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HomeMy WebLinkAboutSouthold Schools Athletic Assoc. 5K TC Checklist for Parade/5KY/Bicye1e"/Town Property/Road Closure Special Events Applications Name of Organization: 6DIAfhold "Ols Aw-H'lnLA-550c', Name of Event: 5 V ky e. Date(s) of Event: *No 5K and Bicycle events during the period of June 1 to November 1X N Event fee check (or request to be waived) J Road clean-up check (CANNOT BE WAIVED) Current Insurance certificate Application sent for approvals to the/ Land Pres. TA Records Mfollowing Depts.: L PD Hwy U \ f / �/ n mnt/TC y � g _v Approval from Chief of Police Cost Analysis from Chief of Police Approval from Land Preservation Approval from Highway Dept. y TB Resolution for approval (once approval and cost analysis comes from Chief of PD) Town Board Reso. #: W a,� ^�15 V Approval letter to Organization's contact person w/copy of TB resolution After Event: ✓ C nfirmation from Chief of PD to release clean-up fee TB Resolution to refund clean-up fee TB Clean-up Reso. #: a ,/. Voucher and copy of TB clean-up Reso. to Accounting Dept. Whole application file to Records Management(include copy of voucher& reso.) Og11FFRI . DENIS NONCARROW ��+® G,=:` Town Hall,53095 Main Road TOWN CLERK p P.O.Box 1179 Z` Southold,New York 11971 REGISTRAR,OF VITAL STATISTICS p • . Fax(631)765-6145 MARRIAGE OFFICER �',�' �' ' RECORDS MANAGEMENT OFFICER ®,( ; . Telephone oldto nny.gov FREEDOM OF INFORMATION OFFICER • wwwsoutholdtownnygov RECEIVED OFFICE OF THE TOWN CLERH TOWN OF SOUTHOLD APPLICATION FOR A PERMIT TO HOLD A SPECIAL EVENT Southold Town Clerk Pleaseprovide ALL of the:information reques ted below.Incomplete applications--WILL;NOT lie reviewed. Date of SubmissionaD&ML2 n D (a 9 Name of Event SUA-\x)1d Se vyova , kyAe—v)c— � t Name of Organization:��, o --- Is this a Not-For-Profit Event. o Contact's Name: \ Mailing Address: QD awabz�o �Wc, soles `Y ad kN i Contact's Phone Number: Contact's Email Address: Event Location and Site Diagram: h [ OCNOed (Use additional paper if necessary) Event Date(s): A LXM W- C� , - (Include set'up'p and shutdown times and dates) Nature of Event: 51Y (Please attach a detailed description to this application) Time Period(Hours)of Event: From to Maximum Number of Expected Attendees:-- o Specify any special requirements(i.e. road closure,police presence): -u If a Tent or other temporary structure will be used please contact the Southold Town Building Department at 631-765-1802 PQ }box, W fn,V.� Mailing Address to Send Event Permit to:%__01 ane Event Fees: V $250 for events with less than 1000 expected attendees � � e $500 for events with 1000 or more expected attendees Cleanup Fees(Can NOT be waived): ✓-u $1,500.00 Clean-up for Bicycle and/or Running Special events(ONLY) $250 or more Clean-up deposit all other events :CERTIFICATE�:OF INSURANCE REOUIRED.: Not less than$2,000,000 naming the Town of Southold as an additional insured. ***NOTE: PLEASE SEE ATTACHED REVISED,_ADOPTED_TOWN POLICY*** Additional information and requirements may be required as deemed necessary by the Town Board. Print name of Authorized Person filling out Signa e f uthorized 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 SOUTHOLD ATHLETIC ASSOCIATION SK Southold, NY S®UTHO D f► '� W �-C !Oa Cemetery •� ®���'cs•� / 09MIDFgRAg_w Ff��TL f Z SECONDARY Q SCHOOL z sOUTHOLD ELEMENTARY. / SCHOOL JOCKEY CREEK RD MgIK RD �j � oaklawn ((/ PINE NECK RD Avenuew NYT Pole r.S / Pole p6 li MAIN BAY1(IEW � y • X RD Kydrant ljr ? g START_ Cemetery Gate i. Certified Course * NY 12101 JG Aehu "` US A Effective: 8/27/2012 ,A Tt1""`UD'x through 12/31/2022 toP rosswalk SIBn Pole � h' JERNICK LA i Measured by G.WesMrfleld 07/17/2012 j ° HOLD HARMLESS AGREEMENT The applicantsouhW S1,wnK of this Special Permit shall defend, u, e af**-- indemnify and hold harmless.the Town of Southold, its officers, employees, and representatives from and against any and all damages, liability,judgments, losses, and expenses, including but not limited to attorney's fees, including damages arising from injuries or death of persons and damage to property which arise from or are connected with the event or events authorized by resolution of the Town Board of the Town of Southold, or caused by the negligent misconduct, and/or omissions under this Agreement and that of applicant's agents, servants and/or employees. If this Agreement is being executed in a representative capacity,the individual executing this Agreement hereby represents that this action has been authorized. Dated: Signature: Name: li ,Authorized Agent On behalf of: M1 (Name of Business Entity) Dates of event(s): —//WMA4 QYV/ 0004 Sworn to before me this Day of ,20,� J SABRINA M BORN Notary Public,State of Newyork No.01 BO6317038 Qualified in Suffolk County commission Expires Dec.22,20 Town of Southold P.O Box 1179 Southold, NY 11971 * * * RECEIPT * * * Date: 09/24/24 Receipt#: 335097 Quantity Transactions Reference Subtotal 1 Clean-Up Deposit 11/2/24 $1,500.00 Total Paid: $1,500.00 Notes: Payment Type Amount Paid By CK#1293 $1,500.00 Southold, School Athletic Assocation Southold Town Clerk's Office 53095 Main Road, PO Box 1179 Southold, NY 11971 Name: Southold, School Athletic Assocation 420 Oaklawn Ave Po Box 470 Southold, NY 11971 Clerk ID: SABRINA Internal ID: 11/2/24 Noncarrow, Denis From: Helf, Nicole <nhelf@southoldufsd.com> Sent: Monday, September 30, 2024 12:52 PM To: Noncarrow, Denis Subject: Fwd: 5K Re: Insurance Just an update! ---------- Forwarded message --------- From: Bazata,Nadine<nbazatagsoutholdufsd.com> Date: Mon, Sep 30, 2024 at 11:17 AM Subject: 5K Re: Insurance To: Helf,Nicole <nhelf@southoldufsd.com> Cc: Charles Scheid<cscheidgsoutholdufsd.com>, Steven Flanagan<sflana an a,southoldufsd.com> Hi Nicole, The check will be audited on Wednesday, then the policy will be issued along with the certificate of insurance. I'll keep you posted as soon as I receive any information. Nadine Thank you, Nadine Bazata Principal Account Clerk Southold UFSD 420 Oaklawn Ave,PO Box 470 Southold,NY 11971 631-765-5400 x 1320 This message is for the sole use of the intended recipient(s)and may contain confidential and/or privileged information of Southold Union Free School District.Any unauthorized review,use,copying,disclosure,or distribution is prohibited.If you are not the intended recipient,please immediately contact the sender by reply email and delete all copies of the original message. On Wed, Sep 25, 2024 at 12:19 PM Helf,Nicole <nhelf@southoldufsd.com>wrote: Hi Nadine! The town had reached out to see if we have heard anything from the insurance company yet. They will need that inorder to approve the event. Thank you! Nicki Helf, MS CCSP Career & Transition Coordinator Southold Union Free School District i Noncarrow, Denis To: Special Events PD Cc: Johnson, Benjamin; Schlachter,Amy (amys@southoldtownny.gov); Noncarrow, Denis Subject: Southold School Athletic Association 5k Attachments: Southold school AL_20241002134520.pdf Please respond on this event. NOTE: the Insurance cert is coming.That will be worded in any approval. Thank you 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). Unauthorized interception, review, use or disclosure is prohibited and may violate applicable laws including the Electronic Communications Privacy Act. If you are not the intended recipient, please contact the sender and destroy all copies of the communication. 1 Noncarrow, Denis From: Grattan, Steven Sent: Wednesday, October 2, 2024 8:53 PM To: Noncarrow, Denis Subject: Re: Southold School Athletic Association 5k No objections. Sent from my iPhone On Oct 2, 2024, at 1:46 PM, Noncarrow, Denis<denisn@southoldtownny.gov>wrote: Please respond on this event. NOTE:the Insurance cert is coming.That will be worded in any approval. Thank you Denis Noncarrow Southold Town Clerk. Town of Southold, New York www.southoldtownn y.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). Unauthorized interception, review, use or disclosure is prohibited and may violate applicable laws including the Electronic Communications Privacy Act. If you are not the intended recipient, please contact the sender and destroy all copies of the communication. <Southold school AL 20241002134520.pdf> i Tay­,outhold Town Board - Letter Board Meeting.of October 8, 2024 RESOLUTION 2024-873 Item# 5.17 ADOPTED DOC ID: 20707 THIS IS TO CERTIFY THAT THE FOLLOWING RESOLUTION NO. 2024-873 WAS ADOPTED AT THE REGULAR MEETING OF THE SOUTHOLD TOWN BOARD ON OCTOBER 8, 2024: RESOLVED that the Town Board of the Town of Southold hereby grants permission to the Southold School District to use certain roads for a 5K race in Southold,New York on Saturday, November 2nd, 2024, start time 8:00 AM, set up at 7:00am, route for the 5K: beginning at the Elementary School parking lot onto Oaklawn Avenue to Route 25, east to Youngs Avenue, to Calves Neck Road,to Harper Road, Hill Road, Wells Road, back to Oaklawn Avenue, to Pine Neck Road to Main Bayview Road to Main Road, Jockey Creek Drive back onto the Southold School property,provided applicant meets all of the requirements as listed in the Town Policy on Special Events and Use of Recreation Areas and Town Roads. Fees for this event have been waived with the exception of the Clean-up deposit. This approval is subject to updated Insurance certificate being presented. Applicant is to coordinate event with Chief Grattan. �L ;��LI-A I Denis Noncarrow Southold Town Clerk RESULT: ADOPTED [UNANIMOUS] MOVER: Louisa P. Evans, Justice SECONDER:Greg Doroski, Councilman AYES: Doroski, Mealy, Smith, Krupski Jr, Doherty, Evans Generated October 9, 2024 Page 35 z r ;�►"co CERTIFICATE'OF LIABILITY INSURANCE DAT 10/22/22//2024(MM024 Y) N THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS,NO.RIGHTS,UP.ON 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 INSURERS); AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER: IMPORTANT: If the certificate•holder is-an ADDITIONAL INSURED, the ppolley(ies)'must have ADDITIONAL INSURED rovisions or be endorsed. If SUBROGATION, IS WAIVED, s f•tfi'e poliubject to the terms and'conditions ocy, certain policies may require an'endorsemerIL A statement an this certificate does not confer right's to the certificate"holder-in lieu of such endorsement(s). PRODUCER, CONTACT.NAME: Mass Merchandising P FAX K&K Ihs&ance Group, Inc: A/c'No"Ext: 1-800 426-2889 Arc No: 1-260-459-51,05, 1712 Magnavox Way aoDRess: info@spbrtsinsurdhce-kk.cOm Fort Wayne IN 46804 PRODUCER CUSTOMER to: _ INSURER(S)AFFORDING COVERAGE` NAICK INSURED 200154287-7 CP$980 INSURER A: AIG Specialty Insurance Company 26883 Southold Union Free•School District INSURER B: PO BOX 470 INSURER C: Southold,NY 11971 INSURER D: A Mernbeirof the Sports,Leisure&Entertainment RPG INSURER E: INSURER F:, COVERAGES CERTIFICATE NUMBER:2000646666 REVISION,NUMBER: THIS ISTO CERTIFY THAT THE POLICIES OF.INSURANCE LISTED BELOW HAVE BEEN ISSUED TOTHE 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 PERTAINJHE 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 1ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE INSD WVD P. - NUMBER MMfDD/YYY MMIDD/YYY A X COMMERCIALGENERAL LIABILITY X 9YAP.G0001334486500 11/02/24 11/03/24 EACH OCCURRENCE $3;000,000 12:01'ANI 12:01 AM DAMAGETORENTEO, $1,000,000 CLAIMS•MIADE OCCUR PREMISES Ea Occurrence- MED EXP(Any one person) $5.000 PERSONAL&,ADV'INJ6AY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER:, GENERAL AGGREGATE, $51000,000- POLICY PROJECT❑LOC PRODUCTS—COMP/OP AGG- _ $3,000;000 OTHER: PROFESSIONAL LIABILITY LEGAL LIAB TO PARTICIPANTS $3,000,000 AUTOMOBILE LIABILITY 'accident COMBINE ING ELI (Ea ANY AUTO BODILY INJURY.(Per person) OWNED: SCHEDULED 80DILYINJURY(0eraccidem AUTOS;ONLY AUTOS PROPERTY DAMAGE - HIRED" NON-OWNED AUTOS ONLY e AUTOS ONLY Per accldcnt LUMBRELLok IAR' OCCUR, EACH OCCURRENCE EXCESS LIAR CLAIMS-MADE AGGREGATE DED RETENTION 'WORKERS COMPENSATION NIA PERSTATUTE OTHER AND EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNER/ Y/•N I E.L.EACH ACCIDENT EXECUTIVEOFFICERIMEMBER ❑ EXCLUDED?'(Maridatary In NH) E.L.DISEASE-EA EMPLOYEE. Ir yes,desc ibe udder E.L.DISEASE=POLICY LIMIT DESCRIPTION OF OPERATIONS below A MEDICAL PAYMENTS FOR PARTICIPANTS 11/02/24 11/03/24' PRIMARY.ME000AL, 9YAPG0001334486500• 12:0,1 AM 12:01 AM EXCESS MEDICAL $25,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Addltlonal Remarks Schedule,may be attached if more space is"required) Event'Name:Southold Schools Athletic,Association 5K Event Type:Walk and Run Event Dates:11024 #of"Participants:250 Event Location:Southold Elementary School,14'2b`baklawn,Ave;Southold,NY 11971 The certificate,holder is added-as an'additionai insured,buYonly for liability caused,in whole or in part,by the acts or omissions of the named insured. CERTIFICATE;HOLDER" CANCELLATION Southold Town SHOULD'ANYAF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE P.-O.Box�1179, EXPIRATION DATE•THEREO_F,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH Southold,NY 11971 1." THE'POLICYPROVISIONS: Owner/Manager/Lessor of.Premises AytHHOR,IIZE6 aEPPi6EriTATIVEE ©1988-2015 AGORD CORPORATION. All rights reserved. Coverage is only,eztended to U.S.'events and-activities. NOTICE TO TEXAS'INSUREDS:The Insurer for the purchasing group may not be subject to all the insurance-16ws and regulations of the State of Texas, ,CORD 25(?01.6103) The ACORD name and logo,are"•registered marks of;ACORD z N. POLICY NUMBER: 9YAPG0001 33448650.0 'COMM EFtCIAL:G EN ERAL LIABILITY CG 20 26 04 13 THIS ENDORSEMENT'CHANGE&THE POLICY. PLEASE READ IT CAREFULLY. -ADDITioNA'L INSWIED,— DESIGNATED PERSON OR ORGANIZATION This endorsement,modifies-insurance provided under the following. : COMMERCIAL GENERAL LIABILITY'COVERAIGE PART SCHEDULE. Name Of Additional Insured Person,(s)0rorganliation(s) Southold Town P.O.Box 1179 Southold, NY 11 V1 Named Insured: Southold Union Free School District. CP#980 Inforirrilatiori rd�Uirqd'to bompl!ete this Sch0d616;,if'not shown above,will be shown'in the Declarations. A. Section 11.=Who Is An Insured is amended to include as,an, B. With respect to,thd in.surarice;aff drded to these additional insureds, ad'ditional insured' e'the or 6r§ahiiiation(s).shown In the the'following is added'to Section III—Limits Of Insurance: Schedul6i but only with respect to1lability-for"bodily injury", If coverage providedTo the additional insured it required by,a ,.property dam.age`,or"personal and advertising injury"-caused,in' contract or agreement,the most we will pay on behalf of the wh6le,or In,part,by your acts or omissions or the acts or omissions "additional insured I I s,.the I amount of.insurance: of those acting onr:your b6half: , . I . 1,. Required by ft.-cdritract or Agreement;or 1. In the performance of your ongoing operations;,or 2; In connection with your premj§os owned by or,re1nte.d,.tQ-.yqu. 2. Availabld.urider the applicableLimits;,of Insurance shown in, the Declarations; However: whichever is less. 1. The irisurancezfforded to sucWadditional insured:only This endorsement shall not increase the,applic'able Limits of applies to the exten(perrriitted;by,Iaw;And Irisuianceshown in the Mclaratiofis. 2. If coverage provided to thle�adI'dit,,bnal insured Is required.by-a contract or agreement,the Insurance afforded to such -additional I.nsured w I il.[not be.broader thA. n that which.ybu.afe required by thelcloritradt or Agreement to provide,for such additional insured. CG`20 26 0413 0 Insurance-Services Office; Inc.,2012 Page 2,9f 2 F 11'T 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 October 22, 2024 Southold Schools Athletic Association Attn: Nicole Helf 420 Oaklawn Ave PO Box 470 Southold,NY 11971 Dear Nicole Helf: The,Southold Town Board, at its regular meeting held on October 8, 2024, granted permission to Southold Schools Athletic Association to hold its 5K Race on November 2, 2024. A certified copy of this resolution is enclosed along with the Town of Southold Policy for Special Events on Town Properties and Roads. Failure to heed the policy may result in the loss of Clean-up deposit. An insurance policy naming the Town of Southold as additionally insured has been filed with this office. Please contact Chief Grattan at the Police Department, as soon as possible, to coordinate traffic control. If you have any questions,please contact me at the Town Clerk's office at 631-765-1800. Good Luck with your event. Sincerely, Sabrina M. Born Deputy Town Clerk Encl. �y1Ff01 0� RESOLUTION 2024-940 ADOPTED DOC ID: 20762 THIS•IS TO CERTIFY THAT THE FOLLOWING RESOLUTION NO. 2024-940 WAS ADOPTED AT THE REGULAR MEETING OF THE SOUTHOLD TOWN BOARD ON NOVEMBER 6,2024: 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, Steve Grattan,has informed the Town Clerk's office that this fee may be refunded, now therefore 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 Southold PTA October 17, 2024 $250.00 c/o Kimberly Kraehling 1530 Boisseau Ave. Southold,NY 11971 Oysterponds PTA October 10, 2024 $250.00 c/o Miriam Foster PO Box 115 Orient,NY 11957 Southold School Athletic Assoc. Sept. 20, 2024 $1500.00 c/o Nicole Helf PO Box 470 Southold,NY 11971 Denis Noncarrow Southold Town Clerk RESULT: ADOPTED [UNANIMOUS] MOVER: Greg Doroski, Councilman SECONDER:Brian O. Mealy, Councilman AYES: Doroski, Mealy, Smith, Krupski Jr, Doherty, Evans Vendor No. Checkbi©: >: = [ ............ Town of Southold, New York - Payment Voucher Vendor Name Vendor Address .............._ ............. Southold School Athletic Association PO. Box 470 ...... Vendor Telephone Number ::�::.-::::�: :::.. .:::::�::'.:.:.::::.:::::::: E::i:::ii:i•. - Southold, NY 11971 - -° 631-765-5400 ext. 1352 TvwtiClerk Vendor Contact •: . :.�:::--:-:::::•::•:: ::� :�::�:.�.:::•:::::::�: ....... ............ Nicole Helf Invoice Invoice Invoice Net Purchase Order : . ....::................ :::.::.....:. ::::;::::.........:............. ::: Number ate Total Discount Amount ClaimedNumber Description of Goods or Services _;_;:Gerietal Iedger:Fundaad:AccnuntNumbe :: 2024-940 11/6/2024 $1,500.00 $1,500.00 5K(1 1/212 0 24) Total: $1,500.00 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 Sign comp yName Date 11/7/2024 Titleature eputy T wn Clerk Date �11 /2024