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HomeMy WebLinkAboutKlug, Brian Landscaper Inc AGREEMENT THIS AGREEMENT, entered into this IS day of October, 2021, by and between the Town of Southold,New York('`the Town"), a municipal corporation organized and existing under the laws of the State of New York with offices at 53095 Main Road, Southold, New York, and Brian V. Klug Landscaper Inc. (the"Contractor"),with an address of PO Box 349, Speonk,NY 11972; WITNESSETH, that the Town and the Contractor, for the consideration hereinafter named, agree as follows: ARTICLE 1. WORK TO BE DONE AND CONSIDERATION THEREFOR The Contractor shall perform the Crown Land Lane Drain Project and all work necessary for completion thereof as set forth in the proposal opened September 17,2021 (see Exhibit A attached). The Contractor will furnish all labor, materials (except that the Town of Southold is supplying the pipe), supplies, equipment and other similar items necessary or proper for, or incidental to, the work contemplated by this Contract, as required by, and as directed by the Town Engineer, and in strict accordance with such changes as are ordered and approved pursuant to this Contract. ARTICLE 2. TIME OF COMPLETION The services to be rendered under this Contract shall be completed no later than thirty(30) days from the date the contract is signed by all parties. Time of performance is of the essence of this Agreement. ARTICLE 3. ACCEPTANCE AND FINAL PAYMENT Upon receipt of written notice that the Contract has been fully performed and an inspection by the Town Engineer to certify that the work has been completed to the satisfaction of the Town, the Contractor shall file with the Town Comptroller an itemized voucher and the Town will pay the Contractor $18,600.00. Payments will be made on the basis of the actual work completed in accordance with the Contract. Contractor will be paid the total Contract amount after the project is completed and there arill be no partial payments. The Town shall pay the Contractor upon the submission of a voucher at the conclusion of the contemplated project. Such voucher shall be due and payable within 45 days after receipt of such voucher,but such sum shall not be due and payable by the Town until the Town Board of the Town has received such a voucher and has audited and approved for payment the voucher to be submitted by Contractor in connection therewith. The Town Board shall process any voucher received from Contractor as expeditiously as possible. In the event that the Town disputes or objects to any portion of any voucher submitted by Contractor pursuant to this paragraph,the Town shall,within 30 days of the receipt of such voucher, notify Contractor in writing of such dispute or objection. Contractor acknowledges that Contractor is familiar with the requirements of section 118 of the Town Law which, in effect, prohibit payment presented to the Town Board or Town Comptroller and shall have been audited and allowed by the Town Board or Town Comptroller. The acceptance by the Contractor of the final payment shall be, and shall operate as a release to the Town from all claims and all liabilities to the Contractor for all the things done or furnished in connection with this work and for every act and neglect of the Totem and others relating to or arising out of, this Contract, except Contractor's claims for interest upon the final payment, if this payment be improperly delayed. No payment, however final or otherwise, shall operate to release the Contractor or its sureties from any obligations under this Contract. ARTICLE 4. CHANGES TO THE CONTRACT AND EXTRA IVORK (a) The Town may at times, without notice to the Contractor's surety and without invalidating the Contract, order extra work or make changes by-altering, adding to, or deducting from the work contemplated herein and may adjust the Contract price accordingly, pursuant to Paragraph (b) below. The Contractor shall not deviate from, add to, delete from, or make changes in the Rork required to be performed hereunder unless so directed by a written Change Order. If the Contractor is directed by the Town to perform extra work prior to an agreement on costs or time, the Contractor shall promptly comply with the Change Order of the Town. No claim for extra work or any change in the work shall be allowed or made unless such extra work or change is ordered by a written Change Order from the Town. (b) The amount of compensation to be paid to the Contractor for any extra work, as so ordered, shall be determined as follows: 1. By a lump sum mutually agreed upon by the Town and the Contractor;or ?. Using the applicable price or prices within the Contract and/or Bid and approved by the Town and the Contractor. (c) Regardless of the method used by the Town in determining the value of a Change Order, the Contractor shall submit to the Town a detailed payment breakdown of the Contractor's estimate of the value of the omitted or extra work. (d) Unless otherwise specifically provided for in a Change Order, the agreed compensation specified therein for extra work includes full payment for extra work covered thereby, and the Contractor waives all rights to any other compensation for such extra work, damage or expense,including claims for delay,damage or expense. (e) The Contractor shall and hereby agrees to produce any and all data the Town may request, including but not limited to, time sheets, certified payrolls, foreman's reports, daily reports, bilis and vouchers of Subcontractors, receiving documents, freight and trucking receipts, etc. (f) All change orders shall be processed, executed and approved in the following manner: (i) if the estimated cost of the extra work is less than $1,000 in the aggregate, a Change Order Form must be processed and executed by the Supervising Department Head; (ii) if the estimated cost of the extra work is greater than$1,000,then a Change Order Form must be executed by the Supervising Department Head and submitted to the Town Board for consideration and approval by resolution. The Contractor must submit a detailed explanation of why the Change Order is needed and must also be submitted to the Town Board prior to its approval. The Change Order must also be approved by the Town Comptroller and the Town Attorney. Once flus procedure is completed,the Contractor may proceed with the extra work. The Town will not accept any alteration to this form and no payment for Extra Work shall be due the Contractor unless it executes a Change Order on this Form. (g) If the Contractor claims that any work which the Contractor has been ordered to perform will be extra work,that the Contractor for any reason cannot comply with the terms and provisions of the Contract, or that any action or omission of the Town is contrary to the terms and provisions of the Contract and will require the Contractor'to perform extra work,the contractor shall: 1. Promptly comply with the Town's direction to perform the work which the contractor claims«gill be extra work; and 2. Proceed diligently, pending and subsequent to the determination of the Town with respect to any said disputed matter, with the performance of the work in accordance with all the instructions of the Town. (h) No claim for extra work shall be allowed unless it was performed pursuant to change order duly approved by the Town Board. The Contractor's failure to comply with any part of this provision shall be deemed to be: 1. A conclusive and binding determination on the part of the Contractor that said change order, work, action or omission does not involve extra work and is not contrary to the terms and provisions of the Contract,and 2. A waiver by the Contractor of all claims for additional compensation, time or damages as a result of said change work,act or omission. (i) The value of claims for extra work, if allowed shall be determined methods described in the Contract including,but not limited to, section(b)immediately above. ARTICLE 5: CONTRACTOR'S OBLIGATIONS (a) The Contractor shall be responsible for the full and correct performance of the Work required by this Contract within the time specified herein, including work of the Contractor's Subcontractors, and any errors therein shall be corrected at the Contractor's own cost and expense. In addition,the Contractor shall indemnify the Town for any costs or expenses attributable to errors in performance by the Contractor or the Contractor's Subcontractors. (b) The Contractor agrees that the Contractor shall protect and shall be solely responsible for all labor and material provided for under this contract, whether or not the same may be erected in place, and for all its plans,tools, equipment,materials,tools of the Contractor's employees and agents, etc. for all adjoining private and public property, and all existing Work on the Project Site, which may be damaged by the Contractor's Work. In no event shall the Town be liable to the Contractor for loss of, pilferage, or damage to any of the same. In the event of said labor and materials, plant, tools or equipment, etc., are damaged, lost or destroyed by reason of fire, theft (irrespective of the negligence of the parties hereto or others), civil commotion, riot, insurrection, violence, war, acts of God, etc., the Contractor's responsibility therefore shall be absolute, and the Contractor shall replace, repair, rebuild, and make good any and all said damage or loss of any and all kinds whatsoever. (c) Contractor shall be responsible for securing all pen-nits required to perform the Work and/or required by the applicable laws, regulations, ordinances, etc., and maintain the validity of all such permits throughout the contract duration,if any. ARTICLE 6. CONTRACTOR'S INSURANCE The Contractor shall not commence work under this Contract until it has obtained all insurance required under this paragraph and such insurance has been approved by the Town. (a) Compensation Insurance: The Contractor shall take out and maintain during the life of this Contract Workers' Compensation Insurance for its employees to be assigned to the work hereunder. (b) Insurance: The Contractor shall take out and maintain during the life of this Contract such general liability, property damage, and commercial auto liability insurance as shall protect it from claims for damages for personal injury, including accidental death, as well as from claims for property damage which may arise from operations under this Contract. The amounts of such insurance shall be as follows: General liability insurance in an amount not less than $1,000,000 for injuries, including wrongful death to any one person and subject to the same limit for each person,in an amount not less than$2,000,000 on account of any one occurrence. Property damage insurance in an amount not less than $300,000 for damage on account of all occurrences. Commercial auto liability insurance in an amount not less than $500,000 for damage on account of all occurrences. The Contractor shall furnish the above insurances to the Town and shall also name the Tours as an additional named insured in said policies. (c) Any accident shall be reported to the office of the Town Clerk as soon as possible and not later than twenty-four (24) hours from the time of such accident. A detailed written report must be submitted to the Town as soon thereafter as possible and not later than three(3)days after the date of such accident. ARTICLE 7. REPRESENTATIONS OF CONTRACTOR The Contractor represents and warrants: (a) That it is financially solvent and that it is experienced in and competent to perform the type of work to be furnished by it;and (b) That it is familiar with all federal, state, municipal and department laws, ordinances and regulations which may in any way affect the work or those employed therein. ARTICLE 8. PERMITS AND REGULATIONS The Contractor shall comply with all permits issued to the Town in connection with the services furnished under this Agreement. ARTICLE 9. NO DAMAGES FOR DELA' The contractor agrees to make no claim for increased costs, charges, expenses or damages for delay in the performance of this Contract, or for any delays or hindrances from any cause whatsoever, and agrees that any such claim shall be fully compensated for by an extension in the time.for substantial and/or,final completion of the work. Should the Contractor be or anticipate being delayed or disputed in performing the work hereunder for any reason, it shall promptly, and in no even more than two (2)business days after the commencement of any condition which is causing or threatening to cause such a delay or disruption, notify the Town in writing of the effect of such condition stating why and in what respects the condition is causing or threatening to cause such delay or disruption. Failure strictly to comply with this notice requirement shall be sufficient cause to deny Contractor a change in Schedule and to require it to conform to the Schedule then in effect. ARTICLE 10. TOWN'S RIGHT TO STOP WORK OR TERMINATE CONTRACT The Town shall have the right to stop work or terminate the Contract if: (a) The Contractor is adjudged bankrupt or makes an assignment for the benefit of creditors; or (b) A receiver or liquidator is appointed for the Contractor or for any of its property and is not dismissed within 20 days after such appointment or the proceedings in connection therewith are not stayed on appeal within the said 20 days; or (c) The Contractor refuses or fails to prosecute the work or any part thereof with due diligence; or (d) The Contractor fails to make prompt payment to persons supplying labor for the work; or (e) The Contractor fails or refuses to comply with all applicable laws or ordinances; or (f) The Contractor is guilty of a substantial violation of any provision of this Contract; (g) The Town's execution and participation in this contract is found to be in violation of an existing collective bargaining agreement. (h) In any event, the Town, without prejudice to any other rights or remedy it may have, may, with our without cause, by seven (7) days' notice to the Contractor, terminate the employment of the Contractor and its right to proceed as to the work. In such case, the Contractor shall not be entitled to receive any further payment beyond what owed in quantum meruit. ARTICLE 11. DAMAGES It is hereby mutually covenanted and agreed that the relation of the Contractor to the work to be performed by it under this Contract shall be that of an independent contractor. As an independent contractor, it will be responsible for all damage, loss or injury to persons or property that may arise in or be incurred during the conduct and progress of said work,whether or not the Contractor,its agents, or employees have been negligent. The Contractor shall hold and keep the Town free and discharged of and from any and all responsibility and liability of any sort or hind. The Contractor shall assume all responsibility for risks or casualties of every description, for loss or injury to persons or property arising out of the nature of the work, from the action of the elements, or from any unforeseen or unusual difficulty. The Contractor shall make good any damages that may occur in consequence of the work or any part of it. The Contractor shall assume all blame, loss and responsibility of any nature by reason of neglect or violation of any federal, state, county or local laws, regulations or ordinances. ARTICLE 12. INDEMNITY AND SAVE HARMLESS AGREEMENT The Contractor agrees to indemnify and save the Town,its officers, agents and employees harmless from any liability imposed upon the Town, its officers,agents and/or employees arising from the negligence,active or passive,of the Contractor and from and against any damages,claims, or expenses,including reasonable attorney's fees, arising-out of Contractor's breach of the Agreement or from Contractor's acts or omissions outside the scope of the Agreement or arising out of claims or actions by third parties against Contractor by virtue of its performance of this Agreement, ARTICLE 13. NO ASSIGNMENT In accordance with the provisions of section 109 of the General Municipal Law, the Contractor is hereby prohibited from assigning,transferring, conveying, subletting or otherwise disposing of this Agreement, or of its right, title or interest in this Agreement, or its power to execute this Agreement, to any other person or corporation without the previous consent in writing of the Town. ARTICLE 14. REQUIRED PROVISIONS OF LAW Each and every provision of law and clause required by law to be inserted in this Contract shall be deemed to have been inserted herein, if any such provision is not inserted, through mistake or otherwise, then upon the application of either party, this Contract shall be physically amended forthwith to make such insertion. In particular,the Contractor shall, among other things,fully comply with: 1 (a) Labor Law section 220-e and Executive Law sections 291-299 and the Civil Rights Law relating to prohibition against discrimination and providing equal opportunity. (b) Affirmative action as required by the Labor Law. (c) Prevention of dust hazard required by Labor Law section 222-a. (d) Preference in employment of persons required by Labor Law section 222. (e) Eight-hour workday as required by Labor Law section 220(2). ARTICLE 15. PREVAILING WAGE RATES REQUIRED BY LAW (a) The parties hereto, in accordance with the provisions of section 220(3) of the Labor Law,if applicable,hereby agree that there shall be paid each employee engaged in work under this Contract not less than the wage rate and supplements set opposite the trade or occupation in which he/she is engaged, which are the wage rates and supplements established as the prevailing rate of wages for the work covered by this Contract. (b) Labor classifications not appearing on the schedule of wages can be used only with the consent of the Owner and then the rate to be paid will be given by the Owner after being advised by the Department of Labor. (e) The Contractor shall post in a prominent and accessible place on the site of the work a legible statement of all wage rates and supplements, as specified in the Contract, for the various classes of mechanics, workingmen/women,or laborers employed on the work. ARTICLE 16. AUTHORITY FOR EXECUTION ON BEHALF OF THE TOWN Scott A. Russell, Supervisor, whose signature appears hereafter, is duly authorized and empowered to execute this instrument and enter into such an Agreement on behalf of the Town. This instrument shall be executed in duplicate. At least one copy shall be permanently filed, after execution thereof,in the office of the Town Clerk,Elizabeth Neville. ARTICLE 17. NOTICES Any and all notices and payments required hereunder shall be addressed as follows, or to such other address as may hereafter be designated in writing by either party hereto: To Town: Elizabeth A. Neville,RMC,CMC Southold Town Clerk P.O. Box 1179 Southold,NY 11971-0959 With Copy To: Michael Collins,Town Engineer P.O. Box 1179 Southold,NY 11971-0959 To Contractor: Brian V. Klug Landscaper Inc. PO Box 349 Speonk,NY 11972 ARTICLE 18. WAITER No waiver of any breach of any condition of the Agreement shall be binding unless in writing and signed by the party waiving said breach. No such waiver shall in any way affect any other term or condition of this Agreement or constitute a cause or excuse for a repetition of such or any other breach unless the waiver shall include the same. ARTICLE 19. MODIFICATION This Agreement constitutes the complete understanding of the parties. No modification of any provisions thereof shall be valid unless in writing and signed by both parties. ARTICLE 20. APPLICABLE LAW This Agreement is governed by the laws of the State of New York. IN WITNESS WHEREOF, the Town of Southold has caused these presents to be signed by Scott A. Russell, its Supervisor, duly authorized to do so, and the Contractor has caused these presents to be signed by its President,the day and year first above written. Brian V.Klug Landscaper Inc. Town of Southold By: / Gfi~e�r��. By: Monied ne) r1 Pre (Title) Scott A. Russell, Supervisor STATE OF NEW YORK) ) ss.: COUNTY OF SUFFOLK) awiw On this kZday of&TWme/bex in the year 2021 before me,the undersigned;personally appeared �n�cr eco (l�fame)the Vi' (title)and authorized agent of Brian V.Klug Landscaper hnc.,personally known to me or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument and acknowledged to me that he executed the same in his capacity and that by his signature on the instrument,the individual or the person upon whose behalf of which the individual acted,executed the instrument. ubl>. STATE OF NEW YORK) - KIMBERLY HONIG ss.: NOTARY t01 H PUBLIC,State f York COUNTY OF SUFFOLK) Qualified in Suffolk County Commission Expiresc�b4r.;;li OQiv�s2Cts On this 1S day of Septe�in the year 2021 before me,the undersigned,personally appeared SCOTT A.RUSSELL,personally known to me or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument and acknowledged to me that he executed the same in his capacity and that by his signature on the instrument,the individual or the person upon whose behalf of which the individual acted,executed the instrument. etZ i '-nom "h2&6h Notary Public LAUREN M. STANDISH Notary Nubtic-State of 01ST616400W York 8 o Qualified in Suffolk County Commission Expires April 9,2023 325.1208 6 it V. Landscaper,Inc.— VUV P.O. Box 349, Speonk,N.Y. 11972 September 17, 2021 Town of Southold Michael Collins, P.E. Engineering Department 53095 Main Road Southold, NY 11971 PROPOSAL: Crown Land Lane A State Route 25 • Replace the–40' section of 18" CMP between Structure crown Ian d-catch3 and Structure crown land-catchl with 15"HDPE • Replace the–5' section of 18" CMP between Structure crownland-catchl , Structure crown land-catchl with 15" HDPE $6,200. 1140 Crown Land Lane • Replace the–50' section of 18" CMP between Structure crown land-catch4 and Structure crownland-catchy with 15"HDPE $6,200. 2390 Crown Land Lane • Replace the–40'section of 18" CMP between Structure crown land-catch6 and Structure crownland-catch7 with 15"HDPE $6,200. • The Southold Highway Dept.will provide the 15"diameter HDPE pipe for this project • The completed pipe trench will be restored with existing clean compacted fill and a minimum of 6+inches of compacted NYSDOT specification RCA to match the existing grade of the asphalt • This job DOES NOT INCLUDE asphalt or curbing restoration • This is a prevailing wage job and certified payrolls will be provided with the final invoice • �� CAJ DATE(MMIDDIYYYY) A�Q'h'D CERTIFICATE OF LIABILITY INSURANCE ��- 10/06/2021 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 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). CONTACT PRODUCER NAME' Nate Perry Quinton Insurance P"Q NE . (800)454-1970 FAX Ho.-JAI (585)388-9531 2700 Elmwood Ave E-MAIL s, service uintoninsurance.com INSURERS AFFORDING COVERAGE NAIC4 Rochester NY 14618 INSURERA: ERIE INSURANCE CO 26263 INSURED INSURER B: FLAGSHIP CITY INSURANCE COMPANY 35585 Brian V Klug Landscaper,Inc 114SURER C: SHELTER POINT 81434 P.O. BOX 349 INSURER D: INSURER E: SPEONK NY 11972-0349 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 ADDL SUER POLICY EFF POLICY FRCP LIMITS LTR TYPEOFINSURANCE POLICY NUMBER MWDD MMIDD X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,004 DAMAGE O RENT D 1,000,000 CLAIMS-MADE FROCCUR PREMISES Ea Occurrence $ MED EXP(Any one person) $ 5,000 A Y Q32-8120097 08/31/2021 08/31/2022 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE U MIT APPLIES PER GENERAL AGGREGATE $ 2,000,000 X JET LOC PRODUCTS-COMPIOPAGG $ 2,000,000 POLICY rl OTHER' AUTOMOBILE LIABILITY Ea aaccident)n SINGLE LIMIT $ 1,000,000 X ANY AUTO BODILY INJURY(Per person) $ A OWNED SCHEDULED Q08-$130206 08/31/2021 08/31/2022 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X HIREDX NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS UAB CLAIMS-MADE Q32-8170039 08/31/2021 08/31/2022 AGGREGATE $ 1,000,000 DED I I RETENTION$ PER $ WORKERS COMPENSATION X STATUTE EOR" AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNERIEXECUTIVE YIN EL EACH ACCIDENT $ 100,000 B OFFICERIMEMBEREXCLUDED? � NIA Q91-6000155 07/10/2021 07/10/2022 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 Ifyes,describe under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ 500,000 Group Short Term Disability C D255547 06121!2021 06/20/2022 statutory DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Town Of Southold is added as additional insured with respects to the general liability policy. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town Of Southold 53095 Main Road AUTHORIZED REPRESENTATIVE Southold,NY 11971 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD STATE OF NEW YORK WORKERS'COMPENSATION BOARD CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE Ia.Legal Name&Address of Insured(Use street address only) lb.Business Telephone Number of Insured Brian V Klug Landscaper,Inc (631)325-1208 P.O.Box 349 Speonk NY 11972-0349 lc.NYS Unemployment Insurance Employer Registration Number of Insured Work Location of Insured (Only required if coverage is specifically limited to certain locations in New York State,i.e., a Id.Federal Employer Identification Number of Insured Wrap-Up Policy)NY or Social Security Number 11-2906829 2.Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) ]FLAGSHIP CITY INSURANCE COMPANY 3b.Policy Number of entity listed in box"Ia" Town of Southold Q91-6000155 53095 Main Road 3c. Policy effective period 07/10/2021-07/10/2022 Southold,NY 11971 3d. The Proprietor,Partners or Executive Officers are: included. (Only check box if all partners/officers included) Q all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box "Y insures the business referenced above in box "la" for workers' compensation under the New York State Workers' Compensation Law (To use this form,New York(NY)must be listed under Item 3A on the INFORMATION PAGE of the workers' compensation insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity luted above as the certificate holder in box"T'. The Insurance Carrier will also notify the above certificate holder within 10 days IF a policy is canceled due to nonpayment of premiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured frons the coverage indicated on this Certificate. (These notices maybe sent by regular mail.) Otherwise; this Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent, or until the policy expiration date listed in box "3c", whichever is earlier. Please Note: Upon the cancellation of the workers' compensation policy indicated on this form,if the business continues to be named on a permit, license or contract issued by a certificate holder,the business must provide that certificate holder with a new Certificate of Workers' Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers'Compensation Law. Under penalty of perjury,I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has the coverage as depicted on this form. Approved by: _Gordon Quinton "/" (Print namus e of Authorized representative or licensed agent of insurance caer) z za`iti $6 K-04 oflIcua.nc Approved by (Signature) (bate) Title. President/Owner Telephone Number of authorized representative or licensed agent of insurance carrier-_(585)38895-0 Please Note: Only insurance carriers and their licensed agents are authorized to issue Form C-105.2. Insurance brokers are NOT authorized to issue it. C-105.2(9-07) wvrw wcb.state ny.us Workers' Compensation Law Section 57. Restriction on issue of permits and the entering into contracts unless compensation is secured. 1 The head of a state or municipal department,board,commission or office authorized or required bylaw to issue any permit for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter, and notwithstanding any general or special statute requiring or authorizing the issue of such permits,shall not issue such permit unless proof duly subscribed by an insurance carver is produced in a form satisfactory to the chair, that compensation for all employees has been secured as provided by this chapter Nothing herein however, shall be construed as creating any liability on the part of such state or municipal department,board,commission or office,to pay any compensation to any such employee if so employed. 2 The head of a state or municipal department,board,commission or office authorized or required bylaw to enter into any contract for or in connection with any work involving the employment of employees in a hazardous employment defined by this chapter, notwithstanding any general or special statute requiring or authorizing any such contract, shall not enter into any such contract unless proof duly subscribed by an insurance carrier is produced in a form satisfactory to the chair,that compensation for all employees has been secured as provided by this chapter C-105.2(9-07)Reverse >- ,r��►t CERTIFICATE OF INSURANCE COVERAGE ------- a?ATf :. CSi3. clnsa�e p8 1`" :Board DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be completed by Disability and Paid Family Leave Benefits Carrier or Licensed Insurance Agent of that Carrier 1a.Legal Name&Address of Insured(use street address only) 1b.Business Telephone Number of Insured BRIAN V KLUG LANDSCAPER INC 631-369-3620 PO BOX 349 SPEONK,NY 11972 1c.Federal Employer Identification Number of Insured or Social Security Number Work Location of Insured(Only required if coverage is specifically limited to certain tocations in New York State,i.e.,wrap-Up Policy) 1 12QO6829 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) ShelterPoint Life Insurance Company TOWN OF SOUTHOLD 53095 MAIN ROAD 3b.Policy Number of Entity Listed in Box"1a" SOUTHOLD, NY 11971 DBI255547 3c.Policy effective period 06/21/2021 to 06120/2022 4. Policy provides the following benefits. ® A.Both disability and paid family leave benefits. B.Disability benefits only. F] C.Paid family leave benefits only. 5. Policy covers. © A.All of the employer's employees eligible under the NYS Disability and Paid Family Leave Benefits Law. QB.Only the following dass or classes of employer's employees- Under penalty of perjury,I certify that I am an authonzed representative or licensed agent of the insurance carrier referenced above and that the named insured has NYS Disability andlor Paid Family Leave Benefits insurance coverage as described above. t c; Date Signed 8/3/2021 Byi J !'J, (Signature of insurance carver's authorized reptesentative or NYS Lcensed Insurance Agent of that insurance carrier) Telephone Number 516-829-8100 Name and Title Richard White, Chief Executive Officer IMPORTANT: If Boxes 4A and 5A are checked,and this form is signed by the Insurance carrier's authorized representative or NYS Licensed Insurance Agent of that carrier,this certificate is COMPLETE. Mall it directly to the certificate holder. If Box 4B,4C or 5B Is checked,this certificate Is NOT COMPLETE for purposes of Section 220,Subd.8 of the NYS Disability and Paid Family Leave Benefits Law. It must be mailed for completion to the Workers'Compensation Board, Pians Acceptance Unit,PO Box 5200,Binghamton,NY 13902-5200. PART 2.To be completed by the NYS Workers'Compensation Board (only if Box 4C or 5113 of Part 1 has been checked) State of New York Workers' Compensation Board According to information maintained by the NYS Workers'Compensation Board,the above-named employer has complied with the NYS Disability and Paid Family Leave Benefits Law with respect to all of his/her employees. Date Signed By (Signature of Authorized NYS Workers'Compensation Board Employee) Telephone Number Name and Title Please Note:Only insurance carriers licensed to write NYS disability and paid family leave benefits insurance policies and NYS licensed insurance agents of those insurance carriers are authorized to issue Form DB-920 1.Insurance brokers are NOT authorized to issue this form. DB-120.1 (10-17) �IIIIIP�'°�°1°°°��111111°11°°�°°°°1°Illll� D13-120.1 (10-17) yc ��aS�gFFOC��o RECEIVED OCT 2 0 2021 Southold Town Clerk Office of the Town Attorney Town of Southold Town Hall Annex, 54375 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone : 631-765-1939 Facsimile: 631-765-6639 MEMORANDUM To: Ms. Elizabeth A. Neville, Town Clerk From: Melissa Mirabelli Secretary to the Town Attorney Date: October 18, 2021 Subject: Agreement between Town of Southold and Brian V. Klug Landscaper Inc. With respect to the above-referenced matter, I am enclosing the original Agreement together with proposal If you have any questions regarding the enclosed, please do not hesitate to call me. Thank you. /mm Enclosures cc: Accounting Engineering