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HomeMy WebLinkAboutBroadway in the Vines RECEIVED Cz SEP 2 2021 Southold Town Clerk <--0 TOWN OF SOUTHOLD Town Code Chapter 205 "Public Entertainment and SpeeWJKVinfg';�� 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$250.00 by the Office of the Town Clerk, unless a waiver is obtained Requesting an expedited review must be submitted in writing to the Town Clerk. The Town Clerk will forward all applications to the Special Events Committee for processing. The Committee will obtain comments on all applications from relevant Town, County and/or State agencies and will forward completed applications to the Town Board with a recommendation as to whether to grant or deny the application. The Town reserves the right to request additional information from an applicant to address issues related to the health, safety, and welfare of the community. When is a Permit Required? All Special Events,per Southold Town Code Article 1, Section 205-2(Definitions)must obtain a permit. Occasional events on private residential properties hosted by the owner thereof that are by invitation such as family gatherings, weddings, graduations, parties or not-for-profit fundraisers do not require permits. Any use of residential property for profit, such as a venue for weddings or other events is prohibited. This application is deemed complete once all the following requirements are submitted to the Town Clerk: Please indicate submission of the following by checking off the boxes and signing below. 16 A completed application form signed by the owner and the event manager. Applications without property owner's signature/approval will be rejected. �FEE: Is the application being submitted at least 60 days before the event Yes `/1 No YN ElIf Yes,Fee of$ has been submitted R"IfNo,Fee of$ 400 - Do has been submitted Updated 8/7/2018 FThe applicant/owner of the property where the special event is proposed to take lace must provide a P certificate of insurance not less than 2 million dollars naming the Town of Southold as an additional sured A Parking/Event Plan: 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) Irl l a 0 Events for three hundred (300) or more people require submission and approval of a traffic control plan acceptable to the Town of Southold AND a qualified traffic controller must be provided at the vent. (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. If 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 APPLICATION FOR A PERMIT TO HOLD A SPECIAL EVENT Please provide ALL of the information requested below.Incomplete applications FILL NOT be reviewed. Fou V De&t S Co VA S LL& Special Event Permit# Applicant(s)name: PD- �5 < < < V C V16A_(a V_0( S Date of Submission 2' 2-1 Name of Event 0 V'_0 a A VV `� t V' _t'V1 e V 1 VA SCTM#'s 1000-Section Block- Lot(s) Dates of Each Event: W I l 1I FI .211 If Multiple Dates are requested, applicant must give all information for all dates. Nature of Event: <<1e SiV) lVl n PC,V-foyma(/l,cc, 0ufatooV'5 V1 YtA (Please attach as de-failed description of EACH event to this application) Time Period(Hours)of Event: From [3�bo 19 VY1 to p VY) Town Services requested: ( )Yes (>}No If yes,Describe Police Dept._Highway Dept. Describe Services I a Maximum Number of Persons Attending At One Time: 200 Zknmber of cars expected �/o Q 0 Is a Tent or other temporary structure being used? [ ] Yes N No If yes provide size(s) Will food be served? [ ]Yes [ ]No If yes provide number and name(s)of food vendor(s) VC I L[a-V Updated 8/7/2018 vv� ein,� Suffolk County permit#(s) Will other vendors be on the premises during the event? [A Yes [ ]No If yes how many? � Describe Type of vendor(s)DSoVI VId - M(/1[�-PASO W1�I�I 0 L Se I� s 10 Fa VV(G(,V11- 4MA H1 V'u V11`1 Q rc ill �In ie( Property Owner(name/address): C 1 sCA �aV1lFeL�ff II � Contact Person and Contact e-mail address vyi o[-�`-( t) V-oS cy l L' l 1 "y C vA(?y a(,d S • two vvi Event Location: Street-Hamlet Address: V H [ [ ( 1 VA C �_o o D ® VC" V I U VL 12 SCTM# Mailing Address to Send Event Permit to: �� 1-1 ( � 1 1C l V1 Have any of the development rights been sold to the Town of Southold[ ] 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 Parking/Event 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 i (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 inspections necessary in connection with this Special Event. i �VAe seg t---v-a,V1 Print name of Owner Signature of Owner n VA dQ ��_{� ( UVVV V-L— Print name o Authorized Person/Representative Signature f uthorized Person/Representative PERMISSION IS HEREBY GRANTED, SUBJECT TO THE FOLLOWING CONDITIONS: i 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. I 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. j 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, tent(s) or temporary structure(s), or temporary 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, ingress/egress/access, tents or temporary structure(s), or temporary sanitary facilities shall be conducted on Suffolk Count Purchase of Development Rights land without a permit issued by the Suffolk County Farmland Committee. 11. Issuance of this permit does not authorize in any manner the occupancy of any building exceeding the legal limitations 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 VIOLATIONS IN CONNECTION WITH THE CONDITIONS LISTED HEREIN WILL TERMINATE THIS PERMIT. APPROVED Town of Southold Resolution Number: Date Issued: Updated 8/7/2018 •r SURVEY OF PROPERTY SITUATEt MATTITUCK Ore on` ffoa TOM OF SOUTHOLD __ -- -�_q•r0'Iq•E8 SUFFOLK COUNTY, NY PA �Y�h0� e ®� ®ve ®aet,r Pvo III r',o ovn SURVEYED 11-5-98 ®� @� \ ° NDD SUFFOLK COUNTY TAX# {� �// • �' �P 1000- 100-4-3 /e CERTIFIED TO. /rOC�s r1� Z�+� I 1 II l i J i BARBARA 5HINN COMMONWEALTH LAND TITLE COMPANY G w a 8 5 NOTES, In u Loa,,-OV, "&/ N ■ MOWINENT FOUL o) D PIPE FOUND n �. LT 1,1"L.I"-1 HEDGE c„ AREA.u•w ACRES <; 17• �� eve • ?�-f'.a�e�vz r�vo N7z• S 720 8 �enlerpn. ti 11 tf CblSlil(SSIOf Y• 'rl,�,��•f h qui 0 u` I N tl Q IL fi v 0 cl `n LDcgx'j E�z �l/.r.>'wre: F e rtit A •s d • i j!, c 5 Tf O7`� �i�e � yafl•r m � 6 N k n o 2010 No 502025 02 JOR L�R, LANONSURVEYOR 6 EAST MAIN STREET RIVERHEAD,N Y 11901 369-8288 Fax 369-8267 GPAf-Hr, :GALE 1"= Inch r'�I 564. 4;00 ca r •yW� _00' - f'�, --»� •y;f..u,v�' ✓ olq •„nw�,r,.I r-, /000-)D?-oS� / 3 - - • I REFERENCE Y 96-270 /J� 5URVEY OF PROPERTY Road TITN SITUATEt MATUCK oregon TOWN, 5OUTHOLD SUFFOLK COUNTY, NY olp�19"8 F SURVEYED 06-16-03 11��9 tS FOUNDATION LOCATION 09-19-2 i FINAL 04-23-2007 1 � SUFFOLK COUNTY TAX� c �� 1000-100-4-3.1 ` 1 f.'OtTIFlIiD TO; $FTIIVN VIIVBYARD LLC0a "®� I - ®� e� = .x I n 6 These two highlighted areas have been convert to parking Q » n v [] a STONEK cz m Q _, c q - V fA x N . 5 �n Orye O c s 27&1A OEGK 9 K a O wrote 3 , orcxz va,�T vt-c VJ eY + pM1y� - T�rb i,a e S67°34'12"W 135.94' �] f f �.✓N�4 7�aTe V�/]2 e4r Gal->iYs'�-o3ssr �7' y 94 Land now or Formerly of: .Ny David Page Barbara Shinn and Town of Southold 56453.85' Land Now or former)u of, p 3 H Farms LLG9a„�ti ••�« 1b CO.�lIF N0TE5: .�...�.��..�. MONUMENT FOUND AREA= 53,016 5F OR 1219 ACRE5 JOHN C. EHLERS LAND SURVEYOR 6 EAST MAIN STREET N.Y.S.LIG NO 50202 GRAPHIC SCALE 1"= 30' RIOWMAD,N.Y.11901 369-8288 Fax 369-8287 REF.1\Compagser.6MsW0SU8-270..M ACC)RV CERTIFICATE OF LIABILITY INSURANCE, DAT E(MWDOIYYIYY) 09/01/2021, 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 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 AaE: EILEEWCUSHMAN GEORGE FORMES jAt9,xg,Ax(1.631-722 4100 FAc'Ne:631,7224500 1116 MAIN'ROAD EMAIL F0 BOX 2336 9p�Ess EILEEN.CUSHMAN@AMERICAN-NATlONAL.COM INSURERS AFFORDING COVERAGE _ NAIC 0 AQUEBOGUE, NY 11931 INSURER A:FARM FAMILY CASUALTY INS.CO. 120 INSURED- 'POUR DECISIONS LLC INSURER B: ROSE'HILL VINEYARDS' INSURER C: 2000 OREGON.RD INSURER D ,MATITUCK,NY 11952 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 MAYBE 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 !NSR ADD B LTR TYPE OF INSURANCE POLICY NUMBER 1tIIDDffYYYY MMIODNYXYY LIMITS A X COMMERCIAL GENERAL LIABILITY X 3102X1587 10131/202010131/2021 EACH OCCURRENCE-FARS 1,DOO;000 Ee�uCAIMS•MADE 7-OCCUR PREM! ES Ee �n _ S 300,000 XX SIM/$2M LIQUOR'LIAB' MED EXP(My one person) •S -10,000 PERSONAL E ADV INJURY I S 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE 5 2,000,000, X POLICY JECT PRO- FLOC PRODUCTS-COMPIOPAGG S 2;000;000 OTHER: g' A AUTOb1OBILELIA0ILITY ' 310105991 01/18/2021 01/1812022 CaMSINEEeOtSINGLELIMIT I g 1,000,000 am ANY AUTO SOMLY INJURY(Per person), I g ALL OWNED, SCHEDULED BODILY,INJURY S AUTOS- X AUTOS (Per acadent) X HIRED AUTOS X AUTOSON-O�NED PROPERdTY-DAMA E S S X X UMSRELLALIAB X OCCUR 3101E3963 10/31/202010/31-/2021 EACH OCCURRENCE i s 3,000,000 EXCESS UAB CLAIMS.M+DE AGGREGATE S -DED•-X I2ETENTlONS' 10 000 Is X WORKERS COMPENSATION 3103W7872 10131/202010/3112021 'U'TUT ETH AND EMPLOYERS'LIABILITY YIN' ANY PROPRIETOR/PARTNER/cXECUTIVE E L.EACH'ACCIDENT S 100,000 OFFICERIMEMBER EXCLUDED? ❑ N I A =E (Mandatory In NH) E L.DISEASE A EMPLOYEE SIt 1 OO OOO D SCR PTION OF Odescribe PERATIONS below _ � E L DISEASE-POLICY-LIMIT S •500',000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES{ACORD 101.Additional Remarks Schedule,may be attached If mor'Space is roqufrad) CERTIFICATE HOLDER AS ADDITIONAL INSURED CERTIFICATE HOLDER 'CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED-BEFORE TOWN OF,SOUTHOL'D THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 53095 RTE 25 ` SOUTHOLD,NY 11971' AUTIIORIZEDR PRESENTATIVE t _ - �`d'C-�C C ��'G-r�tzr� Q 8.2014 ACORD CORPORATION.-'All rights+reserved. ACORD 25(20141011 The ACORD name and.loan are registered marks of ACORD - - C I 2,7 6' ORDER-TO-THE -',au 4.,--- A 4-ga RABANK;N.A. Town of Southold P O Box 1179 Southold, NY 11971 * * * RECEIPT * * * Date: 09/02/21 Receipt#: 286778 Quantity Transactions Reference Subtotal 1 Event Fee rhv1a $150.00 1 Event Fee rhv1 a 1 $25000 Total Paid: $400.00 Notes: Payment Type Amount Paid By CK#2769 $400.00 Pour, Decisions Llc Southold Town Clerk's Office 53095 Main Road, PO Box 1179 Southold, NY 11971 Name: Pour, Decisions Llc 2000 Oregon Road Mattituck, NY 11952 Clerk ID: LYNDAR Internal ID rhvla I 1 7OT9/02/2021 CERTIFICATE OF LIABILITY INSURANCE E(NIMIDDIYYYY) 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 pollcy(les) 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 ondorsement s. PRODUCER NAME CT EILEEN CUSHMAN _ GEORGE FORMES .Wc He,6MI.631-722-4100 _ jyc,_y-oaL631-722-1500 1116 MAIN ROAD E-MAIL EILEEN.CUSHMAN AMERICAN-NATIONAL.COM PO BOX 2336 tNSURERtS)AFFORDING COVERAGE_ NAIC 0- AQUEBOGUE, NY 11931 INSURER A:FARM FAMILY CASUALTY INS.CO. 120 INSURED..�.....a_ _...�..�,.,,._..,.�.,_.,-.,-�.............�...®....., ,-.... INSURER 0: .,._...�..�..� ....._..,____._...,, .,_......w�.n- ____.._. POUR DECISIONS LLC ROSE HILL VINEYARDS INsuRERc 2000 OREGON RD MATITUCK, NY 11952 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, 1�7R� INSURANCE .._—A-1DLt U041- 06LpCYEFF POdUC Y TYPE OF f POLICY NUMBER LIMITS A X COMMERCIAL GENERAL LIABILITY X 3102X1587 10/31/2020 10/31/2021 EACH OCCURRENCE _ I s 1,000,000 CLAIMS•MADE L ,OCCUR :+SEs41,oo encer �'s 300,000 XX SIM/�2M LIQUOR LIAR MLD EXP(An oa.0 parson) s 10,000 ,.. PERSONAL R AOV INJURY is 1,000,000 t GEN L AGGREGATE LIMIT APPLIES PER 9KL4LRAL AGGREGATE S 2.000,00l]-A XI POLBCY PRO I a LOC PRODUCTS- AGG !SS�'^'•'- 2,000,000 71 OTHER Is T �-- A AUTOMOBILE LIABILITY 310105991 01/18/2021 01/18/2022 COMBINEDLIMIT ,s 1,000,000 ..� BODILY INJURY iPer person)-.5--- i ANY AUTO ALL Q:VNED -� SCHEDULED a BODILY INJURY tear acudenq 5 AUTOS WX„. AUTOS --- NON-OWNED PROPERTY DAMAGE i S X HIRED AUTOS X AUTOS lk'4Sa�GrJIl _ — X !X I UMBRELL.ALIAB X OCCUR 3101E3963 110/31/202010131/2021 EACHOCCURRENCE ;$ 3,000,000 J EXCESS LIAR CLAIMS-MADE I -AGGREGATE DEDX RETENTION 5 10 '000 s X WORKERS COMPENSATION3103W7872 10/31/2020 10/31/2021 ___ 's 872 _.. ORH _ AND EMPLOYERS'LIABILITY ANYPROPRIL-TOR)PARTNER4:XECUTIVE YIN EL EACH ACCIDENT I.g_ 100,000 OFFICERiMEMBER EXCLUDED? E N f A - (Mandatory in RH) E L,DISEASE-EA EMP LOYEEI: 100,00 Iles,describe under DESCRIPTION OF OPERATIONS below E,L DISEASE-POLICY LIMIT 4J00,00� I DESCRIPTION OF OPERATIONS I LOCATIONS)VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) CERTIFICATE,HOLDER AS ADDITIONAL INSURED EVENT OF OCTOBER 15,2021 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TOWN OF SOUTHOLD THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS 53095 RTE 25 SOUTHOLD, NY 11971 AUTHORIZED REP E NTATIVE _ f ['eai — I ©19 19WO14 ACORD CORPORATION. All rights reserved. ACORD 25 120141011 The ACORD name and loco are reoisterod marks of ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MMIOplYYYY) 6� 1 09/02/2021 THIS CERTIFICATE IV 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 pollcy(los) 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 cortlficate does not confor rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT 11AryE.'_- EILEEN CUSHMAN __ GEORGE FORMES PHO_Wc.Mq,Eu1.631-722-4100 I lac.Noi:631-722 4500 1116 MAIN ROAD _A qi;F;s,EILEEN.CUSHMANC@AMERICAN-NATIONAL.COM PO BOX 2336 _ INSURER- AFFORDING COVERAGE NAICN AQUEBOGUE, NY 11931 INSURER A:FARM FAMILY CASUALTY INS, CO. 120 INSURED INSURER B; POUR DECISIONS LLC `— ROSE HILL VINEYARDS INSURER C: 2000 OREGON RD INSURER 0: MATITUCK, NY 11952 1NSURERRER Ems_ INSURER F: I 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. IN&R TYPE OF INSURANCE I ODT�S�IBRtunnI POLICY NUMBER RPiM,Do(YEFF 'OL01 pY I LIMITS X COMMERCIAL GENERAL LIABILITY X 3102X1587 10/31/2020 1013112021!EACH OCCURRENCE S 1,000,000 A (TMAGr YO RENTED CLAIMS-MADE ❑OCCURp>3F,h�� $(EO oncurcenceL $ 300,000_ XX $1 M1$2M LIQUOR LIAB MED EXP(Any one Person) S 10,000 PERSONAL E ADV INJURY $ 1,000,000 GEN L AGGREGATE LIMIT APPLIES PER §§( GENERAL AGGREaATE S 2000,000 X POLICY PRO- LOC ; PRODUCTS.COMPIOPAGG S 2,000,000 dECT OTHER S OMBINUU SINGLE LIMIT A, AUTOMOBILE LIABILITY 310105991 01/18/2021 01/1812022.0 — i�_ 1,000,000 e ar:ClrleCFtl ANY AUTO BODILY INJURY(Pe(person) S ALL OWNED SCHEDULED BODILY INJURY(Pet acciceno $ IIIAUTOS X AUTOS "ON-0"A`NED PROPE RTY DAMAGE _ i P r..sTCSS�RLl1? X HIRED AUTOS X I AUTOS17 -- r S X X UMBRELLA LIAB I X OCCUR 3101 E3963 1013112020 10/31/2021 EACH OCCURRENCE3 _ W 3,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE _ $ DED I X RETENTIONS 10,000 3 X WORKERS COMPENSATION 3103W7872 10!31!2020 10131!2021 STf�T aT I SRH- _ _ AND EMPLOYERS'LIABILITY �r� I��" ANY PROPRIETORrPARTNERrE%ECUT{Ve YIN EL EACH A CCIDENT i 100.000 OFRCERIIJEMBEREXCLUDED? NIA (Mandatory In NH) E L DISEASE•EA EMPLOYEE S 100,000 Ityyas,Cescnbe under E L DISEASE.POLICY LIMIT 3 500,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attachod It mora space Is required) CERTIFICATE HOLDER AS ADDITIONAL INSURED EVENT OF DECEMBER 17,2021 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TOWN OF SOUTHOLD THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 53095 RTE 25 SOUTHOLD, NY 11971 AUTHORMEDREPR NTATIVE ©1988 14 ACORD CORPORATION, All rights reserved. ACORD 25(20141011 The ACORD name and loan are roaistered marks of ACORD ACO)RO CERTIFICATE OF LIABILITY INSURANCE P ATE(MM1DDrfYYY) �./ 09/01/2021 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 pollcy(ies) 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 ondorsement(s). PRODUCER CONTACT -AME: EILEEN CUSHMAN GEORGE FORMES E PHON631-722-4100 FaxX PHONts,.yace �• iANe):631-722-4500 1116 MAIN ROAD B.MAIL PO BOX 2336 eQlalis _s•EILEEN.CUSHMAN@AMERICAN-NATIONAL.CO(M INSURER(SjAFFORDING COVERAGE P NAIC 0 AQUEBOGUE, NY 11931 INSURER A:FARMFAMILYCASUALTY INS.CO _ I 120 INSURED � INSURER B: POUR DECISIONS LLC -INSURER C - ROSE HILL VINEYARDS INSUINSU - 2000 OREGON RD INSURER D: MATITUCK, NY 11952 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.(- tLTRi TYPE OF INSURANCE 11 OL�WVn POLICY NUMBER MLOVLDDIYYYFY MMIBOIYY P I LIMITS t X COMMERCIAL GENERAL LIABILITY X 3102X1587 10131120201013112021 EACH OCCURRENCE 5 _1,000,000 A - �7�Ge Yb F2EN7ED ._.__-1,0_00 . 300,000_ CLAIMS occuR ?Bl MLS s E vsturt��1_ = _ _0 XX $1M1S2M LIQUOR LIAB _MEO EXP JA V on.RaL-, __ n) IS _ __ 10,000 �—I PERsoNAt,a ADV INJURY !S � 1,0_00,000_ i_CaE."I L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE 5 µ_ 2,000,000 _ I PRO- PRODUCTS-COMPlOP AGG S 2,000,000 i X POLICY LL_�....__. JECT LOC .g OTHER t 0`ABYNeD SlNGtE LIMIT A AUTOMOBILE LIABILITY 1 31010599101/18/2021 01/1812022 r�n��:den,1 I S 1,000,000 ANY AUTO BOD,LY INJURY(Pit'Person) ALL O.%'NED SCHEDULED BODILY INJURY(Per!-,118n11 AUTOS XNOAUTOS O'NNED PROPERTY DAMAGE X HIRED AUTOS X AUTOS tEgt aCddent) # 5 X X U►dBRELLA LIAB X occuR 3101 E3963 10/31/2020 10/31/2021 EACH OCCURRENCE s 3,000,000 7 EXCESS LIAB I I CLAIMS-MADE AGGREGATE S DED I X I RETENTION$ 10,000 X WORKERS COMPENSATION 3103W7872 10/31/2020�110/31/2021 STATl1TE, �RH AND EMPLOYERS'LIABILITY YIN ANY PROPRtETOR�aARTNERlEXECUTIVE E L EACH ACCIDENT $ 100,000 OFFICE EXCLUDE! N I A DIS 100,000 I(MandatoryInNH) _ E 1 W_ Jif yyes descrICe unset E L DISEASE•POLICY LIN.IT 5 -SDO,ODO 1 DESCRIP710N OF OPERATIONS below k DESCRIPTION OF OPERATIONS I LOCATIO14S I VEHICLES(ACORD 101,Additional Rcmarhs Schedule,may be attached If mora bpaee is required) CERTIFICATE HOLDER AS ADDITIONAL INSURED CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TOWN OF SOUTHOLD THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 53095 RTE 25 SOUTHOLD, NY 11971 AUTHORIZED R PRESENTATIVE �' LES l �Cr"L-rnl,�•ry� @1"8-20114 ACORD CORPORATION. All rights reserved. ACORD 25(20141011 The ACORD name and Joao are realstered marks of ACORD i Rudder, Lynda From: Rudder, Lynda Sent: Thursday, September 2, 2021 1:54 PM To: Mirabelli, Melissa; Noncarrow, Denis Cc: Dinizio,James; Doherty,Jill; Doroski, Bonnie; Ghosio, Bob; Louisa Evans; Nappa, Sarah; Neville, Elizabeth; Norklun, Stacey; Rudder, Lynda; Russell, Scott; Standish, Lauren; Tomaszewski, Michelle; Burke, John; Duffy, Bill; Hagan, Damon Subject: rhv1a application Attachments: rhv1 a_20210902134936.pdf Your message is ready to be sent with the following file or link attachments: rhvla_20210902134936.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