the designated event. Each additional day will require a separate permit application, fee, and related documents for review, etc. at least 60 business days prior to the scheduled event. 7. Adequate temporary sanitary facilities must be provided by applicant for this event and applicant agrees to remove the temporary facilities from the premises within 48 hours after the day of the event. Updated 8/7/2018 Town of Southold Special Event Permit Description of Event: Peconinic is a celebratory picnic to honor Trust supporters. Attendees are invited to experience the land that has been protected through our collective conservation work, and are also invited to participate in educational programming. Supporters from both the north and south forks are invited every year, including our partners at the Town of Southold, to enjoy delicious lunch selections, good music, and informative programming designed to educate and connect guests to our conservation work and rich agricultural and maritime history. PE, CONIC LAND TRUST Emergency and Security Plan Attachment#11 Title of Event:Peconinic 2019 Date(s) of Event:June 1, 2019 Event Description:A thank you picnic for our supporters. Location: The Agricultural Center at Charnews Farm, Southold, NY On scene person in charge of event: Name:Yvette DeBow-Salsedo,Vice—President, phone: 646.284.8028 Bridget Micieh-Martinez, Event&Design Coordinator,phone: 631.312.6224 Email Address:YDebowPecoiiicl,aridTruA.=/ 13lai itiez@�l'e c.�.brnr�.l, { u ar Medical Emergencies Procedure All medical emergencies will be reported to Police, EMS or event personnel as soon as possible either in person or via phone. Event personnel, when notified, will call directly to 911 and report the incident/problem. Responding emergency vehicles will be granted access to the site through 3005 Youngs Avenue Southold, NY, or depending on the location of the emergency, or a location determined by Police or EMS.The onsite person in charge or event coordinator will make sure an area is open to allow emergency personnel,vehicles and equipment to access the event grounds whenever emergency assistance is needed and this access shall be maintained throughout the event. The nearest hospital for receiving patients is Eastern Long Island Hospital which is located at 201 Manor Place, Greenport. Police Emergencies For all police emergencies 911 will be called immediately. All Emergency vehicles will be granted access to the site through 3005 Youngs Avenue, Southold NY. Police enforcement will be provided by the Southold Police Department. Fire Emergencies For all fire emergencies, 911 will be called. All Emergency vehicles will be granted access to the site through 3005 Youngs Avenue, Southold, NY. Onsite personnel will assist with evacuation to the parking field located to the north west area from the event site or if this area is unsuitable to an area designated by the fire personnel or police.Vehicles should not be moved during an emergency response. It is recognized that exiting traffic would inhibit and/or place arriving emergency responders and exiting individuals in peril. Portable fire extinguishers are located in each tent. Additional Firefighting equipment in the nature of water hookup is located on event site next to the dining tent. Lost Child Procedure: Police and onsite event personnel will be notified. In the event a lost child is found he/she should remain at the location he/she is found at unless the location is unsafe or impractical or until it is determined that it is impractical to remain at the location.The child, if able, will be asked to provide parent/guardian information. Audio equipment is available onsite and an announcement of the situation may be made at the decision of on scene police personnel. The child will remain under the supervision of police personnel or their designee (Peconic Land Trust Staff Member Kathy Kennedy) who will ensure the child is comfortable and safe until his/her parent/guardian arrives. Parental identification shall be verified prior to release of the child. Weather Emergency: In the event of any weather emergency the police, event coordinator or onsite event personnel may decide to halt the event for the safety of participants and the public.At no time will the decision to halt an event due to a weather related event by the police be overridden by others. Coordination for the safety of participants and spectators will be accomplished by the event coordinator utilizing PA system, all volunteers and Peconic Land Trust Staff to inform attendees of situations and of next steps. During the entire evacuation/relocation process the local Southampton Police department will be apprised of its progress and status. If and when the weather emergency has passed, a decision will be made by police personnel and the event coordinator as when to allow the event to resume. Communication Plan: All onsite event personnel, event coordinator, EMS, fire and police personnel must have a means of communication during the event. This will be accomplished by cell phone communication and face to face. Personnel Vice President-Yvette Debow 646-284-8028 Event Coordinator: Bridget Micieli-Martinez,631-312-6224 Volunteer Coordinator: Kathy Kennedy 631-278-6183 Emergency Numbers: Police Emergency 911 Town of Southold Police Department 631-765-2600 Southold Fire Department 631-765-3385 Southold Ambulance 631-324-4477 Eastern Long Island Hospital 631-477-1000 OSHA 631-334-3344 New York State Police 631-728-3000 Poison Control 800-222-1221 Plan for Disposal of Garbage, Trash, Rubbish and Sanitary Waste and Sewage: Attachment#12 At the event site there will be a dumpster from Emile Norsic and Sons which will be in place during the day of set-up, 05/31/19) through the day of clean-up. On the day of clean-up (06/03//19) the dumpster will be removed. There will be trash/rubbish bins available for general waste in the main and distribution tent and both bar tents. All trash/rubbish bins will be emptied into the dumpster. At the event site there will be a three single unit restroom facilities with and one handicapped single unit restroom facility provided by Island Portables. An outdoor sink with handwashing capabilities will be set up near the event site. a _ F o v _ w. F tt 1� 1 - TA 51, US � ,mow g _ AN 3 c Peconic Land Trust 296 Hampton Road/PO Box 1776 The Agricultural Center - Charnews Event SCTM#: p/o 1000-63-1-25.4 631-283-3195 Preparedby:J Town of Southold NY Prepared by:Jessie Marcus;2019 Feb 26 . Parkin www.PeconicLandTru s t,org Source Es-::i,DigitalGlobe,Gco Eye,Earthstar Geographies,CNES/Airbus DS,USDA,USGS,AeroGRID,IGN,and the GIS User Community,Suffolk County Real Property Tax Service Agency WL ,ell W E Restricted Area Dumpster 9-Generator Speaker Stage Speaker 20'X 40' Kit erl 40x80 Dining Tent Regi atie 16'X 16' 16'X 16` e Extinguls s 20'x20' Raffle 1P r g Barn Ouse he Restroo iEC N C AND TRLSa Agricultural Center at Charnews Farm , v , K -� - 3005 Youngs Avenue I Southold,NY 1 11971 Peconlnic 2019 Event Site Diagram _' . Town of Southold June 1st,2019 ACC W" TE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE DA01/17/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT. If the certificate holder Is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement($). PRODUCER COONTACT.. Carol LOSquadro Roy H Reeve Agency, Inc. PHONE (631)298-4700 FAX (631)298-3850 (AIC.No.Ext% TA+C,Nn,y,„ PO Box 54 E-MAIL ADDRESS* closquadro@royreeve.com 13400 Main Road INSURER{S AFFORDING COVERAGE 'NAIC It Mattituck NY 11952 INSURERAI Federal Ins Cc 20281 _. .......... -....... INSURED INSURERB: - ...... ..... �� .............. Peconic Land Trust Inc ...� suRER c _- ._ _.... ......._ .- PO BOX 1776 wINSURER D: INSURER E Southampton NY 11969 INSURER F„ COVERAGES CERTIFICATE NUMBER: CL1911709715 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. .- ImNSR POLICY EFF POLICY EXP ILTR TYPE OF INSURANCE SOA n. - I POLICY NUMBER LIMITS �.. MMIDDIYYYY MM1D, ---- X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 CLAIMS-MADE NOCCUR bAMAGE TU'P iVTED 1,000,000 PREMI - SES(Ea occurrence) s MED EXP LAn oneperson) y 10,000 A Y 35816018 02/27/2019 02/27/2020 PERSONAL&ADV INJURY $ 2.000,000 GENLAGGREGA;TE LIMIT APPLIES PER: GENERAL.AGGREGATE s 2.000,000 POLICY E PRO JECT LOC PRODUCTS-COMP/OPAGG s 2,000000 OTB BEP Employee Benefits $ 1,000,000 AUTOMOBILE LIABILITY t,faMBIrRED;alNt"sL.E.I.RPwpIT s '' w,/Ea acr,{di:.rtiCl ANYAUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ _._.. HIRED NON-OWNED 15ROHERfN:AF."� �MAGE.... _. AUTOS ONLY AUTOS ONLY h $ ­— H I. — ­­...........$ X UMBRELLA LIAB JX�[OCCUR EACH OCCURRENCE s 5,000,000 A EXCESS LIAB MS-MADE 93647953 02/27/2019 02/27/2020 AGGREGATE 5 5,000,000 DED RErER1"R"ICN 10,000 5 _. _..... ...... WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN STATUTE � Rd ANY PROPRIETOR/PARTNER/EXECUTIVE CH s OFFICER/MEMBER EXCLUDED? � '...N I A t L.EA.. ACCIDENT _•••••,,,,,,•-•••••.--••,..��, (Mandatory In NH) E..L DISEASE-EA EMPLOYEE $ If yes,describe under �....- DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT s - .....m... ..... . LE _ ......_.... DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICS (ACORD 101,Additional Remarks Schedule,may be attached Ir more space Is required) Peconinic June 1 2019 Certificate holder is named as additional insured by written contract policy form 80-02-2000 CERTIFICATE MOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town Of Southold ACCORDANCE WITH THE POLICY PROVISIONS. Town Clerk's Office 53095 Route 25 PO Box 1179 AUTHORIZED REPRESENTATIVE Southold NY 11971 1 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD ADDITIONAL COVERAGES Ref# Description Coverage Code Form No. Edition Date Liquor Liability LIQUR Limit 1 Limit 2 it 3 Deductible Amount Deductible Type Premium 2,000,000 ...... Ref# Description Coverage Code Form No. Edition Date ........ ..... ... _. Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref# Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref# Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref# Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium .............. Ref# Description Coverage Code Form No. Edition Date Limit 1 TLimit 2 Limit 3 Deductible Amount Deductible Type Premium ................._..........._.._ ........ ._ _................ Ref# Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref# Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref# Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium =# Description Coverage Code Form No. Edition Date ... Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref# Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium OFADTLCV Copyright 2001,AMS Services,Inc. EC NIC LAND TRUST . ...................... ......- a--- ""-" - Bridget Q. Micieli-Martinez Events&Design Coordinator 296 HAMPTON ROAD I P.O.BOX 1776 1 SOUTHAMPTON,NY 11969 TEL:631.283.3195 EXT:13 1 CELL:631.312.6224 BMartinez@PecordcLandTrust.org I www.PeconicLandTrust.org Town of Southold P.O Box 1179 Southold, NY 11971 * * * RECEIPT * * * Date: 03/01/19 Receipt#: 251833 Quantity Transactions Reference Subtotal 1 Event Fee 4 $150.00 Total Paid: $150.00 Notes: Payment Type Amount Paid By CK#36634 $150.00 Peconic, Land Trust Southold Town Clerk's Office 53095 Main Road, PO Box 1179 Southold, NY 11971 Name: Peconic, Land Trust P. O. Box 1776 Southampton, NY 11969 Clerk ID: SABRINA Internal ID:4