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HomeMy WebLinkAboutSC Dept of Labor - PRELIMINARYSouthold Town Board -Letter f^v'`®*~ m ~I Board Meeting of July 15, 2008 RESOLUTION 2008-689 ADOPTED Item # DOC ID: 4058 THIS IS TO CERTIFY THAT THE FOLLOWING RESOLUTION NO. 2008-689 WAS ADOPTED AT THE REGULAR MEETING OF THE SOUTHOLD TOWN BOARD ON JULY 15, 2008: RESOLVED that the Town Board of the Town of Southold hereby authorizes and directs Supervisor Scott A. Russell to execute the Worksite Memorandum of UnderstandinE Agreement between the Town of Southold and the Suffolk County Department of Labor in connection with the work experience programs for eligible Suffolk County residents and other pertinent programs operated by the Department of Labor, for a term that will expire on June 30, 2013, subject to the approval of the Town Attorney. ~~ Elizabeth A. Neville Southold Town Clerk RESULT: ADOPTED [UNANIMOUS] MOVER: William Ruland, Councilman SECONDER: Vincent Orlando, Councilman AYES: Ruland, Orlando, Krupski Jr., Wickham, Evans, Russell Generated July 17, 2008 Page 39 Rev. 11/02107; Law No. 13-LB-025 Worksite MOU -WIA and/or SWEP Worksite Memorandum of Understanding (MOU) This Agreement ("Agreement") is between the County of Suffolk ("County"), a municipal corporation of the State of New York, acting through its duly constituted Department of Labor ("Department"), located at Building 17, North County Complex, 725 Veterans Memorial Highway, Hauppauge, New York 11788; and Town of Southold ("Contractor"), having its principal place of business at 53095 Route 25, Southold, NY 11971-0959 The parties hereto desire to make available for eligible Suffolk County residents an employment and training program that includes work experience under the Workforce Investment Act (WIA) or the Suffolk Works Employment Program (SWEP), and other pertinent programs operated by the Department, and to establish the conditions, limitations and work rules to be observed by the Contractor and the Department under this Agreement. Term of Agreement: 2008 through June 30, 2013. Total Cost of Agreement: No payments to Contractor. Payments to trainees as provided in Exhibit D, attached. Terms and Conditions: Shall be as set forth in Exhibits A through D; attached hereto and made a part hereof. In Witness Whereof, the parties hereto have executed this Agreement as of the latest date written below. Insert Name of C tractor By: ~' ~/a~/a~ Name: Scott Russell Title: Supervisor Fed. Tax ID # 11-6001939 Date: ~ - 25-b$ Approved as to Legality: Christine Malafi, County Attorney By: Cynthia Kay Parry Assistant County Attorney Date: County of Suffolk Jeffrey W. Szabo Deputy County Executive Date: Approved: Department of Labor By: Robert W. Dow, Jr. Commissioner Date: Page 1 of 19 Pages Rev. 11/02/07; Law No. 13-LB-025 Worksite MOU -WIA and/or SWEP Worksite Memorandum of Understanding (MOU) This Agreement ("Agreement") is between the County of Suffolk ("County"), a municipal corporation of the State of New York, acting through its duly constituted Department of Labor ("Department"), located at Building 17, North County Complex, 725 Veterans Memorial Highway, Hauppauge, New York 11788; and Town of Southold ("Contractor"), having its principal place of business at 53095 Route 25, Southold, NY 11971-0959 The parties hereto desire to make available for eligible Suffolk County residents an employment and training program that includes work experience under the Workforce Investment Act (WIA) or the Suffolk Works Employment Program (SWEP), and other pertinent programs operated by the Department, and to establish the conditions, limitations and work rules to be observed by the Contractor and the Department under this Agreement. Term of Agreement: 2008 through June 30, 2013. Total Cost of Agreement: No payments to Contractor. Payments to trainees as provided in Exhibit D, attached. Terms and Conditions: Shall be as set forth in Exhibits A through D; attached hereto and made a part hereof. In Witness Whereof, the parties hereto have executed this Agreement as of the latest date written below. Insert Name of Contractor By: Na :Scott ussell Title: Supervisor Fed. Tax I # 11-6001939 Date: -~5~0`b Approved as to Legality: Christine Malafi, County Attorney By: Cynthia Kay Parry Assistant County Attorney Date: County of Suffolk Jeffrey W. Szabo Deputy County Executive Date: Approved: Department of Labor By: Robert W. Dow, Jr. Commissioner Date: Page 1 of 19 Pages Rev. 11/02/07; Law No. 13-LB-025 Worksite MOU -WIA and/or SWEP Worksite Memorandum of Understanding (MOU) This Agreement ("Agreement") is between the County of Suffolk ("County"), a municipal corporation of the State of New York, acting through its duly constituted Department of Labor ("Department"), located at Building 17, North County Complex, 725 Veterans Memorial Highway, Hauppauge, New York 11788; and Town of Southold ("Contractor"), having its principal place of business at 53095 Route 25, Southold, NY 11971-0959 The parties hereto desire to make available for eligible Suffolk County residents an employment and training program that includes work experience under the Workforce Investment Act (WIA) or the Suffolk Works Employment Program (SWEP), and other pertinent programs operated by the Department, and to establish the conditions, limitations and work rules to be observed by the Contractor and the Department under this Agreement. Term of Agreement: 2008 through June 30, 2013. Total Cost of Agreement: No payments to Contractor. Payments to trainees as provided in Exhibit D, attached. Terms and Conditions: Shall be as set forth in Exhibits A through D; attached hereto and made a part hereof. In Witness Whereof, the parties hereto have executed this Agreement as of the latest date written below. Insert Nam f Contractor By: N e: Scott ussell Title: Supervisor Fed. Tax ID # 11-6001939 Date: (n -25 0$ Approved as to Legality: Christine Malafi, County Attorney By: Cynthia Kay Parry Assistant County Attorney Date: By: County of Suffolk Jeffrey W. Szabo Deputy County Executive Date: Approved: Department of Labor By: Robert W. Dow, Jr. Commissioner Date: Page 1 of 19 Pages CERTIFICATION REGARDING LOBBYING, DEBARMENT, SUSPENSION AND OTHER RESPONSIBILITY MATTERS, AND DRUG-FREE WORKPLACE REQUIREMENTS Applicant should refer to the regulations cited below to determine the certification included in the regulations before completing the form. Signature of this form provides for compliance with certification requirements under 34 CFR Part 82, "New Restrictions on Lobbying," and 34 CFR Part 85, "Government-wide Debarment and Suspension (Non-Procurement) and representation of fact upon which reliance will be placed when the Department of Labor determines to award the covered transaction grant, or cooperative agreement. 1. LOBBYING of or had a civil judgement rendered against [hem for commission of Fraud or As required by Section 1352, Title 31 of [he U.S. a criminal offense in connection with Code and implemented at 34 CFR Part 82 For obtaining, attempting to obtain, or persons entering into a gran[ or cooperative performing a public (Federal, Slate or agreement over $100,000, as defined at 34 CFR local) transaction or contracts under a Part 82, Section 82.105 and 82.110, the applicant public transaction, violation of federal or certifies that: State antitrust statutes or commission of embezzlement, theft, forgery, bribery, (a) No Federal appropriated funds have been paid or falsification or destruction of records, will be paid, by or on behalf of the undersigned, to making false statements, or receiving any persons for influencing or attempting to stolen property; influence an officer or employee of any agency, a Member of Congress, an officer or employee of (c) Are not presently indicated or otherwise Congress, or an employee of a Member of criminally or civilly charged by a Congress in connection with the making of any Government entity (Federal, State or Federal grant, the entering into of any cooperative local) with commission of any of the agreement, and the extension, continuation, offenses enumerated in paragraph A (b) renewal, amendment, or modification of any of the certification; and Federal grant or cooperative agreement. (d) Have not within athree-year period (b) If any funds other than federally appropriated funds preceding this application had one or have been paid or will be paid [o any person for more public transactions (Federal, Slate influencing or attempting to influence an officer or and locap for cause or default; and employee of a member of Congress in connection with the making of any Federal grant, the entering B. Where the applicant is unable to certify [o into of any cooperative agreement, and the any of the statements in this certification, extension, continuation, renewal, amendment, or he or she shall attach and explanation to modification of any Federal gran[ or cooperative [his application. agreement. (c) The undersigned shall require that the language of this certification be included in the award documents for all subawards at all tiers (including subgran[s, contracts under grants and cooperative agreements and subcontracts) and that all subrecipients shall certify and disclose accordingly. DRUG-FREE WORKPLACE (GRANTEES OTHER THAN INDIVIDUALS) As required by the Drug-Free Workplace Act of 1988, and implemented at 34 CFR part 85, Subpart F, for grantees, as defined at 34 CFR Part 85, Sections 85.605 and 85.610. 2. DEBARMENT, SUSPENSION, AND OTHER RESPONSIBILITY MATTERS As required by Executive Order 12549, Debarments and Suspension, and implemented at 34 CFR Part 85, for prospective participants in primary covered transactions, as defined at 34 CFR part 85, Sections 83.105 and 85.110. A. The applicant certifies that it and its principals: (a) Are no[ presently debarred, suspended, proposed for debazment, declared ineligible, or voluntarily excluded from covered transactions by any Federal department of agency; (b) Have not within athree-year, period preceding [his application been convicted A. The applicant that it will or will continue to provide adrug-free workplace by: (a) Publishing a statement notifying employees that the manufacture, distribution, dispensing, possession, or use of a controlled substance is prohibited in the grantee's workplace and specifying the actions that will betaken against employees for violation of such prohibition; (b) Establishing an on-going drug-free awareness program to inform employees about: The dangers of drug abuse in the workplace; GM 50 (1-92) 2. The grantee's policy of maintaining a drug-free workplace; 3. Any available drug counseling, rehabilitation, and employee assistance program; and 4. The penalties [hat may be imposed upon employee for drug abuse violation occurring in the workplace: (c) Making it a requirement that each employee [o be engaged in [he performance of the grant be given a copy of the statement required by paragraph (a); (d) Notifying the employee in the statement required by paragraph (a) that as a condition of employment under the grant, the employee will: 1. Abide by the terms of the statement and; 2. Notify the employer in writing of his or her conviction for a violation of a criminal drug statute occurring in the workplace no later than five calendar days after such conviction; (e) Notifying the agency, in writing within 10 calendar days after having received notice under subparagraph (dx2) from an employee or otherwise receiving actual police of such conviction. Employers of convicted employees must provide notice, including position title, to: Director, Grants Management Bureau, State Office Building Campus, Albany, New York 12240. Notice shall include the identification number(s) of each affected grant. (t) Taking one of the following action, within 30 calendar days of receiving notice under subparagraph (dx2), with respect to any employee who is so convicted: Taking appropriate personnel action against such an employee, up to and including termination, consistent with the Requirements of the Rehabilitation Act of 1973, as amended; or 2. Requiring such employee to participate satisfactorily in a drug abuse assistance or rehabilitation program approved for such purpose by a Federal, State or local health, law enforcement, or other appropriate agency; g. making a good faith effort to continue to maintain a dmg-free workplace through implementation of paragraphs (a), (b), (c), (d), (e), (~, B. The grantee may insert in the space provided below the site(s) for the performance of work done in connection with this specific grant. Place of Performance (street, address, city, county, state, zip code). DRUG-FREE WORKPLACE (GRANTEES WHO ARE INDIVIDUALS) As required by the Drug-Free Workplace Ac[ of 1988, and implemented at 34 CFR part 8S, Subpart F, for grantees, as defined at 34 CFR Part SS, Sections 85.605 and 85.610. A. As a condition of the grant, I certify [hat I will not engage in the unlawful manufacture, distribution, dispensing, possession, or use of a controlled substance in conducting any activity with the grant and B. If convicted of a criminal drug offense resulting from a violation occurring during [he conduct of any grant activity, I will report the conviction, in writing, within 10 calendar days of [he conviction, [o: Director, grants Management Bureau, Slate Office Building Campus, Albany, NY 12240. Notice shall include the identification number(s) of each affected grant. Check if there are workplaces on file that are not identified here. As the duly authorized representative of the applicant, I hereby certify that the applicant will comply with the above certifications. GM 50 (1-92) Town of Southold Name of ApplicanUGrantee/Subgrantee CERTTFICATION REGARDING LOBBYING, DEBARMENT, SUSPENSION AND OTHER RESPONSIBILITY MATTERS, AND DRUG-FREE WORKPLACE REQUIREMENTS Applicant should refer to the regulations cited below to determine the certification included in the regulations before completing the form. Signature of [his form provides for compliance with certification requirements under 34 CFR Part 82, "New ResVictions on Lobbying," and 34 CFR Part 85, "Government-wide Debarment and Suspension (Non-Procurement) and representation of fact upon which reliance will be placed when the Department of Labor determines to award the covered transaction grant, or cooperative agreement. 1. LOBBYING of or had a civil judgement rendered against them for commission of fraud or As required by Section 1352, Title 31 of the U.S. a criminal offense in connection with Code and implemented a[ 34 CFR Part 82 for obtaining, attempting to obtain, or persons entering into a grant or cooperative performing a public (Federal, State or agreement over $100,000, as defined a[ 34 CFR local) transaction or contracts under a Part 82, Section 82.105 and 82.1 l0, the applicant public transaction, violation of federal or certifies that: State antitrust statutes or commission of embezzlement, theft, forgery, bribery, (a) No Federal appropriated funds have been paid or falsification or destruction of records, will be paid, by or on behalf of the undersigned, to making false statements, or receiving any persons for influencing or attempting to stolen property; influence an officer or employee of any agency, a Member of Congress, an officer or employee of (c) Are not presently indicated or otherwise Congress, or an employee of a Member of criminally or civilly charged by a Congress in connection with the making of any Govemment entity (Federal, State or Federal gran[, [he entering into of any cooperative local) with commission of any of the agreement, and the extension, continuation, offenses enumerated in paragraph A (b) renewal, amendment, or modification of any of the certification; and Federal grant or cooperative agreement. (d) Have not within athree-year period (b) If any funds other than federally appropriated funds preceding this application had one or have been paid or will be paid [o any person for more public transactions (Federal, Slate influencing or attempting to influence an officer or and local) for cause or default; and employee of a member of Congress in connection with the making of any Federal grant, [he entering B. Where [he applicant is unable [o certify to into of any cooperative agreement, and [he any of the statements in this certification, extension, continuation, renewal, amendment, or he or she shall attach and explanation to modification of any Federal grant or cooperative this application. agreement. 3. DRUG-FREE WORKPLACE (GRANTEES (c) The undersigned shall require that [he language of OTHER THAN INDIVIDUALS) this certification be included in the award documents for all subawards a[ all tiers (including As required by the Drug-Free Workplace Act of subgran[s, contracts under grants and cooperative 1988, and implemented at 34 CFR part 85, Subpart agreements and subcontracts) and that all F, for grantees, as defined at 34 CFR Part 85, subrecipien[s shall certify and disclose accordingly. Sections 85.605 and 85.610. 2. DEBARMENT, SUSPENSION, AND OTHER A. The applicant that it will or will continue RESPONSIBILITY MATTERS to provide adrug-free workplace by: As required by Executive Order 12549, (a) Publishing a statement notifying Debarments and Suspension, and implemented a[ employees that the manufacture, 34 CFR Part 85, for prospective participants in distribution, dispensing, possession, or primary covered transactions, as defined at 34 CFR use of a controlled substance is part 85, Sections 83.105 and 85.110. prohibited in [he grantee's workplace and specifying the actions [hat will be taken A. The applicant certifies that it and its against employees for violation of such principals: prohibition; (a) Are not presently debarred, suspended, (b) Establishing an on-going drug-free proposed for debarment, declared awazeness program to inform employees ineligible, or voluntarily excluded from about: covered transactions by any Federal department of agency; L The dangers of drug abuse in the workplace; (b) Have not within athree-year period preceding this application been convicted GM 50 (1-92) 2. The grantee's policy of maintaining a including termination, consistent with the drug-free workplace; Requirements of [he Rehabilitation Act of 1973, as amended; or 3. Any available drug counseling, rehabilitation, and employee assistance 2. Requiring such employee to participate program; and satisfactorily in a drug abuse assistance or rehabilitation program approved for 4. The penalties that may be imposed upon such purpose by a Federal, State or local employee for drug abuse violation health, law enforcement, or other occurring in the workplace: appropriate agency; (c) Making it a requirement that each g. making a good faith effort to continue to employee to be engaged in the maintain a dmg-free workplace through performance of the gran[ begiven a copy implementation of paragraphs (a), (b), of the statement required by paragraph (c), (d), (e), (t), (a); B. The grantee may insert in the space (d) Notifying the employee in the statement provided below the site(s) for the required by paragraph (a) that as a performance of work done in connection condition of employment under [he grant, with this specific grant. the employee will: Place of Performance (street, address, 1. Abide by the terms of the statement and; city, county, state, zip code). 2. Notify the employer in writing of his or DRUG-FREE WORKPLACE (GRANTEES WHO her conviction for a violation of a ARE INDIVIDUALS) criminal drug statute occurring in the workplace no later than five calendaz As required by the Drug-Free Workplace Act of days after such conviction; 1988, and implemented at 34 CFR part 85, Subpart F, for grantees, as defined a[ 34 CFR Part 85, (e) Notifying the agency, in writing within Sections 85.605 and 85.610. 10 calendar days after having received notice under subparagraph (dx2) from an A. As a condition of the grant, I certify that I employee or otherwise receiving actual will not engage in the unlawful police of such conviction. Employers of manufacture, distribution, dispensing, convicted employees must provide possession, or use of a controlled notice, including position title, to: substance in conducting any activity with Director, Grants Management Bureau, the grant; and State Office Building Campus, Albany, New York 12240. Notice shall include B. If convicted of a criminal drug offense the identification number(s) of each resulting from a violation occurring affected gran[. during the conduct of any grant activity, I will report the conviction, in writing, (f) Taking one of the following action, within 10 calendar days of the within 30 calendar days of receiving conviction, to: Director, grants notice under subparagraph (dx2), with Management Bureau, Stale Office respect [o any employee who is so Building Campus, Albany, NY 12240. convicted: Notice shall include the identification number(s) of each affected grant. 1. Taking appropriate personnel action against such an employee, up to and Check if there are workplaces on file that are not identified here. As the duly authorized representative of the applicant, I hereby certify that the applicant will comply with the above certifications. Town of Southold Name of Applicant/Grantee/Subgrantee Printed Name GM 50 (1-92) CERTIFICATION REGARDING LOBBYING, DEBARMENT, SUSPENSION AND OTHER RESPONSIBILITY MATTERS, AND DRUG-FREE WORKPLACE REQUIREMENTS Applicant should refer to [he regulations cited below to determine the certification included in the regulations before completing the form. Signature of this form provides for compliance with certification requirements under 34 CFR Part 82, "New Restrictions on Lobbying," and 34 CFR Part 85, "Government-wide Debarment an d Suspension (Non-Procurement) and representation of fact upon which reliance will be placed when the Department of Labor deter mines to award the covered transaction grant, or cooperative agreement. I. LOBBYING of or had a civil judgement rendered against them for commission of fraud or As required by Section 1352, Title 31 of [he U. S. a criminal offense in connection with Code and implemented at 34 CFR Part 82 for obtaining, attempting to obtain, or persons entering into a gran[ or cooperative performing a public (Federal, State or agreement over $100,000, as defined at 34 CFR local) transaction or contracts under a Part 82, Section 82.105 and 82.110, the applicant public transaction, violation of federal or certifies that State antitrust statutes or commission of embezzlement, theft, forgery, bribery, (a) No Federal appropriated funds have been paid or falsification or destruction of records, will be paid, by or on behalf of the undersigned, to making false statements, or receiving any persons for influencing or attempting to stolen property; influence an officer or employee of any agency, a Member of Congress, an officer or employee of (c) Are not presently indicated or otherwise Congress, or an employee of a Member of criminally or civilly charged by a Congress in connection with the making of any Govemment entity (Federal, State or Federal grant, the entering into of any cooperative local) with commission of any of the agreement, and the extension, continuation, offenses enumerated in paragraph A (b) renewal, amendment, or modification of any of the certification; and Federal grant or cooperative agreement. (d) Have no[ within athree-year period (b) If any funds other than federally appropriated funds preceding [his application had one or have been paid or will be paid to any person for more public transactions (Federal, State influencing or attempting to influence an officer or and local) for cause or default; and employee of a member of Congress in connection with [he making of any Federal grant, the entering ~ B. Where the applicant is unable to certify to into of any cooperative agreement, and the any of [he statements in this certification, extension, continuation, renewal, amendment, or he or she shall attach and explanation to modification of any Federal grant or cooperative this application. agreement. 3. DRUG-FREE WORKPLACE (GRANTEES (c) The undersigned shall require that the language of OTHER THAN INDIVIDUALS) this certification be included in the award documents for all subawards at all tiers (including As required by the Drug-Free Workplace Ac[ of subgrants, contracts under grants and cooperative 1988, and implemented at 34 CFR part 85, Subpart agreements and subcontracts) and that all F, for grantees, as defined at 34 CFR Part 85, subrecipients shall certify and disclose accordingly. Sections 85.605 and 85.610. 2. DEBARMENT, SUSPENSION, AND OTHER A. The applicant that it will or will continue RESPONSIBILITY MATTERS to provide adrug-free workplace by: As required by Executive Order 12549, (a) Publishing a statement notifying Debarments and Suspension, and implemented at employees that [he manufacture, 34 CFR Part 85, for prospective participants in distribution, dispensing, possession, or primary covered transactions, as defined at 34 CFR use of a controlled substance is part 85, Sections 83.105 and 85.1 ] 0. prohibited in the grantee's workplace and specifying the actions that will be taken A. The applicant certifies that i[ and its against employees for violation of such principals: prohibition; (a) Are not presently debarred, suspended, (b) Establishing an on-going drug-free proposed for debarment, declared awareness program to inform employees ineligible, or voluntazily excluded from about: covered transactions by any Federal department of agency; 1. The dangers of drug abuse in the workplace; (b) Have not within athree-year period preceding this application been convicted GM 50 (1-92) 2. The grantee's policy of maintaining a including termination, consistent with the drug-free workplace; Requirements of the Rehabilitation Act of 1973, as amended; or 3. Any available drug counseling rehabilitation, and employee assistance 2. Requiring such employee to participate program; and satisfactorily in a drug abuse assistance or rehabilitation program approved for 4. The penalties that may be imposed upon such purpose by a Federal, S[a[e or local employee for drug abuse violation health, law enforcement, or other occurring in the workplace: appropriate agency; (c) Making it a requirement [hat each g. making a good faith effort to continue to employee to be engaged in [he maintain adrug-free workplace through performance of the grant be given a copy implementation of paragraphs (a), (b), of the statement required by paragraph (c), (d), (e), (t), (a); B. The grantee may insert in the space (d) Notifying [he employee in the statement provided below the site(s) for the required by paragraph (a) that as a performance of work done in connection condition of employment under the grant, with this specific grant. the employee will: Place of Performance (street, address, I. Abide by the terms of [he statement and; city, county, state, zip code). 2. Notify the employer in writing of his or DRUG-FREE WORKPLACE (GRANTEES WHO her conviction for a violation of a ARE INDIVIDUALS) criminal drug statute owurring in the workplace no later than five calendar As required by the Drug-Free Workplace Act of days after such conviction; 1988, and implemented at 34 CFR part 85, Subpart F, for grantees, as defined at 34 CFR Part 85, (e) Notifying the agency, in writing within Sections 85.605 and 85.610. 10 calendar days after having received notice under subparagraph (dx2) from an A. As a condition of [he grant, I certify that I employee or otherwise receiving actual will not engage in [he unlawful police of such conviction. Employers of manufacture, distribution, dispensing, convicted employees must provide possession, or use of a conGOlled notice, including position title, to: substance in conducting any activity with Director, Grants Management Bureau, the graph, and State Office Building Campus, Albany, New York 12240. Notice shall include B. If convicted of a criminal drug offense the identification number(s) of each resulting from a violation occurring affected gran[. during the conduct of any grant activity, I will report [he conviction, in writing, (~ Taking one of the following action, within 10 calendar days of [he within 30 calendar days of receiving conviction, [o: Director, grants notice under subparagraph (dx2), with Management Bureau, State Office respect [o any employee who is so Building Campus, Albany, NY 12240. convicted: Notice shall include [he identification number(s) of each affected grant. I. Taking appropriate personnel action against such an employee, up [o and Check if there are workplaces on file that are not identifed here. As the duly authorized representative of the applicant, I hereby certify that the applicant will comply with the above certif cations. GM 50 (1-92) Town of Southold Name of ApplicanUGrantee/Subgrantee SUFFOLK COUNTY DEPARTMENT OF LABOR -LIVING WAGE UNIT LIVING WACE CERTIFICATION/DECLARATION -SUBJECT TO AUDIT If either of the following definitions of `compensation' (Living Wage Law Chapter 347 - 2) applies to the contractor's/recipient's business or transaction with Suffolk County, the contractor/recipient must complete Sections 1, 3, 4 below; and Form LW-1 (Notice of Application for County Compensation). If the following definitions do not apply, the contractor/recipient must complete Sections 2, 3 and 4 below. Completed forms must be submitted to the awarding agency. "Any gran[, loan, tax incentive or abatement, bond financing subsidy or other form of compensation of more that $50,000 which is realized by or provided to an employer of at least ten (10) employees by or through the authority or approval of the County of Suffolk," or "Any service contract or subcontract let to a contractor with ten (10) or more employees by the County of Suffolk for the furnishing of services to or for the County of Suffolk (except contracts where services are incidental to the delivery of products, equipment or commodities) which involve an expenditure equal to or greater than $10,000. For the purposes of this definition, the amount of expenditure for more than one contract for the same service shall be aggregated. A contract for the purchase or lease of goods, products, equipment, supplies or other property is not `compensation' for the purposes of this definition." Section 1 The Lrvrng Wage Law applies to this contract. I/we hereby agree to comply with al] the provisions of Suffolk County Local Law No. 12-2001, the Suffolk County Living Wage Law (the Law) and, as such, will provide to all full, part-time or temporary employed persons who perform work or render services on or for a project, matter, contract or subcontract where this company has received compensation, from the County of Suffolk as defined in the Law (compensation) a wage rate of no less than $10.40 ($9.25 for child care providers) per hour worked with health benefits, as described m the Law, or otherwise $11.84 ($10.50 for child care providers) per hour or the rates as may be adjusted annually in accordance with the Law. (Chapter 347-3 B) Check if applicable I/we further agree that any tenant or leaseholder of this company [hat employs atleast ten (10) persons and occupies property or uses equipment or property that is improved or developed as a result of compensation or any contractor or subcontractor of this company that employs at least ten (10) persons in producing or providing goods or services to this company that are used in the project or matter for which [his company has received compensation shall comply with all the provisions of the Law, including those specified above. (Chapter 347-2) I/we further agree to permit access to work sites and relevant payroll records by authorized County representatives for the purpose of monitoring compliance with regulations under this Chapter of the Suffolk County Code, investigating employee complaints of noncompliance and evaluating the operation and effects of this Chapter, including the production for inspection & copying of payroll records for any or all employees for the term of the contract or for five (5) years, whichever period of compliance is longer. All payroll and benefit records requued by the County will be maintained for inspection for a similar period of time. (Chapter 347-7 D) The County Department of Labor shall review the records of any Covered Employer at least once every three years to verify compliance with the provisions of the Law. (Chapter 347-4 C) Section II The Lrving Wage Law does not apply to this contract for the No Coun[v Funds Expended Check if applicable Section III Contractor Name: Federal Employer ID#: Town of Southhold 11-6001939 Contractor Address: 53095 Route 25 // P.O. Box 1179 Amount of compensation: Southold, NY 11971-0959 Vendor #: Contractor Phone #: 765-1889 Description of project or service: Provision of work experience to elieible aroeram aarticioants Section IV I declare under penalty of p ury under the Laws of the State of New York that the undersigned is authorized to provide this certification, and that the above is true d correct. ' 08 Authorized Signa Date Scott Russell, Supervisor Print Name and Title of Authorized Representative LW 38 (revised 6-07, replaces forms LW2, LW3, and LW33) SUFFOLK COUNTY DEPARTMENT OF LABOR -LIVING WACE UNIT LIVING WACE CERTIFICATION/DECLARATION -SUBJECT TO AUDIT [f either of the following definitions of `compensation' (Living Wage Law Chapter 347 - 2) applies to the contractor's/recipient's business or transaction with Suffolk County, the contractor/recipient must complete Sections 1, 3, 4 below; and Form LW-1 (Notice of Application For County Compensation). If the following definitions do not apply, the contractor/recipient must complete Sections 2, 3 and 4 below. Completed forms must be submitted [o the awarding agency. "Any grant, loan, tax incentive or abatement, bond financing subsidy or other form of compensation of more that $50,000 which is realized by or provided to an employer of at least ten (10) employees by or through the authority or approval of the County of Suffolk," or "Any service contract or subcontract let to a contractor with ten (10) or more employees by the County of Suffolk for the famishing of services to or for the County of Suffolk (except contracts where services are incidental to the delivery of products, equipment or commodities) which involve an expenditure equal to or greater than $10,000. For the purposes of this definition, the amount of expenditure for more than one contract for the same service shall be aggregated. A contract for the purchase or lease of goods, products, equipment, supplies or other property is not `compensation' for the purposes of this definition." Section I The Living Wage Law applies to this contract. I/we hereby agree to comply with all the provisions of Suffolk County Local Law No. 12-2001, the Suffolk County Living Wage Law (the Law) and, as such, will provide to all full, part-time or temporary employed persons who perform work or render services on or for a project, matter, contract or subcontract where this company has received compensation, from the County of Suffolk as defined in the Law (compensation) a wage rate of no less than $10.40 ($9.25 for child care providers) per hour worked with health benefits, as described in the Law, or otherwise $11.84 ($10.50 for child care providers) per hour or the rates as may be adjusted annually in accordance with the Law. (Chapter 347-3 B) Check if applicable I/we further agree that any tenant or leaseholder of this company that employs at least ten (10) persons and occupies property or uses equipment or property that is improved or developed as a result of compensation or any contractor or subcontractor of this company that employs at least ten (10) persons in producing or providing goods or services to this company that are used in the project or matter for which this company has received compensation shall comply with all the provisions of the Law, including those specified above. (Chapter 347-2) I/we further agree to permit access to work sites and relevant payroll records by authorized County representatives for the purpose of monitoring compliance with regulations under this Chapter of the Suffolk County Code, investigating employee complaints of noncompliance and evaluating the operation and effects of this Chapter, including the production for inspection & copying of payroll records for any or all employees for the term of the contract or for five (5) years, whichever period of compliance is longer. All payroll and benefit records required by the County will be maintained for inspection for a similar period of time. (Chapter 347-7 D) The County Department of Labor shall review the records of any Covered Employer at least once every three years to verify compliance with the provisions of the Law. (Chapter 347-4 C) Living Wage Law does not apply to this contract reason(s): No County Funds Expended Check if applicable Section III Contractor Name: Federal Employer ID#: Town of Southhold Contractor Address: 53095 Route 25 // P.O. Box 1179 Amount of compensation: Southold, NY 11971-0959 Vendor #: Contractor Phone #: 765-1889 11-6001939 Description of project or service: Provision of work experience to elieible pro¢ram participants Section IV I declare under penalty perjury under the Laws of the Stale of New York that the undersigned is authorized to provide this certification, and that the abo~e is '+~corcec ~ - Authorized Signature Date Scott Russell, Supervisor Print Name and Title of Authorized Representative LW 38 (revised 6-07, replaces forms LW2, LW3, and LW33) SUFFOLK COUNTY DEPARTMENT OF LABOR -LIVING WAGE UNIT LIVING WAGE CERTIFICATION/DECLARATION -SUBJECT TO AUDIT If either of the following definitions of `compensation' (Living Wage Law Chapter 347 - 2) applies to the contractor's/recipient's business or transaction with Suffolk County, the contractor/recipient must complete Sections 1, 3, 4 below; and Form LW-1 (Notice of Application for County Compensation). If the following definitions do not apply, the contractor/recipient must complete Sections 2, 3 and 4 below. Completed forms must be submitted to the awarding agency. "Any grant, loan, tax incentive or abatement, bond financing subsidy or other form of compensation of more that $50,000 which is realized by or provided to an employer of at least ten (10) employees by or through the authority or approval of the County of Suffolk," or "Any service contract or subcontract let to a contractor with ten (]0) or more employees by the County of Suffolk for the furnishing of services to or for the County of Suffolk (except contracts where services are incidental to the delivery of products, equipment or commodities) which involve an expenditure equal to or greater than $10,000. For the purposes of this definition, the amount of expenditure for more than one contract for the same service shall be aggregated. A contract For the purchase or lease of goods, products, equipment, supplies or other property is not `compensation' for the purposes of this definition." Section I The Living Wage Law applies to this contract. I/we hereby agree to comply with al] the provisions of Suffolk County Local Law No. 12-2001, the Suffolk County Living Wage Law (the Law) and, as such, will provide to all full, part-time or temporary employed persons who perform work or render services on or for a project, matter, contract or subcontract where this company has received compensation, from the County of Suffolk as defined in the Law (compensation) a wage rate of no less than $10.40 ($9.25 for child care providers) per hour worked with health benefits, as described in the Law, or otherwise $ 11.84 ($10.50 for child care providers) per hour or the rates as may be adjusted annually in accordance with the Law. (Chapter 347-3 B) Check if applicable I/we further agree that any tenant or leaseholder of this company that employs at least ten (10) persons and occupies property or uses equipment or property that is improved or developed as a result of compensation or any contractor or subcontractor of this company that employs at ]east ten (10) persons in producing or providing goods or services to this company that are used in the project or matter for which this company has received compensation shall comply with all the provisions of the Law, including those specified above. (Chapter 347-2) Uwe further agree to permit access to work sites and relevant payroll records by authorized County representatives for the purpose of monitoring compliance with regulations under this Chapter of the Suffolk County Code, investigating employee complaints of noncompliance and evaluating the operation and effects of this Chapter, including the production for inspection & copying of payroll records for any or al] employees for the term of the contract or for five (5) years, whichever period of compliance is longer. All payroll and benefit records required by the County will be maintained for inspection for a similar period of time. (Chapter 347-7 D) Section II The Living Wage Law does not apply to this contract for the No Coun Funds Ex ended The County Department of Labor shall review the records of any Covered Employer at least once every three years to verify compliance with the provisions of the Law. (Chapter 347-4 C) Check if applicable Section III Contractor Name: Federal Employer ID#: Town of Southhold 11-6001939 Contractor Address: 53095 Route 25 // P.O. Box 1179 Amount of compensation: Southold, NY 11971-0959 Vendor #: Contractor Phone #: 765-1889 Description of project or service: Provision of work experience [o eligible program participants. Section IV I declare under penalty erjury under the Laws of the State of New York that the undersigned is authorized to provide this certification, and that the above is and correct. 2S' 08 Authorized Signature D e Name and Title LW 38 (revised 6-07, replaces forms LW2, LW3, and LW33) Suffolk County Form 22 Contractor'sNendor's Public Disclosure Statement Pursuant to Section AS-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 1 through 11 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'sNendor'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_Par[nership_Sole Proprietorship_Other S.a Is contractor/vendor entering into or has contractor/vendor entered into a contract with Suffolk County in excess of $1,000? _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 $1,000? _Yes_No. 6. Table of Organization. List names and addresses of all principals; that is, all individuals serving on the Boazd 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'sNendor's Public Disclosure Statement with the contract. (Describe general nature of the contract.) Page 1 of 3 Public Disclosure Form 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 1 through 11 herein: a) Hospital X b) Educational or governmental entities c) Not-for-profit corporations d) Contracts providing for foster care, family day-care providers or child protective services. 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 he/she has read and understood the foregoing statements and that they are, to his/her own 1 wledge, true. ~~,/ Dated: 2. s' a i~ Signed: Q(>et/- ~1N Printed Nameof Sign r: Scott Russell Title of Signer: Supervisor Name of Contractor/Vendor: Town of Southold UNIFORM CERTIFICATE OF ACKNOWLEDGMENT (Within New York State) STATE OF NEW YORK) COUNTY OF ) ss.: On the d~ day of ~ in the year 2008 before me, the undersigned, personally appeared SeoTr H - 2usss~c. U 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 his/her/their capacity(ies) and that by his/her/their signature(s) on the instrument, the individual(s), or the person upon behalf of which the individual(s) acted, executed the instrument. (signature dnd office Kf individual flaking acknowledgement) LINDA J COGPER NOTARY PUBLIC. ;!~a ,,r flew Yor(r NO.O1C04f32~55~.,;.,. ';?unt Terre Exp+res Decemo;r ;; i, 20~ Page 2 of 3 Public Disclosure Form UNIFORM CERTIFICATE OF ACKNOWLEDGEMENT (Without New York State) STATE OF ) )ss.: COUNTY OF ) On the day of in the year 2008 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 his/her/their capacity(ies) and that by his/her/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) Contractor's/Vendor's Public Disclosure Statement Form (Rev. 3/04) Page 3 of 3 Public Disclosure Form C:\Documents and Settings\kmancini\My Documents\MOO Sutr Co Exhibit Pub Disc Form 22-l.doc Suffolk County Form 22 Contractor'sNendor's Public Disclosure Statement Pursuant to Section AS-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 1 through 11 below, so indicate at pazagraph number 12 below setting forth the reason for such exemption. Notwithstanding such exempt status, you must execute this form below before a notary public. Contractor'sNendor's 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 $1,000? _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 $1,000? _Yes_No. 6. Table of Organization. List names and addresses of all principals; that is, all individuals serving on the Boazd of Directors or compazable 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's/Vendor's Public Disclosure Statement with the contract. (Describe general nature of the contract.) Page 1 of 3 Public Disclosure Form 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 1 through 11 herein: a) Hospital X b) Educational or governmental entities c) Not-for-profit corporations d) Contracts providing for foster care, family day-care providers or child protective services. 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, the/she has read and understood the foregoing statements and that they are, to his/her own wledge e. Dated: 2 0~ Signed: Printed N e of gner: Scott Russell Title of Signer: Name of Contractor/Vendor: Supervisor Town of Southold UNIFORM CERTIFICATE OF ACKNOWLEDGMENT (Within New York State) STATE OF NEW YORK) COUNTY OF ) ss.: On the o7'-l day of ~[,t.R~ in the year 2008 before me, the undersigned, personally appeared Se6n` fj-,G/~sst~c. U person-ally 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 his/her/their capacity(ies) and that by his/her/their signature(s) on the instrument, the individual(s), or the person upon behalf of which the individual(s) acted, executed the instrument. (signatur offic of indivi al taking acknowledgement) NOTARY PUBLIC, St^~~~~~,~.., N0.01C04822563, S;.r'-_ Y^rk Term Expires DecemCar ~ Page 2 of 3 Public Disclosure Form UNIFORM CERTIFICATE OF ACKNOWLEDGEMENT (Without New York State) STATE OF ) )ss.: COUNTY OF ) On the day of in the year 2008 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 his/her/their capacity(ies) and that by his/her/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) Contractor's/Vendor's Public Disclosure Statement Form (Rev. 3/04) Page 3 of 3 Public Disclosure Form C:U)ocuments and Settings\kmancini\My Documen[sU100 Suff Co Exhibit Pub Disc Form 22d.doc Suffolk County Form 22 Contractor'sNendor's Public Disclosure Statement Pursuant to Section AS-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 1 through 11 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'sNendor'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 $1,000? _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 $1,000? _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?_YesNo. 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's/Vendor's Public Disclosure Statement with the contract. (Describe general nature of the contract.) Page 1 of 3 Public Disclosure Form 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 1 through 11 herein: _ a) Hospital X b) Educational or governmental entities c) Not-for-profit corporations d) Contracts providing for foster care, family day-care providers or child protective services. 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, t the/she has read and understood the foregoing statements and that they are, to his/her own owledge, true. Dated: 6 2v- 08 Signed: ~C7` Printed Name of Si ner: Scott Russell Title of Signer: Name of Contractor/Vendor: Supervisor Town of Southold UNIFORM CERTIFICATE OF ACKNOWLEDGMENT (Within New York State) STATE OF NEW YORK) COUNTY OF ) ss.: On the „~~`day of in the year 2008 before me, the undersigned, personally appeared SC6TT A-- Gvss~~c 0 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 his/her/their capacity(ies) and that by his/her/their signature(s) on the instrument, the individual(s), or the person upon behalf of which the individual(s) acted, executed the instrument. Vc ~a.F1_~'/cJ (signature office of ndividual t ing acknowledgement) ,VOTARY P r ';~,J COOPER Yo e ~ E POes~Dece r5ut.~f NCo ~ tuber 3Y, ~p~ Page 2 of 3 Public Disclosure Form UNIFORM CERTIFICATE OF ACKNOWLEDGEMENT (Without New York State) STATE OF ) )ss.: COUNTY OF ) On the day of in the year 2008 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 his/her/their capacity(ies) and that by his/her/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) Contractor's/Vendor's Public Disclosure Statement Form (Rev. 3/04) Page 3 of 3 Public Disclosure Form C:\Documents and Settings\kmancini\My Documents\MOU SuR Co Exhibit Pub Disc Form 22-l.doc Suffolk County Form 22 Contractor's/Vendor's Public Disclosure Statement Pursuant to Section AS-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 1 through 11 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 $1,000? _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 $1,000? 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'sNendor's Public Disclosure Statement with the contract. (Describe general nature of the contract.) Page 1 of 3 Public Disclosure Form 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 1 through 11 herein: a) Hospital X b) Educational or governmental entities c) Not-for-profit corporations d) Contracts providing for foster care, family day-care providers or child protective services. 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 kn edge, tr e. Dated: ~2.I' ~ Signed: Printed Name of Signer: Scott Russell Title of Signer: Name of Contractor/Vendor: Supervisor Town of Southold UNIFORM CERTIFICATE OF ACKNOWLEDGMENT (Within New York State) STATE OF NEW YORK) COUNTY OF ) ss.: On the as day of c~ in the year 2008 before me, the undersigned, personally appeared SCo>t' A.,C.usssc- v 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 his/her/their capacity(ies) and that by his/her/their signature(s) on the instrument, the individual(s), or the person upon behalf of which the individual(s) acted, executed the instrument. ~~ J ~ ~~ (signature an of~rce of i div-~ak4ng acknowledgement) LINDA J COOPEA NOTORC048 25631 SuffolkCounltryyk Term Expires December 31, 20.(1L Page 2 of 3 Public Disclosure Form UNIFORM CERTIFICATE OF ACKNOWLEDGEMENT (Without New York State) STATE OF ) )ss.: COUNTY OF ) On the day of in the year 2008 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 his/her/their capacity(ies) and that by his/her/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) Contractor's/Vendor's Public Disclosure Statement Form (Rev. 3/04) Page 3 of 3 Public Disclosure Form C:\Documents and Settings\kmancini\My DocumentsUN00 Surf Co Exhibit Pub Disc Form 22d.doc Suffolk County, New York Department of Labor SUFFOLK COUNTY DEPARTMENT OF LABOR -LABOR MEDIATION UNIT UNION ORGANIZING CERTIFICATION/DECLARATION -SUBJECT TO AUDIT If the following definition of °`County Contractor" (Union Organizing Law Chapter 466-2) applies to the contractor's/beneficiary's business or transaction with Suffolk County, the contractor/beneficiary must complete Sections I, III, and IV below. If the following definitions do not apply, the contractor/beneficiary must complete Sections II, III and IV below. Completed forms must be submitted to the awarding agency. County Contractor: "Any employer that receives more than $50,000 in County funds for supplying goods or services pursuant to a written contract with the County of Suffolk or any of its agencies; pursuant to a Suffolk County grant; pursuant to a Suffolk County program; pursuant to a Suffolk County reimbursement for services provided in any calendar year; or pursuant to a subcontract with any of the above" Section I ^ The Union Organizing Law applies to this contract. I/we hereby agree to comply with all the provisions of Suffolk County Local Law No. 26-2003, the Suffolk County Union Organizing Law (the law) and, as to the goods and/or services that are the subject of the contract with the County of Suffolk shall not use County funds to assist, promote, Check if or deter union organizing (Chapter 466-3 A), nor seek reimbursement from the County for costs incurred to assist, Applicable promote, or deter union organizing. (Chapter 466-3 B) I/we further agree to take all action necessary to ensure that County funds are not used to assist, promote, or deter union organizing. (Chapter 466-3 H) I/we further agree that I/we will not use County property to hold meetings to assist, promote, or deter union organizing. (Chapter 466-3E) I/we further agree that if any expenditures or costs incurred to assist, promote, or deter union organizing are made, I/we shall maintain records sufficient to show that no County funds were used for those expenditures and, as applicable, that no reimbursement from County funds has been sought for such costs. I/we agree that such records shall be made available to the pertinent County agency or authority, the County Comptroller, or the County Department of Law upon request. (Chapter 466-3 I) I/we further affirm to the following as to the goods and/or services that are the subject of the contract with the County of Suffolk: • I/we will not express to employees any false or misleading information that is intended to influence the determination of employee preferences regarding union representation; • I/we will not coerce or intimidate employees, explicitly or implicitly, in selecting or not selecting a bargaining representative; • I/we will not require an employee, individually or in a group, to attend a meeting or an event that is intended to influence his or her decision in selecting or not selecting a bargaining representative; • I/we understand my/our obligation to limit disruptions caused by prerecognition labor disputes through the adoption of nonconfrontational procedures for the resolution of prerecognition labor disputes with employees engaged in the production of goods or the rendering of services for the County; and • I/we have or will adopt any or all of the above-referenced procedures, or their functional equivalent, to ensure the efficient, timely, and quality provision of goods and services to the County. Uwe shall include a list of said procedures in such certification. Section II ^ The Union Organizing Law does not apply to this contract for the following reason(s): No Countv Funds Expended Check if Applicable DOL-LOl (3/5/08) Suffolk County, New York Department of Labor Section III Contractor Name: Contractor Address: Town of Southold Federal Employer ID#: 11-6001939 53095 Route 25 // P.O. Box 1179 Amount of Assistance: Southold, NY 11971-0959 Vendor #: Contractor Phone: 765-1889 Description of project or service: Provision of work experience to eligible program participants. Section IV In the event any part of the Union Organizing Law, Chapter 466 of the Laws of Suffolk County, is found by a court of competent jurisdiction to be preempted by federal and/or state law, this certification declaration shall be void ab initio. Section V I declare under pena of perjury under the Laws of the State of New York that the undersigned is authorized to provide this certification, and dr a above is tru nd correct. ~ ~/~~a~ Authorized Signature Date Scott Russell, Supervisor Print Name and Title of Authorized Representative DOL-LOl (3/5/08) Suffolk County, New York Department of Labor Si1FFOLK COUNTY DEPARTMENT OF LABOR -LABOR MEDIATION UNIT UNION ORGANIZING CERTIFICATIONNECLARATION -SUBJECT TO AUDIT If the following definition of "County Contractor" (Union Organizing Law Chapter 466-2) applies to the contractor's/beneficiary's business or transaction with Suffolk County, the contractor/beneficiary must complete Sections I, [II, and IV below. If the following definitions do not apply, the contractor/beneficiary must complete Sections II, III and IV below. Completed forms must be submitted to the awarding agency. County Contractor: "Any employer that receives more than $50,000 in County funds for supplying goods or services pursuant to a written contract with the County of Suffolk or any of its agencies; pursuant to a Suffolk County grant; pursuant to a Suffolk County program; pursuant to a Suffolk County reimbursement for services provided in any calendar year; or pursuant to a subcontract with any of the above." Section I ^ The Union Organizing Law applies to this contract. I/we hereby agree to comply with all the provisions of Suffolk County Local Law No. 26-2003, the Suffolk County Union Organizing Law (the law) and, as to the goods and/or services that are the subject of the contract with the County of Suffolk shall not use County funds to assist, promote, Check if or deter union organizing (Chapter 466-3 A), nor seek reimbursement from the County for costs incurred to assist, Applicable promote, or deter union organizing. (Chapter 466-3 B) I/we further agree to take all action necessary to ensure that County funds are not used to assist, promote, or deter union organizing. (Chapter 466-3 H) [/we further agree that I/we will not use County property to hold meetings to assist, promote, or deter union organizing. (Chapter 4663E) I/we further agree that if any expenditures or costs incurred to assist, promote, or deter union organizing aze made, I/we shall maintain records sufficient to show that no County funds were used for those expenditures and, as applicable, that no reimbursement from County funds has been sought for such costs. I/we agree that such records shall be made available to the pertinent County agency or authority, the County Comptroller, or the County Department of Law upon request. (Chapter 466-3 I) I/we further affirm to the following as to the goods and/or services that are the subject of the contract with the County of Suffolk: • I/we will not express to employees any false or misleading information that is intended to influence the determination of employee preferences regarding union representation; • I/we will not coerce or intimidate employees, explicitly or implicitly, in selecting or not selecting a bargaining representative; • I/we will not require an employee, individually or in a group, to attend a meeting or an event that is intended to influence his or her decision in selecting or not selecting a bargaining representative; • I/we understand my/our obligation to limit disruptions caused by prerecognition labor disputes through the adoption of nonconfrontational procedures for the resolution of prerecognition labor disputes with employees engaged in the production of goods or the rendering of services for the County; and • Uwe have or will adopt any or all of the above-referenced procedures, or their functional equivalent, to ensure the efficient, timely, and quality provision of goods and services to the County. I/we shall include a list of said procedures in such certification. Section II Check if Applicable The Union Organizing Law does not apply to this contract for the following reason(s): No Countv Funds Expended DOL-LO1 (3/5/08) Suffolk County, New York Section III Contractor Name: Town of Southold Federal Employer ID#: 11-6001939 Contractor Address: 53095 Route 25 // P.O. Box 1179 Amoun[ of Assistance: NY 11971-0959 Vendor #: Contractor Phone: 765-1589 Description of project or service: Provision of work experience to eligible program participants. Section IV In the event any part of the Union Organizing Law, Chapter 466 of the Laws of Suffolk County, is found by a court of competent jurisdiction to be preempted by federal and/or state law, this certification/declaration shall be void ab rnitio. Section V I declare under penalty perjury under the Laws of the State of New York that the undersigned is authorized to provide this certification, and that t ove is true d correct. Authorized Sig lure Scott Russell, Supervisor .Print Name and Title of Authorized Representative Date DOL-LOI (3/5/08) Suffolk County, New York Department of Labor SUFFOLK COUNTY DEPARTMENT OF LABOR -LABOR MEDIATION UNIT UNION ORGANIZING CERTIFICATION/DECLARATION -SUBJECT TO AUDIT [f the following definition of "County Contractor" (Union Organizing Law Chapter 466-2) applies to the contractor's/beneficiary's business or transaction with Suffolk County, the contractor/beneficiary must complete Sections I, III, and [V below. If the following definitions do not apply, the contractor/beneficiary must complete Sections II, III and IV below. Completed forms must be submitted to the awarding agency. County Contractor: "Any employer that receives more than $50,000 in County funds for supplying goods or services pursuant to a written contract with the County of Suffolk or any of its agencies; pursuant to a Suffolk County grant; pursuant to a Suffolk County program; pursuant to a Suffolk County reimbursement for services provided in any calendar year; or pursuant to a subcontract with any of the above." Section I ^ The Union Organizing Law applies to this contract. I/we hereby agree to comply with all [he provisions of Suffolk County Local Law No. 26-2003, the Suffolk County Union Organizing Law (the law) and, as to the goods and/or services that are the subject of the contract with the County of Suffolk shall not use County funds to assist, promote, Check if or deter union organizing (Chapter 466-3 A), nor seek reimbursement from the County for costs incurred to assist, Applicable promote, or deter union organizing. (Chapter 466-3 B) I/we further agree to take all action necessary to ensure that County funds are not used to assist, promote, or deter union organizing. (Chapter 466-3 H) I/we further agree that I/we will not use County property to hold meetings to assist, promote, or deter union organizing. (Chapter 466-3E) I/we further agree that if any expenditures or costs incurred to assist, promote, or deter union organizing are made, I/we shall maintain records sufficient to show that no County funds were used for those expenditures and, as applicable, that no reimbursement from County funds has been sought for such costs. I/we agree that such records shall be made available to the pertinent County agency or authority, the County Comptroller, or the County Department of Law upon request. (Chapter 466-3 I) I/we further affirm to the following as to the goods and/or services that are the subject of the contract with the County of Suffolk: • I/we will not express to employees any false or misleading information that is intended to influence the determination of employee preferences regarding union representation; • I/we will not coerce or intimidate employees, explicitly or implicitly, in selecting or not selecting a bazgaining representative; • I/we will not require an employee, individually or in a group, to attend a meeting or an event that is intended to influence his or her decision in selecting or no[ selecting a bargaining representative; • I/we understand my/our obligation to limit disruptions caused by prerecognition labor disputes through the adoption of nonconfrontational procedures for the resolution of prerecognition labor disputes with employees engaged in the production of goods or the rendering of services for the County; and • I/we have or will adopt any or all of the above-referenced procedures, or their functional equivalent, to ensure the efficient, timely, and quality provision of goods and services to the County. I/we shall include a list of said procedures in such certification. Section II Check if Applicable The Union Organizing Law does not apply to this contract for the following reason(s): No Countv Funds Expended DOL-LO1 (3/5/08) Suffolk County, New York Department of Labor Section III Contractor Name: Contractor Address: Town of Southold Federal Employer ID#: 11-6001939 53095 Route 25 // P.O. Box 1179 Amount of Assistance: Southold, NY 11971-0959 Vendor #: Contractor Phone: 765-1889 Description of project or service: Provision of work experience [o eligible program participants. Section IV [n the event any part of the Union Organizing Law, Chapter 466 of the Laws of Suffolk County, is found by a court of competent jurisdiction to be preempted by federal and/or state ]aw, this certification/declazation shall be void ab initio. Section V I declare under penal of perjury under the Laws of the State of New York that the undersigned is authorized to provide this certification, and tha a above is and correct. /Zs-~~ Authorized Signature Date Scott Russell, Supervisor Print Name and Title of Authorized Representative DOL-LO1 (3/5/OS) YY) ACORD CERTIFICATE OF LIABILITY INSURANCE DAT TM 0721/20 8 PRODUCER Phone'. (831)299-0700 Fax: 631-299-x850 ROY H REEVE AGENCY INC. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION , PO BOX 54 ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR MATTITUCK NY 11952 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC # INSURED I INSURER A PraetOnan Ins. Co TH LD INSURER a American AI[efnative Insurence Company CIO SOUTHOLD TOWN HALL ---- _--- - - -- --- -- ---- P.O. BOX 1179 INSURER C _ L- SOUTHOLD NY 11971 INSURER D: INSURER E: VV VCRXVCJ 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 ANV CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAV BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BV THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAV HAVE BEEN REDUCED BV PAID CLAIMS. INSR1 A00' ~ I POLICY EFFECTIVE j POLICY EXPIRATION LTR IrvSR TYPE OF INSURANCE POLICY NUMBER LIMITS DATE MmlDwrr DATE mMmD GENERAL LIABILITY H634.000008-00 ' 01/01/08 01/01/09 EACH OCCURRENCE 1,000,000 $ X COMMERCIAL GENERAL LIABILITY i DAmALE TO RENTED __ $ ~ 1 000 000 PREMISES (Ea Deco nee) , , J CLAIMS MADE OCCUR MED EXP (Any one person) . $ 5,000 A X $50,000. DEDUCTIBLE (SIR) PERSONAL B ADV INJURY _ $ 1,000 000 Ir X CONTRACTUAL LIABILITY GENERAL AGGREGATE 1 $ $ 000 000 I GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG , 1 $ 1 000 000 P ~ . , , EO ~~LOC POLICY ~ AUT -- OMOBILE LIABILITY H634-000008-00 01/01108 01/01/09 COMBINED SINGLE LIMIT ~', I~X ANY AUTO i (Ea accident) $ 1/0001000 ' ~ ~ ALL OWNED AUTOS BODILY INJURY ' i ' ~ SCHEDULED AUTOS I (Per person) $ A -_ 1 HIRED AUTOS 1 -1 NON-OWNED AUTOS II i BODILY INJURY (Pera¢Ident) $ - I PROPERTY DAMAGE g (Par eccidenp GARAGE LIABILITY $ ': AUTO ONLY-EA ACCIDENT ~ ANV AUTO I I OTHER THAN EA ACC $ AUTO ONLY: AGG _ $ ~I EXCESSI UMBRELLA LIABILITY SOA2UB000057704 01/01/0$ 01/01/09 EACH OCCURRENCE $ 10 000 000 , 1 i X OCCUR n CLAIMS MADE AGGREGATE ~ $ 10,0001000 DEDUCTIBLE g X RETENTION $ 10 000 -- , $ WORKERS COMPENSATION AND wL STAiu- OTHER EMPLOYERS' LIABILITY TORY LIMITS ANT PROPRIETOR/PARTNER/E%ELUTIVE D EL. EACH ACCIDENT ______ $ OFFICERIMEMBER E%CLUOEDT II yec OevMbn unJn E. L. DISEASE-EA EMPLOYEE - $ , i SPECULPRDVIeloms below El. DISEASE-POLICY LIMIT $ OTHER: I I DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLESIEXCIUSIONS ADDED BY ENDORSEMENTI SPECIAL PROVISIONS CERTIFICATE HOLDER IS LISTED AS ADDITIONAL INSURED WITH RESPECT TO GENERAL LIABILITY ONLY. CERTIFICATE HOLDER cANCELLArION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS THE SUFFOLK COUNTY DEPARTMENT OF LABOR WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, 725 VETS MEMORIAL HIGHWAY ITS AGENTS OR REPRESENTATIVES. NORTH COUNTY COMPLEX BUILDING 17 , HAUPPAUGE, NEW YORK 11788 AUTHORIZED REPRESENTATIVE Attention: Th ACORD 25 (2001/08) Certificate # 11911 ©ACORD CORPORATION 1966 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. ni,vrtu <oro ~ewuvol Certificate #11911