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HomeMy WebLinkAboutShamrock Shuffle DENIS NONCARROW ,+ Town Hall,53095 Main Road TOWN CLERK P.O.Box 1179 to Southold,New York 11971 REGISTRAR OF VITAL STATISTICS Fax(631)765-6145 MARRIAGE OFFICER Telephone(631)765-1800 RECORDS MANAGEMENT OFFICER .( J FREE Q��Q �4�ATION OFFICER _ � www southoldtownnygov �G�+�1 V GLJ . OFFICE OF THE TOWN CLERK He at TOWN OF SOUTHOLD Southold Town Clerk APPLICATION FOR A PERMIT TO HOLD A SPECIAL E'V#`NT Pld se`pHVWde.ALL of the information requested-Below.ItrcomnWe application§'WILL-;NOT-,be reviewed. Date of Submission Name of Even G-WI y"OG_k Name of Organization: MOLY-717( Ck- OfCe..--e- Al Raa4tK, Ckcl Is this a Not-For-Profit Event?'ONO Contact's Name: I I C rl a fl F QGLr k. Mailing Address: 4/1r 1!r I Q i baPu G0 k+f;h.ar1e- Y Y lI`t-r2- Contact's Phone Number: 43 1 - 3`F `IT 11 - Contact's Email Address: C.L 2�Tm y PTo N lam/NE /t/�T' Event Location and Site Diagram: s p e (Use additional paper if necessary) Event Date(s): _ 3 a i (e f Z S (Include set up and shutdown times+ and dates) Nature of Event: iUnaf�a�i off✓ �`T✓ �OOS'� �,�(� (Please at a detailed description to this application) 120 ce S4r c3 f0 CIL Time Period(Hours)of Event: From :Zc, to �Z . dA 111440 Maximum Number of Expected Attendees: . 3®O. - Specify any special requirements (i.e. road closure,police presence): .J 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: /KI c"t C&-k— IIC A a adl.e, hil a -t-14-cic- 1y.Y 119 rZ Eventes: .$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 CERTIFICATE OF INSIMA=IdQUIR:CI): 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: M i C6lle Print name of Authorized Person filling out Signature of Authorized 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 2022 Shamrock Shuffle Race Route: • Start on the eastern side of Tasker Park on Carroll Ave • Make a Right onto the North Road • Make a Right onto Old North Road @Wesnofske Farms • Make a Right onto Ackerly Pond Lane • Make right onto Lower Road • Make Right onto Main Road to Completion at Greenport Brewery With using Carroll Ave as a start race will thin by North Road and the same when reaching the Main Road utilzing the shoulder of the Road 1 2/13/22,8:29 PM Google Maps � L Googfe Maps • . _. �, „ v f.-..ram v;,.= •;,,, + w- `.„ � £` ,.�-' .. r11Ck-5 v?'ilfltf: . '�.,a r '�,rTM' `a�'' ... . .` :Y.. 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F ., ...�..... ... mm Map data 02D22 1000 h i https:t/www.google.com/maps/@41.0524636,-72.4531988,15z 1/1 MATTATH-01 ACOLLETTI CERTIFICATE OF LIABILITY INSURANCE DATE A E(MNU 025 ) 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 NA Neefus Stype Agency a�"N E,:(631)722-3600 ac,No:(631)722-3591 711 Union Ave. MAIL Aquebogue,NY 11931 E- .info@nsainsure.com INSURERS AFFORDING COVERAGE NAIC# INSURER A:U.S. Liability Insurance Co 25895 INSURED INSURER B: Mattituck-Cutchogue Athletic Booster Club INSURER C: PO Box 1241 INSURER D: Mattituck,NY 11962 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTRA X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 3,000,000 CLAIMS-MADE FX] OCCUR X SE1142662 3/16/2026 3/17/2026 DAMAGETORENTED occurren $ 100,000 MED EXP An one person) $ ,000 PERSONAL&ADV INJURY $ 3,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 NPOLICY PRO- LOCJECT PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY Me accident)COMBINED SINGLE LIMIT $ ANY AUTO BODILY INJURY Per erson $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY Per accident $ HIRED NON-0WNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY Per accident $ UMBRELLA LIAB OCCUR I EACH OCCURRENCE $ F'rEXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? NIA (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) 3M6/25-Shamrock Shuffle 5k at Tasker Park,Carrol Ave,Peconic,NY 11958 Certificate holder is listed as additional insured in respect to general liability per written contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Strong Island Running Club ACCORDANCE WITH THE POLICY PROVISIONS. 22 Buckingham Meadow Rd East Setauket,NY 11733 AUTHORIZED REPRESENTATIVE Ei/w'Y v ACORD 26(2016/03) ©1988-2016 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD MATTATH-01 ACOLLETTI ':4COR00 F CERTIFICATE OF LIABILITY INSURANCE DATE 2/(MMIDD(MM/DD/YYYY) 5 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 Neefus Stype Agency a/CC,NN,Ext:(631)722-3500 ac,No:(631)722-3591 711 Union Ave. E-MAIL Aquebogue,NY 11931 s .info@nsainsure.com INSURERS AFFORDING COVERAGE NAIC# INSURER A:U.S. L'tabill Insurance Co 25896 INSURED INSURER B: Mattituck-Cutchogue Athletic Booster Club INSURER C: PO Box 1241 INSURER D: Mattituck,NY 11962 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBINSODR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTRA X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 3,009,400 CLAIMS-MADE [X]OCCUR X SE1142662 3/16/2026 3/17/2026 DAMAGE TO RENTED $ 10 1,000 MED EXP An one person) $ ,000 PERSONAL&ADV INJURY $ 3,000,00.0 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 X POLICY❑PECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMITtF $ ANY AUTO BODILY INJURY Per erson $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY Per accident $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PERTUTE OTH- AND EMPLOYERS'LIABILITY S Y/N OFFICER/MEM ER EXCLUDED?ECUTIVE ❑ N/A E.L.EACH ACCIDENT $ (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) 3H6/25-Shamrook Shuffle 5k at Tasker Park,Carrol Ave,Peconic,NY 11958 Certificate holder is listed as additional insured in respect to general liability per written contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Southold ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 117 Southold,NY 11971 AUTHORIZED REPRESENTATIVE ACORD 26(2016103) 01988-2016 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD HOLD HARMLESS AGREEMENT The applicant JW r ck lte UadI, of this Special Permit shall defend, 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: ,Authorized Agent fCkZ On behalf of: (Name of Business Entity) Us / CJ" Dates of event(s): 3 Sworn to before me this o2 1 Day ort6raoL 20tR5. IlUW 0 AY p�gUC,STA NEW VOW peglsl a#m Na 01MU8429M Town of Southold P.O Box 1179 Southold, NY 11971 * * * RECEIPT * * * Date: 02/21/25 Receipt#: 337762 Quantity Transactions Reference Subtotal 1 Clean-Up Deposit 3/16/2025 $1,500.00 Total Paid: $1,500.00 Notes: Payment Type Amount Paid By CK#5707 $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 c/o Michelle Clark 415 Village Lane Mattituck, NY 11952 Clerk ID: JENNIFER Internal'ID:3/16/2025 Mudd, Jennifer From: Grattan, Steven Sent: Friday, February 21, 2025 4:08 PM To: Mudd,Jennifer Cc: Noncarrow, Denis Subject: RE: Emailing: Shamrock Shuffle - Matt-Cutch Athletic Booster Club.pdf Attachments: Shamrock Shuffle 2025.xis No objections to this event. Attached is my cost analysis. Steve -----Original Message----- From: Mudd,Jennifer<jennifer.mudd@town.southold.ny.us> Sent: Friday, February 21, 2025 3:55 PM To: Blasko, Regina <rblasko@town.southold.ny.us>; Goodwin, Dan <dang@southoldtownny.gov>; Grattan, Steven <sgrattan@southoldtownny.gov>; McCullough, Lillian <lillianm@southoldtownny.gov>; Mudd,Jennifer <jennifer.mudd@town.southold.ny.us>; Norklun, Stacey<Stacey.Norklun@town.southold.ny.us>; Orientale, Michael <michaelo@southoldtownny.gov>; Stype,John <johnst@southoldtownny.gov>; DeChance, Paul <pauld@southoldtownny.gov>;Johnson, Benjamin <benjaminj@southoldtownny.gov>; McGivney,Julie <juliem@southoldtownny.gov>;Schlachter,Amy<amys@southoldtownny.gov>;Squicciarini,James <jacks@southoldtownny.gov> Cc: Noncarrow, Denis<denisn@southoldtownny.gov>; Born, Sabrina <sabrina.born @town.southo Id.ny.us> Subject: Emailing: Shamrock Shuffle- Matt-Cutch Athletic Booster Club.pdf Good Afternoon, Please see attached Special Event Application from the Mattituck-Cutchogue Athletic Booster Club. Thank you, Jen Jennifer M. Mudd Sub-Registrar and Deputy Town Clerk Account Clerk Southold Town Clerk's Office 53095 Route 25 P.O. Box 1179 Southold, NY 11971 Phone: 631-765-1800 ext. 1274 Fax: 631-765-6145 Your message is ready to be sent with the following file or link attachments: Shamrock Shuffle- Matt-Cutch Athletic Booster Club.pdf 1 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. 2 Town of Southold Police Department Special Event Cost Analysis Event: Shamrock Shuffle Date(s): March 16, 2025 Location: Carrol Ave Peconic Patllocation.for Event h7z ,K _ Reg Hours OT Hrs Hrly Wage Total Comments Pokers Sergeant 2 $91.93 $183.86 Police Officer 2 $28.30 $56.60 °xe^ak 9" t 'r' ' Reg Hours OT Hrs Hrly Wage Total Comments PO Chen he 2 $78.17 $156.34 PO Sanders $0.00 Bicy4c[e Patrol" $0.00 $0.00 $0.00 K:,9 Unit �a; $0.00 .High—Y at_�ol'wf'-f PO Onufrak 2 $79.09 $158.18 PO Flatley 2 $79.09 $158.18 'Marne Units:. ..a. Tra f,c Control z a 6 td Reg Hours OT Hrs Hrly Wage Total Comments 77%,� PD Vehicles #of vehicles Y Hours $/hr Total 5 10 $20.00 $200.00 Command Van Marine Patrol Boats Total Department Cost for Event = $913.16 Prepared by Chief S. Grattan 2/24/2025 Pagel UFFOLIrea DENIS NONCARROW o~� G.f� Town Hall,53095 Main Road TOWN CLERK P.O.Box 1179 y Z Southold,New York 11971 REGISTRAR,OF VITAL STATISTICS 5 Fax(631)765-6145 MARRIAGE OFFICER 0 aQ� Telephone(631)765-1800 RECORDS MANAGEMENT OFFICER 1 `�► www.southoldtownny.gov FREEDOM OF INFORMATION OFFICER OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD Mattituck-Cutchogue Athletic Booster Club March 5,2025 Michelle Clark 45 Village Lane Mattituck,New York 11952 Dear Michelle, _ _ The Southold Town Board at its regular meeting held March 4th, 2025 granted permission to the Mattituck-Cutchogue Athletic Booster Club to hold its Shamrock Shuffle on Sunday, March 16',2025 as applied for.A certified copy of the resolution is enclosed. An insurance policy naming the Town of Southold as additionally insured has been filed with this office. Please contact Captain Grattan at the Southold Town Police Department as soon as possible to set up traffic control. If you have any further questions, please do not hesitate to contact the Town Clerk's office at(631) 765- 1800. Best of luck with your event. ly Denis Noncarrow Town Clerk Enc. RESOLUTION 2025-196 °Ya ADOPTED DOC ID: 21120 THIS IS TO CERTIFY THAT THE FOLLOWING RESOLUTION NO. 2025-196 WAS ADOPTED AT THE REGULAR MEETING OF THE SOUTHOLD TOWN BOARD ON MARCH 4, 2025: RESOLVED that the Town Board of the Town of Southold hereby grants permission to Mattituck-Cutchogue Athletic Booster Club to use the following route for its 2025 Shamrock Shuffle 5K on Sunday, March 16, 2025, 10:00AM to 12:OOPM (set-up starting at 7:OOAM): belZinning on the eastern side of Tasker Park on Carroll Avenue, right onto County Road 48, right onto Old North Road (&,Wesnofske Farms, right onto Ackerly Pond Lane, right onto Lower 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 $1,500.00 clean-up deposit (deposit to be returned after event upon recommendation of Chief Grattan, Southold Town Police Department). Failure to comply with all provisions and conditions will result in the revocation of the permit. Denis Nonearrow Southold Town Clerk RESULT: ADOPTED [UNANIMOUS] MOVER: Anne H. Smith, Councilperson SECONDER:Greg Doroski, Councilperson AYES: Mealy, Smith, Doherty, Evans, Doroski ABSENT: Albert J Krupski Jr sa outhold Town Board- Letter Board Meeting of April 1, 2025 RESOLUTION 2025-263 Item# 5.18 ADOPTED DOC ID: 21192 THIS IS TO CERTIFY THAT THE FOLLOWING RESOLUTION NO. 2025-263 WAS ADOPTED AT THE REGULAR MEETING OF THE SOUTHOLD TOWN BOARD ON APRIL 1,2025: 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, Steven 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 North Fork Chamber of Commerce & 1/10/2025 $250.00 Cutchogue Fire Dept. c/o Joseph Corso 2520 Fairway Drive Cutchogue,NY 11935 Mattituck-Cutchogue Athletic Booster Club 2/21/2025 $1,500.00 PO Box 1241 Mattituck,NY 11952 t Denis Noncarrow Southold Town Clerk RESULT: ADOPTED [UNANIMOUS] MOVER: Greg Doroski, Councilperson SECONDER:Brian O. Mealy, Councilperson AYES: Mealy, Smith, Doherty, Evans, Doroski, Krupski Jr Generated April 2, 2025 Page 32 TC Checklist for Parade/5KY/Bicyc1e*/Town Property/Road Closure Special Events Applications Name of Organization: µ&v, V►hg k - Wk h0oU2 AUK16Hc. 10d&1 ejt't� Name of Event: _, 1YW& lr LIC Date(s) of Event: (Ct o� *No 5K and Bicycle events during the period of June 1 to November 1X DL- Event fee check(or1reque�st to_b�—� ) ✓ Road clean-up check (CANNOT BE WAIVED) ,./ Current Insurance certificate Application sent for approvals to thefollowing Depts.: PD ✓ Hwy ✓/Land Pres. ` ' T A '-�Records Mngmnt/TC ✓ Approval from Chief of Police v Cost Analysis from Chief of Police Approval from Land Preservation / Approval from Highway Dept. .J TB Resolution for approval (once approval and cost analysis comes from Chief of PD) Town Board Reso. ff: Approval letter to Organization's contact person w/copy of TB resolution After Event: Confirmation from Chief of PD to release clean-up fee JTB Resolution to refund clean-up fee TB Clean-up Reso. #: o�FJ`o2�Pj Voucher and copy of TB clean-up Reso. to Accounting Dept. Whole application file to Records Management (include copy of voucher& reso.) Vendor No. Check No. Town of Southold, New York - Payment Voucher Vendor Name Vendor Address Entered by Mattituck-Cutchogue Athletic Booster Club c/o Michelle Clark 415 Village Lane Audit Date Vendor Telephone Number Mattituck, NY 11952 631-334-4511 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 2025-263 4/1/25 1,500.00 1,500.00 5K c/u deposit return A.1410.4.600.100 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. Si4ar Title:DeputyjTown �Clerk C Signature r� Company Name Date 7 ( .J Title:Deputy Town Clerk Date'7 R5