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HomeMy WebLinkAboutNorth Fork Country Club ELIZABETH A.NEVILLE,MMC Town Hall,53095 Main Road TOWN CLERK ® P.O.Box 1179 CA Southold,New York 11971 REGISTRAR.OF VITAL STATISTICS 1�6 ® Fax(631)765-6145 MARRIAGE OFFICER �� ®@ Telephone(631)765-1800 RECORDS MANAGEMENT OFFICER ®j ,� FREEDOM OF INFORMATION OFFICER www-southoldtownny.gov OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD June 30, 2021 George Haase, Jr North Fork Country Club PO Box 725 Cutchogue, NY 11935 Dear Mr. Haase: The Southold Town Board, at its regular meeting held on June 1, 2021, granted permission to the North Fork Country Club to hold its Annual Golf Outing on July 23-24, 2021. A certified copy of this 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 the loss of Clean-up deposit. An insurance policy naming the Town of Southold as additionally insured has been filed with this office. Applicant must comply with all executive orders of the State of New York. Please contact Captain Kruszeski at the Police Department, as soon as possible, to coordinate traffic control. If you have any questions please contact me at the Town Clerk's office at 631-765-1800. Good Luck with your event. Sincerely, Lynda M Rudder Deputy Town Clerk enc 4 Southold Town Board - Letter Board Meeting of June 1, 2021 RESOLUTION 2021-437 Item 4 5.14 ADOPTED DOC ID: 17095 THIS IS TO CERTIFY THAT THE FOLLOWING RESOLUTION NO. 2021-437 WAS ADOPTED AT THE REGULAR MEETING OF THE SOUTHOLD TOWN BOARD ON JUNE 1,2021: RESOLVED the Town Board of the Town of Southold hereby grants permission to the North Fork Country Club for their Annual Golf Tournament in Cutchogue for a limited closure of Moore's Lane, from the Main Road to the southerly line of the "Country Club Estates" subdivision, total closure from that southerly point south to the northern line of the William Tyree land parcel, and limited closure from that point south to the intersection of Moores Lane and New Suffolk Avenue (closures would permit access to residents of Moores Lane and "Country Club Estates"), on Friday, July 23, 2021 from 7:00 AM to 5:00 PM and Saturday, July 24, 2021 from 7:00 AM to 2:00 PM provided they adhere to the Town of Southold Policy for Special Events on Town Properties and Roads. They must notify Capt. Kruszeski immediately upon the approval of this resolution to coordinate traffic control. ", Oaoil� Elizabeth A. Neville Southold Town Clerk RESULT: ADOPTED [UNANIMOUS] MOVER: James Dinizio Jr, Councilman SECONDER:Robert Ghosio, Councilman AYES: Nappa, Dinizio Jr, Doherty, Ghosio, Evans, Russell Generated June 2. 2021 Pa°e 30 Vendor No. Check No. Town of Southold, New York - Payment Voucher Vendor Name II 1 Vendor Address Entered,by �UY It CaU niY, 1 Ub -�b I\IlU Audit Date Vendor Telephone Number t +� 1p �' 3q �1c'1' Iol1 C U�- Town Clerk G0-0 5e- Tr. Invoice Invoice Invoice INet Purchase Order Numher Date Total Discount Amount Claimed Number Description of Goods or Services General Ledger Fund and Account Number 303-\- ty 6 soot-, a 5 60- 0 lea yl u P&Y1 A T1.030 i i I I - Total Ooo 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 staled,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 payme approved. Signati c �-f1� Title De ut Town CI k Signature Uk WL Company Name Date g oaf Title:Deputy Town Clerk Date fs--,;C U4-1 1 Southold Town Board - Letter Board Meeting of August 10, 2021 RESOLUTION 2021-646 Item # 5.21 ADOPTED DOC ID: 17300 THIS IS TO CERTIFY THAT THE FOLLOWING RESOLUTION NO. 2021-646 WAS ADOPTED AT THE REGULAR MEETING OF THE SOUTHOLD TOWN BOARD ON AUGUST 10, 2021: 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 North Fork Country Club 5/20/21 $250.00 George Haase, Jr Po Box 725 Cutchogue, NY 11935 Mattituck Chamber of Commerce 5/20/21 $250.00 Kelly Fogarty PO Box 1056 Mattituck,NY 11952 Elizabeth A. Neville Southold Town Clerk RESULT: ADOPTED (UNANIMOUS) MOVER: Jill Doherty, Councilwoman SECONDER:Robert Ghosio, Councilman AYES: Nappa, Dinizio Jr, Doherty, Ghosio, Russell ABSENT: Louisa P. Evans Generated August 10, 2021 Page 32 Town of Southold P.O Box 1179 Southold, NY 11971 * * * RECEIPT * * * Date: 05/20/21 Receipt#: 281084 Quantity Transactions Reference Subtotal 1 Clean-Up Deposit 7/23-24a $25000 1 Event Fee 7/23-24 $250.00 Total Paid: $50000 Notes: Payment Type Amount Paid By CK#044805 $25000 North, Fork Country Club CK#044806 $250.00 North, Fork Country Club Southold Town Clerk's Office 53095 Main Road, PO Box 1179 Southold, NY 11971 Name: North, Fork Country Club Pob 725 Main Road Cutchoque, NY 11935 Clerk ID: LYNDAR Internal ID 7/23-24 Rudder, Lynda From: Flatley, Martin Sent: Thursday, May 20, 2021 3:13 PM To: Rudder, Lynda; Blasko, Regina; Doroski, Melanie; Duffy, Bill; Easton,James; Hagan, Damon; Kruszeski, Frank; Mirabelli, Melissa; Norklun, Stacey; Spiro, Melissa Subject: RE: NFCC Attachments: NFCC Tourney.xls I have no objections to this event being approved. 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 The information contained in this electronic message and any attachments to this message are intended for the exclusive use of the addressee(s) and may contain information that is privileged, confidential and exempt from disclosure under applicable law. If the reader of this message is not the intended recipient,you are hereby notified that any review, retransmission, conversion to hard copy, copying, reproduction, circulation, publication, dissemination or other use of,or taking of any action, or omission to take action, in reliance upon this communication by persons or entities other than the intended recipient is strictly prohibited. If you have received this communication in error, please (i) notify us immediately by telephone at 631.765.2600, (ii) return the original message and all copies to us at the address above via the U.S. Postal Service, and (iii) delete the message and any material attached thereto from any computer, disk drive, diskette, or other storage device or media. -----Original Message----- From: Rudder, Lynda <lynda.rudder@town.southold.ny.us> Sent:Thursday, May 20, 20211:52 PM To: Blasko, Regina <rblasko@town.southold.ny.us>; Doroski, Melanie<Melanie.Doroski@town.southold.ny.us>; Duffy, Bill<billd@southoldtownny.gov>; Easton,James<jamese@southoldtownny.gov>; Flatley, Martin <mflatley@town.southold.ny.us>; Hagan, Damon <damonh@southoldtownny.gov>; Kruszeski, Frank <fkruszeski@town.southold.ny.us>; Mirabelli, Melissa <melissam@southoldtownny.gov>; Norklun, Stacey <Stacey.Norklun@town.southold.ny.us>;Spiro, Melissa <Melissa.Spiro@town.southold.ny.us> Subject: NFCC Your message is ready to be sent with the following file or link attachments: nfcc 20210520135629.pdf 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 RESOLUTION 2020-456 ADOPTED DOC ID: 16307 THIS IS TO CERTIFY THAT THE FOLLOWING RESOLUTION NO. 2020-456 WAS ADOPTED AT THE REGULAR MEETING OF THE SOUTHOLD TOWN BOARD ON JULY 28,2020: RESOLVED theTown Board of the Town of Southold hereby ratifies the resolution granting permission to the North Fork Country Club for their Annual Golf Tournament in Cutchogue for a limited closure of Moore's Lane, from the Main Road to the southerly line of the"Country Club Estates" subdivision, total closure from that southerly point south to the northern line of the William Tyree land parcel, and limited closure from that point south to the intersection of Moores Lane and New Suffolk Avenue (closures would permit access to residents of Moores Lane and"Country Club Estates"), on Friday, July 24, 2020 from 8:00 AM to 5:30 PM and Saturday, July 25, 2020 from 8:00 AM to 2:00 PM provided they adhere to the Town of Southold Policy for Special Events on Town Properties and Roads. They must notify Capt. Kruszeski immediately upon the approval of this resolution to coordinate traffic control and be it further RESOLVED that all fees paid by North Fork Country Club be refunded, as this event was not a Special event but a road closure. The event fee of$16-68 and the $250.00 file fee charged for special events for a total refund of$4066-.66. Z 5U c l e-a^ a 5-00 Elizabeth A. Neville Southold Town Clerk RESULT: ADOPTED [UNANIMOUS] MOVER: Robert Ghosio, Councilman SECONDER:Jill Doherty, Councilwoman AYES: Nappa, Dinizio Jr, Doherty, Ghosio, Evans, Russell t IR ELIZABETH A.NEVILLE, MMC Town Hall,53095 Main Road TOWN CLERK :a ? ' F P.O.Box 1179 a`± r y1," Southold,New York 11971 REGISTRAR OF VITAL STATISTICS - ~_ _ {� Fax(631)765-6145 MARRIAGE OFFICER ` � t Telephone(631)765-1800 RECORDS MANAGEMENT OFFICER ?- � www.southoldtownny.gov FREEDOM OF INFORMATION OFFICER OFFICE OF THE TOWN CLERK RECEIVED r TOWN OF SOUTHOLD ?, MAY 2 0 2021 APPLICATION FOR A PERMIT TO HOLD A Southold Town Clerk SPECIAL EVENT Plea�vidc LLL or the information requested below. 11 'FLL NOT be reviewed. Date of Submission Name of Event 10 KRr Name of Organization: �o� f!'� �dAIL L' Oa A,3 ;i21� Is this a Not-For-Profit Event. Ye o Contact's Name: c'"P 1� -� v 2 c Z Mailing Address: _ Contact's Phone Number: 1,T)- -71,1 - 7/39 c JK Contact's Email Address: b3yi. MAr� Event Location and Site Diagram: ,Z (Use additional paper if necessary) Event Date(s): 7Xa s ' (include set up and shutdown times and dates) Nature of Event: _&e�L Jr d9v fid & (Please attach a detailed descriptiotto�this applica ®n)., 7/ . av : ®v �M 2� Time Period (Hours) of Event: From_3 �� to J'� Maximum Number of Expected Attendees:_JI.1—__ Specify any special requirements (i.e. road closure, police presence): jtA44141c 9JVICdk Pi.zscro�e-c: 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 Mailing Address to Send Event Permit to: {P® 13 O X 7 X 40' C Event Fees: _$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) x $250 or more Clean-up deposit all other events CI:RTIF RE UIRED: Not less than $2,000,000 naming the Town of .Southold as ari,additional ipsured. ***,N0TE,: PLT✓A5E StM ATTAC T D REVISES ADOPTED TO Iii, POLICY' Additional information and requirements may be required as deemed necessary by the Town Board. IIARs'gr -4,-A Print name of Authorized Person filling out Signature of uthorized Perso 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 N s r C � .t• � (Rj 1!7 y r , %. R CERTIFICATE OF LIABILITY INSURANCE DATE5/19/(MMfDDIYYM 021 `--''� 05/19/2021 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 ORALTERTHE COVERAGE AFFORDED BYTHE 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(iss)must 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 RPS Bollinger NAME 200 Jefferson Park (PVCC"N Ed): IFAX Whippany, NJ 07981 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A Illinois National Insurance Company INSURED INSURER B: North Fork Country Club,Inc. INSURER C. PO Box 725 INSURER D. Cutchogue,NY 11935 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 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 DL POLICY NUMBER (M LLICy EFF (POLICY EXP LIMITS LTR UISR MIDD/YYYY) (MMIDDIYYYY) GENERAL LIABILITY EACH OCCURRENCE 13,000,000 ,000,000 COMMERCIAL GENERAL LIABILITY 06-LX-007509385-20 12/31/2020 12/31/2021 DAMAS�E T RENTED PREMISES(Ea occurrence) 00,000 CLAIMS-MADE ©OCCUR MED EXP(Any one person) 5,000 PERSONAL✓1<ADV INJURY ,000,000 GENERAL AGGREGATE GEN'LAGGREGATELIMIT APPLIES PER PRODUCTS-COMP/OP AGG $3,000,000 POLICY R JEC LOC AUTOMOBILE LIABILITY Ea acadent ANY AUTO BODILY INJURY(Per person) AUTOS OWNED SCHEDULED BODILY INJURY(Per acadent) HIREDAUTOS NON eMED PROPERTY AMAGE AUTOS (Per acctdent� UMBRELLA LIAR HOCCUR EACH OCCURRENCE EXCESS LJAB CLAIMS-MADE AGGREGATE DED 0 RETENTION$MOM yy gTgT� TH MEMOpE�M�PpM,YEERSw uABIL N YIN TORY LIMITS OR OFFlCER/IVIEMBOER E7(OLUDELW OUTIVE ❑ NIA E.L.EACH ACCIDENT � SCRIPTI({Myannddatoorryn In NH) E.L.DISEASE-EA EMPLOYEE Dt OF OPERATIONS tteb. I I E.L.DISEASE—POLICY LIMIT DESCRIPTION OF OPERATIONSILOCATIONSAIEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) The Certificate Holder is named as Additional Insured as respects to Men's Invitational Gaff Tournament July 23-24 2021. Additional Insured per Country Club General Liability Extension Endorsement Form 79262 4/02. CERTIFICATE HOLDER CANCELLATION Own Of Southold SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 53095 Main Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Southold,NY 11971 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1998-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Town of Southold Police Department Special Event Cost Analysis Event: North Fork Country Club Tournament Date(s): July 23-24, 2021 Location: North Fork Country Club, Cutchogue 7 '777;; —6— ffii FIAII&W6 fdr,Even Reg Hours OT Hrs Hrly Wage -total Comments `Pik '61MI10 7 7 7-777' ' ia a Reg Hours OT Hrs Hrly WageTotal Comments MirirfiUjil ' '-y"T,q jl� '4� �T 0—Wld� 9 TI Rea Hours OT Hrs Hrly Wage Total Comments TC Officer#1 19 $18.00 $342.00 TCOfficer#2 19 $18.00 $342.00 TC Officer TC Officer TC Officer gq PD Vehicles #of vehicles $/hr Total 1 $10.00 $190.00 $190.00 Command Van Marine Patrol Boats [Total Department Cost for Event= $874.00 Prepared by Chief M Flatley 5/21/2021 Page 1 Rudder, Lynda From: Duffy, Bill Sent: Thursday, May 20, 202113:26 PM To: Rudder, Lynda Subject: RE: NFCC 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: Rudder, Lynda <lynda.rudder@town.southold.ny.us> Sent:Thursday, May 20, 20211:52 PM To: Blasko, Regina <rblasko@town.southold.ny.us>; Doroski, Melanie<Melanie.Doroski@town.southold.ny.us>; Duffy, Bill <billd@southoldtownny.gov>; Easton,James<jamese@southoldtownny.gov>; Flatley, Martin <mflatley@town.southold.ny.us>; Hagan, Damon <damonh@southoldtownny.gov>; Kruszeski, Frank <fkruszeski@town.southold.ny.us>; Mirabelli, Melissa <melissam@southoldtownny.gov>; Norklun, Stacey <Stacey.Norklun@town.southold.ny.us>; Spiro, Melissa <Melissa.Spiro@town.southold.ny.us> Subject: NFCC Your message is ready to be sent with the following file or link attachments: nfcc_20210520135629.pdf 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. Rudder, Lynda From: Easton,James Sent: Friday, May 21, 2021 7:44 AM To: Rudder, Lynda Subject: RE: NFCC I have no concerns with this event taking place. James Easton Fire Marshal,Town of Southold JamesE@southoldtownny.gov (W) 631-765-1802 PRIVELEGED AND CONFIDENTIAL COMMUNICATION CONFIDENTIALITY NOTICE: This electronic mail transmission is intended only for the use of the individual or entity to which it is addressed and may contain confidential information belonging to the sender which is protected by privilege. If you are not the intended recipient,you are hereby notified that any disclosure, copying, distribution, or the taking of any action in reliance on the contents of this information is strictly prohibited. If you have received this transmission in error, please notify the sender immediately by e-mail and delete the original message. -----Original Message----- From: Rudder, Lynda <lynda.rudder@town.southold.ny.us> Sent:Thursday, May 20, 20211:52 PM To: Blasko, Regina <rblasko@town.southold.ny.us>; Doroski, Melanie<Melanie.Doroski@town.southold.ny.us>; Duffy, Bill <billd@southoldtownny.gov>; Easton,James<jamese@southoldtownny.gov>; Flatley, Martin <mflatley@town.southold.ny.us>; Hagan, Damon <damonh@southoldtownny.gov>; Kruszeski, Frank <fkruszeski@town.southold.ny.us>; Mirabelli, Melissa <melissam@southoldtownny.gov>; Norklun, Stacey <Stacey.Norklun@town.southold.ny.us>; Spiro, Melissa <Melissa.Spiro@town.southold.ny.us> Subject: NFCC Your message is ready to be sent with the following file or link attachments: nfcc 20210520135629.pdf 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 C. Rudder, Lynda From: Spiro, Melissa Sent: Thursday, May 20, 2021 1:56 PM To: Rudder, Lynda; Blasko, Regina; Doroski, Melanie; Duffy, Bill; Easton,James; Flatley, Martin; Hagan, Damon; Kruszeski, Frank; Mirabelli, Melissa; Nbrklun, Stacey Subject: RE: NFCC This is not preserved lands. Melissa S. -----Original Message----- From: Rudder, Lynda Sent:Thursday, May 20, 20211:52 PM To: Blasko, Regina <rblasko@town.southold.ny.us>; Doroski, Melanie<Melanie.Doroski@town.southold.ny.us>; Duffy, Bill <billd@southoldtownny.gov>; Easton,James<jamese@southoldtownny.gov>; Flatley, Martin <mflatley@town.southold.ny.us>; Hagan, Damon <damonh@southoldtownny.gov>; Kruszeski, Frank <fkruszeski@town.southbld.ny.us>; Mirabelli, Melissa <melissam@southoldtownny.gov>; Norklun, Stacey <Stacey.Norklun@town.southold.ny.us>; Spiro, Melissa <Melissa.Spiro@town.southold.ny.us> Subject: NFCC Your message is ready to be sent with the following file or link attachments: nfcc_20210520135629.pdf - 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 ELIZABETH A. NEVILLE, MMC Town Hall,53095 Main Road P.O.Box 1179 TOWN CLERK6 ,�, ry '� Southold,New York 11971 � � ; � x� REGISTRAR OF VITAL STATISTICS �� �'; �lr � �� Fax(631)765-6145 Telephone Tele 631 765-1800 MARRIAGE OFFICERp P ( ) ' www.southoldtownny.gov RECORDS MANAGEMENT OFFICER FREEDOM OF INFORMATION OFFICER Ft' -s OFFICE OF THE TOWN CLERK RECEIVED TOWN OF SOUTHOLD MAY 2 2021 APPLICATION FOR A PERMIT TO HOLD A Southold Town Clerk SPECIAL EVENT I`lnrrst° ����r:�v��l�°�"�LL ��i"il►rxrr�"1��_nr�stigs���a.� ii�°,� �1 h�4���wir'w������ ����1�� �ad��plicli�Gr�z� �VII�� a" (),1'm4a�;° revic`ved. Date of Submission 17 � � _ ��.m_ ...�._ Name of Event,,,,, ® W _. ...�..r Name of Organization: Is this allot-For-Profit Event'. e� o �-.... Contact's Name: --- P __. Mailing Address: _.._,.� ._ �..._.... _ .s °��� Contact's Phone Number: Contact's Email Address: Event Location and Site Diagram: "- (Use additional paper if necessary) Event Date(s): �� d shutdown times � (Include set up an-� es and dates) Nature of Event: &PLdr (Please attach a detailed duscrip' n t this applic;� ion) Time Period (Hours) of Event: Prone _ . - A( to _.!f a�-.P� Maximum Number of Expected Attendees: �_.�. _ __.___— Specify any special requirements (i.e. road closure, police presence): rjLeWS`e o,� - _ . 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 Mailing Address to Send Event Permit to: Event ees® $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 it i it 1t iHZI,�D: Not less than $2,000,000 narning the Town of TN. Southold as an additional insured, !.U41 L�ZFIVTS,li, POLICY'k" Additional information and requirements may be required as deemed necessary by the Town Board, A_S9C 4'0— Y, l°jo�ized filling out application PTint name of Authodzed Person filling out Signature o U application 1� *Upon the request by applicant,the Town Board may waive in whole or in part any of the application requirements. 2 Revised 3/21/16 i it l i e lies : 10 u ` ke id J i t Peter Cowan 1Golf Professional GCS"' fYr f pp C HIED GOLF COURSE SUPERINTENDENT Robert Dkkerson r �l Superintendent 1r, j o� GOLF AssoclATE s rx� 800) 438.8726 C CERTIFICATE I INSURANCE DA 05119120,2'1 .......... THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND ORALTERTHE COVERAGE AFFORDED BYTHE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER. PORTANT: If the certificate holder is an ADDITIONAL INSURED,the po l y(ies)must be endorsed. If SUBROUATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsament s PRODUCER ACT RPS Bollinger 200 Jefferson Park (52%Ert): (FX.No,)c Whippany, NJ 07981 IES s IINSURER(a)AFFORDING COVERAGE NAIC$ INSURER A. Illinois National Insurance Conipany INSURE=D INSURER B: North Fork Country Club,Inc. INSURER C: PO Box 725 INSURER D: Cutchogue,NY 11935 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 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. uLTR TYPE OF INSURANCE (NSR POLICY NUMBER P rCyr EFF PO Y FJ(P LIMITS (�DD�M1fYY) (MMI GENERAL LIABILITY EACH OCCURRENCE 1,000 000 COMMERCIAL GENERAL LIABILITY 06.-LX-007509385-20 12/31/2020 12/31/2021 FE STER Occurrence)HD300,000 CLAIMS-MADE ©OCCUR MED EXP(Any one person) 15,000 PERSONAL BADV INJURY 1,000,000 GENERAL AGGREGATE � 3,000,000 GEN'L.AGGREGATE LIMIT APPLIES PIER PRODUCTS-COMP/OP AGG $3,ODO,ODO POLICY % 1:1LOC AUTOMOBILE LIABILITY INGLE 13W m ydergt ANY AUTO BODILY INJURY(Per person) AUTOWNED SAOVKULED BODILY INJURY(Per accident) HIRED AUTOS N8VPNED (PROPERTY DAMAGE AtdrCd9 (Per ac c4ent) ,I UMBRELLA LIAR HOCCUR EACH OCCURRENCE EXCESS LIAB CLAIMS-MADE AGGREGATE DED RETENTION$ yyC TU TH AND MPLOYFRS N dLITY yM TORY LAMITS R OFFlCERIME BE DW& CUTNE WA E.L.E4CH ACCIDENT (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE I I O��r EBPERATIONS Wow E.L.DISEASE—POLICY LIM11 rr DESCRIPTION OF OPERATIONS/LOCATIONSIVEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space Is required) The Certificate Holder is named as Additional Insured as respects to Men's Invitational Golf Tournament July 23-24 2021. Additional Insured per Country Club General Liability Extension Endorsement Form 79262 4/02. CERTIFICATE HOLDER CANCELLATION Own Of Southold SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 53095 Main Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Southold,NY 11971 AUTHORIZED REPRESENTATIVE ©1998-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD