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HomeMy WebLinkAbout5K Run - Good day for a Run @ Pindar Vineyards C VE JUL 2 3 2020 Southold Town Clerk APPLICATION FOR A PERMIT TO MOLD A SPECIAL EVENT Please provide ALL of the information requested below.Incomplete applications WILL NOT be reviewed. Special Event Permit# Applicant(s)nam k Date of SubmissionV7A) Name of Event SCTM#'s 1000-Section Block- Lots) Dates of Each Event: If Multiple Dates are requested,applicant must give all information for all dates. Nature of Event: 1 (Please'attach a detailed description of EA H event to this application) Time Period(Hours)of Event: From to Town Services requested: ( )Yes (XNo If yes,Describe Police Dept._Highway Dept. Describe Services Maximum Number of Persons Attending At One Time: Number of cars expected Is a Tent or ther 7trarysocture being used? [Na Yes [ ]No If yes provide size(s) P t AO -1 Will food be served? [ ]Yes [ ]No If yes provide number and name(s)of food vendor(s Updated 8/7/2018 L - n If Aa ID b l Suffolk County permit#(s) IT W Will other vendors be on the premises during the event?[\J Yes [ ]No If yes how many? Describe Type of vendor(s) „ /f � < 1 Property Owner(name/address): `�✓ Contact Person and Contact Tel.# 0) IQZ/ < I e-mail address Event Location: Street-Hamlet Address: SCTM# Mailing Address to Send Event Permit to: 09 7 � T12C Have any of the development rights been sold tojhe Town of Southoldy Yes No and/or Suffolk County Agricultural Program? [ ]Yes No If yes to either or both,also indicate on the attached plan the boundaries of the reserved area upon 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 page) A ParkingXvent 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 i ions necessary in ec(t)ion with 's Special Event. Print name of Owner Si ature of Owner Q71 d)O (e7 ri�Wt name of Authorized Perso epresentative ature o u or zed rso epresentative PERMISSION IS BEREBY 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 additional 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. 9. NO activities associated with this event, including but not limited to parking; ingress/egress/access, tents or temporary structure(s�, or tempop nary sanitary facilities, shall be conducted on Town of Southold Purchase of Development Rights land. 10. NO activities associated with this event, including but not limited to parking,_u�gress/egress/access, tent(s) or temporary structure(s), or tempor= sas•nitary facilities; shall be conducted on Suffolk County Purchase of Development Rights land without a permit issued by the Suffolk County Farmland Committee. ti 11. 1s'suance of this permit does not authorize in any manner the occupancy of any building exceeding the legal imitations 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 areas and any additional area where emergencies may occur. Two emergency-fire exits and exit paths from the building(s) on the property, to a public way or remote' safe area,' shall, remain open and unobstructed at all times. 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 Town of Southold during the hours of the special event to make any and all inspections necessary in connection,with this Special Event 16. ADDITIONAL CONDITIONS.- ANY ONDITIONS:ANY VIOLATIONS IN CONNECTION WITH THE CONDITIONS LISTED HEREIN WILL TERMINATE THIS PERMIT. APPROVED Town of Southold Resolution Number: Date Issued: Updated 8/7/2018 , ,Client#: 1650901 PINDAV,IN DATE(MMIDDNYYY) ACORD. CERTIFICATE OF LIABILITY INSURANCE 7/20/2020 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(les)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terns and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer any rights to the certificate holder in lieu of such endorsement(s). PRODUCER NAME T Christine Chipurnoi USI Insurance Services,LLC arc°No Ext,212842-3700 plc No: " 261 Madison Ave E-MAIL ADDRESS: New York,NY 10016 INSURER(S)AFFORDING COVERAGE NAIC# 212 842-3700 lNs'RERA:Great Northern Insurance Company 20303 INSURED' INSURER B:Federal Insurance Company. 20281 Pindar Vineyards LLC INSURER 591 Bicycle Path,Suite A : INSURER D: Port Jefferson Station,NY 11776 INSURER E 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 CONTRACTOR 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 TYPE OF INSURANCE INRL U R POLICY NUMBER MMIDDY�F MMIDDY°`P LIMITS A X COMMERCIAL GENERAL LIABILITY 35931460 0513112020 05/31/2021 EAACHOCTCURRENCE $1,000,000 CLAIMS-MADE �OCCUR - PREMISES EaouErr0ena3 $1,000,000 MED EXP(Any one person) $10,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $2,000,000 POLICY ECOT X LOC PRODUCTS-COMP/OPAGG $2,000,000 OTHER $ B AUTOMOBILE LIABILITY 73560257 5/31/2020 05/31/2021 Ea accid,ntSINGLE LIMIT 1,000,000 X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS $ X AUTOS ONLY 1XI AUTOSNON-OWNED LY PROPERTY AUTOS ONLY B X UMBRELLA LIAB X, OCCUR 79874674 D513112020 05/31/2021 EACH OCCURRENCE $10,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $10,000,000 DED RETENTION$ $ WORKERS COMPENSATION PER OTH-, AND EMPLOYERS'LIABILITY YIN N ANY PROPRIETOR/PARTNERIEXECUTIVE EL EACH ACCIDENT $ OFRCER/MEMBER EXCLUDED? NIA (Mandatory In NH) EL DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT $ A Liquor Liability 35931460 LIO 0513112020 05/31/2021 1,000,000 Occ. 1,000,000 Agg. DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORO 101,Additional Remarks Schedule,may be attached K more space Is required) The certificate holder is included as Additional Insured as required by written contract or agreement. - CERTIFICATE HOLDER CANCELLATION Town Of Southold SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE tiDELIVERED IN 53095 Route 25,PO BOX 1179 ACCORDANCE WITH THE POLICY PROVISIONS. Southold,NY 11971 AUTHORIZED REPRESENTATIVE LIM ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016103) 1 of 1 The ACORD name and logo are registered marks of ACORD #S294137131M29009964 MCI i ,� -� �,��. � 1_ +-,,��. �,,� .\ Z`• 1 �, yam.,,t \". �9"P ' '-, `� Asa„'^ ',• �.�+�` �'� ys����i�,T fit~ � � •� � l ;�- '.S. ! Vineyard's .,�5;� kZ '+y,. '",L .rn 4 `t,'+ `_ „` *�,t .•`.. 37645 Main Road, { , o QJNonh Fork G•i G 3/9/2020 37645 Main Rd-Google Maps 'o 37645 Main Rd Peconniic,NY 11958 O c®! ® O Directions Save Nearby Send to your Share phone Photos .q https://www.google.com/maps/place/37645+Main+Rd,+Peconic,+NY+11958/@41.0320407,72.4671449,218m/data=!3mlIle3l4ml3!lm7!3m6!lsOx8ge89085ba2687b7:Ox26027ae2524165e2!2s37645... 2/2 Run The Vineyards Pindar 5K - Lane, :7 t "I a p PeConicop 1 C o v 3 2 � CR 48 4 25 Truck QP� laq 5 } V NY 25 a a U a a `��/.`V ti'JQ f_.. lad , �J } G•` `��• o rJ 4�'�.i�11 � p '' oma' �'`., vo_1`..a%�yti-`•� o" �m-1t�� ' ' � arty°c '� ,o Jo . 0 �A V e "' Y \ • R'r�t� ej 0 "Nh 6 v " S 300 m ,� Ma Data©O enStreetMa Contributors 1000 ft P P P 18m 111 1 A 4 1 ROUTE DIRECTIONS No Km Turn Directions 1 5.126 lvn uj, il � c6l( 16P q-hroaq n 41v 4-ree , - 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$250.00 by the Office of the Town Clerk, unless a waiver is obtained. Requesting an expedited review must be submitted in writing to the Town Clerk. The Town Clerk will forward all applications to the Special Events Committee for processing. The Committee will obtain comments on all applications from relevant Town, County and/or State agencies and will forward completed applications to the Town Board with a recommendation as to whether to grant or deny the application. The Town reserves the right to request additional information from an applicant to address issues related to the health, safety,and welfare of the community. When is a Permit Required? All Special Events,per Southold Town Code Article I, Section 205-2(Definitions)must obtain a permit. Occasional events on private residential properties hosted by the owner thereof that are by invitation such as family gatherings, weddings, graduations, parties or not-for-profit fundraisers do not require permits. Any use of residential property for profit,such as avenue for weddings or other events is prohibited. This application is deemed complete once all the following requirements are submitted to the Town Cle • Please indicaft submission of the following by checkinj off the boxes and signing elo . A completed application form signed by the owner and the event manager. Applications without property owner's signature/approval will be rejected. FEE: Is the application being submitted at least 60 days before the event[ ] Yes [<0 If Yes,Fee of$ has been submitted If No,Fee of$ �i 0 has been submitted Updated 8/7/2018 VThe 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' - insured a ZA__L���/EvePl[an: 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 " p-Im 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 V17f 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 Town of Southold P0Box 1179 Southold, NY 11971 * * * RECEIPT * * * Date: 07/24/20 Receipt#: 272303 Quantity Transactions Reference Subtotal 1 Event Fee Pint-a $15000 1 Late Fee Pint-late $250.00 Total Paid: $400.00 Notes: Payment Type Amount Paid By CK#1680 $25000 Pindar, Vineyards Credit Card-Ref# $15000 Plndar, Vineyards Southold Town Clerk's Office 53095 Main Road, PO-Box 1179 Southold, NY 11971 Name: 'Pindar, Vineyards P O Box 332 Peconic, NY 11958 Clerk ID: BONNIED Internal Io Pine-late C, -7"ft�xj r -E Li.S.-PO&A PAJ177 M �$ ; 4 -,--1 F EN' C hicu" n PROLN9 . NY -JUL- AMOUNT -Do X1,1101F.S., M. 1000 i lig7l R2305MI48279-05- Cu n o-C- �c34�o CleQV-- OTIC J004old Ajyr�1 I