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Home My WebLink AboutCub Mobile ELIZABETH A. NEVILLE,MMCTown Hall,53095 Main Road TOWN CLERK f"' ,i �' , P.O,Box 1179 d Southold,New York 11971 631 Fax 765-6145 REGISTRAR OF VITAL STATISTICS ( ) " u d Telephone(631)765-1800 MARRIAGE OFFICER RECORDS MANAGEMENT OFFICER x www.southoldtovcnury.gov FREEDOM OF INFORMATION OFFICER RECEIVED OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD S �w Iwo APPLICATION FOR A PERMITTO HOLDSouthold Town Clerk SPECIAL EVENT �� ' 1��i Isle 1 ,��.�,I6(aw�� Ie 1_LnN1t'.^(lm�ua ��N . len �� "1�s�"�wwi�:, rI�L.,€�I,��r, i�� .� . �.�..�....� �°t„vi ►��:d. Date of Submission _ ..._..._ as .._........� ._. Name ofEvcnt. �i �...._ _..�.. i,b �"� .. _...._ . ...� .. tl U i s �(, 4 1„J b•� t.e' t�5 PACV., S9 Name of allot-For Lv Organization: Is ent � sNo Contact's Name ..... .......... . �l Mailing Address _iter i � y e _ ii _.. Contact's Phone Number: . ...w Contact's Email Address: -a ....— i ". VI' ... Event Location and Site Diagram: - Use additional paper if necessary) Event Date(s): lncBrNde set u p and shutdown tia own ra m ( es and dates) '. .._. (Please attach a detailed description to this application) Time Period (Hours) of Event: From � ��'�Aw to Maximum Number of Expected Attendees: Specify any special requirements (i,e, road closure, police presence): „ SPA 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 to: -in"l, c)-r0406,Wz-�, 1,Jj" 16,3 5 Mailing Address to Send Event Permit ..................... Event Fees: $250 for events with less than l000 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 11T) Not less than $2,000,000 naming the Town of Southold as an additional insured. 1) REVI I S'ED AW SEEAT -ACAIE, '110111cy*** Additional information and requirements may be required as deemed necessary by the Town Board, 12.04,10a) I—,.......... Signature of Authorized Person filling out application Print name of Authorized Person filling out 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 CERTIFICATE OF LIABILITY INSURANCE UATEIMMdDDBYYYY) 1 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFIC °FOLDER."II 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 CON ACT 7dAME: Laura Craig Marsh&McLennan Agency LLC P14ONE FAX 8144 Walnut Hill Lane, 16th Floor c g 2 0 1X32 _�,tAlcygg 972.771) 53 mm_ Dallas TX 75231 E-MAIL ADDRESS_/aura CrabfamarShmma.Com INSURERIS)AFFORDING COVERAGE NAIC# ... ..._. ... .__ INSURER A:Evanston Insurance Company 35378 INSURED INSURER B: _buoy,Scouts of Arnerica,.National Council a90 All of Its,.affiliates.aftd,subsldlarles INSURER C: Suffolkount Council#404 7 '.INSURER D: : - 7 Scouting Blvd. _INSUREREc .......... � ......... ... Medford, NY 11763 i INSURER F: COVERAGES CERTIFICATE NUMBER:941251576 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 .,... ADDLSUr3Gd�. POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE POLICY NUMBER MMIDD MMIDDIYYYY A X COMMERCIALGENERAL LIABILITY MKLV4PBC001681 3/1/2021 3/1/2022 EACH OCCURRENCE $1,000,000 .�,.......,� VED CLAIMS MADE �...X I OCCUR P RLMt$E;!(E pgpurmreIf wp $1,0,00,000 MED EXP(Any one person) $ PERSONAL&ADV INJURY $1,000,000 ... ...... ........ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATEi$10_,_000,000 POLICY PRO, IOP" ..PRODUCTS COMPIOP AGG $ _ )CCT O 9 HEIq" $ I AUTOMOBILE LIABILITY7 �o oc COMBINED , G 001l" $ '..ANY AUTO BODILY INJURY(Per person) ...._. OWNED I SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY 1AUTOS ", - HIRED NON-OWNED PRtIF F'RTY DAMAtJE. 1 AUTOS ONLY �--..... AUTOS ONLY ; I IF'.r ac+,k�punt),,,, ,.,_„a ,,,, $ .. _,,,, ......... Is A X I UMBRELLALIAB � ;OCCUR MKLV4EUL103145 3/1/2021 3/102022 EACH OCCURRENCE i$6,500.000 EXCESS LIAB �.. ---- ....... ..._ i DED 1 X RETENTION$ I AGGREGATE $13.000.000 ..... .. I 1 CU1IM MADF $ WORKERS COMPENSATION j I srA UTE I ER ERH AND EMPLOYERS'LIABILITY Y I N ANYPROPRIETORIPARTNERIEXECUTIVE EL.EACH ACCIDENT $ ,. OFFICERIMEMBEREXCLUDEO? INIA (Mandatory in NH) E.L_DISEASE f -EA EMPLOYEE $ , DESCRIPTION OF OPERATIONS below I j E,L.DISEASE-POLICY LIMIT $ I 1 I DESCRIPTION OF OPERATIONS d LOCATIONS f VEHICLES (ACORD IRIS AddlionA Rumaatrs Schoduln,may be aRilached of snore apace Rs rego0red'I C,eibfRoate holder is named as an additionat insured by virtue of a Written or oral contract or by the issuance/existence of a permit or certificate of insurance but only With respect to operations by or on behalf of the Insured„or to facilities of,of facilities used by the Insured and then only of the limits of liability specified in such contract For the event specified.Primary;and Non•ContrOulory applies as required by Written contract or agreement.Waiver of Subrogation applies When required by Written contract or agreement. SeuUal Molestation coverage Is incorporated in the policy and addressed by endorsment and is subject to the policy period,terms,limits and conditions of the policy, Certificate holders include directors,ofilr.,ers„agents,owners,volunteers,mortgagees and landlords as. required by Written contract or agreement, For:All Official Scout Activities CERT'IFICAT'E HOLDER CANCELLATION T ,.,,.,. .-...---- TOWn of Southold SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 530 cute 25 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Southold, 11971 AUTHORIZED REPRESENTATIVE O 1988-2015 ACORD CORPORATION. All rights reserved. ACO (2016103) The ACORD name and logo are registered marks of ACORD