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HomeMy WebLinkAboutL I Antique Power - Tractor Ride iVendor No. ; Check No. Town of Southold, New York - Payment Voucher Vendor Name Vendor Address Entered by L I Antique Power Assoc. PO Box 1134 Audit Date Vendor Telephone Number Riverhead, NY 11901 631-88-7378 Town Clerk Stephen Barker Invoice Invoice Invoice Net Purchase Order Number Date Total Discount Amount Claimed Number Description of Goods or Services General Ledger Fund and Account Number 2020-431 7/2/2020 250.00 I 250.00 2020 Charity Tractor T1.030 i Ride i I I i Total 250.00 Payee Certification Department Certification The undersigned(Claimant)(Acting on behalf of the above named claimant) I hereby certify that the materials above specified have been received by me does hereby certify that the foregoing claim is true and correct,that no part has in good condition without substitution,the services properly been paid,except as therein stated,that the balance therein stated is actually performed and that the quantities thereof have been verified with the exceptions due and owing,and that taxes from which the Town is exempt are excluded. or discrepancies noted,and pay me tis approved 1 Signatu V Title fes+ Signature 1 Company Name Date 7 ' 2 2, ' ZD Title Date "� Town of Southold P.O Box 1179 Southold, NY 11971 (631) 765-1800 RECEIPT #4126/2020 07/11/2020 L I, Antique Power Assoc. P O Box 1134 Riverhead, NY 11901 Received $ 250.00 for Event Fee, on 02/14/2020. Thank you for stopping by the Treasurer's Office. As always, it is our pleasure to serve you. Elizabeth A. Neville Southold Town Clerk Southold Town Board - Letter Board Meeting of July 14, 2020 RESOLUTION 2020-431 Item# 5.18 3 ° ADOPTED DOC ID: 16285 THIS IS TO CERTIFY THAT THE FOLLOWING RESOLUTION NO. 2020-431 WAS ADOPTED AT THE REGULAR MEETING OF THE SOUTHOLD TOWN BOARD ON JULY 14, 2020: WHEREAS the following groups have supplied.the Town of Southold with a refundable Clean- up Deposit fee, for their events and WHEREAS the Southold Town Police Chief, Martin Flatley, has informed the Town Clerk's office that this fee may be refunded, now therefor be it RESOLVED that Town Board of the Town of Southold hereby authorizes a refund be issued in the amount of the deposit made to the following Name Date Received Amount of Deposit EventPower 1111119 $1,500.00 162 Long Island Avenue, #179 Holtsville,NY 11742 Mattituck Lions Club 1/31/20 250.00 PO Box 91 Mattituck,NY 11952 Mattituck American Legion Post 861 2/7/20 250.00 PO Box 861 Mattituck, NY 11952 Bicycle Shows USA 3/3/20 1,500.00 230 Smith Hughes Road Narrowburg, NY 12764 Southold Village Merchants 3/12/20 250.00 PO Box 1356 Southold,NY 11971 L I Antique Power Assdc. 2/14/20 250.00 PO Box 1134 Riverhead, NY 11901 Generated July 17, 2020 Page 29 ILI ELIZABETH A.NEVILLE,MMC Ste' '' `p` Town Hall,53095 Main Road TOWN CLERK P.O.Box 1179 Southold,New York 11971 REGISTRAR OF VITAL STATISTICS Fax(631)765-6145 ° "^�' Telephone 631 765-1800 MARRIAGE OFFICER ,�.,�., , , ,°:- *�., p ( ) RECORDS MANAGEMENT OFFICER ? *"" www.southoldtownny.gov FREEDOM OF INFORMATION OFFICER OFFICE OF THE TOWN CLERK RECEIVED TOWN OF SOUTHOLD FEB 1 4 2020 APPLICATION FOR A PERMIT TO HOLD A Southold Town Clerk SPECIAL EVENT S Please provide ALL of the information requested below,Incomplete applications WILL NOT be reviewed. Date of Submission d I Name of Event LO. -�`G A ti v e— C- Name of Organization: Is this a Not-For-Profit Event? o Contact's Name: �or�vJle �1��, Gc� 11999 Mailing Address: _ y Contact's Phone Number: �j O V � / 9 �4 ® Contact's Email Address: �� o ion Event Location and Site Diagram: - .- o A L CA (Use additional paper if necessary) Event Date(s): >t�' l` (Include Aset u and shutdown trmes and dates) ` Nature of Event: n -v�� C'' °��app (Please attach a detailed description to tion) 0 1 Time Period (Hours) of Event: From 19 �^ to CX A% Maximum Number of Expected Attendees: S O h ` t'� n �j ► Specify any special requirements(i.e. road closure, police presence): 0\� Revised 8/5/15 If a Tent or other temporary structure will be used please contact the Southold Town Building Department at 631-765-180261 �r Mailing Address to Send Event Permit to: �j C.V\��V (rev Voll, LAJ Event Fees: Elp' W Itk ; $250 for events with less than 1000 expected attendees $500 for events with 1000 or more expected attendees Clean-up Fees (Can NOT be waived): $1,500.00 Clean-up for Bicycle and/or Running Special events (ONLY) _$250 or more Clean-up deposit all other events CEI$tIFIGATE.()F-1NSURANCE'RE()UIRED: Not less than$2,000,000 naming the Town of Southold-as an additional insured, ***NOTE:. PLEASE-St tATTACHED REVISED ADOPTED TOWN POLICk ' a Additional information and requirements may be required as deemed necessary by the Town Board. Print n e of Authorized Person filling out Signat of Authorized erson filling out application application *Upon the request by applicant,the Town Board may waive in whole or in part any of the application requirements. 2 Revised 3/21/16 Seco oRL> CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) ' 02/11/2020 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(s). PRODUCER CONTACT AME: Eric Kirk N Farm Family Casualty Insurance Company a/c°NE No.Ext 631-727-7767 AA/� No):631-727-7941 18 First Street ADDRESS, karla.ayala@american-national.com Riverhead, NY 11901 INSURERS AFFORDING COVERAGE NAIC# INSURERA. Farm Family Casualty Insurance Company 13803 INSURED INSURER B: Long Island Antique Power Assoc. INSURER C: PO Box 1134 INSURER D INSURER E Riverhead NY 11901 INSURER F COVERAGES CERTIFICATE NUMBER: 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 CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE 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 INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LTR D POLICYNUMBER MM/DD/YYYY MM/DD/YYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X 3101X1843 12/22/201912/22/2020 FX OCCUR DAMAGE TO RENTED PREMISES Ea occurrence $ CLAIMS-MADE 100,000 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERALAGGREGATE $ 2,000,000 X PRO ❑ LOC PRODUCTS-COMP/OPAGG $ 2,000,000 POLICY 1:1JECT OTHER $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTYDAMAGE AUTOS ONLY AUTOS ONLY Per accident $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ r—rDED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE E L EACH ACCIDENT $ OFFICER/MEMBEREXCLUDED9 ❑ N/A (Mandatory in NH) E L DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Certificate holder is listed as additionally insured. CERTIFICATE HOLDER CANCELLATION Town of Southold SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 53095 Route 25 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 1179 Southold, NY 11971 AUTHORIZED REPRESENTATIVE Kirk Associates LTD ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD boroski, Bonnie From: Duffy, Bill Sent: Thursday, February 20, 2020 9:45 AM To: Doroski, Bonnie - Subject: RE: Emailing: spec evnt-tractor ride_20200218092957 No objection William M. Duffy, Esq,. Town Attorney Town of Southold Southold Town Annex 54375 Route 25 (Main Road) P.O. Box 1179 Southold, New York 11971-0959 Office: 631.765-1939 Fax: 631.765.6639 Email: billd@southoldtownny.gov -----Original Message----- From: Doroski, Bonnie <Bonnie.Doroski town.southold.ny.us> Sent:Tuesday, February 18, 2020 9:39 AM To: Blasko, Regina <rblasko@town.southold.nv.us>; Burke,John<iohnbu@southoldtownny.gov>; Doroski, Melanie <Melanie.Doroski@town.southold.nv.us>; Duffy, Bill <billd@southoldtownnv.gov>; Fisher, Robert <Robert.Fisher town.southold.nv.us>; Flatley, Martin<mflatlev town.southold.nv.us>; Hagan, Damon <damonh@southoldtownnv.gov>; Kruszeski, Frank<fkruszeski@town.south old.nv.us>; Norklun, Stacey <Stacey.Norklun@town.southold.nv.us>; Silleck,'Mary<marvs@town.southold.nv.us>; Spiro, Melissa <Melissa.Spiro@town.southold.ny.us> Subject: Emailing: spec evnt-tractor ride_20200218092957 Please review and send any comments/concerns to this office re: the attached application received from LI Antique Power re:their annual tractor ride. Thankyou, Your message is ready to be sent with the following file or link attachments: spec evnt-tractor ride_20200218092957 Note:To protect against computer viruses, e-mail programs may prevent sending or receiving certain types of file attachments. Check your e-mail security settings to determine how attachments are handled. 1 Town of Southold Police Department Special Event Cost Analysis Event: Annual Ride For A Cause (Tractor Ride) F Date(s): April 26, 2020 1 1 Location: Mattituck-Cutchogue P to rol:Allocaton'-forEvenf , Reg Hours-'r6T--H rs Hrly Wage W "Total Comments RegHours10"T'4ris lHrlyWage Total Comments ".tr I U Highway-Patrol, _ -06 Onufrak 4 $284.40 -7" T�afficControlw JReg Hours -"6t-Hrs Hrly Wage Total comments TC Officer TC Officer TC Officer TC Officer TC Officer 77 7 131)Vehicles 4 of Tehicles $/h r Total 1 $10.00 $50.00 $150.00 Command Van Marine Patrol Boats I Total Department Cost for Event = $434.40_ Prepared by Chief M. Flatley 2/20/2020 Page 1 Doroski, Bonnie From: Flatley, Martin Sent: Tuesday, February 18, 2020 12:19 PM To: Doroski, Bonnie; Blasko, Regina; Burke,John; Doroski, Melanie; Duffy, Bill; Fisher, Robert; Hagan, Damon; Kruszeski, Frank; Norklun, Stacey; Silleck, Mary; Spiro, Melissa Subject: RE: Emailing:spec evnt-tractor ride_20200218092957 Attachments: Tractor Ride.xls I have no objections to this event being approved as in the past. My cost analysis is attached Martin Flatley, Chief of Police Town of Southold Police Department 41405 State Route 25 Peconic, N.Y. 11958 Tel: 631-765-3115 -----Original Message----- From: Doroski, Bonnie<Bonnie.Doroski town.southold.ny.us> Sent: Tuesday, February 18, 2020 9:39 AM To: Blasko, Regina <rblasko@town.southold.nv.us>; Burke,John <iohnbu@southoldtownny.gov>; Doroski, Melanie <Melanie.Doroski town.southold.nv.us>; Duffy, Bill<billd@southoldtownnv.gov_>; Fisher, Robert <Robert.Fisher@town.southold.nv.us>; Flatley, Martin<mflatley@town.southold.ny.us>; Hagan, Damon <damonh@southoldtownnv.gov>; Kruszeski, Frank<fkruszeski@town.southold.nv.us>; Norklun, Stacey <Stacey.Norklun@town.southold.nv.us>; Silleck, Mary<marvs@town.southold.nv.us>; Spiro, Melissa <Melissa.Spiro@town.southold.ny.us> Subject: Emailing: spec evnt-tractor ride_20200218092957 Please review and send any comments/concerns to this office re: the attached application received from LI Antique Power re: their annual tractor ride. Thank you Your message is ready to be sent with the following file or link attachments: spec evnt-tractor ride_20200218092957 Note:To protect against computer viruses, e-mail programs may prevent sending or receiving certain types of file attachments. Check your e-mail security settings to determine how attachments are handled. i r 'Doroski, Bonnie From: Doroski, B nnie Sent: Tuesday, F bruary 18, 2020 9:39 AM To: Blasko, Regina; Burke,John; Doroski, Melanie; Duffy, Bill; Fisher, Robert; Flatley, Martin; Hagan, Da on; Kruszeski, Frank; Norklun, Stacey; Silleck, Mary, Spiro, Melissa Subject: Emailing: s ec evnt-tractor ride_20200218092957 Attachments: spec evnt-t actor ride_20200218092957.pdf Please review and send any comments/conc rns to this office re: the attached application received from LI Antique Power re:their annual tractor ride. Thank you Your message is ready to be sent with the foll wing file or link attachments: spec evnt-tractor ride_20200218092957 Note:To protect against computer viruses, e- ail programs may prevent sending or receiving certain types of file attachments. Check your e-mail security setti gs to determine how attachments are handled. 1 �A lob 7 U,)() Route Specifics: Leaving LIAPA Barn ga px� SS,v Left onto Sound Avenue to Route 48 b; Left onto ane I Left onto Oregon Road Left onto,E*jah Lane Right onto Route 48 Return to LIAPA Barn � y 1 � f O11 iI V J ELIZABETH A.NEVILLE,MMC aZ. r/$ Town Hall,53095 Main Road - TOWN CLERK ® P.O.Box 1179 Cdo Southold,New York 11971 REGISTRAR OF VITAL STATISTICS p ® Fax(631)765'-6145 MARRIAGE OFFICER �'� ®�` Telephone(631)765-1800 RECORDS MANAGEMENT OFFICER FREEDOM OF INFORMATION OFFICER www.southoldtownny.gov OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD February 27, 2020 Stephen Barker LI Antique Power Association 51 Evelyn Court Manorville,NY 11949 Dear Mr. Barker, - The Southold Town Board, at its regular meeting held February 25, 2020, granted permission to The Long Island Antique Power Association to hold its Long Island Antique Power Charity ' Tractor Ride on April 26, 2020. A certified copy of the resolution is enclosed, along with the Town of Southold Policy for Special Events on Town Properties and Roads. Failure to heed the policy may result in toss of the clean-up 'deposit. An insurance policy naming the Town of Southold as additionally insured has been filed with this office. Please contact Captain Kruszeski at the Southold Town Police Department as soon as possible, to coordinate traffic control. If you have any further questions,please do not hesitate to contact the Town Clerk's office at (631) 765-1800. Best of luck with your event. Sincerely, Bonnie J. Doroski Deputy Town Clerk Enc. RESOLUTION 2020-192 ADOPTED DOC ID: 16054 y THIS IS TO CERTIFY THAT THE FOLLOWING RESOLUTION NO. 2020-192 WAS ADOPTED AT THE REGULAR MEETING OF THE SOUTHOLD TOWN BOARD ON FEBRUARY 25, 2020: RESOLVED that the Town Board of the Town of Southold hereby grants permission to LI Antique Power Association to hold a Charity Tractor Ride on April 26, 2020,traveling on Sound Avenue to Route 48, left onto Cox Lane, left onto Oregon Road, left onto Grand Avenue to Wickham Avenue, right onto Route 48 provided they adhere to the Town of Southold Policy for Special Events on Town Properties and Roads. All Town fees for this event, with the exception of the Clean-up Deposit, are waived. Elizabeth A. Neville Southold Town Clerk RESULT: ADOPTED [UNANIMOUS] MOVER: James Dinizio Jr, Councilman SECONDER:Louisa P. Evans, Justice AYES: Nappa, Dinizio Jr, Doherty, Ghosio, Evans ABSENT: Scott A. Russell 1 ELIZABETH A.NEVILLE,MMC �;I �� , " Town Hall,53095 Main Road TOWN CLERK P,O.Box 1179 Southold,New York 11971 REGISTRAR OF VITAL STATISTICS ;� Fax(631)765-6145 MARRIAGE OFFICER �4b �,� �� Telephone(631)765-1800 °` ti ) .,pd www.southoldtownny.gov �� RECORDS MANAGEMENT OFFICER �� � t�° ��' FREEDOM OF INFORMATION OFFICER OFFICE OF THE TOWN CLERK RECEIVED TOWN OF SOUTHOLD FH APPLICATION FOR A PERMIT TO HOLD A Southold raw�j Cr SPECIAL EVENT Please a� aviule, ,lyN. t��f�1�cinforrnsatirt t°�t t�ettl laciaaw, lNaattrr hate tll°ud�iraabsIYC. 1C "I ltt. (� vievtiped. Date of Submission - mm.....� Name of Event P0 Name of Organization: Is this allot-For-Profit Event? o..,.� �...�_—... Contact's Name. :. . . Mailing Address: ti�,.... � . .. I ' l' .... .. �.._. Contact's Phone Number: � m Contact's Email Address: (' � c�" ) a a Location and Site Diagram: '"°' Event Lo (Use additional paper if necessary) °..._..._.._..� _. .... _ _.w . ....._ ..... d ��_�..m..�.W...��... .. Event Date(s): (Include set a and shutdown times and dates) Nature of Event: V044 Please attach a detailed description escription to this appy ,ation) Time Period (Hours) of Event: From _n % ...to Maximum Number of Expected Attendees: Specify any special requirements(i.e. road closure, police presence): a � ' ...,� ... ....en._..... e�,.._ Revised 8/5/15 If a Tent or other temporary structure will be used please contact the Southold Town Building Department at 631-765-1802 �1 Mailing Address to Send Event Permit to: _ _ '' ,- Event Fees: $250 for events with less than 1.000 expected attendees - - $500 for events with 1000 or more expected attendees Clean-up Fees (Can NOT be waived): $1,500.00 Clean-up for Bicycle and/or Running Special events(ONLY) __$250 or more Clean-up deposit all other events t4 RTII l�Tld� t11 11,i11wf"1; 1 l 41,1'11t1A;1.1: Not less than$2,000,000 naming the Town of So��tloicl as an additioiaN insured. ***N T ® I ASE E C-H REVISED ADOPTEDTOWN LICY*** Additional information and requirements may be required as deemed necessary by the Town Board. .w Print nc of Au: �r haeed Person filling out Sig c'1Authorized czs�a filling out application application *Upon the request by applicant,the Town Board may waive in whole or in part any of the application requirements, 2 Revised 3/21/16 DATE(MMIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 02/11/2020 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(s). PRODUCER CONTACT Eric Kirk _ r..„ ,Farm Family Casualty Insurance Company PHONE 631-727-7767 AiC®N q) 631-727-79 41 — .MAIL 18 First Street ADDRESS karia.ayala@american-national.com ala american-nation�Icom ..... _..... ... ......... Riverhead, NY 11901 INSURER(S)AFFORDINGCOVERAGE NAIC# INSURER„A! Farm Family Casualty Insurance Company „13803 INSURED INSURER B Long Island Antique Power Assoc. INSURERC. PO Box 1134 ..., ........ INSURER.,� .,,, ,,,,. ,,,,. ------........ ---- ..._..---- --....__ INSURER E Riverhead NY 11901 INSURER F. COVERAGES CERTIFICATE NUMBER: 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 CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE 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. — ......... LTR ..........._. .__............. YLT R TYPE OF INSURANCE A DL�SUBR, POLICY EFF POLICY EXP D - ) V POLICY NUMBER MMIDD/YYYY M/DD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE- $ 1,000,000 A _......... X 3101X1843 12/22/2019”12/22/2020 hAMAOE Tu REN TED— — 100,000 L. .' CLAIMS-MADE �X OCCUR1 MED IXPAnaonepreson) ..$ ...... .. ,.._5,000 ... „ -..... y person)) $ PERSONAL 8 ADV INJURY $ 1,000,000 XNLAGGREGATEPLIMITAPPLIES �Ee _ 11 -CC- R: GENERAL $ 2,000,000 POLICY JEGT PRODUCTS-COMP/OP AGG $ 2,000 000 ..... ..... OTHER: I (OMBIEO 71NGLE LI.PodT AUTOMOBILE LIABILITY $Iru . .. .... ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS _,.. HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY $ I I UMBRELLA LIAB I I FACH OCCURRENCE $ OCCUR m _ EXCESS LIABPoGOREGATE $ CLAIMS-MADE DED RETENTION$ ) $ - WORKERSCOMPENSATION ". PEROTH AND EMPLOYERS'LIABILITY 7 STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE Y/ � NIA E L EACH ACCIDENT $OFFICER/MEMBEREXCLUDED? " (Mandatory in NH) +.. E L DISEASE EA EMPLOYEE.$ If yes,describe under m DESCRIPTION OF OPERATIONS belowE L.DISEASE POLICY LIMIT $ .,........... �,.......�....... _ __.._.. ... .—�—�.,. DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Certificate holder is listed as additionally insured. CERTIFICATE HOLDER CANCELLATION Town of Southold SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE 53095 Route 25 ACCORDANCEION W THDATE THEREOF,THE POLICY PROVISIONS.NOTICE WILL BE DELIVERED IN PO Box 1179 Southold, NY 11971 AUTHORIZED REPRESENTATIVE I Kirk Associates LTD ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD