HomeMy WebLinkAboutDylan Newman Forever 5 Foundation RESOLUTION 2025-418
to ® t
ADOPTED DOC ID: 21326
THIS IS TO CERTIFY THAT THE FOLLOWING RESOLUTION NO. 2025-418 WAS
ADOPTED AT THE REGULAR MEETING OF THE SOUTHOLD TOWN BOARD ON
MAY 28,2025:
RESOLVED that the Town Board of the Town of Southold hereby grants permission to the
Dylan Newman Forever 5 Foundation to hold its Fundraiser and Softball Tournament in Cochran
park on Saturday June 7th and Sunday June 8th 2025 from 8:00am to 1 OPM. The applicant filed
a Two Million Dollar Certificate of Insurance with the Town Clerk, naming the Town of
Southold as additional insured.
The Town board is requiring the applicant to:
1)Direct the Volunteers to park at the Community center
2) let participants know they can park on Carol avenue.
3) No Parking Permitted in the Tasker Park fields.
4)Use care when putting in Tent Spikes and repair any damage to grass.
Please review Special event requirements for holding this event.
Denis Noncarrow
Southold Town Clerk
RESULT: ADOPTED [UNANIMOUS]
MOVER: Louisa P. Evans, Councilperson
SECONDER:Greg Doroski, Councilperson
AYES: Mealy, Smith, Doherty, Evans, Doroski, Krupski Jr
TC Checklist for Parade/5KY/BicycleY/Town Property/Road
Closure Special Events Applications
Name of Organization: 'r 5
Name of Event: CeN, Date(s) of Event: (bx
*No 5K and Bicycle events during the period of June 1 to November
_Event fee check(or request to be waived)
,Road clean-up check(CANNOT BE WAIVED)
✓ Current Insurance certificate
Application sent for approvals'to the following Depts.: /
PD ✓ Hwy ✓ Land Pies. ✓ TA ✓ Records Mngmnt/TC
Approval from Chief of Police � �/J
Cost Analysis from Chief of Police T r Pvt
Approval from Land Preservation co c vL
Approval from Highway Dept.
TB Resolution for approval (once approval and cost analysis comes from Chief of PD)
Town Board Reso. #:
Approval letter to Organization's contact person w/copy of TB resolution
After Event:
Confirmation from Chief of PD to release clean-up fee
TB Resolution to refund clean-up fee
TB Clean-up Reso. #:
Voucher and copy of TB clean-up Reso. to Accounting Dept.
Whole application file to Records Management (include copy of voucher& reso.)
S , � a Z 2.
Mudd, Jennifer
From: Mudd,Jennifer
Sent: Tuesday, May 13, 2025 9:24 AM
To: Noncarrow, Denis; Born, Sabrina; Franke, Diana; Blasko, Regina; Goodwin, Dan; Grattan,
Steven; McCullough, Lillian; Mudd,Jennifer; Norklun, Stacey; Orientale, Michael; Stype,
John; DeChance, Paul;Johnson, Benjamin; McGivney,Julie; Schlachter,Amy; Squicciarini,
James
Cc: Douglass,Janet; Schroeder, Gwynn
Subject: Special Event - DNFSF (Softball Tournament &Chinese Auction)
Attachments: Special Event - DNFSF (SB Tournament &Chinese Auction).pdf
Good Morning,
Please see attached Special Event Application from the Dylan Newman Forever 5 Foundation for a
Softball Tournament and Chinese Auction to be held June 7t" & 8t', 2025 from Sam— 1 Opm at Cochran
Park. Please provide feedback/cost analysis.
Thank you,
Jew
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
i
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 Telephone(631)765-1800
RECORDS MANAGEMENT OFFICER www.southoldtownny.gov
FREEDOM OF INFORMATION OFFICER
RECEIVED
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD MAY
.. 'y.YY..
APPLICATION FOR A PERMIT TO HOLD A Southold Town'°Cierk
SPECIAL EVtNT
Please provide ALL of the information requested below. Incomplete applications WILL NOT be
reviewed.
Date of Submission
Name of Event Dy/z&& /v�� ,� �"�'e��� J �H ,�L/ 'mil -h�cwe •&-1
Name of Organization: �J ��•'� �e eye-^ .15— • 44 p
Is this a Not-For-Profit Event? Yes/No 1-0
Contact's Name: r�o yr Gc7A A '
Mailing Address: /'
Contact's Phone Number: CDP— �. ,/- 70V 5�
Contact's Email Address: ��A�-� �s`�l l9rD��1�i1.��
Event Location and Site Diagram:
(Use additional paper if necessa )
Event Date(s): W -
(Include s up and sh /d''own times and dates)
Nature of Event:
(Please attach a detailed description to this application)
60
Time Period (Hours) of Event: From to �G✓ _
Maximum Number of Expected Attendees:
Specify any special requirements (i.e. road closure, police presence): ( l✓L.Q_
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 FeW..
$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):
V$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 REQUIRED: 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 gnature orized Person filling out app i
application
*Upon the request by applicant,the Town Board may waive in whole or in part any of the application
requirements.
2
TOWN OF SOUTHOLD
Policy for Special Events on Town Properties and Roads
In addition to the criteria set forth in Chapter 205 of the Southold Town Code with respect to the
review of events that are proposed to utilize or be held on any land owned, leased or controlled
by the Town of Southold and, in particular, special events on Town roads, and with the exception
of community organized parades, the issuance of a Special Event Permit by the Town Board will
be subject to the following guidelines:
1. All events must be sponsored by a not-for-profit organization or recognized charity and
the applicant must verify that all proceeds generated by the event are wholly for the
benefit of said organization or recognized charity.
2. Events that require the closing of a road shall not be held on a holiday or at the same time
or location of previously approved community or special events absent authorization
from the Chief or Captain of the Police Department.
3. All motorcycle events shall be limited to 600 participants.
4. Applicants may only receive approval for one event in each calendar year.
5. The prior issuance of an approval does not bind the Town Board to approve the same or a
similar event in the future.
6. Failure to comply with any condition of approval may result in revocation of approval
and/or denial of future applications.
In addition to the above, all Bicycle and/or Running Special Events shall be subject to the
following guidelines:
1. There shall be no bicycle and/or running special events conducted within the Town of
Southold during the period of June 1 to November 1.
2. Organizers and participants of bicycle and/or running special events shall fully adhere to
the"rules of the road" including every applicable provision of the New York State
Vehicle and Traffic Law, including but not limited to VTL §§1231-1234.
3. Organizers of bicycle and/or running special events shall post a deposit of one,thousand
five hundred dollars ($1,500.00) to ensure that the roads are returned to pre-event
condition.
4. Where the expected number of persons or the duration of the bicycle and/or running
special event may impact the health, safety and welfare of the public, as a condition to
granting the permit, the Town Board, upon the recommendation of the Chief of Police,
may require the applicant to reimburse the Town for the costs of increased police
protection, public safety oversight, and public works facilitation, including any additional
equipment as may be deemed necessary by the Chief of Police to adequately and safely
control and protect the persons attending the event, the event area and traffic in and
3
around the event area. Such costs shall include all necessary staffing and shall be
provided to the applicant prior to the issuance of the permit.
5. All bicycle events and/or running special events shall be limited to 600 participants.
All special event approvals shall be subject to compliance with the following conditions:
1. They file with the Town Clerk a Two Million Dollar Certificate of Insurance
naming the Town of Southold as an additional insured; a$250 or $500 filing fee
(depending on size of event); a remuneration fee determined by the Chief or Captain of
the Police Department for traffic control; $250.00 or more deposit for clean-up (deposit
to be returned after event upon recommendation of the Southold Town Police Chief;
Southold Town Police Department);
2. Make every effort to control noise;
3. Comply with Chapter 205 of the Southold Town Code to notify neighbors in
advance of event;
4. Coordinate traffic control upon notification of the adoption of a Town Board
resolution with Police Captain;
5. No permanent markings be placed on Town, County or State roads or property for the
event;
6. Any road markings or signs for the event be removed within twenty-four(24)
hours of the completion of the event; and
7. Any parade participants shall not throw candy or other objects at or in the
direction of spectators along the parade route but such items may be handed
directly to spectators.
The Town Board reserves the right to waive or modify any or all of the above guidelines and
conditions as it may deem appropriate under the circumstances presented and to deny any
application for a special event that is determined to not be in the best interest of the residents of
the Town of Southold.
4
Janet Douglass of sa�T 970 Peconic Lane
Recreation Supervisor `os'� `°�, PO Box 267
TOWN OF SOUTHOLD Peconic NY,11958
rm aka
Phone: 631.765.5182
Cou
JanetD@SoutholdTownNY.gov
TOWN OF SOUTHOLD
RECREATION DEPARTMENT
MEMORANDUM
TO: Gwynn Schroeder
FROM: Janet Douglass
DATE: May 9, 2025
RE: Special Event: ylan Newman Forever 5 Softball Tournament
The Dylan Newman Forever 5 Foundation has been holding this softball
tournament at Cochran Park for the last few years under `Field Use'. Despite field
use applications being due two months before the requested event, the applicant
dropped off his application to Town Hall, and it was given to me on 5/2/25.
Application reviewed at the Parks, Beach & Recreation Committee on 5/7/25 as we
now have a better understanding of the size and impact of the event. The
Committee recommends that it be treated as a Special Event going forward.
Some issues that were brought up include:
• Traffic Mitigation: Two other groups have already have had their field use
approved to use Cochran Park (NF United Soccer Club & North Fork Little
League) during this time on other fields. Pickleball courts across the street
put additional pressure on parking.
• Tent stakes: This organization has been putting up tents and driving large
tent stakes into the grounds. Possible mark-out needed depending on
where they are putting the tents.
• Vehicles on field/track: No vehicles should be driven on track or grounds.
• Event has been promoted on Facebook by the organizations several weeks
prior to the application being turned into the Town.
Please let me know if you have any questions.
Ao��flFsouryo�o Janet Douglass 970 Peconic Lane
Recreation Supervisor P.O. Box 267
• Town of Southold Peconic, NY 11958
JanetD@Sou tholdTownNY.gov 631.765.5182
TOWN OF SOUTHOLD
RECREATION DEPARTMENT
APPLICATION FOR USE OF SOUTHOLD PARKS FACIILITIES
PLEASE PRINT LEGIBLY
APPLICATIONS DUE AT LEAST TWO (2) MONTHS BEFORE EVENT
Payment is due at time of application
Today's Date: L Ae
Requesting Organization: &ZV4440 P N'-L
Applicant's Name: B AP 112 4?A4 b Aj F
Address: 4A C-zA/1&a_ 11 fZ1 / ,f
Home Phone: Business: Cell:
E-mail Address:
Facility Requested:
Day(s)and date(s) of use:
Requested Time for Field/Park/Court/Use:
0
From: To: 41
T
Requested time for lights to be on (if applicable). Field/court lighting will not be available
from January 1—March 1.
From: To:
NOTE: LIGHTS MUST BE TURNED OFF BY 10:00 P.M.
Reason For Use(Please be specific and give details):
{
Is admission being charged? Yes No
If yes,how much is being charged?
Please provide a detailed explanation of how the proceeds are to be used:
�II)FS2
Applicant's Signature:
S
J S 1
HOLD HARMLESS AGREEMENT
The applicant/group/organization agrees to indemnify and hold harmless the Town of
Southold, its officials, employees, and/or agents from all claims, lawsuits, hospital and/or
doctor bills, actions, proceedings, and liabilities for the loss or damage to property, or any
injury, the death of a person, including any expenses incurred by the Town of Southold
defending any claims, lawsuits, or action that may arise as a result of the conduct, actions,
including the negligence of the applicant/group/organization to the fullest extent permitted
by applicable law.
I have read the attached "SOUTHOLD TOWN FACILITY RULES AND
REGULATIONS" and agree to abide by them.
Name of Organization: OtIldil New~-, e,dV' C�.7
Please Print
I— o A)e,o*t4,.
Da Please Print(Principal/Authorized Representative).
Applicant's Signature:
We are glad that we are able to provide your group/organization league
with a facility. Your group is required to make certain that the
field is free of debris when you leave for the day.
Our staff has maintenance schedules exclusive of
outside groups who use our facilities and we need to make
sure that the field is ready for future groups and activities.
Thank you for your time and cooperation regarding this matter.
ltil-�/�/�l�l�l•�/�l�l-�l-�l�Il•�f�/�/�/�f�/�l-�/�/�/�l�l�/�/�f�1�/�l-�/�/�l-�l•�l-�/�/�l-�I�l-�/�l-�/�/�l•�l•�/�l-�l�l�l-�l-�t�/�f�/�l-�/�l-�/til-�f��
FOR OFFICE USE ONLY
Certificate of Insurance Required? OYES 13 NO
Special Events Application Required? EIYES LINO
If yes,please fill out the attached application.
Facility Is: Request Is:
Available { } Approved { }
Not Available { } Denied { }
Recreation Department Supervisor
SOUTHOLD TOWN FACILITY RULES AND REGULATIONS
J ,
1. Permits are required for use of all town fields. Permit applications are available
through the Southold Town Recreation Department. Permits are required for all
groups. Preference is given to applicants and/or groups that are residents of the
Town of Southold. To meet the requirement for a resident group, 65% of
players/participants must be Southold Town Residents. Active rosters listing
current players are required for all sport leagues. Proof of residency (tax bill,
utility bill, etc.) is required for every member on the roster. Reservations are to be
made through the recreation department. Priority will be given to scheduling
games and scrimmages. Practices are on a first come, first serve basis. Fields
will not be reserved for practices.
2. Fee schedule:
TIER# TIER DESCRIPTIO
Tier 1 Town of Southold, little leagues, local non- No Charge
profit groups, civic organizations, local
schools, charitable groups, etc.
. $75/1/2 day/field
'Pier 2 Resident For Profit (up to 4 hours)
groups that charge fees •°°°°°°°•
and travel teams $150/full day/field
(up to 8 hours)
All travel teams must °°°°°°°°°
obtain Town Board approval $250 travel team season:
(resolution) for field use winter,spring,
summer, fall
Tier 3 Non-Resident Groups, Schools, Leagues, etc.
up to 4 hours)
Verification is required for non-profit groups ( 2 day/field
Application is reviewed by Park& (up t
Recreation Committee, followed by Town
Board resolution. Application is $100/ full day/field
pending until final approval. (up to 8 hours)
Tier 4 Non-Resident For Profit
Groups that charge fees $200 1/2 day/field
(up to 4 hours)
Application is reviewed by Park & °°°°°°°°°
Recreation Committee, followed by Town $400/full day/field
Board resolution. Application is (up to 8 hours)
pending until final approval.
Fees may be waived if group/organization league is willing to donate or
make improvements to the facility. This is subject to the approval of the
parks, beaches, and recreation committee and the Southold Town
Board. The Town reserves the right to waive fees.
J
3. Town sponsored activities shall take precedence in the use of the facility. If
necessary, groups may be asked to change scheduled dates or cancel facility use
in the event that fields need maintenance, can't be played on due to excessive use,
etc. We will try to avoid this situation and adhere to your scheduled activity.
4. Persons requesting use of a town facility are required to provide a Certificate of
Insurance naming the TOWN OF SOUTHOLD as additional insured. If
requesting use of Strawberry Fields, the COUNTY OF SUFFOLK must also be
included as additional insured. The Certificate of Insurance will not be accepted
unless it states all the correct information. It is up to the applicant to maintain a
current and up-to-date certificate of insurance. The applicant must sign a hold
harmless agreement.
The general liability policy should include:
Each Occurrence $2,000,000
Damage to Rented Premises $50,000
Med Exp $5,000
Personal & Adv Injury $2,000,000
General Aggregate $2,000,000
Products-Comp/OP Agg $2,000,000
5. The facility must be left clean and orderly and in its original condition. Trash
clean-up after events is the responsibility of the organization. Please make sure
teams pick up water bottles, litter, lost and found articles, etc. after practices
and games. Trash, garbage, and all other litter shall be placed in containers
provided for this purpose, and shall be limited to litter accumulated during use of
town recreation areas. It shall be unlawful for any person to deposit any refuse
brought from private property in receptacles located in town parks or facilities.
Nothing in this section is intended to prohibit the disposal of refuse generated
from park use such as picnics, barbecues, lunches, etc.
6. The responsibility for safety and order during facility use is that of the applicant.
The use of the fields when standing water is present, footing is unsure and
slippery, during heavy rain or severe weather storms, or following heavy rain will
not be allowed. It is the responsibility of the organization's coach, supervisor,
director, etc. to cancel the event during such conditions. Failure to cooperate with
this may result in loss of field privileges as it will result in compaction of the turf
and unsafe playing conditions for all that use the facility.
7. Lights are to be for group play only and must be turned off by 10:00 PM. Use of
lights past 10:00 PM may result in loss of privileges for future activities.
Individuals are not allowed to use lights for individual use or non-organizational
activity.
8. It is up to the applicant to make sure that if food or beverages are to be sold at
your events, the vendor has the proper health department certificates and
certificates of insurance. Requesting organization must approve vendors. Outside
vendors will not be allowed on the facility. The town may require proof of these
documents from vendors.
9. Alcoholic beverages or other controlled or illegal substances are NOT permitted
on town property.
10. No open fires are allowed. Smoking is not allowed on any town owned facility
including playgrounds and park facilities.
11. Consider other park users. Boisterous, immoral, or indecent conduct will not be
tolerated. It is unlawful to use profane or abusive language or to conduct oneself
in a manner that interferes with the reasonable use of the park by the general
public.
12. Use or discharge of any type of air gun, slingshot, or explosive is prohibited.
13. Please cooperate in keeping the rest rooms and washrooms in a neat and sanitary
condition.
14. It is unlawful to remove, destroy, mutilate or deface any structure, monument,
statue, vase, fountain, wall fence, railing, vehicle, bench, shrub, tree, fern, plant
flower, lighting system or sprinkling system or other property in any park.
15. It is against park policy to play car stereos, radios, or "boom boxes" - portable
audio equipment, such as tape or compact disc players - so loudly they interfere
with normal conversations or cause annoying vibrations at a distance of 75 feet or
more.
16. The applicant must assume prompt responsibility for any damage to the grounds
while being used by their group or organization.
17. Abuse of Policy
The following steps will be adhered to for any abuse of the policy:
First Offense:
Written warning to team and President/Director of the organization.
Second Offense:
Suspension of the team or organization from practicing on fields for one week.
Forfeiture of a team or organization's privilege to either practice or play games on
Town of Southold fields for the remainder of the season and denial of future
applications for permits submitted by such team, group, or organization.
Field Permits will be revoked for:
*Unsafe playing conditions (see#5)
*Use of alcohol or other controlled substances at field sites
*Excessive litter
*Cars parked on fields and other grass areas
*Use of foul and abusive language
•Failure to adhere to Town ordinances.
18. Town of Southold - Code of Conduct
The Town of Southold has adopted the following code of conduct as a result of its
concerns for good sportsmanship in all athletic events.
Sports can be used as an opportunity for young and old alike to learn how to engage in
healthy competition while maintaining respect for their opponents. All parties involved in
athletic competitions should adhere to the highest standards of constructive support for
the contestants. By utilizing the Town of Southold recreation facilities, all parties must
abide by this Code of Conduct. Violations may result in the loss of privileges at town
facilities.
*Participants and spectators will be a positive role model and encourage sportsmanship
by showing respect and courtesy for all players, coaches, officials, and spectators at every
game, practice, or sporting event.
•We will not engage in any kind of unsportsmanlike conduct with any official, coach,
player or parent, such as booing and taunting, refusing to shake hands, or using profane
language or gestures.
•We will respect the officials and their authority and will refrain from questioning,
discussing, or confronting coaches during the game. If warranted, we will take the time
to speak with the officials or coaches at an agreed upon time and place in a courteous and
considerate manner.
•We will keep in mind that children participate to have fun and that the game is for the
youth, not the adults. Adult leagues, please take heed of your behavior during
participation in your particular sport.
•We will provide a sports environment that is free from drugs and alcohol and will
refrain from their use at all sports events.
•We will remain respectful of the athletic facility in which we are using and will not
damage or deface park or town property.
*In a nutshell, play fair, be a good sport and role model, and remember the golden
rule.
19. The applicant/group/organization agrees to indemnify and hold harmless -the
Town of Southold, its officials, employees, and/or agents from all claims,
lawsuits, hospital and/or doctor bills, actions, proceedings, and liabilities for the
loss or damage to property, or any injury, the death of a person, including any
expenses incurred by the Town of Southold defending any claims, lawsuits, or
action that may arise as a result of the conduct, actions, including the negligence
of the applicant/group/organization to the fullest extent permitted by applicable
law.
FOR FURTHER INFORMATION, PLEASE CONTACT THE
SOUTHOLD RECREATION DEPARTMENT AT 631.765.5182.
THEDYLA-01 MROMANO
�AcoRo� CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY)
4/30/2025
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((es)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
East End Insurance Agency PHONE FAX
P.O.Box 1406 A/C,No,Ezt:(631)765-3811 A/C,N,:(631)765-3846
Southold,NY 11971 EMAIL s-
INSURER S AFFORDING COVERAGE NAIC#
INSURER A:U.S. Underwriters Insurance Company 35416
INSURED INSURER B:
The Dylan Newman Forever 6 Foundation INSURERC:
486 Gardiners Lane INSURER D:
Southold,NY 11971
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 ADDLSUBRJ WVD POLICY NUMBER POLICY EFF POLICY EXPLTR LIMITS
A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000
CLAIMS-MADE � OCCUR X NBP3660397 7/9/2024 7/9/2026 DAMAGPREME TO RtE.ENTED ce $ 100�00�
MED EXP(Any oneperson) $ 6,000
PERSONAL&ADV INJURY $
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
X POLICY SECT LOC PRODUCTS-COMP/OP AGG $
OTHER: $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
c' e $
ANY AUTO BODILY INJURY Perperson) $
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 PER OTH-
AND EMPLOYERS'LIABILITY Y/N
ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ E.L.EACH ACCIDENT $
OFFICER/MEMBE_}?EXCLUDED? N/A
(Mandatory in N )
E.L.DISEASE-EA EMPLOYE $
If yes,describe under
DESCRIPTION OF OPERATIONS below I E.L.DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached ff more lace is uired)
Certificate holder Is included as additional insured with respects to general liability as required by wri�ten contract
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Town of Southold THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
To
To 1179 Sou
ACCORDANCE WITH THE POLICY PROVISIONS.
Southold,NY 11971
AUTHORIZED REPRESENTATIVE
ACORD 25(2016103) 01988-2016 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
Town of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 05/13/25 Receipt#: 339785
Quantity Transactions Reference Subtotal
1 Clean-Up Deposit June 7-8, 2025 $250.00
Total Paid: $250.00
Notes:
Payment Type Amount Paid By
CK#0213 $250.00 Dylan Newman Forever 5
Foundation, Inc.
Southold Town Clerk's Office
53095 Main Road, PO Box 1179
Southold, NY 11971
Name: Dylan Newman Forever 5 Foundation, Inc.
485 Gardiners Ln
Southold, NY 11971
Clerk ID: JENNIFER Internal ID:June 7-8,2025_
Noncarrow, Denis
From: Noncarrow, Denis
To: todnew45@gmail.net
Subject: Resolution
Attachments: Printout-21326-1034-M65244.doc
HI Todd
As we spoke
See you then.
Denis Noncarrow
Southold Town Clerk.
Town of Southold, New York
www.southoldtownny.gov
denisn @southold townny.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