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HomeMy WebLinkAboutNorthforker Wine & Food Classic ! //� atm/r-,,1,/ (5) �o�OSUFFo(,��OGs RECEIVED o � o ® JINN 2 3 @22 L tho Id Town Clerk TOWN OF SOUTHOLD Town Code Chapter 205 "Public Entertainment and Special Events" SPECIAL EVENT PERMIT INSTRUCTIONS AND APPLICATION FORM Applications for a Special Event Permit are subject to an inter-departmental coordinated review by the Southold Town Board,Town Attorney,Town Assessors,Land Preservation,Building,Planning,Zoning Board of Appeals and Police Departments, and the Suffolk County Planning Commission. Ap c i'on 'fe WK 100 er app$ , Up to six (6) multiple events of the same type, occurring over a period of three months,may e permitted on one(1) application for a fee of$150.00. However, specific details of each event must be included with this application. All applications must be submitted at least 60 business days before the event. Applicants are encouraged to submit applications as early as possible. Any completed application that is not submitted 60 or more business days prior to the scheduled event may be rejected or subject to a late processing fee of$250.00 by the Office of the Town Clerk, unless a waiver is obtained. Requesting an expedited review must be submitted in writing to the Town Clerk.The Town Clerk will forward all applications to the Special Events Committee for processing. The Committee will obtain comments on all applications from relevant Town, County and/or State agencies and will forward completed applications to the Town Board with a recommendation as to whether to grant or deny the application. The Town reserves the right to request additional information from an applicant to address issues related to the health, safety, and welfare of the community. When is a Permit Required? All Special Events,per Southold Town Code Article I, Section 205-2 (Definitions)must obtain a permit. Occasional events on private residential properties hosted by the owner thereof that are by invitation such as family gatherings, weddings, graduations, parties or not-for-profit fundraisers do not require permits. Any use of residential proper1y for profit, such as a venue for weddings or other events is prohibited. This application is deemed complete once all the following requirements are submitted to the Town Clerk: Please indicate submission of the followingby checking off the boxes and signing below. VA completed application form signed by the owner and the event manager. Applications without property owner's signature/approval will be rejected. 7E: Is the application being submitted at least 60 days before the event[�es [ ]No If Yes,Fee of$ �� has been submitted If No, Fee of$ has been submitted Updated 8/7/2018 VIThe applicant/owner of the property where the special event is proposed to take place must provide a certificate of insurance not less than 2 million dollars naming the Town of Southold as an additional insured A Parkin /Event Plan: consisting of a survey, site plan and/or aerial view of the subject property that Parking/Event g Y� p J p P tY includes the locations of on-site parking, sanitary facilities, and tents or other temporary structure(s). See application form for details) Events for three hundred (300) or more people require submission and approval of a traffic control 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. -a2 � 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 WILL NOT be reviewed. Special Event Permit## Applicant(s)name: Date of Submission 6' Name of Event Nbk+h� R�inav Arld FMd DQ;!SS1C SCTM#'s 1000-Section i O 0C) Block- `Z.,OC) Lot(s) I B(a=J`J Dates of Each Event: �'hu25� If Multiple Dates are requested,applicant must give all information for all dates. Nature of Event: Q. lot-ml �,N np� QZXZ6 � CA (Please attach a detailed description of EACH event to this application) Time Period(Hours)of Event: From to l l PM Town Services requested: §C)Yes ( )No If yes, Describe Police Dept._Highway Dept. Describe Servicesqrr- �c� Qssls��c fold nY1 i�\\�•j�, v�i� CS�1�-Rs�1 Maximum Number of Persons Attending At One Time:i�Number of cars expected ' Q Is a Tent or other temporary structyre being used? [ Yes [ ]No If yes provide size(s) Will food be served?[ Yes [ ]No If yes provide number and name(s)of food vendor(s) cig=e Updated 8/7/2018 7raCO��Gf�N/f�� //OwS' Suffolk County permit#(s) Qp)cs__'� Will other vendors be on the premises during the event?[V]Yes [ ]No If yes how many? $- 1 C Describe Type of vendor(s) CC.QI t__►nE aL`j-Z�S Property Owner(name/address): G_1 w Q(1C11G�e��' Contact Person and Contact Tel.# t =, r-�Et� �A �`��- s?_cr � e-mail address S(`( 1/ 'r\na mts9'L%k %;_az o CL�YI Event Location: Street-Hamlet Address: SCTM# ( - _ 2 Mailing Address to Send Event Permit to: —�-l�L� I !V l� •� �Ct�2 Have any of the development rights been sold t the Town of Southold[ ] Yes [/No and/or Suffolk County Agricultural Program? [ ] Yes VNo 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 ineans of ingress and egress for such parking areas. The parking spaces must allow for 300 sq. ft. per car. (9) A traffic control plan for vehicles entering and leaving the site for the proposed event. (10) Plan for the use of live outdoor music, loudspeakers and other sounds which will be used, if any, and the type and location of speakers and other audio equipment. (11) A description of emergency access and facilities related to the event. (12) Provisions to dispose of any garbage,trash,rubbish or other refuse. (13) Location and description of any additional lighting to be utilized in conjunction with the event. Updated 8/7/2018 (14) Location of sanitary facilities on site. Traffic Control Plan Events for three hundred(300) or more people also require submission and approval of a traffic control plan, acceptable to the Town of Southold,AND a qualified traffic controller must be provided. Please attached a written description and/or notate on the parking event plan the following: 1)Who will be conducting traffic,2)Where they will be stationed on site, 3)How they will direct the entrance, circulation,parking, and exiting of cars on site, and 4) Contact information for use by Southold Town Police. OWNER'S SIGNATURE: I am the Owner of the Property where this event is to be held and I agree to comply with the laws, rules, regulations, conditions, and requirements of the Code of the Town of Southold, including but not limited to the conditions listed below, as well as all other applicable agency rules and regulations pertaining to the activities under this event. Furthermore,I hereby swear or affirm that the information contained herein and attachments hereto are true and correct to the best of my knowledge, and agree to provide notice to the Town immediately should there be any material changes regarding to this application. . Furthermore,I hereby authorize Code Enforcement Personnel of the Town of Southold to enter the property during the hours of the permitted special event to make any and all inspections necessary in connection with this Special Event. J 1<_Oyl�njlt7i Iscor'll/tese— Print name of Owner Si a e of Owner � l/eN/ 96/(�m/cA/ A4__O� Print name of Authorized Person/Representative Signature of Authorized Person/Representative PERMISSION IS HEREBY GRANTED, SUBJECT TO THE FOLLOWING CONDITIONS: 1. By acceptance of this permit, applicant agrees to adequately supervise and direct all parking to be on the premises or at another site, and to provide parking assistants and any additional traffic controls necessary for this event. Parking is strictly prohibited on ANY Town, County or State Roads or Rights of Way- 2. Traffic control at events for three hundred(300)or more people shall be provided by a qualified traffic controller in accordance with the attached, approved traffic control plan. 3. One "on-premises" sign not larger than six (6) square feet in size may be displayed not longer than thirty (30) days before this event, and removed immediately after the event. Directional parking signs shall be adequately displayed. 4. Applicant indemnifies and holds harnfless the Town of Southold from all claims, damages, expenses, suits and losses including but not limited to attorney's fees arising from activities under this permit. 5. Tent proposals must receive permit approval from the Southold Town Building Inspector before placement on the property and must meet all fire and safety codes. 6. This permit is valid only for the time, date, place and use specified above, and for the designated event. Each additional day will require a separate permit application, fee, and related documents for review,etc. at least 60 business days prior to the scheduled event. 7. Adequate temporary sanitary facilities must be provided by applicant for this event and applicant agrees to remove the temporary facilities from the premises within 48 hours after the day of the event. Updated 8/7/2018 8. On-site food preparation is NOT permitted, although food may be catered subject to all Suffolk County Department of Health regulations. 9. NO activities associated with this event, including but not limited to parking, ingress/egress/access, tent(s) or temporary structure(,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 tent(s) or temporary structure(s) or temporary sanitary facilities shall be conducted on Suffolk County 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 inust 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 Town of Southold 53095 Route 25 PO Box 1179 Southold, NY 1197 631=765-1800 To Whom It May Concern: Please find enclosed an application for a Special event permit from the Times Review Media Group. We would like to hold the 1St Annual Northforker Wine & Food Classic at Borghese Vineyard on Thursday, September 111, 2022 and hereby requests permission from the Town of Southold for the special event. Times Review Media Group is putting on this event to celebrate all things local on the North Fork and we will be supporting the Eastern Long Island Hospital Foundation and they will receive a part of the proceeds from this event. Please find enclosed the following materials: 1. Special Event Permit Application including supporting materials 2. Additional 'End to End" information about the event pre, post, and during. 3. Larger images of the setup and entry/parking flow Our tent company, NY TENT,will be processing the Tent Permit separately for the tent used for the event. Grace & Grit will be coordinating supplying the liquor license. We thank you very much for considering our application. Please do not hesitate to contact me at 631.520.8063 if you require additional information. We are truly looking forward to this wonderful event which will help support local businesses and ELIHF. Sincerely, Steven McKenna SMcKenna@TimesReview.com Vice President,Times Review Media Group -•W: rn '�, /r°-^ ` �`*' , V!C -T H#omm olillri, - .. � i � � �q3 jam- ,�•�� r'rss"�,,•a - a� Bomhese V r icy Y.- r- vr f,/,✓'f��'} LFI >`'��J J 'Z ,. �rj' FjJ •y6r e •a i Forms �r_ ♦'�` y��`y 1 t �;'.� '1 _i lam`a � Y Ilk V" �'*,�'�^���'� ,�tic Y� ,<-, ��♦t11`,, ,, OI sNS �`��`�! 'a�.�_•'\ %" � „�^r 4,4 ir 40-" Y^'+ EU Ir * Iia. r ✓ si ♦ .htf� ��G ogle ✓ sf�! ®c yP" �: Alp �3 A `��.R trr}- `Y L Ire' ` t.: �S. •` _ ,-^` r'r. `QarRY�i•.,• /�QatW Vo�5� -'y� f Y+ .�. . Property is � '� .%„fir • ,(�r� 275'X 400, '1♦`�ht � �� �� � � ` ` �! _ ° y 2� Fac. •� +tr rY+F t 1 J w M1y h \ a `� �`\\,\ 'i tom\ � \� �••.. - 1 �'s�} y `t� �� �. ��b. `' �4� �F�*�""7� 2,, `4 t��. ��. , \^t��`4��� � S'�w.� -fGoo jle S-�r t t ''t � �`\ �W'l• � �t7Nir ,1 Y._�\ L. •.�'F...��-i.���^� �+ „O'MI OATGouR�e.Mtvictr'A:'t LLvv.ir[MA3Oe11kw Yi,1�CS WG GJCMI UYSCUI[!s TMM ftt/hY .`wvtl kvm k 'All. 3. Tenting The Times Review Media Group will have a 60'x160' tent for the event. The tent will be provided by NY Tent and installed by NY Tent two days prior and removed the day after the event. NY Tent will apply for the Tent Permit. M=Vendor Tables 60' X 160' Tent - open no side panels �� =Fire Extinguishers Main Entrance/Exit r S .q U Li Stage Band Speakers .q .a Q 4. Power&Lighting The Times Review Media Group will use Ocean Electric for the event generator that will power all of the event needs. We will use Shadowbox for lighting and sound.They will make sure to provide the following safety lighting: Exit Signs and Emergency Lighting(in tents as required by Fire Marshall Rules).There will be NO search lights,strobe lights, laser lights or revolving lights at the event.They will provide downward facing spotlights for the parking lot and string lighting within the tent. 5. Details for Refuse Removal and Provisions for Sanitation Facilities The Times Review Media Group will order a 20-yard dumpster from National Waste Services to be on-site at for refuse removal.We will also have 20-30 trash bins on-site to place around the venue for garbage.All garbage,trash and recycling will be disposed in the dumpster.Americart L.I. will be providing self-contained bathroom trailers as well as a ADA compliant bathroom. Grace & Grit will have attendants during the event for refuse removal. The dumpster will be delivered on Tuesday, August 30th and picked up on Friday, September 2nd 6. Security Plan The Times Review Media Group will use Platinum Executive Security, a Mattituck company that is familiar with Borghese Vineyard &the North Fork.There will be 4 security guards on-site and 1 supervisor.There will also be one overnight security guard on Wednesday,August 31St 7. Medical/Emergency Plan& Personnel All medical emergencies will be reported to Police, EMS, or event personnel as soon as possible either in person or via phone. Event personnel, when notified, will call directly to 911 or notice onsite EMS and Police and report the incident/problem. Responding emergency vehicles will have unrestricted &expedient access to the location of any emergency.The onsite person in charge will make sure an area is open to allow emergency personnel,vehicles and equipment to access the event grounds whenever emergency assistance is needed and this shall be maintained throughout the event. All onsite event personnel, event coordinator, EMS, fire and police personnel will have a means of communication during the event.This will be accomplished by cell phones and supplied portable radios as well as announcements made on the PA system. . tar•.tS'� y - �I ff � / •••i y�,� �_ ,S� , i � 7,� f: f »•dQy�l,a,yt�F•. f � .1._f ;•v`� 1, � L.-, ` !• 'i a; Fx y f� ' T.. . { �Y..r• � I. ; + r - y Sfr rF� `�i r. y�y, r,,•��� .t' r _ ,�'''' •„r.` \,� ,t^ f .� T. .j'_� � j r.7 4 rr - i� �, ~;� i{,, , �.� � .er �,`.i: Qa�t '.��\C\��e� � � � '! `/ j�� fr�'�'�� •- j +`� rt .:f -.: '` f tf r. 'g'•�-.`�� r - \'�� r •� w'� 4_ ^.y>Qea���M�y . .. « � �~ �- _ '�Qrr"3�kfr-�� �1 T~ ., J ��-.ry!•r���a Property is `k 275' X 400' r •� r ,``s`'.5,.��v.`,',T,i.� `.� ,i� �` *'4 -�{..:. � w' "S• Y "ro"�[ �'�e wj� P C '� �'�d'."`.i. t'r' '�.�^ +.� +'�'},y A� ` tel`\'r 4#t``y�'�� i"��M,�••.�S',1'.1�,�� �r'4' -2' f , `� f .'�. ��}., ��'`�-` ,�•4 '+�• �-;'. SA �N4 Nl�1* NX y �y •- • c„ "4te` •. „•j_ -! - '. .R`� r '„� yr.�:� �`�.\ any "`a % lit a ♦ `fir 'h. ^R `�' `• #. �a t4+� � �t,,,�= �' .\�, ,` •�`'c' ��� <� •�. .� - �' /'� .,�. r � "� �'�.��, �'-1 j� a��,,•�� `y, ` any,,�y�. �� 2D,4'7 IN Ni- 17 z• _ w * +. `�`. :• { S� - -may ,.'•l+ , + a� \ It i '.-�'` �`'' ttr'w•k\",. ��' '•`'' �'�, `S�a'- as`k3— Google aY�' rr \ "L_•^' \ _''rC4 {'" � ® i` ��, •. g' ' �, r' 4• •-�'L Imageryj®2022 G le.Imaom®2022 Maxxx Technol ies Ncw York GIS,Madata02022 United des -`Send feedback 50 ft.�- "- « S...,z3.4 aiu"1'u3aifi• �.�f �l �'�a � °1 Z' �, \\�'�4�� k\�"" � /r OF N .> 411eaH aw0H'a1eam*. ®=Vendor Tables 60' X 160' Tent - open no side panels =Fire Extinguishers Main Entrance/Exit IN fr S EXIS ageBandT ® � ® � Speakers A`R ® CERTIFICATE OF LIABILITY INSURANCE FDATE(MM/DDIYYYY) 06/22/2022 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). PRODUCER CONTACT NAME: MM—Short Term Special Events K&K Insurance Group,Inc. PAHi°Nr o Ext): 1-877-648-6404 (AAic,No): 1-260-459-5502 1712 Magnavox Way E-MAIL Fort Wayne IN 46804 ADDRESS: info@eventinsurance-kk.com PRODUCER CUSTOMER ID: INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURERA: Markel Insurance Company 38970 Times Review Media Group INSURER B: PO Box 1500 INSURER C: Mattituck,NY 11952 A Member of the Sports,Leisure&Entertainment RPG INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: W02230333 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. INR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD WVD MMIDD MM/DD/YYYY A X COMMERCIAL GENERAL LIABILITY X MIRPG0000000017400 09/01/2022 09/02/2022 EACH OCCURRENCE $1,000,000 CLAIMS- OCCUR 12:01 AM EDT 12:01 AMRE MADEFXI PREMISES Ea Occurrence $1,000,000 MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 X Host Liquor Liability Included GENERAL AGGREGATE $5,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS—COMP/OP AGG $1,000,000 POLICY ❑PRO ❑LOC PROFESSIONAL LIABILITY JECT OTHER: BODILY INJURY TO PARTICIPANTS AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident ANY AUTO BODILY INJURY(Per person) OWNED AUTOS B SCHEDULED ONLY AUTOS BODILY INJURY(Per accident) HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY Per accident NOT PROVIDED WHILE IN HAWAII UMBRELLA LIAB OCCUR EACH OCCURRENCE EXCESS LIAR CLAIMS-MADE AGGREGATE DED RETENTION WORKERS COMPENSATION AND N/,4 PER OTHER EMPLOYERS'LIABILITY UTELI ANY PROPRIETORIPARTNER/ YIN E.L.EACH ACCIDENT EXECUTIVE OFFICER/MEMBER ElEXCLUDED?(Mandatory in NH) E.L.DISEASE—EA EMPLOYEE If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE—POLICY LIMIT MEDICAL PAYMENTS FOR PARTICIPANTS PRIMARY MEDICAL EXCESS MEDICAL DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Event Name:Northforker Wine and Food Classic;Event Date:09/01/2022 to 09/01/2022;#of attendees:600 Event Location:17150 Middle Rd,Cutchogue,New York 11935 Liquor Liability(as provided by CG 00 01 04 13)applies only if the insured is not in the business of manufacturing,distributing,selling,serving or furnishing alcoholic beverages. The certificate holder is added as an additional insured,but only for liability caused,in whole or in part,by the acts or omissions of the named insured. CERTIFICATE HOLDER CANCELLATION Town of Southold SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 53095 Route 25 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Southold,NY 11971 ACCORDANCE WITH THE POLICY PROVISIONS. (Owner/Lessor of Premises) AUTHORIZED REPRESENTATIVE Coverage is only extended to U.S.events and activities. "NOTICE TO TEXAS INSUREDS:The Insurer for the purchasing group may not be subject to all the insurance laws and regulations of the State of Texas ACORD 25(2016/03) @ 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: M1 RPG000000O017400 COMMERCIAL GENERAL LIABILITY CG 20 26 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Persons Or Organization(s) Town of Southold 53095 Route 25 Southold,NY 11971 Named Insured: Times Review Media Group Information required to complete this Schedule, if not shown above,will be shown in the Declarations. A. Section II—Who Is An Insured is amended to include B. With respect to the insurance afforded to these as an additional insured the person(s) or organization(s) additional insureds, the following is added to Section III shown in the Schedule, but only with respect to liability —Limits Of Insurance: for "bodily injury", "property damage" or "personal and If coverage provided to the additional insured is required advertising injury" caused, in whole or in part, by your by a contract or agreement, the most we will pay on acts or omissions or the acts or omissions of those behalf of the additional insured is the amount of acting on your behalf: insurance: 1. In the performance of your ongoing operations; or 1. Required by the contract or agreement; or 2. In connection with your premises owned by or 2. Available under the applicable Limits of Insurance rented to you. shown in the Declarations; However: whichever is less. 1. The insurance afforded to such additional insured This endorsement shall not increase the applicable only applies to the extent permitted by law; and Limits of Insurance shown in the Declarations. 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. CG 20 26 0413 ©Insurance Services Office, Inc.,2012 Page 1 of 1 MARKEL INSURANCE COMPANY MARKEL° MEMBER CERTIFICATE CERTIFICATE NUMBER: W02230332 DATE: 06/22/2022 THIS CERTIFICATE REPRESENTS INSURANCE PROVIDED IN ACCORDANCE WITH THE FOLLOWING: MASTER POLICY NUMBER: M1 RPG000000O017400 FIRST NAMED INSURED(MASTER POLICY HOLDER): Sports, Leisure and Entertainment Risk Purchasing Group IN RETURN FOR THE PAYMENT OF THE PREMIUM AND SUBJECT TO ALL THE TERMS OF THE MASTER POLICY,WE AGREE TO PROVIDE THE INSURANCE AS STATED IN THIS CERTIFICATE. NAMED INSURED(CERTIFICATE HOLDER) Name and Mailing Address (No., Street, Town or City, County, State, Zip Code): Times Review Media Group PO Box 1500, Mattituck, NY 11952 Effective Date: 09/01/2022 at 12:01 AM EDT Expiration Date: 09/02/2022 12:01 AM This replaces prior Certificate Number: Plan Administered By Insurer K&K Insurance Group, Inc. Markel Insurance Company 1712 Magnavox Way 10275 West Higgins Road, Suite 750 Fort Wayne IN 46804 Rosemont, IL 60018 Contact Information Producer Name And Mailing Address Name: MM—Short Term Special Events K&K Insurance Group, Inc. Phone 1-877-648-6404 1712 Magnavox Way Fax: 1-260-459-5502 Fort Wayne IN 46804 Email: info@eventinsurance-kk.com To Report A Claim By Phone: 1-800-237-2917 By Fax: 1-312-381-9077 By E-mail: KK.Claims@kandkinsurance.com By Mail K&K Insurance Group, Inc. 1712 Magnavox Way P.O. Box 2338 Fort Wayne, Indiana 46801 Online: www.kandkinsurance.com MCGL 1002 07 21 Page 1 of 3 Description Of Operations, Premises, And Operations Description Of Operations: Event Name: Northforker Wine and Food Classic; Event Date: 09/01/2022 to 09/01/2022; #of attendees: 600 Event Location:17150 Middle Rd,Cutchogue,New York 11935 Liquor Liability(as provided by CG 00 01 04 13)applies only if the insured is not in the business of manufacturing,distributing,selling,serving or furnishing alcoholic beverages. Premises And Operations: Location No. Address Operations Refer to coverage form MGL1578 Limits of Insurance Commercial General Liability General Aggregate $5,000,000 Products/Completed Operations Aggregate $1,000,000 Personal And Advertising Injury $1,000,000 Any One Person or Organization Each Occurrence $1,000,000 Damage to Premises Rented To You $1,000,000 Any One Premises Medical Expense $5,000 Any One Person Additional Coverages In addition to the Commercial General Liability coverages shown above, the following additional coverages are provided. If a coverage is not listed below, such coverage, including its corresponding endorsement, does not apply to this Member Certificate. Limit Of Insurance Endorsements Forms and endorsements applying to this Member Certificate and made part of the policy at time of issue: Refer to master policy including all state amendatory endorsements applicable to the state of this Member Certificate This Member Certificate, together with the Coverage Form and any Endorsement(s) attached to the Master Policy, complete the above numbered certificate. Coverage is subject to all terms, conditions, limitations, exclusions, and other provisions contained therein. Member Certificate Premium Commercial General Liability Premium: $415.00 MCGL 1002 07 21 Page 2 of 3 To review the Master Policy: Please send a written request to the Plan Administrator shown above. Countersigned: 06/22/2022 By: Date AUTHORIZED REPRESENTATIVE MCGL 1002 07 21 Page 3 of 3 Town of Southold P.O Box 1179 Southold, NY 11971 * * * RECEIPT" Date: 06/23/22 Receipt#: 301740 Quantity Transactions Reference Subtotal 1 Event Fee 1 $150.00 Total Paid: $150.00 •Notes: Payment Type Amount Paid By CK#30389 $150.00 Times, Review Southold Town Clerk's Office 53095 Main Road, PO Box 1179 Southold, NY 11971 - Name: Times, Review P.o. Box 1500 Mattituck, NY 11952 Clerk ID: DENISN Internal ID: 1 Noncarrow, Denis To: Mirabelli, Melissa Cc: Rudder, Lynda Subject:. Special event from Times Review Attachments: Times Review event_20220623101647.pdf Thanks! Denis Noncarrow Southold Town Clerk. Town of Southold, New York www.southoldtownny.gov denisn@southoldtownny.gov 631-765-1800 CONFIDENTIALITY NOTICE: This communication with its contents may contain confidential and/or legally privileged information. It is solely for the use of the intended recipient(s). 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