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HomeMy WebLinkAboutAmerican Girl Qg%fF ELIZABETH A.NEVILLE,MMC �.t► �y Town Hall,53095 Main Road TOWN CLERK P.O.Box 1179 Southold,New York 11971 REGISTRAR OF VITAL STATISTICS p MARRIAGE OFFICER Fax(631)765-6145 y� Q`' Telephone(631)765-1800 RECORDS MANAGEMENT OFFICER �•( �►a www.southoldtownnygov FREEDOM OF INFORMATION OFFICER OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD FILMING/STILL PHOTOGRAPHY PERMIT Issued to: UTOPIA-The Aaency,Inc. for American Girl Photoshoot i Date(s),Time(s) and Location: Total of 1 DAY. Thursday,July 11 2013 (r/d Friday. July 12, 2013) 67 Steps Beach, end of Sound Road Greenport Permit No. 037 Issue Date: July 8,2013 Elizabeth A. Neville Southold Town Clerk (Town Seal) s Q��g�FfOL,��O ELIZABETH A.NEVILLE,MMC �� �y� lbwn Hall,53095 Main Road P.O.Box 1179 TOWN CLERK H Z Southold,New York 11971 y REGISTRAR OF VITAL STATISTICS Fax(631)765-6145 MARRIAGE OFFICER ��',�� aQ�� Telephone(631)765-1800 RECORDS MANAGEMENT OFFICER www.southoldtownny.gov FREEDOM OF INFORMATION OFFICER OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD August 8,2013 Attn: Carolyn Bodner UTOPIA 601 w 26T" St#1223 New York NY 10001 Dear Ms.Bodner: Enclosed herewith is your Clean-Up deposit Check,in the amount of$250. The area was left in good condition and it is my pleasure to return your deposit. Very truly yours, Linda J. Cooper Deputy Town Clerk Encl. k r r �f7`fiiE EYENf TF9SK `tOBT, MEOW TER Ll � +. ?HE Ply A. puRc � , fi Joe. . r �. L9 wa c Ap 7 a app ,� ...`^- � .. a�� ��t v'` � � �v; YT M .> y`i aau x �f t `*y r „ r Its nl00 8 1:0 2600 7 7 7 3t. 4 7 0 213 5100 EXHIBIT 3(to Project Document between Utopia and American Girl) Photo Shoot k Photographer: Location: -v;x Amer1can Gilff i RELEASE AND AGREEMENT—STRUCTURES,EXTERIORSANTERIORS —CONFIDENTIAL— For valuable consideration received,I._:a Co r' _ A• (please print name),as the owner or legally authorized agent or representative of -r6ly.0 e14' &orlrz5ac.41 (if representing an organization or site,please list the nam/e).of (01 G = L' '01r G,eyLLJIDA r- At Y7 (print address of location to hep otographed,hereinafter the"Premises"),hereby expressly consent and give American Girl Brands,L1.17,American Girl.l.l.C,and those acting under their authority(together referred to as "American Girl")the following absolute and irrevocable rights and permissions: (1)To enter onto the Premises with persons and equipment for the pur}wscs of photographing and to create photographs and likenesses of the exteriors! is(strike those which do not apply),whctltet tape or niasrc Mate: follor ng%"Qtur0(s*; laces°or. V.6 1),on the following dates(s)and times) THu,e s6 NY., '4122 /Wh 7 ii (collectively,the"Photographs"),,and (2)To take,use,reuse,reproduce,edit,and produce the said Photographs for use in any and all markets and media now known or hereafter devised,including marketing,editorial,advertising or promotional use,in connection with publications,products,and l marketing by American Girl•and its affiliated companies,including use on American Girl's website(s),American Girl's Facebook 1 page,and other social media sites;and r (3)To use the name and likeness of the structure,place,or event listed above in connection with the use of the Photographs. American Girl has no obligation to use the Photographs. �. (4)1 acknowledge that American Girl is the sole,exclusive,and perpetual owner of'thc Photographs which ownership entitles American(virl.among other things,to exclusive and perpetual: j a. Ownership of all duplicates or derivatives of any Photographs and any displays or promotional materials, b. Right to control,display,and use the Photographs and any performance rights embodied therein-, I c. Right to reproduce,modify,distribute,manufacture,advertise,sell,lease,license or otherwise use or dispose of such Photographs,and d. Right to use and display such Photographs in any medium by any means and for any purposes whatsoever. i I American Girl shall own all rights.title.and interest in the Photographs,including copyright. Any model release,voucher,time card,waiver.or other document provided to American Girl.even if signed by an American Girl representative,that conflicts with the terms of this Agreement will not be effective. 1.as owner or authorized agent,hereby waive the opportunity and right to inspect or approve the Photographs or any use to which they may be put. Each party,their officers,directors,agents and employees,and those acting under their authority,hereby releases the other party from all claims,actions.demands,and liabilities of any kind arising out of or in connection with the taking and use of the Photographs described above. j /� E Dated this 7 7%, day of .TULY .2013. I Ow•ncriRepresen a Contact It ormation: fly: (Signature) Address: .�.30GS' Qf o7 S' 460 //79 Print Name: 5 CD rr /9 R4OSSLJGGCity.State: 5Dz!TW0e,,6 /�Y For: 7-40WI., 4F Zip: /119 7� Title 0f not owner):SL/P�i�'i/l Sb/e- Phone: Copyright S?1013 American Girt Anachmenc(s)-_.. yK ...�no I I I FFot,�� ELIZABETH A.NEVILLE,MMIC 0 Town Hall,53095 Main Road TOWN CLERK P.O.Box 1179 = Southold,New York 11971 REGISTRAR OF VITAL STATISTICS Q .� Fax(631)765-6145 MARRIAGE OFFICER #4 aQ�' Telephone(631)765-1800 RECORDS MANAGEMENT OFFICER www.southoldtownny.gov FREEDOM OF INFORMATION OFFICER OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD PARKING PERMIT DATE: TfWMDAY, JULY 11,2013 (rain date 7/12/13) TIME; 7:00 A.M. TO 8:00 P.M. LOCATION: 67 STEPS BEACH, end of Sound Road, Greenport Utopia for American Girl Photo Shoot PLACE THIS PERMIT ON THE DASHBOARD, PASSENGER SIDE OF VEHICLE -7- Elizabeth A.Neville Town Seal Southold Town Clerk APPLICATION FOR FILMING/STILL PHOTOGRAPHY PERMIT NO: Please Print or Type APPLICATION DATE: CJ1 3 NAME OF APPLICANT: p MAILING ADDRESS: (001 1). �}' -. -4,112-2-51 PHONE: BUSINESS: o2_12- (034-0j 2$a HOME: NAME OF ORGANIZATIION/COMPANY: MAILING ADDRESS: 001 A 121=5 PHONE: oZt Z- r,234- i Z s o FAX: 2A 1 G13 q 2 v * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * DESCRIBE TYPE OF ACTIVI Y(e.g. Motion Picture, Commercial, Television. Catalog, Magazine, etc.): 1 i DATE(S) AND T E(S) PROPOSED FILMING/PHOTOGRAPHY: PROPO D LOCATION(S) OF MING/PHOTOGRAPH attach additional sheet, if necessary) NAME OF PERSON IN CHARGE AT SITE: Lka—VI Im as NUMBER OF PERSONS AT LOCATION (cast& crew clu ed): �r NUMBER AND TYPE OF VECHILES AT LOCATION: TYPE OF SPECIAL EQUIPMENT: Vo v ANY SPECIAL REQUIREMENTS: Signature Return to: Southold Town Clerk Southold Town Hall 53095 Main Road P.O. Box 1179 Southold, NY 11971 —�� CREAT-4 OP ID: TJ ,4�ofRo. CERTIFICATE OF LIABILITY INSURANCE D061141201YY) 06!14!2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER Phone:201-225-9099 NCONTCT AMEA Suburban General Insurance Agy PHONE -- --- -- 625 From Road Fax:201-225-0253 AIC No Ext: AIC No Paramus,NJ 07652 E-MAIL Suburban General Insurance Agy ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC 0 INSURER A:The Hartford 22357 INSURED Utopia-The Agency, Inc. INSURER B:Peerless Insurance Company 24198 &Air Represents INSURER C: 601 West 26th Street 12th Fl. New York,NY 10001 INSURER D: INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR AIJUL POLICY EFF POLICY EXP TYPE OF INSURANCE LTR POLICY NUMBER MM1DDlYYYY MMIDDlYYYY LIMBS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 _7W7ZETC,RENTED A X COMMERCIAL GENERAL LIABILITY 13SBALQ5878 05/2512013 05/25/2014 PREMISES(Ea occurrence) $ 31 CLAIMS-MADE OCCUR MED EXP(Any one person) $ 10,00 PERSONAL&ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,00 X POLICY PRO " CT LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 Ea accident $ A ANY AUTO 13SBALQ5878 05/2512013 05/25/2014 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURYaccident Per $ AUTOS AUTOS ( ) NON-OWNED PROPERTY DAMAGE X HIRED AUTOS Ix AUTOS PeraccIden[ $ X UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 4,000,00 A EXCESS LIAB CLAIMS-MADE 13SBALQ5878 05/25/2013 05/25/2014 AGGREGATE $ 4,000,00 DED I X RETENTION$ 10,000 $ WORKERS COMPENSATION WCSTATU- OTH- AND EMPLOYERS'LIABILITY X T RY LIMI ER A ANY PROPRIETORIPARTNERIEXEClIT1VE YIN— !N 13WECBN4209 10/28/2012 10/2812013 E.L.EACH ACCIDENT $ 100,00 OFFICERIMEMBER EXCLUDED? � N I A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 100,00 If yes,describe under DESCRIPTION OF OPERATIONS below E .DISEASE-POLICY LIMIT $ 500,00 B RENTED EQUIPMENT IM8368503 12/0112012 12/0112013 Limit 100,00 II Risk Per Item 20,00 DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHCLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Re: American Girl Shoot July 11 and 12, 2013 CERTIFICATE HOLDER CANCELLATION AMERICN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN American Girl ACCORDANCE WITH THE POLICY PROVISIONS. 67 Steps Beach Southold Town,NY 11971 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD * * * RECEIPT * * * Date: 07/08/13 Receipt#: 155193 Quantity Transactions Reference Subtotal 1 Application Fee- Non-Refund 37 $100.00 4 Beach Permits 37b $40.00 1 Daily Filming Permit 37a $100.00 Total Paid: $240.00 Notes: Payment Type Amount Paid By Multi-Entry#3 Checks $240.00 Utopia, The Agency Name: Utopia, The Agency Carol Bodner 601 W 26th St#1223 New York, NY 10001 Clerk ID: LINDAC Internal ID:37a CCq) d(J-�Ou'V.SD, -�-1,, b j�. � • CJS INDEMNIFICATION AGREEMENT TOWN OF SOUTHOLD FILMING/STILL PHOTOGRAPHY PERMIT The Applicant shall indemnify and hold harmless the Town from and against all suits, claims, demands or actions for any damage and/or injury sustained or alleged to be sustained by any party or parties in connection with the performance of filming or still photography by the Applicant, his employees or agents or any subcontractor and in case of any such action brought against the Town, the applicant shall immediately take charge of and defend the same at his own cost and expense. In addition, the Applicant will name the Town as an additional insured on any applicable policies. Signature Date Printed nq6e l�t?K-P.✓ 1�$► Title TOWN CLERK'S CHECKLIST FOR FILMING PERMIT NOTE: All payments must be cash or certified check a Applicant: a 7-0 /e Date Received: ,.21a 3 C pleted application $100 nonrefundable application fee Certificate of insurance that evidences a public liability insurance policy covering the town as an additional insured in the amount of$1,000,000 (one million dollars) per occurrence for the duration of the filming or still hotography. Indemnification agreement stating the applicant agrees to assume all liability for and will indemnify and hold the town harmless of and free from any and all damages that occur to persons or property by reason of said filming or still photography. Forward completed application to Chief of Police for approval or disapproval and determination if Traffic Control Fee is required Approved Disapproved No Fee Required Fee in the amount of$ required Forward certificate of insurance and indemnification agreement to Town Attorney foproval ( Approved Disapproved COLLECT FEES AS FOLLOWS: Permit Fees (Prior to issuance of permit): ✓ Film Fee - $100 per day of each day covered by the permit ✓ Cleanup deposit: Separate certified check for$250 for each day covered by the permit. Traffic control fee - $1000 for each day covered by the permit if required by the Chief of Police. NOTE: Additional funds may be required by Police if it is determined that $1000 per day fee will be expended prior to the termination of the permit period. Beach Parking fee - $10 per vehicle, per day between May 1 and September 30. ISSUED PERMIT Countersign application Issue permit with name of applicant, locations(s), date(s), and time(s) NOTIFICATION of ISSUED PERMIT Chief of Police Chief Building Inspector Fire Marshal Code Enforcement Officer Superintendent of Highways Superintendent of Parks and Recreation REQUEST FOR EXTENSION OF PERMIT Forward extension permit request to Chief of Police If granted, collect additional $100 per day filming fee Amend permit to indicate granted extension period COMPLETION OF PERMIT PERIOD Chief of Police to provide applicant with statement of cost for providing Traffic Control and police coverage. (Refund overpayment or collect for additional costs within 30 days of termination of permit) Superintendent of Highways inspections locations listed on permit and determine if cleanup efforts by town personnel is required. *If cleanup is required, Superintendent will provide Town Clerk with a statement of actual costs. (Refund overpayment or collect for additional costs within 30 days of termination of permit) *If not cleanup is required, Superintendent of Highways will notify Town Clerk and Town Clerk will remit the $250 certified check to applicant. APPLICANT'S CHECKLIST FOR FILMING PERMIT NOTE: All payments must be cash or certified check. V Completed application $100 nonrefundable application fee Certificate of insurance that evidences a public liability insurance policy covering the town as an additional insured in the amount of$1,000,000 (one million dollars)per occurrence for the duration of the filming or still / photography. ✓ Indemnification agreement stating the applicant agrees to assume all liability for and will indemnify and hold the town harmless of and free from any and all damages that occur to persons or property by reason of said filming or still photography. n Permit Fees (Prior to issuance of permit): CCS Film Fee - $100 per day of each day covered by the permit CcJ�L Cleanup deposit: Separate check for $250 for each day covered by the OM-$'540 permit. Traffic control fee - $1000 for each day covered by the permit if required by the Chief of Police. C � Beach Parking fee - $10 per vehicle, per day between May I and b02.$S September 30. ALL CHECKS MUST BE CERTIFIED NOTE: Additional fees for Cleanup and Traffic Control may be required at the direction of the Chief of Police and Superintendent of Highways Cooper, Linda From: Flatley, Martin Sent: Wednesday, July 03, 2013 7:50 AM To: Cooper, Linda Cc: Blasko, Regina; Kruszeski, Frank Subject: RE: Utopia Permit Request: 67 steps beach for American Girl Shoot. I have no objections to this permit being approved, however,they should display the permit on vehicles parked at this location since there are parking restrictions in place at this location. ��'wrtGlc �lattrig� Chief of Police Southold Town Police Department 41405 State Rt. 25 Peconic, N.Y. 11958 631-765-3115 From: Cooper, Linda Sent: Tuesday, July 02, 2013 12:28 PM To: Flatley, Martin Cc: Blasko, Regina; Kruszeski, Frank Subject: FW: Utopia Permit Request: 67 steps beach for American Girl Shoot. Oh boy! Another photo shoot application. Please review and let me know if it is okay to process. Thank you. From: Nate Woodruff[mailto:nate@ utopianyc.com] Sent: Tuesday, July 02, 2013 12:14 PM To: Cooper, Linda Cc: Carol Lee; Carolyn Bodner Subject: Utopia Permit Request: 67 steps beach for American Girl Shoot. Hi Linda, Attached are files of all the Documents and Checks that are coming your way via fedex(sent today.) This is for the American Girl shoot on 7-11-13 with a rain day option for the 7-12-13.Shooting on 67 steps Beach. Attached as followed. 1_application filled out in full. 2—certificate of insurance. 3—indemnification agreement signed. 4 Breakdown of Certified Checks. Please confirm that with the arrival of the fedex envelope containing all of the above and attached (original checks),that you have all you need to move forward with approving this location shoot permit. Thank you, Nate Woodruff 212-634-9280 601 West 26th Street#1223 New York, NY. 10001 1