HomeMy WebLinkAboutSC DPW Traffic Signal Mattituck
.,
Town of South old with COS
Law Dept.No. t)6-~-~7b
Agreement Location: CR 48. Middle Road@
Westphalia Road, Hamlet of Mattituck
Revised 8/3/05
AGREEMENT FOR THE INSTALLATION OF
TRAFFIC CONTROL DEVICES
This AGREEMENT is between the County of Suffolk ("COUNTY"), a municipal corporation of
the State of New York, having its principal office at the County Center, Riverhead, New York 11901,
acting through its duly constituted Department of Public Works ("the DEPARTMENT") located at 335
Yaphank Avenue, Yaphank, New York 11980-9744, and the Town of SOUTHOLD ("TOWN"), having
its principal office at 53095 Main Road, Southold, NY, 11971.
TERMS AND CONDITIONS: Shall be as set forth in "Exhibit A" and "Exhibit B" attached
hereto and made a part hereof.
IN WITNESS WHEREOF, the parties hereto have executed this Agreement as of the latest date
written below:
TOWN OF SOUTHOLD
B, ~aA. ",v-I
SCO A. RUSSELL
Supervisor
'$-(~
Date
APPROVED AS TO LEGALITY:
CHRISTINE MALAFI
~;ffolk Cf)Ounty Attorney /
, < /~~/ 94:JAx,
-....r. / ! Date
BASIA DEREN BRADDISH, ESQ,
Assistant County Attorney
APPROVED:
8-/1-06
,P.E.
Date
COUNTY OF SUFFOLK
By:
f/cu...O Ao (16 tJ
PAUL SABATINO II
Chief Deputy County Executive
/o/~')d/.
Date
Town of Southold with COS
Agreement Location: CR 48, Middle Road @
Westphalia Road, Hamlet of Mallituck
Law Dept. No.
Revised 8/3/05
EXHIBIT A
WHEREAS, the DEPARTMENT operates a program to improve traffic signals, markings, signs
and the like ("Devices") in order to ensure the safe and continuous movement of traffic, and
WHEREAS, the DEPARTMENT has determined that certain Devices are necessary along CR 48,
Middle Road @ Westphalia Road, Hamlet of Mattituck for the improvement of traffic conditions at the
said location within the TOWN, and the TOWN accepts said determination, and
WHEREAS, pursuant to Section 136 of the New York State Highway Law, the Commissioner of
the Suffolk County Department of Public Works ("Commissioner") is empowered to erect Devices, as
authorized by the County Legislature, in order to improve traffic conditions, and
WHEREAS, the parties hereto desire to provide for the installation and maintenance of Devices at
the aforesaid location within the TOWN for the improvement of traffic conditions, in accordance with a
traffic signal plan on file with the DEPARTMENT:
NOW, THEREFORE, in consideration of the individual and mutual covenants, promises and
representations herein contained, the parties hereto agree as follows:
1. Definitions:
meaning:
The following terms whenever used in this Agreement shall have the following
Devices: Traffic signals and associated appurtenances.
Traffic Signal Service Report: A report of any and all work performed on the Devices.
2. Desi!!n: Installation: The COUNTY shall install, at the expense of the Permit Applicant or through
the COUNTY'S Capital or Operating Budget, Devices of the type, and at the location, set forth above.
3. Ownership:
A. Any and all Devices installed pursuant to this Agreement shall be the sole and exclusive property
of the TOWN.
B. Any Devices removed from the site(s) designated herein shall be delivered to either the
DEPARTMENT or the TOWN, as directed by the Commissioner.
4. Operation and Maintenance:
A. All costs incurred in the operation and maintenance of the Devices, including any and all charges
for electricity, shall be borne by the TOWN or, in the case of a Permit Signal, the Permit
Applicant, until such time as responsibility for the operation and maintenance of the Devices is
assumed by the TOWN.
B. At such time as responsibility for the operation and maintenance of the Devices is assumed by the
TOWN, the TOWN shall operate and maintain the Devices in accordance with the current
Maintenance Specifications of the DEPARTMENT. A copy of said specifications is available
upon request at the DEPARTMENT.
Page I
Town of South old with cas
A~eement Location: CR 48, Middle Road @
Westphalia Road, Hamlet of Matti tuck
Law Dept. No.
Revised 8/3/05
C. In the event that the TOWN has a set of Maintenance Specifications equivalent to that of the
DEPARTMENT, the TOWN may, subject to the review and approval of same by the DE-
PARTMENT, use same in lieu of the DEPARTMENT'S Maintenance Specifications.
D. In connection with its maintenance of the Devices, the TOWN shall provide the COUNTY with a
Traffic Signal Service Report whenever and wherever a maintenance problem exists which
prevents the device from operating as designed.
E. The TOWN shall keep all local police authorities aware of the party responsible for maintenance
of the Devices. The TOWN shall establish procedures that will allow maintenance contractors
and/or TOWN employees to provide maintenance services for the Devices on a 24-hour basis.
5. Modification of Devices: The TOWN shall not alter the signal operation or timing of the Devices
without the prior written approval of the DEPARTMENT. In the event of any alteration to the signal
operation or timing of the Devices, the TOWN shall furnish the DEPARTMENT with one (I) set of wiring
diagrams for ach alteration.
6. Representations and Warranties:
A. The TOWN shall enact any ordinance, order, rule or regulation necessary for the installation and
maintenance of the Devices.
B. The TOWN shall comply, and shall require its officers, directors, partners, trustees and other
members of its governing body, as well as any personnel employed to render services under this
Agreement, to comply, with all applicable rules, regulations and requirements of law, including
Suffolk County local preference laws and other applicable Suffolk County local laws, and reso-
lutions ofthe Suffolk County Legislature.
C. The TOWN shall maintain full and complete books and records of any and all Traffic Signal
Service Reports. Such books and records shall be retained for a period of seven (7) years and shall
be available for inspection by the DEPARTMENT, or its duly designated representative, upon
written notice during regular business hours.
D. The COUNTY agrees to transfer any and all warranties and representations on all equipment and
materials installed by the COUNTY or its permittees to the TOWN.
7. Violation
A. In the event that the TOWN fails to maintain the Devices in accordance with the terms of this
Agreement, the COUNTY, in addition to any other remedies t6 which it may be entitled, may
withhold funds for traffic improvements within the TOWN.
B. The COUNTY shall provide the TOWN with written notice of the TOWN'S failure to maintain
the Devices. Such notice shall specify the particular failure. The TOWN shall be given a
reasonable period oftime to correct any said failure.
Page 2
Town of Soul hold with COS
Agreement Location: CR 48, Middle Road @
Westphalia Road, Hamlet of Mallituck
Law Dept. No.
Revised 8/3/05
8. Insurance (See Exhibit B)
A. The TOWN shall procure, pay the entire premium for, and maintain throughout the term of this
Agreement, insurance in amounts and types specified by the COUNTY. The TOWN agrees to
require all of its subcontractors in connection with work performed for the TOWN related to this
Agreement, procure, pay the entire premium for and maintain throughout the term of this
Agreement, insurance in amounts and types equal to that specified by the COUNTY for the
TOWN. Unless otherwise specified by the COUNTY and agreed to by the TOWN, in writing,
such insurance shall be as follows:
i. COMMERCIAL GENERAL LIABILITY INSURANCE, including contractual
coverage, in an amount not less than TWO MILLION AND NO/IOOTHS ($2,000,000.00)
DOLLARS per occurrence for bodily injury and TWO MILLION AND NO/IOOTHS
($2,000,000.00) DOLLARS per occurrence for property damage.
ii. AUTOMOBILE LIABILITY INSURANCE, (if any vehicles are used by the TOWN in
the performance of this Agreement including owned, non-owned, and hired cars) in an amount
not less than Five Hundred Thousand Dollars ($500,000) per person, per accident, for bodily
injury and not less than One Hundred Thousand Dollars ($100,000) for property damage per
occurrence.
iii. WORKER'S COMPENSATION AND EMPLOYER'S LIABILITY INSURANCE, in
compliance with all applicable New York State laws and regulations and DISABILITY
BENEFITS INSURANCE, if required by law. The TOWN shall furnish to the COUNTY, prior
to its execution of the Agreement, the documentation required by the State of New York
Workers' Compensation Board of coverage or exemption from coverage pursuant to llll57 and
220 of the Workers' Compensation Law. In accordance with General Municipal Law II 108,
this Agreement shall be void and of no effect unless the TOWN shall provide and maintain
coverage during the term of this Agreement for the benefit of such employees as are required to
be covered by the provisions of the Workers' Compensation Law.
iv. PROFESSIONAL LIABILITY INSURANCE (ERRORS AND OMISSIONS), that
covers any damage arising out of the TOWN'S performance of professional services
caused by an error, omission, or negligent acts, in an amount not less than Two Million
Dollars ($2,000,000) on either a per occurrence or claims made coverage basis.
v. In the event the TOWN maintains a COMPREHENSIVE GENERAL
LIABILITY INSURANCE policy form in lieu of Commercial General Liability, said
policy must include all of the above requirements plus premises/operations,
independent contractors, contractual, and broad form property damage.
B. All policies providing such coverage shall be issued by insurance companies with an
A.M. best rating of A- or better. All insurance shall be obtained from companies licensed to
do business in the State of New York.
Page 3
Town of Southold with cas
Ae:reemcnt Location: CR 48, Middle Road @
Westphalia Road, Hamlet of Mattituck
Law Dept. No.
Revised 8/3/05
C. The County of Suffolk must be named Additional Insured and the TOWN shall
furnish to the COUNTY a declaration page for each such policy of insurance, and
upon request, a true and certified original copy of each such policy, evidencing
compliance with the aforesaid insurance requirements. In the case of commercial
general liability insurance, the County of Suffolk shall be named as an additional
insured and the TOWN shall furnish a Declaration page and endorsement page
evidencing the County's status as an additional insured on said policy. Where work
under this Agreement is sub-contracted, the TOWN must require the subcontractor to
provide that the COUNTY be named as an additional insured on all required policies,
as well as require the subcontractor to provide the COUNTY with all required
evidence of insurance.
D. All such Declaration Pages, certificates and other evidence of insurance shall provide for
the County of Suffolk to be notified in writing thirty (30) days prior to any cancellation,
non-renewal or material change in said policies. Required limits of insurance are not to be
modified by deductibles that the COUNTY deems excessive without the COUNTY'S written
permission. All such Declaration Pages, certificates, policies and other evidence of
insurance and notices shall be mailed to the DEPARTMENT and to the Suffolk County
Risk Management and Benefit Division [700 Veterans Memorial Highway, 2nd Floor,
Hauppauge, New York 11788, or such other address of which the COUNTY shall have
given the TOWN written notice].
E. If the TOWN, as a municipal corporation, has a self insurance program under which it acts as
a self insurer for any of such for any such required coverage, it may provide self-funded
coverage, declarations and certificates or other evidence of such self-insurance in lieu of
insurance issued by insurance companies.
F. In the event the TOWN fails to provide the Declaration Pages or certificates of insurance or to
maintain any insurance required by this Agreement, the COUNTY may, but shall not be
required to, obtain such policies and deduct the cost thereof from payments due the TOWN
under this Agreement or any other Agreement between the COUNTY and the TOWN.
G. The COUNTY will not authorize work to begin under this Agreement until all the required
insurance has been obtained and said insurance has been approved and filed by the
COUNTY. Approval of the insurance by the County shall not relieve or decrease the liability
of the TOWN. The TOWN shall assume all responsibility for the insurance requirements of
any applicable sub-consultants.
9. Indemnification: To the greatest extent permitted by law, the TOWN agrees that it shall protect,
indemnify and hold harmless the County and its officers, officials, employees, contractors, agents and other
persons (the "County Indemnified Parties") from and against all liabilities, fines, penalties, actions,
damages, claims, demands, judgments, losses, costs, expenses, suits or actions and reasonable attorneys'
fees, arising out of the acts or omissions or the negligence of the Contractor in connections with the
services described or referred to in this Agreement. The TOWN shall defend the County in any suit,
including appeals, or at the County's option, pay reasonable attorney's fees for defense of any such suit
arising out of the acts or omissions or negligence of the TOWN, its officers, officials, employees,
subcontractors or agents, if any, in connection with the services described or referred to in this Agreement.
Page 4
Town of Southold with COS
Agreement Location: CR48, Middle Road @
Westphalia Road, Hamlet of Matti tuck
Law Dept. No,
Revised 8/3/05
10. Licenses: The TOWN covenants, warrants and represents that it has, and shall have throughout the
term of this Agreement, and that, to the extent applicable, its employees, agents and subcontractors have,
and shall have throughout the term of this Agreement, the required education, knowledge, experience and
character necessary to qualify them individually for the particular duties they are to perform with respect to
this Agreement (the "Services"), and that the TOWN has, and shall have, and, to the extent applicable, its
employees, agents and subcontractors have, and shall have throughout the term of this Agreement, all
required authorization(s), registration(s), license(s) or permit(s) [hereinafter collectively referred to as a
"License"] required by State, COUNTY or local authorities for the Services. The TOWN shall forward to
the DEPARTMENT a copy of its License or, if applicable, a complete list of its employees, agents and
subcontractors providing Services, including names, area of License, License numbers and copies of
License(s), The TOWN shall furnish the DEPARTMENT with copies of any updates, additions or
deletions to such list as the same may occur, together with copies of any new or renewal License(s). The
TOWN shall inunediately notify the DEPARTMENT, in writing, of any disciplinary proceedings against
the holder of any License. In the event that the TOWN or such other holder of a License is no longer
licensed for anyone or more of the Services, the TOWN shall immediately so notity the DEPARTMENT.
11. Offset of Arrears or Default: The TOWN warrants that it is not, and shall not be during the term of
this Agreement, in arrears to the COUNTY for taxes or upon debt or contract and that it is not, and shall
not be during the term of this Agreement, in default as surety, contractor or otherwise on any obligation to
the COUNTY. The COUNTY may withhold the amount of any such arrearage or default from amounts
payable to the TOWN under this Agreement.
12. Termination: In the event that the COUNTY assumes responsibility for the maintenance of the
Devices, this Agreement shall automatically be deemed terminated,
13. Men!er: Modification: This Agreement represents the entire agreement of the parties. All previous
understandings of the parties concerning the terms hereof are merged into this Agreement. No modification
of this Agreement shall be valid unless written and executed by both parties,
14. Local Law No. 32-1980: TOWN warrants and represents that TOWN has not offered or given any
gratuity to any official, employee or agent of Suffolk County, New York State or any political party with
the purpose or intent of securing an agreement or securing favorable treatment with respect to the awarding
or amending of an agreement, or the making of any determinations with respect to the performance of an
agreement, and that TOWN has read and is familiar with the provisions of Suffolk County Local Law
Number 32- 1980 (Chapter 386 of the Suffolk County Code).
15. Livin!! Wa!!e Law: This Agreement is subject to the Living Wage Law of the County of Suffolk. The
law requires that, unless specific exemptions apply, or a waiver is granted, all employers (as defmed) under
service contracts and recipients of county fmancial assistance (as defmed) shall provide payment of a
minimum wage to employees as set forth in the Living Wage Law. Such rate shall be adjusted annually
pursuant to the terms of the Suffolk County Living Wage Law of the County of Suffolk. Under the provisions
of the Living Wage Law, the COUNTY shall have the authority, under appropriate circumstances, to
terminate this Agreement and to seek other remedies as set forth therein, for violations of this law.
16. Child Sexual Abuse Reoortin!! Policv: The TOWN agrees to comply with Chapter 577, Article IV of
the Suffolk County Code, entitled, "Child Sexual Abuse Reporting Policy", as now in effect or amended
hereafter or of any other Suffolk County Local Law that may become applicable during the term of this
Agreement with regard to child sexual abuse reporting policy.
Page 5
Town of South old with cas
AlITeement Location: CR 48, Middle Road @
Westphalia Road, Hamlet of Matti tuck
Law Dept. No.
Revised 8/3/05
17. Public Disclosure Statement: The TOWN represents and warrants that the TOWN has filed with
the Comptroller of Suffolk County the verified public disclosure statement required by Suffolk County
Administrative Code Section A5-7 and shall file an update of such statement with the said Comptroller on
or before the 31 st day of January in each year of this Agreement's duration. The TOWN acknowledges that
such filing is a material, contractual and statutory duty and that the failure to file such statement shall
constitute a material breach of this Agreement, for which the County shall be entitled, upon a
determination that such breach has occurred, to damages, in addition to all other legal remedies, of fifteen
percent (15%) of the amount of the Agreement.
18. Certification: The parties to this Agreement hereby certify that, other than the funds provided in
this Agreement and other valid Agreements with the County, there is no known relationship within the
third degree of consanguinity, life partner, or business, commercial, economic, or fmancial relationship
between the parties, the signatories to this Agreement, and any partners, members, directors, or
shareholders of five percent (5%) (or more) of any party to this Agreement.
19. Set-Off Rights: The County shall have all of its common law, equitable, and statutory rights of set-
off. These rights shall include, but not be limited to, the County's option to withllOld, for the purposes of
set-off, any moneys due to the Contractor under this contract up to any amounts due and owing to the
County with regard to this contract and/or any other contract with any County department or agency,
including any contract for a term commencing prior to the term of this contract, plus any amounts due and
owing to the County for any other reason including, without limitation, tax delinquencies, fee
delinquencies or monetary penalties relative thereto. The County shall exercise its set-off rights in
accordance with normal County practices including, in cases of set-off pursuant to an audit, the fmalization
of such audit by the County agency, its representatives, or the County Comptroller, and only after legal
consultation with the County Attorney.
20. Use of County Resources to Interfere with Collective Bargaining Activities
Local Law No. 26-2003: The Contractor represents and warrants that it has read and is familiar with the
requirements of Article I, Chapter 466 of the Suffolk County Local Laws, "Use of County Resources to
Interfere with Collective Bargaining Activities". County Contractors (as defmed) shall comply with all
requirements of Local Law No. 26-2003 including the following prohibitions:
a. The Contractor shall not use County funds to assist, promote, or deter union organizing.
b. No County funds shall be used to reimburse the Contractor for any costs incurred to assist,
promote, or deter union organizing.
c. The County of Suffolk shall not use County funds to assist, promote, or deter union organizing.
d. No employer shall use County property to hold a meeting with employees or supervisors if the
purpose of such meeting is to assist, promote, or deter union organizing.
If Contractor services are performed on County property the Contractor must adopt a reasonable access
agreement, a neutrality agreement, fair communication agreement, non-intimidation agreement and a
majority authorization card agreement.
If Contractor services are for the provision of human services and such services are not to be performed on
County property, the Contractor must adopt, at the least, a neutrality agreement.
Under the provisions of Local Law No. 26-2003, the County shall have the authority, under appropriate
circumstances, to terminate this Agreement and to seek other remedies as set forth therein, for violations of
this Law.
Page 6
End of Text
Suffolk County Living Wage Requirements Exhibit
As Last Revised by the Suffolk County Department of Labor on 9/26/02
Suffolk County Living Wage Requirements Exhibit
As Last Revised by the Suffolk County Department of Labor on 9/26/02
Pursuant to Section 6 of Chapter 347 of the Suffolk County Local Law No. 12-2001, "A Local Law to
Implement Living Wage Policy for the County of Suffolk" (the "Living Wage Law"), all RFP's,
County contracts and financial assistance agreements subject to the law shall contain the following
two paragraphs or substantially equivalent language:
This Agreement is subject to the Living Wage Law of the County of Suffolk. The law requires
that, unless specific exemptions apply, or a waiver is granted, all employers (as defined) under
service contracts and recipients of county financial assistance, (as defined) shall provide
payment of a minimum wage of employees (as defined) of $9.00 per hour with health benefits
of at least $1.25 per or otherwise $10.25 per hours. Such rate shall he adjusted annually
pursuant to the terms of the Suffolk County Living Wage Law, of the County of Suffolk.
Under the provisions of the Living Wage Law, the County shall have the authority, under the
appropriate circumstances, to terminate this Agreement and to seek other remedies as set
forth therein, for violations of this law.
Suffolk County Local Law No. -2002, "A Local Law to Implement Living Wage Policy for the
County of Suffolk" provided for certain amendments to the Living Wage Law.
Forms for Completion and/or Signature (as applicable)
. Suffolk County Department of Labor - Living Wage Unit
Notice of Application for County Assistance (Contract)
Form LW-I (consists of! page)
. Suffolk County Department of Labor - Living Wage Unit
Certification of Compliance
Form LW-2 (consists of 1 page)
. Suffolk County Department of Labor - Living Wage Unit
Certificate of the Non-Applicability of the Living Wage Law
Form LW-3 (consists of2 pages)
· Suffolk County Department of Labor - Living Wage Unit
Request for General Living Wage Exemption
Form LW-4 (consists of 1 page)
· Suffolk County Department of Labor - Living Wage Unit
Request for Specific Living Wage Exemption
Form LW-5 (consists of2 pages)
I of2 pages
Suffolk County Living Wage Requirements Exhibit
As Last Revised by the Suffolk County Department of Labor on 9/26/02
. Suffolk County Department of Labor - Living Wage Unit
Declaration of Compliance - Subject to Audit
Form LW-33 (consists ofl page)
Note: Pursuant to Section 7 of Local Law No. -2002, "A Local Law to Implement Living
Wage Policy for County of Suffolk", all employers subject to the provisions of the Living
Wage Law shall submit a completed and sworn (under +penalty of perjury) Certification
of Compliance Subject to Audit form, signed by an authorized representative, as part of an
executed contract with the County of Suffolk. The complete Declaration of Compliance
form shall be made a part of any executed contract or project agreement and made
available to the public upon request.
. To certify Living Wage compliance: Return Form LW-l, Form LW-222 and Form LW-33.
Or
. To certify non-applicability of Living Wage law: Return Form LW-3.
Or
. To request and document a general living wage exemption: Return Form L W-, L W-2 and Form
LW-4
Or
. To request and docnment a specific living wage exemption: Return Form LW-l, LW-2 and Form
LW-5.
. In the event that there is a change in circumstances, it is the Contractor's responsibility of submit
to the County additional Living Wage forms which either replace or supplement prior submissions
of Living Wage forms.
. Living Wage Law Information Fact Sheet, text of the Local Law, Frequently Asked Questions,
Forms, and Rules and Regulations can be found on the Suffolk County web site at
www.co.suffolk.nv.us
Click
Department Directory
Labor
Living Wage Law Info
. Suffolk County Department of Labor Living Wage Unit Tel. (631) 853-3808
End of Text for Suffolk County Living Wage Requirements Exhibit
As Last Revised by the Suffolk County Department of Labor on 9/26/02
2 of 2 pages
SUFFOLK COUNTY DEPARTMENT OF LABOR - LIVING WAGE UNIT
CERTIFICATION OF THE NON-APPLICABILITY OF THE LIVING WAGE LAW
Living Wage Law, Suffolk County Code, Chapter 347 (2001)
To Be Completed by Applicant (Employer)
1) EMPLOYER NAME: Town of Southold
2) ADDRESS: Southold Town Hall. PO Box 1179. Southold. NY. 11971
3) CONTACT: Supervisor Scott A. Russell
4) TELEPHONE #: 765-1889
5) PROJECT NAME: (IF DIFFERENT FROM #1)
6) ORIGIN OF ASSISTANCE SOUGHT: (E.G., State of County assistance program and
contracting Department).
7) AMOUNT OF CONTRACT:
8: TERMS OF CONTRACT: N/A
9) BRIEF DESCRIPTION OF PROJECT OR SERVICE: Traffic Si!!Dal Al!I'eement for:
CR 48, Middle Road @ Westphalia Road, Hamlet of Mattituck
10) PROJECTED EMPLOYMENT NEEDS: (attach a statement of projected needs by job
classification, under the prospective assistance, including calculation of estimated net increase or
decrease in jobs as a result of assistance).
Reason Living Wage Law is not applicable:
No Monev Involved
I hereby attest that the provisions of Suffolk County Local Law No. 12-2001, the Suffolk County
Living Wage Law, are not applicable to this agency, organization, employer, contract or assistance
applied for. I declare under penalty of perjury under the Laws of the State of New York that the
undersigned is uthorized to provide this certification, and that the above attestation is true and
correct.
c:r -(-0(,
Date
Scott A. Russell, Supervisor
Print Name & Title Vendor #
CR 48, Middle Road (it) Westphalia Road, Hamlet of Mattituek
Suffolk County Form 22
Contractor' sIVendor' s Public Disclosure Statement
Pursuant to Section A5-7 of the Suffolk County Administrative Code, this Public Disclosure Statement
must be completed by all contractors/vendors that have a contract with Suffolk County. In the event
contractor/vendor is exempt from completing paragraphs numbered I through II below, so indicate at
paragraph number 12 below setting forth the reason for such exemption. Notwithstanding such exempt
status, you must execute this form below before a notary public.
1. Contractor's/Vendor's Name
Address
City and State Zip Code
2. Contracting Department's Name
Address
3. Payee Identification or Social Security No.
4. Type of Business_Corporation _Partnership_Sole Proprietorship_Other
S.a Is contractor/vendor entering into or has contractor/vendor entered into a contract with Suffolk
County in excess of$I,OOO? _Yes_No.
S.b Has contractor/vendor entered into three or more contracts, including the one for which you are
now completing this form, with Suffolk County, any three of which, when combined, exceed
$I,OOO? Yes No.
6. Table of Organization. List names and addresses of all principals; that is, all individuals serving
on the Board of Directors or comparable body, names and addresses of all partners, and names
and addresses of all corporate officers. Conspicuously identify any person in this table of
organization who is also an officer or an employee of Suffolk County. (Attach additional sheet if
necessary.)
7. List all names and addresses of those individual shareholders holding more than five percent
(5%) interest in the contractor/vendor. Conspicuously identify any shareholder who is also an
officer or an employee of Suffolk County. (Attach additional sheet if necessary).
8. Does contractor/vendor derive 50% or more of its total revenues from its contractual or vendor
relationship with Suffolk County?_Yes_No.
9. If you answered yes to 8 above, you must submit with this disclosure statement, a complete
financial statement listing all assets and liabilities as well as a profit and loss statement. These
statements must be certified by a Certified Public Accountant. (Strike this out if not applicable.)
10. The undersigned shall include this Contractor'slVendor's Public Disclosure Statement with the
contract. (Describe general nature of the contract.)
11. Remedies. The failure to file a verified public disclosure statement as required under local law
shall constitute a material breach of contract. Suffolk County may resort, use or employ any
remedies contained in Article II of the Uniform Commercial Code of the State of New York. In
addition to all legal remedies, Suffolk County shall be entitled, upon a determination that a
breach has occurred, to damages equal to fifteen percent (15%) of the amount of the contract.
12. If you are one of the entities listed below at a) through c) or you qualify under d) below, you are
exempt from completing paragraphs numbered I through 11 herein:
a) Hospital
~ b) Educational or governmental entities
~ c) Not-for-profit corporations
~ d) Contracts providing for foster care, family day-care providers or child protective
servl ces
Please check to the left side of the appropriate exemption.
13. Verification. This section must be signed by an officer or principal of the contractor/vendor
authorized to sign for the company for the purpose of executing contracts. The undersigned
being sworn, affirms under the penalties of perjury, that e/she has read and understood the
foregoing statements and that they are, to his/her own kno edge, true.
Dated: 0-/- 0 (p
Printed Name of Signer:
Title of Signer:
Name of ContractorN endor:
Signed:
Scott A. RUB el
SuperV1S0r
Town Or: bOUl::.UOl.U
UNIFORM CERTIFICATE OF ACKNOWLEDGMENT
(Within New York State)
STATE OF NEW YORK)
COUNTY OF ) ss.:
On the I~r day of fli(6-{.{ST in the year 20~ before me, the undersigned, personally
appeared S cot t A. Ru sse 11 personally known to me or proved to me on the basis of satisfactory
evidence to be the individual(s) whose name(s) is (are) subscribed to the within instrument and
acknowledged to me that he/she/they executed the same in hislher/their capacity(ies) and that by
hislher/their signature(s) on the instrument, the individual(s), or the person upon behalf of which the
individual(s) acted, executed the instrument.
L1NDAJ COOPER
NOTARY PUBLIC. Slota cf New York
NO. 01C04822563, 2",' .,K cou~
Term Expires December 31. 20 tb
UNIFORM CERTIFICATE OF ACKNOWLEDGEMENT
(Without New York State)
STATE OF
)
)ss.:
)
COUNTY OF
On the day of in the year 20_ before me, the undersigned,
personally appeared personally known to me or proved to me on the basis
of satisfactory evidence to be the individual(s) whose name(s) is (are) subscribed to the within
instrument and acknowledged to me that he/she/they executed the same in hislher/their capacity(ies) and
that by hislher/their signature(s) on the instrument, the individual(s), or the person upon behalf of which
the individual(s) acted, executed the instrument, and that such individual(s) made such appearance
before the undersigned in
(Insert the city or other political subdivision and the state or country or other place the acknowledgement
was taken)
(signature and office of individual taking acknowledgement)
ACORD CERTIFICATE OF LIABILITY INSURANCE I DATE (MM/DDIYYYY)
TM 08/02/2006
PRODUCER Phone: (631)298-4700 Fax 631-298-3850 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ROY H REEVE AGENCY, INC. ONLY AND CONfERS NO RIGHTS UPON THE CERTIFICATE
PO BOX 54 ~~;~;~uJ~IS CERTIFICATE DOES ~~T AMEND, EXT~~~, ,~~
MATTITUCK NY 11952
INSURERS AFFORDING COVERAGE NAIC#
---
INSURED INSURER A: MARKEL AMERICAN INS CO 28932
TOWN OF SOUTHOLD INSURER B: American Alternative Insura~~e Company
C/O SOUTHOLD TOWN HALL INSURER c'
P.O. BOX 1179
SOUTHOLD NY 11971 INSURER 0:
INSURER E:
COVERAGES
THE POLICIES OF INSUAANCE 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 WTH 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 AGGREGATE LIMITS SHO\M.I MAY HAVE BEEN REDUCED BY PAID CLAIMS.
--
INSR ADD' TYPE OF INSURANCE POLICY NUMBER Pgii~ ~~~~~E P~i:,~~~~N LIMITS
'" INSR
~NERAl LIABILITY CPEL.1001.06 01/01/06 01/01/07 EACH OCCURRENCE $ 1,000,000
X COMMERCIAL GENERAL LIABILITY ~~?s~~~ERaE~c:~~n~) $ N/A
l CLAIMS MADE0 OCCUR MED. EXP (Anyone person) $ N1A
A 0- $50,000. DEDUCTIBLE{SIR) PERSONAL & ADV INJURY $ 1,000,000
0- CONTRACTUAL LIABILITY GENERAL AGGREGATE $ 3,000,000
n'LAGGREPl LIMIT APPnPER PRODUCTS-COMP/OP AGG , 1,000,000
PRO-
POLICY JECT LOC
~OMOBIL.E LIABILITY CPEL.l001-06 01/01/06 01/01/07 COMBINED SINGLE LIMIT
~ ANY AUTO (Eaaccidenl) , 1,000,000
I-- ALL OWNED AUTOS BODILY INJURY
{Per person) ,
I-- SCHEDULED AUTOS
I-- HIRED AUTOS BODILY INJURY
,
I-- NON-OWNED AUTOS {Per accident)
I-- PROPERTY DAMAGE $
Peraccidenl)
RRAGE LIABILITY AUTO ONLY - EA ACCIDENT $
ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
0ESS I UMBRELLA LIABILITY 60A2UBOOO057702 01101106 01/01/07 EACH OCCURRENCE $ 10,000,000
X OCCUR D CLAIMS MADE AGGREGATE $
B $
~ DEDUCTIBLE ,
X RETENTION $ 10,000 ,
WORKERS COMPENSATION AND I ~gR~tt~~s I I OTHER
EMPLOYERS' UABlUTY
ANY PROPRIETORIPARTNERlEXECUTIVE E.L. EACH ACCIDENT ,
OFFICER/MEMBER EXCLUDfO? E.L. DISEASE-EA EMPLOYEE ,
IfY.S,o.scrllMund... E.L. DISEASE-POLICY LIMIT ,
SPECIAL PROVISIONS lMlow
OTHER:
DESCRIPTION OF OPERATIONS/LOCATlONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS
CERTIFICATE HOLDER IS LISTED AS ADDITIONAL INSURED WITH RESPECT TO TRAFFIC SIGNAL AGREEMENT FOR CR48, MIDDLE ROAD &
WESTPHALlA RD, MATTITUCK, NY 119S2 UNDER GENERAL LIABILITY ONLY.
CERTIFICATE HOLDER
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING INSURER VIALL ENDEAVOR TO MAlL 30 DAYS
WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO
CDUNTY OF SUFFOLK DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS
SUFF CTY RISK MGMT & BENEFIT DIVISION AGENTS OR REPRESENTATIVES.
700 VETS MEMORIAL HWY, 2ND FLOOR AUTHORIZED REPRESENTATIVE ~~
HAUPPAUGE NY 11788
Attention:
ACORD 25 (2001/08)
Certificate #
8083
@ACORDCORPORATION1988
IMPORTANT
If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. A statement
on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
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).
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not constitute a contract between
the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it
affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon.
ACORD 25-8 (2001/08)
Certificate #8083
ACORD CERTIFICATE OF LIABILITY INSURANCE I DATE (MMJODIYYYY)
TM. 08/0212006
PRODUCER Phone: (631)298-4700 Fax: 631-298-3850 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ROY H REEVE AGENCY, INC. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
PO BOX 54 ~~;~~~!HIS CERTIFICATE DOES ~~~~..MEND. EX!~~? ~R
MATTITUCK NY 11952
INSURERS AFFORDING COVERAGE NAlC#
INSURED INSURER A: MARKEL AMERICAN INS CO 28932
TOWN OF SOUTH OLD INSURER B: American AJternatlve Insurance Comnany
C/O SOUTHOLD TOWN HALL INSURER C:
P.O. BOX 1179
SOUTHOLD NY 11971 INSURER D:
INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POL.ICY PERIOD INDICATED, NOTWITHSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT If.JlTH 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. AGGREGATE LIMITS SHOV'.N MAY HAVE BEEN REDUCED BY PAID CLAlMS.
INSRI ADD'I TYPE OF INSURANCE
LTR.liNSRJ:
~:.~~
01/01/06
POLICY NUMBER
~fe'=~~
01/01107
GENERAL LIABILITY
rx COMMERCIAL GENERAL LIABILITY
I CLAIMS MAOEC!] OCCUR
A ~ $50,000. DEOUCTIBLE(SlR)
..!.. CONTRACTUAL LIABILITY
~LAGGREGATE L~ AP~PER:
I POLICY n JECT I I LOC
~OMOBlLe UABlUTY
X ANY AUTO
-
_ ALL OWNED AUTOS
I-- SCHEDULED AUTOS
I-- HIRED AUTOS
NON-QWNED AUTOS
f--
f--
CPEL.1001.o6
EACH OCCURRENCE
=S~~~E~~
MED. EXP (Anyone person)
PERSONAL & ADV INJURY
GENERAL AGGREGATE
PRODUCT5-COMP/OP AGG.
CPEL.1001.o6
01/01106
01/01107
COMBINED SINGLE LIMIT
(Eaaccident)
BODILY INJURY
(Per person)
80DIL Y INJURY
(Per accident)
I ~&:~~gAMAGE
B
GARAGE UABtUTY
R ANY AUTO
EXCESS J UMBRELlA UABtUTY
~~ OCCUR D CLAIMS MADE
I DEDUCTIBLE
xl RETENTION $ 10,000
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
AHY PROPRIETOIWARTHERlEXECU1l\IE
OFFICERlMEMBER EXCLUOEO?
",...descrlIMuncler
SPEClALPRQVlSIONS.......
I ~T~~S I I OllER
E.l. EACH ACCIDENT $
E.l. DISEASE-EA EMPLOYEE $
E.L. DISEASE-POLICY LIMIT $
AUTO ONLY - EA ACCIDENT
OTHER THAN
AUTO ONLY:
60A2UB00005n02
01/01/06
01/01107
EACH OCCURRENCE
AGGREGATE
OTHER:
LIMITS
.
.
.
.
.
.
1,000.000
NlA
NlA
1,000,000
3,000,000
1,000,000
.
1,000,000
.
.
.
.
EA ACe $
AGG S
.
.
.
.
10,000,000
.
DESCRIPTION OF OPERATIONSlLOCATIONSNEHICLESlEXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS
CERTIFICATE HOLDER IS USTED AS ADDITIONAL INSURED WITH RESPECT TO TRAFFIC SIGNAL AGREEMENT FOR CR48, MIDDLE ROAD &
WESTPHAUA RD, MATTITUCK, NY 11952 UNDER GENERAL LIABILITY ONLY.
EXHIBIT B (Insurance, #8)
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING INSURER 'MLL ENDEAVOR TO MAIL 30 DAYS
WRITTEN NOTICE TO THE CERTIFICATE HOlDER NA~D TO THE LEFT,BUTFAlLURETO
COUNTY OF SUFFOLK DO so SHALL IMPOse NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, Irs
SUFF CTY RISK MGMT & BENEFIT DIVISION AGENTS OR REPRESENTATIVES.
700 VETS MEMORIAL HWY, 2ND FLOOR AUTHORIZED REPRESENTATIVE ~~
HAUPPAUGE NY 11788
Attention:
CERTIFICATE HOLDER
CANCELLATION
ACORD 25 (2001108)
Certificate #
8083
@ACORDCORPORATlON 1988
IMPORTANT
If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement
on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
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).
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not constitute a contract between
the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it
affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon.
ACORD 25-S (2001/08)
Certificate #8083