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Mattituck-Cutchogue Athletic Booster Club Shamrock Shuffle 5K
Southold Town Board- Letter Board Meeting of January 17, 2023 RESOLUTION 2023-106 Item# 5.11 ADOPTED DOC ID: 18812 THIS IS TO CERTIFY THAT THE FOLLOWING RESOLUTION NO. 2023-106 WAS ADOPTED AT THE REGULAR MEETING OF THE SOUTHOLD TOWN BOARD ON JANUARY 17,2023: RESOLVED that the Town Board of the Town of Southold hereby grants permission to G , attituck=Cutcicaethletie Booster Club to use the following route for its '�2S3�.S'haroek hu e x e SSI on Sunday, `Parch 19, 2� d3: b egrinninIZ on the eastern side of Tasker Park on Carroll Avenue, right onto County Road 48, right onto Old North Road (a_Wesnofske Farms, right onto Ackerly Pond Lane, right onto Mower Road, right onto Route 25 to the finish at Greenport Brewery,provided they follow all the conditions in the Town's Policy for Special Events on Town Properties. The fees have been waived for this event with the exception of the clean-up deposit. IL 9 Denis Nonearrow Southold Town Clerk RESULT: ADOPTED [UNANIMOUS] MOVER: Brian O. Mealy, Councilman SECONDER:Sarah E. Nappa, Councilwoman AYES: Nappa, Doroski, Mealy, Evans, Russell EXCUSED: Jill Doherty Generated January 18, 2023 Page 22 DENIS NONCARROW Town Hall,53095 Main Road TOWN CLERK P.O.Box 1179 Southold,New York 11971 REGISTRAR OF VITAL STATISTICS ; ® Fax(631)765-6145 MARRIAGE OFFICER ��® ®� Telephone(631)765-1800 RECORDS MANAGEMENT OFFICER www.southoldtownny.gov FREEDOM OF INFORMATION OFFICER OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD January 18, 2023 Mattituck Athletic Booster Club c/o Jennifer Nemschick P.O. Box 1241 Mattituck,NY 11952 Dear Ms.Nemschick, The Southold Town Board, at its regular meeting held on January 17th, the Town Board granted permission to the Mattituck Athletic Booster Club to have its 2023 Shamrock Shuffle 5K on Sunday, March 191h, 2023. A certified copy of the resolution is enclosed. An insurance policy naming the Town as additionally insured has been filed with this office. Please be sure to contact Captain Ginas at the Police Department, 631-765-2600, as soon as possible,to coordinate traffic control. Very truly yours, Denis Noncarrow Southold Town Clerk Enc. ELIZABETH A.NE MLLE>1VI10ICR :S � �;`` Town Hall,53095 Main Road f P.O.Box 1179 TOWN CLERK ` Southold,New York 11971 Ma ,..u,; Fax(631)765-6145 REGISTRAR OF VITAL STATISTICS ,sem .�'W �; • , � MARRIAGE OFFICER - r' co Telephone(631)765-1800 RECORDS MANAGEMENT OFFICER ,E�?� www.southoldtownny.gov FREEDOM OF INFORMATION OFFICER "` N }' DECEIVED OFFICE OF THE TOWN CLERK. TOWN OF SOUTHOLD JAN - 6 2023 APPLICATION FOR A PERMIT TO HOLD A Southold Town Clerk SPECIAL EVENT Please n•aviac ALL ol'tltc itiformatiitnt t•ec ttestccl 1�elo�i'. ;lnct�nt Ietc a �ticritiotis�3'I:11L NUT.bi, revie-wed. Date of Submission Name of Event Name of Organization: -MCt fh tuc 1�-, .A-�Lt�G O !,4e-r— C-�U b Is this a Not-For-Profit Event e /No Contact's Name: ,�iA�Lk V- 1 v!'�� C �C Mailing Address: (a� � cry Contact's Phone Number: T . Contact's Email Address; � �-5 (I � �� It rU Yl& - Event Location and Site Diagram: (Use additional paper if necessary) Event Date(s): 311 C1 (Include set up and shutdown times and dates) �d P-cus.e e, Nature of Event: (Please attach a detailed description to this application) Time Period (Hours) of Event: From 15Dto 123 Maximum Number of Expected Attendees: Specify any special requirements(i,e. road closure, police presence): Revised 8/5/15 If a Tent or other temporary structure will be used please contact the Southold Town Building Department at 631-765-1802. Mailing Address to Send Event Permit to: Event Fees: l VvCV Y`L./ $250 for events with less than 1000 expected attendees $500 for events with 1000 or more expected attendees Clean-up Fees (Can NOT be waived): $1,500.00 Clean-up for Bicycle and/or Running Special events(ONLY) $250 or more Clean-up deposit all other events CEl1TI1'ICAT1?O)p'INS URANC ,*:lZE lJ_1HEQ:- Not less than$2,000,000 naming the Town of .Southold as an-,additional insured. ***NOTEi PLEASE SEE ATTACHED DEVISED, ADOPTED TOwI�', POLICY*** Additional information and requirements may be required as deemed necessary by the Town Board. Print name of Authorized Person filling out Signature guthorized Person filling out application application *Upon the request by applicant,the Town Board may waive in whole or in part any of the application requirements. 2 Revised 3/21/16 ellN f�r��, rfj ',Baa x Jo., Lind, ne"s Park k f ,r �''` ' Trerf�er Farms '" Ae 4 .� � � SOWTHOLD GULF Wesnofske Farms z �,� y �3��a yr'F �a. � ,d1�• 4`�i ti+�'�. ,n� � ... b��, �"rr� wr,� ��. �� �n+c ;,-z � m .,� ��t r".��� � �1* � � '�' �t�` � � � �♦ ��. •At�� oke a ms$ow S r •� Ley s Y � 1F M ,=;„+� tv'��' '` rrc C, t,le nStriute, � ti � F � � ��;c� CatapricF,arms, arlD Dairy arrn � ?a� a lattebella virievartls Dart s TreeFarm b ` y�Xfir' "e ,r KeCEXH(rC wF v�$r v fiA,A, t Y �. , G € } ' x Corey Creek Tjap Raamr � .. Ufllte(�, 43te5. '� " DuCkWalkaVrneyards; tPc�s4al Ser�YCCe Kk ,? . . Croteaux Vineyards` �" .� by °,« x De arEfel� Sllb St�ti0l1 a a =Tasker Parks + '�• " " empotanly`elased p k OsprQypiDomi ion � �� Out laid Dag P rk r$ rks� t" a �o, +t "3YylA�ya � " _nYw Al ,GreenporitHarbor Breweryland estauran, mr SouMotu An`irrigStielte54Lr Y A A`"R ® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) 12/14/2022 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: Mass Merchandising Underwriting K&K Insurance Group, Inc. ° E 800-426-2889 FAX 260-459-5105 1712 Magnavox Way E-MAIL o Ext): (A/C,No Fort Wayne IN 46804 ADDRESS: info@sportsinsurance-kk.com PRODUCER CUSTOMER ID: INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURERA: Nationwide Mutual Insurance Company 23787 Mattituck-Cutchogue Athletic Booster Club INSURER B: PO Box 1241 Mattituck,NY 11952 INSURER C: A Member of the Sports,Leisure&Entertainment RPG INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: W02354916 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD WVD MMIDD MM/DDIYYYY A X COMMERCIAL GENERAL LIABILITY 6BRPG0000007787200 03/19/2023 03/20/2023 EACH OCCURRENCE $1,000,000 CLAIMS- ['X]OCCUR 12:01 AM EDT 12:01 AM DAMAGE TO RENTED MADE PREMISES Ea Occurrence) $1,000,000 MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $5,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS—COMP/OP AGG $1,000,000 POLICY ❑PRO- r_1 PROFESSIONAL LIABILITY JECT OTHER: LEGAL LIAB TO PARTICIPANTS $1,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident ANY AUTO BODILY INJURY(Per person) OWNED AUTOSSCHEDULED ONLY AUTOS BODILY INJURY(Per accident) HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY Per accident NOT PROVIDED WHILE IN HAWAII UMBRELLALIAB OCCUR EACH OCCURRENCE EXCESS LIAB CLAIMS-MADE AGGREGATE DED RETENTION WORKERS COMPENSATION AND N/A PER OTHER EMPLOYERS,LIABILITY STATUTE ANY PROPRIETOR/PARTNER/ Y/N E.L.EACH ACCIDENT EXECUTIVE OFFICER/MEMBER F7EXCLUDED?(Mandatory in NH) E.L.DISEASE—EA EMPLOYEE If yes,describe under DESCRIPTION E.L.DISEASE—POLICY LIMIT OF OPERATIONS below A MEDICAL PAYMENTS FOR PARTICIPANTS 6BRPG0000007787200 03/19/2023 03/20/2023 PRIMARY MEDICAL 12:01 AM EDT 12:01 AM EXCESS MEDICAL $25,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Legal Liability to Participants(LLP)limit is a per occurrence limit. Event Name:Shamrock Shuffle Type of Event:Run Distance:5K Event Date(including ancillary events and set-up/tear-down):3/19/2023 to 3/19/2023 Number of Participants:300 Event Location:Tasker Park CERTIFICATE HOLDER CANCELLATION Evidence of Coverage SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 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(2016103) @ 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD AC<:> CERTIFICATE OF LIABILITY INSURANCE 712/14/2022 TE(MM/DD/YYYY) 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 endorsements . PRODUCER CONTACT NAME: Mass Merchandising Underwriting K&K Insurance Group, Inc. PHONE A/c No Ext): 800-426-2889 FAX No: 260-459-5105 1712 Magnavox Way E-MAIL Fort Wayne IN 46804 ADDRESS: info@sportsinsurance-kk.com PRODUCER CUSTOMER to: INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURERA: Nationwide Mutual Insurance Company 23787 Mattituck-Cutchogue Athletic Booster Club INSURER B: PO Bax 1241 Mattituck,NY 11952 INSURER C: A Member of the Sports,Leisure&Entertainment RPG INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: W02354918 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD WVD MMIDD MMIDD A X COMMERCIAL GENERAL LIABILITY X 6BRPG0000007787200 03/19/2023 03/20/2023 EACH OCCURRENCE $1,000,000 CLAIMS- OCCUR 12:01 AM EDT 12:01 AM DA AG TO RENTED $1,000,000 MADE PREMISES Ea Occurrence MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $5,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS–COMP/OP AGG $1,000,000 POLICY F—]PRO- ❑LOC PROFESSIONAL LIABILITY JECT OTHER: LEGAL LIAB TO PARTICIPANTS $1,000,000 AUTOMOBILE LIABILITY COMBINED SGLE LIM T Ea accident ANY AUTO BODILY INJURY(Per person) OWNED AUTOSSCHEDULED 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 NIA PER OTHER EMPLOYERS'LIABILITY STATUTE ANY PROPRIETOR/PARTNER/ YIN E.L.EACH ACCIDENT EXECUTIVE OFFICERIMEMBER ElEXCLUDED?(Mandatory In NH) E.L.DISEASE–EA EMPLOYEE If yes,describe under DESCRIPTION E.L.DISEASE–POLICY LIMIT OF OPERATIONS below A MEDICAL PAYMENTS FOR PARTICIPANTS 6BRP00000007787200 03/19/2023 03/20/2023 PRIMARY MEDICAL 12:01 AM EDT 12:01 AM EXCESS MEDICAL $25,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Legal Liability to Participants(LLP)limit is a per occurrence limit. Event Name:Shamrock Shuffle Type of Event:Run Distance:5K Event Date(including ancillary events and set-up/tear-down):3/19/2023 to 3/19/2023 Number of Participants:300 Event Location:Tasker Park,Carrol Ave, Southold 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 PO Box 117 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: 6BRPG0000007787200 COMMERCIAL GENERAL LIABILITY CG 20 26 04 13 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 PO Box 117 Southold,NY 11971 Named Insured: Mattituck-Cutchogue Athletic Booster Club 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 04 13 ©Insurance Services Office, Inc.,2012 Page 1 of 1 '4COORCERTIFICATE OF LIABILITY INSURANCE 712/14/2022 TE(MMIDDIYYYY) 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 endorsements . PRODUCER CONTACT NAME: Mass Merchandising Underwriting K&K Insurance Group,Inc. PHONE, 800-426-2889 260-459-5105 1712 Magnavox Way AICA No Ext): A/C No Fort Wayne IN 46804 ADDRESS: info@sportsinsurance-kk.com PRODUCER CUSTOMER ID: INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: Nationwide Mutual Insurance Company 23787 Mattituck-Cutchogue Athletic Booster Club INSURER B: PO Box 1241 Mattituck,NY 11952 INSURER C: A Member of the Sports,Leisure&Entertainment RPG INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: W02354920 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD WVD MMIDD YYY MMIDD/ Y A X COMMERCIAL GENERAL LIABILITY X 6BRPG0000007787200 03/19/2023 03/20/2023 EACH OCCURRENCE $1,000,000 CLAIMS- 7 OCCUR 12:01 AM EDT 12:01 AM DAM E T RENTED MADE PREMISES Ea Occurrence $1,000,000 MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $5,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: PRODUCTS—COM PIOPAGG $1,000,000 POLICY ❑PRO- ❑LOC PROFESSIONAL LIABILITY JECT OTHER: LEGAL LIAB TO PARTICIPANTS $1,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident ANY AUTO BODILY INJURY(Per person) OWNED AUTOSSCHEDULED ONLY AUTOS BODILY INJURY(Per accident) HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY Per accident NOT PROVIDED WHILE IN HAWAII UMBRELLA LIABOCCUR EACH OCCURRENCE EXCESS LIAB ECLAIMS-MADE AGGREGATE DED RETENTION WORKERS COMPENSATION AND N/A PER OTHER EMPLOYERS'LIABILITY STATUTE ANY PROPRIETOR/PARTNER/ YIN E.L.EACH ACCIDENT EXECUTIVE OFFICER/MEMBER ❑ EXCLUDED?(Mandatory in NH) E.L.DISEASE—EA EMPLOYEE If yes,describe under DESCRIPTION E.L.DISEASE—POLICY LIMIT OF OPERATIONS below A MEDICAL PAYMENTS FOR PARTICIPANTS 6BRPG0000007787200 03/19/2023 03/20/2023 PRIMARY MEDICAL 12:01 AM EDT 12:01 AM EXCESS MEDICAL $25,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Legal Liability to Participants(LLP)limit is a per occurrence limit. Event Name:Shamrock Shuffle Type of Event:Run Distance:5K Event Date(including ancillary events and set-up/tear-down):3/19/2023 to 3/19/2023 Number of Participants:300 Event Location:Tasker Park,Carrol Ave, Southold 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 Strong Island Running Club SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 22 Buckingham Meadow Rd THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN E Setauket,NY 11733 ACCORDANCE WITH THE POLICY PROVISIONS. (Co-promoter) 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: 6BRPG0000007787200 COMMERCIAL GENERAL LIABILITY CG 20 26 04 13 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) Strong Island Running Club 22 Buckingham Meadow Rd E Setauket,NY 11733 Named Insured: Mattituck-Cutchogue Athletic Booster Club 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 04 13 ©Insurance Services Office, Inc.,2012 Page 1 of 1 K&K Insurance Group, Inc. K&K, 1712 Magnavox Way Fort Wayne, IN 46804 Phone 1-877-648-6404 Fax 1-260-459-5502 Insuring the world's fun! Claims 1-800-237-2917 Application Date :12/14/2022 .. ,.„.r,,. s�..: a .. u, ;: z. ;. ..� .,,. ��: �s`:�,',�'� ,"x •�' Hi n^' • e 'Are you an insurance agentor lYes broker? Named insured (as it should appear E on the policy): Mattituck-Cutchogue Athletic Booster Club i Doing business as (DBA): Contact first name: Jennifer `Contact last name: Nemschick Mailing address: f PO Box 1241 City: Mattituck 'State:lNewYork jzip: 11952 Phone: 1631-939-3675 Fax: ;Cell: I ;E-mail: iJnems@oPtonline.riet _ ---- - - I ..- i Website: j 'This is a new account r ,I do NOT wish to receive a i -- commission :Agency name: lNeefus-Stype Agency Inc. `Agency mailing address: 1711 Union Ave - --- - ------------ - —-------- _ —.�__ — City lAquebogue !State: New York zip: 11931 !Agent/contact first name: Gena :Agent/contact last name: iAcona i `Agency phone: 16317223500 lf9ency _.ax Agent/contact e-mail: !gancona0threevilla4ebennett.com Eligibility 'Are any of thefollowingevents/activities offered?} ! Activist rallies/marches/protests; Adventure Races; College or university level championships events; Endurance races; Events involving animals others } than service animals; Events where the distance is more than 16 miles; !I Events with water activities or cycling activities; Full marathons (distances 3 k greater than 16 miles); Glow runs, color runs and similar types events or 11 runs; Hiking events; Iron man events ; Mud runs/warrior runs/zombie iNo { runs/obstacle course runs/urbanathons (competitions, exhibitions or foot iraces that involve man-made obstacle courses, man-made mud pits, man- j made slippery slopes, wall climbs, or other similar man-made obstacles); i !r i Political events; Professional sport events, try-outs and training ; i camps/clinics; Triathlons/duathlons. } �� Desired coverage dates (including setup and teardown-no more than 5 days 03/19/2023 °I allowed): I Does your event involve more than 3 days of walking/running activities? 'No ;In what state is the person/organization purchasing this coverage located? New York IType-of Event: lRun Name of Event: ]Shamr ock Shuffle Name of Location: (Tasker Park Address: Carrol Ave City: Southold J State: New York Zip: 11971 'Distance of the race/event: 15K Does your event involve any animals other than service animals? iNo ------ _J1 Is the event a professional sporting event, try out or training camp? y JNo :Is this event a college or university level championship event? No Do you have any vendors at your event? 1 Yes ;Are they required to carry their own liability coverage? Yes Do you require all "participants" and/or parents/guardians of minors to sign a Yes release/waiver? Will alcoholic beverages be sold/provided at this event? -7 Wai'll k Run' Ev '_`"ent "Rating Runners Number of competitive/timed participants: 300J Number of non-competitive participants: 0 Total Number of Participants ...300_ Co-verage & Limits- Each Occurrence: $ 1,000,000 General Aggregate other than Products-completed Operations): Products-completed Operations Aggregate: $ 1,000,000 Personal and Advertising Injury: $ 1,000,000 Damage to Premises Rented to You (Fire Legal Liability): -IF— $ 1,000,000 Medical Expense (other than participants): $ 5,000 1 11-egal Liability to Participants: $ 1,000,000 1 - ---------- Medical Payments for Participants (excess - $100 deductible): $ 25,000 Tdta1-,Cdmm4drc161,,dendra1 U'W1lty-Prpm;1um $30'0.00 dd ri A iiio, all Coverages ;Abuse, Molestation, Harassment or Sexual Conduct Defense Cost Reimbursement i Do y,o-1 u want to add this coverage to the quote? No, Th 11 ank you I u Ahallar,V,Activities/Events Liability ,Do you want to add this coverage to the quote? No, Thank you Total, m m e rc i atd e'n giri.'aii I'll b i I ity Pre'm i U M. .00 Notable Zxciusions:, J 7 T, p fglloWi,ng ex clus io hs,',a,are co nta i n e d in:the commercial general liability, coverage verage provided by this - .p"rogr6m. 2"4-hourpremise's liabi'lity'; Abu:s`e,':mole I sta I t,ion,,ha'r'jassmen't.1'or'rSeXUa;J 'co h'd 6ci'�(u n lesS,,o'i3iio n ial 'coverage is.purchasbcl); Aircraft/hot a-frballoon; Airport;iAmdsemie•ht devices (the'owne,rship,.operation, maintena'n,c'e','.o'r':'use".of:..,':a'ny mechanical'or.;no'n'-�rnechanical� ride' 'slide: '6,r water: sild6"',any,'inflatabl'e recr-6a'ti6nali-,'d'e�ice, 'any bung6e oper'at"o, n, o'r,.equiprhlent,, ,aIny vertical device or 'equipment, used 'for , climbing-either,permanently afflx�d or�t6m orarily erected; or dunk'tank.`Amusement devicddods'not, Jncl6cle:an� vidbo%a'rcacle,or, ter games); Ancillary 1 ' % activ_i�tia's�.thatrequire �aseparate ',a'dmiss to charge and/or &re open:to,the.pUblicjunless 6ptionaVc6verag� ls:purchased); Animals (.injury.or. to r , .6r,injury,,ceathor'propery,c6mag� iiusec ,by Any'animal owned; rentedor hired byy6u), :Asbest6s'- 'sp -walking .Athletic or sbo'rts bartJc1i5,pnts,..Jn.,,qny other, ort/athle�ic--.,,activlt� other,than or,-running; Cornrim"erci"aLageneral. liability standard exclusions -(CG0001 404/13 .editio,n};-ACoinmunice6le "Diseases; Cryogenic chambers/the`r, - :Employment-related 'practices;."rEvents held outside 'the, United Sta'tes';" " Events-with,over°10,000,in"total"attendance;•'Events-that•last more-than.3,days (not including set-up'and ,tear-dow-n);'un'less.reported;-approved; and the appropriate premium has been paid;,Fireworks;.Fungi or bacteria;`Haunted attractions; Heavy. m'etal', electronic,,rap;"hip-ho'p concerts/shows; Lead;`L'egal liability to `participants, for professional athletes. and"celebHiyy`participants;-Medical payments;for participant,for, ,professional athletes and celebrity- ,,•participants;" Nuclear "ene`rgy a"liabili'ty;,Operation, o .'.' wnership• or management of.any facility,or,.premises;other than while being used for' covered'activities; Operations of. indep,endent`,concessionaires; exhibitors and `vendors .at,,yobr event; Performers; ,Rodeos; Room and" boar"d,liabiiity;.:Saddie animals,,Snowmobile; Violationof statutes that"go"veru•,e,=.ma•fis, faxes; phone calls or, other methods of''sending;mate ria ls"'or.�information. Those"operations• listed'7as,ineligible Activ'i 'st rallies/marches/protests, Adventure races, College or university"level championships events; Endurance races; Events"":involving• animals, other.,than ;service ,anima,is;-•.Events'•with ,water';activities or. cycling° activities, Events.where :the' distance Js more•:,than 16'..rhiles;F611"marathons, Glow, runs, color runs and; simil"ar "types",^"events_•,;or "runs; 'Hiking• events; " iron, man events; Mud. :runs/Wderior;,runs/zom'ble," runs/obstacle.:course runs/urbanathons•(competitions,"exhibitions or"foot races.that involve man-made, obstacle courses, man=made mud pits, man-made slippery slopes, wall,climbs, or.other similar man-made,. "obstacles); ;:Political ••"events, Professional sports 'events tryouts.: 'and training ;camps/clinics; Triath°Ions/duathlbns.:. ; ,Terms &"Conditions: i i 1. Any exposure changes that deviate from the original enrollment form must be reported in writing. l 2. Premiums are 100% fully earned and are non-refundable once the coverage begins. 3. Coverage will be effective upon receipt of the completed enrollment form and premium payment. 4. Cancellation or changes must be reported prior to the scheduled start date of event, and confirmed in writing for a refund or credit to be considered. € 5. Commercial General Liability Broadening Endorsement: • Expected or intended bodily injury or property damage resulting from the use of reasonable force to protect persons or property. • Non-owned Watercraft- extended to 58 feet. • Supplementary Payments - $2,500 bail bonds, $500 a day loss of earnings. • Waiver of Right of Recovery. i • Bodily Injury definition expanded to include mental anguish, mental injury, shock, fright, humiliation, emotional distress or death resulting from bodily injury, sickness or disease. • Damage to Premises Rented to You - the term fire is replaced with fire, lightning, explosion, smoke and leaks from sprinklers. i • Additional Coverage: , o Emergency Real Estate Consultant Fee - $25,000 T o Identity Theft Exposure - $25,000 o Key Individual Replacement Cost- $50,000 o Lease Cancellation Moving Expense - $2,500 I o Temporary Meeting Space - $25,000 o Terrorism Travel Reimbursement- $25,000 o Workplace Violence Counseling - $25,000 6. Acceptance of this quote confirms your desire to obtain liability insurance through the Sports, Leisure and Entertainment Risk Purchasing Group. K&K deserves the right to decline any request 1 for coverage. ' 7. Coverage is contingent upon receipt of premium payment. No coverage will be deemed in effect until premium is received by the company or their representative. Additilonal,",Certificate Request 11_77._-__1_____11___1:_ __--_:_e_. ---._� _a_ w:.__. 7111 . _.........,..,__.... ...",_, .-1.°.._1._11... .._,,,.,,_,.•,.w,_, ,,_ „_„”. -1.1"""..i 1 Do you need to request any additional Certificate(s) of Insurance to present to a third #Yes party? y' ----- ------ ----- -7777_----- 1777 ---------------- ---------t--- 7171 Entity name: ITown of Southold i 7111-7111... ___,_,._,._,. . _.. ..,._-1111__„___-°_.- ...,.�..._._,.__„__,....__ _,__..,.,____._,,._.,.,__..�.,_..___,�.,.�,_..._..._-_._..__•.__._ .._, Mailing address: !PO Box 117 • � f ;City: ;Southold State, f New York Zip: 1197 Relationship: !Owner, manager or lessor of the premises where the event takes place 1171 7711__ 1117. ._.,,._-..__..,_... ..........._ ,.....__... ._ ._.....,.._ 1-777 _..,_...,.,..,.., ._..._•... ...._,,...__... _.,_,.•._..µ,.........,.•.•,,,� Walk Run Event: Tasker Park, Carrol Ave, Southold, New York 11971 ' �._-_..7777.__._.___,__7711_. ..._,_,._-___._______._g_________._.__.____,�.._-._._•_.�r-.____._..___�_._,_.______-.. _._,..____. ;_ ... ._.,.__._.. _ _. -r_ -7711._- 1111 __. _,,.,,.____._-._-•__.,,..___.___.___...,_.___..__".,.._._._.__�..,_.__..._..,-__..___�._._.,__..___._.__.______ Entity name: `Strong Island Running Club . ....... _ .._.._.-_._ .,_.._._....,._.._ 1111,"...,_...................,. ,__,.__." .._ _,...__._,,_....___• ,...•._._.__,_...-_......___..... .... ._ 1711..-........,,..__, 'Mailing address: :22 Buckingham Meadow Rd 'City: E Setauket (State: New York iZip: 111733 Relationship: Co-promoter — --- --_----_-_-_- -- 1 j Walk Run Event: Tasker Park, Carrol Ave, Southold, New York 11971 , a .b a ..; ,�+,,e..,„`�.,t:',r r. ,.;; ::�._ a .,,,-�.r:. ""�,�,N\•, %1111. r (gat •. �� ... n....... .. ,e, r , 4,,. iI understand that the insurance company, in determining whether to provide insurance coverage, will rely on the information contained in this form and all other information being submitted. I hereby ;warrant, represent and confirm that, to the best of my knowledge, all information provided is complete, (true and correct. ;WII accept, on behalf of the Insured I am aware that the insurance company expects accurate reporting for my premium calculation, and 'should my figures exceed my estimates during the coverage term I will make arrangements to pay the radditional premium. I understand that my book and records may be examined or audited by the! insurance company at any time during the coverage period and up to three years thereafter. Intentional misrepresentation or misreporting may jeopardize coverage. K&K reserves the right to 'decline/void any ineligible coverage. —� I accept, on behalf of the Insured ! I further acknowledge that, I have reviewed all information provided with this enrollment form and' understand the exclusions which apply, as well as the activities and operations for which coverage is not provided. The information I provided on this enrollment form becomes a part of the insurance contract. I accept, on behalf of the Insured ;I represent and warrant as an insurance producer that I currently maintain, and will maintain, all i individual, corporate or agency licenses or permits required in order to conduct insurance business in the state coverage for this insured is being written. I further represent and warrant that I currently! !maintain, and will maintain, errors and omissions insurance with a minimum limit of $1,000,000 forI l myself, my officers, and employees. If requested by K&K, I will provide K&K with reasonably `satisfactory evidence of all of the above mentioned items, i : I accept ;Name of the person completing this 'First name: ;Gena Last name: lAncona form: ; F IN. t V" 4 A , n ", .. _ . .... .,.,. .:;,,...s.:ixvu p.r.. :...��w .' .:� .s�'"...i..5�?�;.v.� ,=.n�,.,,"e.: •F .>' :.�"„'`�y„ "'.s��. .�r�. :y. ,bv.:��Foy, !Commercial General Liability: $ 300.00 j — `Sexual Abuse/Sexual Molestation: Not Covered p i j _;'Ancillary Activities/Events Liability: Not Covered 1 ; _. ...,.... __.,..,,.,. .._. ____.y: _.__. . .__. ._... ,w_..__.�.... ..__.__.. .... _ .._.._ _.. ...,. _...__. _......__.._ .__.. Notal Commercial General Liability: 4 $ 300.00 Total Premium.: $ 300:00: RPG Administration Fee $15.00 . .,.,s.'?.. . � . .. ,,,r� :�"w.-; •Ws: 's���s�”;y.`� ��.,�.�"e=„.:a'” ;:'r.: cv"e„ "�;t.�" ��r,...;� ".�;„” ...a ~..�,�y:�.�"" 'r ,,:,a .€* :.�,;a..>:,.y, ....a.�. "•;.*;c.a> ':3:. xr, .•�, ,.'i4�:,:"a' '"�."• �d.�t,.�a..�'�., ,.yAw,+^ ,..a;X�.. >;,ksup^ 'L'. ^'lr »"`a�+'�.'�`"..av:azw:.... t., .o���i:.« "!! "��� .,t��,.« x\r; «..,a,� �,...:::x•hF'+,L,�pwa c�^�'F. «. � ,5 ^: Premium,subject'to changeif;not completing purclhase s"ame,day a's quoting ;This summary isnot a.contracf of insurance:'You.miast'refer.to+the actual',policy,for, 6mplete information' regarding coverage;aerms;,conditions„and exclusions,as they.may',change.from'one.coverage,period"to,; the'.nexta Please.reniember;that.you will rec''eive eviden'ce'of.cove'rage immediately"if"purchased online: youIfr 6y.re'quest a,copy.of.the;full.policy by submitfirig'a"written request.: Acceptance of this quoto "confirms your-,tlesire;to obtain4iability,,insura„rice,through.the"Sports`;¢Leisure and: Enhertainmenf'RisK Purchasing.Group,(where applicable).'An RPG provides group purcliasing:'powerfor ':` -similar risks resulting An potential advantageous cove r.age`te'r.ms,;competiti.ve rates,'risk,.management bulletins,,and rewards for,favorable group loss:experience.. , An RN,administration fee_may be,cha,rged. :Fair'Ctied it.Rep6irt`Act Notice Personal..informaut tion-aboyou,;including information'from.a`credit or other investigat've;�re'port,.rray, ' be,:colleeteo;from apeFsons,'.other tha;n,:yoa ,.iriconnection;with:.,this,:appl'ication,:•for, insuran'ce>;,Pnd, sub"sequerit amendments':and .reriewais.'Su"ch:"inforr►iation'as`'well."as,•other ,personal:"and: privileged '. information collected',by'-,us�.o.r-.our agents may,in"certain cir`curnstances,b�e:disclosed_to Ehird:.parties without your`autho`rization,',Credif,scoring, information: may,,6e used to help' determine.'°either.."your'; eligibiHty,;for•;in5urance-or the,:°premium-yoa-'wiil"be cha`rge'd:;We'may,use a. ti ir8 party`lrr�,connectlo`n`; with.the'"development`of'your,score.,,You'have`the„,,ri,ght,to revieW yo'ur,personal,inforrimation in our.="fii'' and can”"request correction of'a'ny ;ina%ccuracies 'A�mor.e detailed,:description of your rigilt6.`and our practices;regarding such'-information;is•available-,upon.'requesE; 'Contact;.your agent,;or broke"r irikir tions-on•,how to`sub mit`a'request'to us.'. -' .._-_.Y_v:.-_.w..........»__.".`__a_._......s._._x....-.-_.,.„_a ".a..,.w....._...._,.,,..........r..'«a_..._...<..,-.a.a_._._._µr,,w-.,...-,_...:�.,.,,.......,...,„r`>ra _ .....»,,,"......-...._..a..��..,.-..".,... _....__.. ,Fraud,Warning.. y�. p,p,lieable in-.AL'- Ak,% DC,'a1A, MD, NM,:.-RI`a'hd`WVE:":Any ;person,.who:..knowingly=;(or"willfully)*; presents"'a' false or--,fraudu'lent cla'im,jor_`,payment sof:a io'ss or""benefit or''knowingly.•(or;w.iilfully.}.* `presents false information' in' an,application fon,` 6ois,guilty, of a�-,,`crime-and 'may bd, bject,to:.; 'fines,and:confinerrl•ent.in,p'rison *Applies i'n,MD,only. '',.c,..":`''• �` Applicable`,in^COd It is ,unia.wfiul <tii`knowingly;provide.• false, ;incorirplete;: or misleading. facts o,r information ,to:an.insurance company tifor`"-the".purpose of-de,fra'uding;or;attempting".to; defraud, the"' company: fPenalttes may include 'imprisonment; fine"s, ,denial of=insurance and civil damages..Any.- Insurance,company.or-agent of an ,ihsurance:com,pant, who, knowingly;`"provides false,,incomplete,tor,' 'm,isleading,, facts .or.'tnformation'','to'`':a ;policyholder:.'' claimant• :for-,thea,purpose. of,.,d^ Yauding •or attempting,..to:defraud,�the,poiicy,holder,�or,claimant-w,ith.regard,to:,a;'settlement:or award payable";from;' insurance proceeds shall-,be,reported;to the'C,olorado•'Division of Insurance.within,the Department Reg,ulatory;;Agencies. r . Applicabl'e.in•FL;;and:,OK:nAny'person'who.,know.ingl y,,a;nd,_withq:intenf t6linj6re; defraud;;or.::dec,eiv"e,,, any insurer files ua4statement,of.claim',or an,application containing,any,false,.incomplete,• or misleading':' information'•is'guiityof a felony':(of th'e third degree)* *Applies;in Fl_only. 4 Applicable in KS:' Any;person.who;';knowingly',and" with ,intentµto 4d'efraud; preserits;:;causes to, b,e:,;, preserited;or;,prepares,with:knowledge:or•beIief•that.it;wiii b"e,presented'to"br.by arr insurer,apurporte'd ' insureri,',broker.q"'.µany agent-thereof, 'a'nywritten,,electronic,'electronic`impulse;`facSi mil„e,:magnetic, ' "oral,;ar telephonic: communication or:statement as part of,•or in••support of, an application for-the „>issuance,of,•or:.the •ra”ting',of,.an insurance.policy. for.•persona► or•commercial insurance, or a'claim:for:-, y payment or.other;benefit pursiian't,to en.;'insurance policy for. commercial or personal,insurancewhich.s Sul knows,to`',00ntain,"mate ria concarning aany `fact material Chereto,"or .Con'ceals,.,for the purpose' of misleading, information;:concerning an-y factmaterial-tfereto`Comtsiits'a fraudulent insurance act, ,. ..-•,a Applicable,in:.KY,-NY,,�,OH and.-PA: Any:person• who��knowingiy. and' with,`intent,`tg, defraud'a'ny"j1 insurance company or other person files an•application for.insurance or statement,of claim.contaihing;a a`ny,materially false.information or.conceals for the,purpose'of;misleading.,information`.concerning,any' ~fact material'thereto;commits a f'audulent;.insurance act 'which is a crrme:,,and subjectssuch'pe'rson to. critri.anal'a'nd"civii:'p,enailti6s=,(not to a"xce'ed�five,:thousa'nd-doIlars and:~the stated:`vatue;'of`th"e claim`for,`' each such violatipn)* `*.Applies in NY only. plicable in',ME;'TN;_VA'and WA It-is;a chine to.know ingly.provi, e6`-aIse,,arieomplete:or m'isleading., information-to'an�insurance�company,for;the purpose of defraudingthe:cor`ppany. Penalties,,(m:a,y}*, inclUde;imprisonment, fines.and.denial'ofinsurance benefits *Applies rn ME'only.E:.. Appligeble in MNp A,person who°files:a:claim•with:intent to.defraud or°helps commit;aa;fraud�against"an' insurer ms gulp' f a crime: Applicable.;in".N]':Any "person,••wli,o<,includes,.any false or irmisieading °information',on;a,n•application`for ' an.insurance;pol►cy„is sub 6c't`W7'criminal and;civil.penaities.; ” .",. "`: :.• ;>3 ,.., `:Applicable In'0 .Any, person whb,`knowingly and with.Intent-to.defraud°ar,solicit'anothe'r to;defraud ; -the,insure'r..b,y_s.ubmitting an application co_Oininy,'la,afalse. statement'as .to;-any,material'fact,:ma, be violating state la'µ: ,Applicable`in;•-VT:`'Any••persgnµ.µbo;,know,iri6iw,presents a',false•,'stateme`nt ;in -am',application:for insGrance may beaguilty'of a crirnmal;offense'and subject;►' penalties under=state law. `.::, Applica•tiie in all':dther'states:"Any°person who knowingly and•„with:'intent.toAefra'ud any insurance' co npany;,:or. ;other'person'^files„an-.appltcation-for•tnsu'ra.nce or statement,of claim co"ntaining,.:any;'y .. materially;false.'-information. or conce"als for•:the,purpose;of�misleading, information:co,ncernin'g'any;faet" materiel thereto commits a;:fraudulent,insurance'act, ;which is a,crime and.>subjects•such:;person :to. criminal and civi'I penalties Copyright 2009 K&K Insurance,Group.Inc.; K&K ins"urance.Group, Inc. is a licensed insurance producer in all states:(FL license #1_0,07299, TX license #13924); Age operating,in CA, NY and MYas K&K Insurance ncy (CA'i_icense 40334819)' Born, Sabrina From: Spiro, Melissa Sent: Friday,January 6, 2023 3:38 PM To: Born, Sabrina Subject: RE: Sp. Ev.-Matt-Cutch.ABC Shamrock Shuffle 5K Event appears to be on roads and does not appear on any preserved lands. Melissa S. From: Born,Sabrina <sabrina.born @town-.southold.ny.us> Sent: Friday,January 6, 2023 3:30 PM To: Blasko, Regina <rblasko@town.southold.ny.us>; Flatley, Martin <mflatley@tow.n.southold.ny.us>; Ginas,James <jginas@town.southold.ny.us>; Goodwin, Dan <dang@so.utholdtownny.gov>; Hagan, Damon <damonh@southoldtownny.gov>; Mirabelli, Melissa <melissa.mirabelli@town.southold.ny.us>; Noncarrow, Denis <denisn@southoldtownny.gov>; Norklun,Stacey<Stacey.Norklun@town.southold.ny.us>; Orientale, Michael <michaelo@southoldtownny.gov>; Spiro, Melissa<Melissa.Spiro@town.southold.ny.us> Subject:Sp. Ev.-Matt-Cutch.ABC Shamrock Shuffle 5K Please approve/disapprove and provide a cost analyst. Thank you, Sabrina M. Born Sub-Registrar& Deputy Town Clerk Senior Account Clerk Typist Southold Town Clerk's Office 53095 Route 25 P.O. Box 1179 Southold,NY 11971 Ph: 631-765-1800 ext. 1226 Fax: 631-765-6145 Your message is ready to be sent with the following file or link attachments: r Sp Ev-3_20230106162329.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 Born, Sabrina From: Flatley, Martin Sent: Monday,January 9, 2023 10:23 AM To: Born, Sabrina Subject: RE: Sp, Ev.-Matt-Cutch.ABC Shamrock Shuffle 5K Attachments: Shamrock5kCA2023.xls I have no objections to this event being approved, my cost analysis is attached Martin Flatley, Chief of Police Town of Southold Police Department 41405 State Route 25 Peconic, N.Y. 11958 Tel: 631-765-3115 ,r The information contained in this electronic message and any attachments to this message are intended for the exclusive use of the addressee(s)and may contain information that is privileged,confidential and exempt from disclosure under applicable law. If the reader of this message is not the intended recipient,you are hereby notified that any review,retransmission,conversion to-hard copy,copying,reproduction,circulation,publication, dissemination or other use of,or taking of any action,or omission to take action,in reliance upon this communication by persons or entities other than the intended recipient is strictly prohibited. If you have received this communication in error,please(i)notify us immediately by telephone at 631.765.2600, (ii)return the original message and all copies to us at the address above via the U.S. Postal Service,and(iii)delete.the message and any material attached thereto from any computer,disk drive,diskette, or other storage device or media. From: Born,Sabrina <sabrina.born @town.southo Id.ny.us> Sent: Friday,January 6, 2023 3:30 PM To: Blasko, Regina <rblasko@town.southold.ny.us>; Flatley, Martin<mflatley@town.southold.ny.us>; Ginas,James <jginas@town.southold.ny.us>; Goodwin, Dan<dang@southoldtownny.gov>; Hagan, Damon <damonh@southoldtownny.gov>; Mirabelli, Melissa <melissa.mirabelli@town.southold.ny.us>;,Noncarrow, Denis <denisn@southoldtow.nny.gov>; Norklun,Stacey<Stacey.Norkiun@town.southold.ny.us>; Orientale, Michael <michaelo@southoldtownny.gov>; Spiro, Melissa<Melissa.Spiro@town.southold.ny.us> Subject:Sp. Ev.-Matt-Cutch.ABC Shamrock Shuffle 5K Please approve/disapprove and provide a cost analyst. Thank you, ,�aeni�aa?�S�an� Sabrina M. Born Sub-Registrar& Deputy Town Clerk Senior Account Clerk Typist Southold Town Clerk's Office 53095 Route 25 P.O. Box 1179 Southold,NY 11971 Ph: 631-765-1800 ext. 12.26 Fax: 631-765-6145 1 Town of Southold Police Department Special Event Cost Analysis Event: Shamrock Shuffle 5K Run Date(s): March 19, 2023 Location: Peconic Area Patrol Allocaticin for:Event mrJT:... .m_ -^ Reg Hours OT Hrs lHrly Wage Total Comments Police Officers_ PO Hinderliter __- 2 $77.96 PO Krause 2 $53.50 Sgt Garcia 3 $219.81 Special,Patrol. Reg Hours m OT Ars Total Comments CRU" _.. _:...... ... P.O. Chenche 3 $205.08 PO Sanders 3 165.57 Bicycle Patrola",w,,- HighwayPatrol,,; w` P.O. Onufrak 3 $217.47 P.O. Flatley 3 $217.47 Marine Units T affic Control ::. Reg Hours\ OTWHrs_ Hrly Wage _TotalComments\ TC Officer#1 TC Officer#2 TC Officer TC Officer TC Officer iii me"riosts PD Vehicles #sof vehicles $/hr Total 6 $10.00 $150.00 $160.00 Command Van Marine Patrol Boats Total Department Cost for Event = $1,316.86 Prepared by Chief M. Flatley 1/9/2023 Pagel Vendor No. Check No. Town of Southold, New York -Payment Voucher Vendor Name Vendor Address Entered by �A+�••+�u �k � G�-�hogue A-F1�IC-I-ice -; F�pOSj-F�C CIU�b ; box 2.�' Audit Date Vendor Telephone Number t 1.31—3615 D + _C- �( �'� Town'Clerk Invoice Invoice Invoice Net Purchase Order ` Number Date Total Discount (Amount Claimed Number Description of Goods or Services General Ledger Fund and Account Number. 12025 - 30 .3/2412.2; 1,560.00' _C40.00 T1.030 I I I i I Total Payee Certification Department Certification The undersigned(Claimant)(Acting on behalf of the"above named claimant) I hereby certify that the materials above specified have been received by me does hereby certify that the foregoing claim is true and correct,that no part has in good condition without substitution,the services properly been paid,except as therein stated,that the balance therein stated is actually performed and that the quantities thereof have been verified with the exceptions due and owing,and that taxes from which the Town is exempt are excluded. or discrepancies noted,and payment is approved. Signature Title:Deputy Town Clerk Signature Company Name Date Title.• e u To Clerk Date 2 Southold Town Board - Letter Board Meeting of March 28, 2023 RESOLUTION 2023-309 Item# 5.11 ADOPTED DOC ID: 19008 THIS IS TO CERTIFY THAT THE FOLLOWING RESOLUTION NO. 2023-309 WAS ADOPTED AT THE REGULAR MEETING OF THE SOUTHOLD TOWN BOARD ON MARCH 28, 2023: WHEREAS the following groups have supplied the Town of Southold with a refundable Clean- up Deposit fee, for their events and WHEREAS the Southold Town Police Chief, Martin Flatley, has informed the Town Clerk's office that this fee may be refunded, now therefor be it RESOLVED that Town Board of the Town of Southold hereby authorizes a refund be issued in the amount of the deposit made to the following - Name Date Received Amount of Deposit North Fork Chamber of Commerce 1/13/23 $250.00 Southold School Athletic Assoc. 1/18/23 $1,500.00 Mattituck-Cutchogue Athletic 1/6/23 1,500.00 Booster Club s � Denis Noncarrow Southold Town Clerk RESULT: ADOPTED [UNANIMOUS] MOVER: Jill Doherty, Councilwoman SECONDER:Brian O. Mealy, Councilman AYES: Nappa, Doroski, Mealy, Doherty, Evans, Russell Generated March 29, 2023 Page 25 Town of Southold ' P.O Box 1179 Southold, NY 11971 * * * RECEIPT * * * Date: 01/06/23 Receipt#: 307599 Quantity Transactions Reference Subtotal 1 Clean-Up Deposit 3/19/23 $1,500.00 Total Paid: $1,500.00 Notes: Payment Type Amount Paid By CK#5643 $1,500.00 Mattituck-cutchogue, Athletic Booster Cl Southold Town Clerk's Office 53095 Main Road, PO Box 1179 Southold, NY 11971 Name: Mattituck-cutchogue, Athletic Booster Club Po Box 1241 Mattituck, NY 11952 Clerk ID: SABRINA Internal ID:3/19/23