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HomeMy WebLinkAboutOn The Mark Locations for Brynn Creative UFFO(�►�o ELIZABETH A.NEVILLE,MMC may► l/y Town Hall, 53095 Main Road TOWN CLERKo P.O.Box 1179 CA Z Southold,New York 11971 REGISTRAR OF VITAL STATISTICS p • Fax(631)765-6145 MARRIAGE OFFICERTelephone y� `► RECORDS MANAGEMENT OFFICER Ol ��� FREEDOM OF INFORMATION OFFICER www.southoldtownny.gov 765-1800 www.southoldtownny.gov OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD FILMING/STILL PHOTOGRAPHY PERMIT Issued to: On The Mark Locations for Brynn Creative Date(s), Time(s) and Location: Total of 1 DAY. Tuesday, July 16, 2013 8:00 am to 6:00 pm End Rocky Point Road and Rocky Point Beach, East Marion for print Photoshot. Permit No. 036 Issue Date: July 1, 2013 Elizabeth A. Neville Southold Town Clerk (Town Seal) TOWN CLERK'S CHECKLIST FOR FILMING PERMIT NOTE: All payments must be cash or certified check Applicant: On + e Mcg k L a cc-irt cMs Date Received: To e, _] 070 I ✓ 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$1,000,000 (one million dollars)per occurrence for the duration of the filming or still photography. 1/ Indemnification agreement stating the applicant agrees to assume all liability for and will indemnify and hold the town harmless of and free from any and all damages that occur to persons or property by reason of said filming or still photography. ✓ Forward completed application to Chief of Police for approval or disapproval and determination if Traffic Control Fee is required i/ Approved Disapproved No Fee Required Fee in the amount of$ required Forward certificate of insurance and indemnification agreement to Town Attorney for approval 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 v 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. RECEIVED JUN 2 7 2413 Southold Town Clerk q 1� aag- a�s� ecu ubii e K p�V-r^4 APPLICATION FOR FILMING/STILL PHOTOGRAPHY �q� Sig PERMIT NO: Please Print or Type APPLICATION DATE: 6/27/13 NAME OF APPLICANT: ON THE MARK LOCATIONS FOR BRYNN CREATIVE MAILING ADDRESS: 310 GREENWICH ST#38G,NEW YORK,NY 10031 PHONE: BUSINESS: 212-571-1522 HOME: NAME OF ORGANIZATION/COMPANY: ON THE MARK LOCATIONS MAILING ADDRESS: PHONE: 212-571-1522 FAX: 646-837-7320 * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * DESCRIBE TYPE OF ACTIVITY (e.g. Motion Picture, Commercial, Television. Catalog, Magazine, etc.): PRINT PHOTOSHOOT DATE(S) AND TIME(S) OF PROPOSED FILMING/PHOTOGRAPHY: _TUESDAY JULY 16, 2013 8AM-6PM PROPOSED LOCATION(S) OF FILMING/PHOTOGRAPHY: (attach additional sheet, if necessary) END OF ROAD, ROCKY POINT BEACH NAME OF PERSON IN CHARGE AT SITE: YAEL KNOPF—646 270 7754 NUMBER OF PERSONS AT LOCATION (cast&crew included): 13 PEOPLE NUMBER AND TYPE OF VECHILES AT LOCATION: 2 VANS & 1 PERSONAL VEHICLE TYPE OF SPECIAL EQUIPMENT: PHOTO EQUIPMENT ANY SPECIAL REQUIREMENTS: NONE Signature Return to: Southold Town Clerk Southold Town Hall 53095 Main Road 1V� P.O. Box 1179 Southold,NY 11971 Rudder, Lynda From: Flatley, Martin Sent: Friday, June 28, 2013 3:13 PM To: Rudder, Lynda Cc: Blasko, Regina; Kruszeski, Frank Subject: RE: Application for Shooting 7/16/13 1 have no objections to this photoshoot being approved,there will be no cost to our department unless this company has indicated any need for traffic or security. %V4112W Chief of Police Southold Town Police Department 41405 State Rt. 25 Peconic, N.Y. 11958 631-765-3115 From: Rudder, Lynda Sent: Friday, June 28, 2013 8:21 AM To: Flatley, Martin; Blasko, Regina; Kruszeski, Frank Subject: Application for Shooting 7/16/13 Please approve/disapprove and send cost analysis. This will pretty much be the same as last year. 0 168058 DATE(MM/DD/YYYY) ,°► �' CERTIFICATE OF LIABILITY INSURANCE 6/28/2013 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 CONTACT Yasmine Luevano NAME: Commercial Lines—(972)588-6456 PHONE 972.588.6428 F01C 855.605.8264 AIC No Wells Fargo Insurance Services USA, Inc. AIL ADDRESS: Yasmine.Luevano@wellsfargo.com 5151 Belt Line Road,Suite 200 INSURERS AFFORDING COVERAGE NAIC# Dallas,TX 75254 INSURER A: Liberty Mutual Fire Insurance Cc 23035 INSURED INSURER B: National Union Fire Ins.Co.of Pittsburgh, PA 19445 The Neiman Marcus Group,Inc. INSURER C: Liberty Insurance Corporation 42404 1201 Elm Street,Suite 2900 INSURER D: INSURER E: Dallas TX 75270 INSURER F: COVERAGES CERTIFICATE NUMBER: 6287847 REVISION NUMBER: See below THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SU13R POLICPOLICY NUMBER MM/DDY EFF/YYYY MM/DY EXP LIMITS LTRWVD A DA GENERAL LIABILITY EB2611004216342 08/01/12 08/01/13 EACHOCCURRENCE $ 1,500.000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ 500,000 CLAIMS-MADE 7 OCCUR MED EXP(Any one person) $ X SIR-$500,000 PERSONAL&ADV INJURY $ 2.000,000 GENERAL AGGREGATE $ 10,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY PRO LOC $ A AUTOMOBILE LIABILITY AS2611004216462 08/01/12 08/01/13 COMBINED e aBckiSINGLE LIMIT ' 2,000,000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE X HIRED AUTOS x AUTOS Per accident $ B X UMBRELLA LIAB X OCCUR 13273304 08/01/12 08/01/13 EACH OCCURRENCE $ 1.000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1,000,000 DED I I RETENTION$ $ WORKERS COMPENSATION x WC STATU- OTH- C AND EMPLOYERS'LIABILITY Y/N WA761 D004216322 08/01/12 08/01/13 JORY LIMITS ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1'000'000 OFFICER/MEMBER EXCLUDED? ❑N N/A Excludes Texas (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE,$ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Photo Shoot from July 16 to July 17,2013 Location:Rocky Point Beach,East Marion,NY Town Of Southold and Rocky Point Beach, Beach at end of Rocky Point Road, East Marion, NY 11939 are included as additional insureds with respect to the General Liability policy as required by written contract. CERTIFICATE HOLDER CANCELLATION Town Of Southold/Rocky Point Beach Greenport SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 53095 Main Road THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Southold NY 11971 AUTHORIZED REPRESENTATIVE The ACORD name and logo are registered marks of ACORD ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) (This-dilitl119 red—.1 ifi-W 6287405 i—d on&2&20131 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. 1 ature D to le�CA I-P Printed name L+4 �p uAlwo fia 6 MKV- L-D CA:T' Title April 25, 2013 Attn: Dana Zemsky On The Mark Locations, Ltd 310 Greenwich Street, Suite 38G New York,New York 10023 Re: Southold Town Filming Permit No,,.034 Dear Ms. Zemsky: Returned herewith is Check No. 9633 in the amount of$250.00 for the cleanup deposit as required by the Southold Town Code,' An inspection of the permit sites was made and no cleanup was necessary. Also included is the receipt for the permits. Very truly yours, Linda l Cooper Deputy Town Clerk Enc. Town of Southold P.O Box 1179 Southold, NY 11971 * * * RECEIPT * * * Date: 04/04/13 Receipt#: 148303 Transaction(s): Reference Subtotal 1 1 Application Fee-Non-Refund 034 $100.00 1 1 Daily Filming Permit 034a $100.00 Check#: 9632 Total Paid: $200.00 i t THE. $14'GREO WYO WAS' "° "" "• .•� NEW DATE OR' I Z7. 4 0- 7`JColo _...,s w..,. x. .:.w-,waw7s+ii•*9--nwKat�. `9�/ 4 sin V . ..... F w Bank ., ....iWPitu N.A. ..... 91009633111 1:02 &L10 ? Name: On, The Mark Locations Ltd 310 Greenwich St., Ste 38 G New York, NY 10013 Clerk ID: LINDAC Intemal ID:034 Page 1 of 1 Cooper, Linda From: Flatley, Martin Sent: Friday, April 12, 2013 9:39 AM To: Cooper, Linda Cc: Kruszeski, Frank; Blasko, Regina Subject: RE: Photo shoot No problem with it Linda Sent from my Android phone using TouchDown (www.nitrodesk.com) -----Original Message----- From:Cooper, Linda [Linda.Cooper@town.southold.ny.us] Received: Friday, 12 Apr 2013, 9:34am To: Flatley, Martin [mflatley@town.southold.ny.us] CC: Kruszeski, Frank [fkruszeski@town.south old.ny.us]; Blasko, Regina [rblasko@town.southold.ny.us] Subject: Photo shoot I just received an email from the production company and there is a possibility that they may need to add tomorrow to their permit. Would you have a problem with this? I asked that they let us know ASAP and no later than 2:30-3:OOpm today. Linda J. Cooper Deputy Town Clerk Town of Southold 631-765-1800 Life may not be the party we hoped for,but as long as we are here, we might as well dance! The difference between try and triumph is a little"umph"i 4/12/2013 Page 1 of 3 Cooper, Linda From: On The Mark Locations [dena@onthemarklocations.com] Sent: Friday, April 12, 2013 9:23 AM To: Cooper, Linda Subject: Re: question/permit Ok. Thanks. Please forgive my typos Sent from my iPhone On Apr 12, 2013, at 9:21 AM, "Cooper, Linda" <Linda.Cooper ,town.southold.ny.us> wrote: We close at 4pm so if you can let me know by 2:30-3:00pm at the latest. Linda J. Cooper Deputy Town Clerk Town of Southold 631-765-1800 Life may not be the party we hoped for,but as long as we arehere, we might as well dance! The difference between try and triumph is a little"umph"! From: On The Mark Locations [mailto:dena@onthemarklocations.com] Sent: Friday, April 12, 2013 9:20 AM To: Cooper, Linda Subject: Re: question/permit Great to know. Like I said probably won't happen but nice to have options. What time would be the latest to let you know? I will tell location manager. I will touch base with you either way. Dena Please forgive my typos Sent from my iPhone On Apr 12, 2013, at 9:18 AM, "Cooper, Linda" <Linda.Cooperktown.southold.ny.us> wrote: IF you decide to add tomorrow please let me know ASAP and there will be an additional $100 fee. I will give the police department a heads up that there be another day added to the permit. Linda J. Cooper Deputy Town Clerk Town of Southold 631-765-1800 Life may not be the party we hoped for,but as long as we arehere, we might as well dance! The difference between try and triumph is a little"umph From: On The Mark Locations [mailto:dena@onthemarklocations.com] Sent: Friday, April 12, 2013 9:12 AM To: Cooper, Linda Subject: Re: question/permit I love you tag on your signature. Thanks. It made me smile. 4/12/2013 • Page 2 of 3 Another question. If for some reason and it probably won't happen. But if they decide to stay another day to shoot without rain could we turn that around today?Just thinking ahead just in case. They rarely can get everyone to stay vi you never know Dena Please forgive my typos Sent from my iPhone On Apr 12, 2013, at 9:08 AM, "Cooper, Linda" <Linda.Cooper(i�town.southold.ny.us> wrote: Good luck with the shoot. Linda T Cooper Deputy Town Clerk Town of Southold 631-765-1800 Life may not be the party we hoped for,but as long as we arehere, we might as well dance! The difference between try and triumph is a little"umph"! From: On The Mark Locations [mailto:denaC&onthemarklocations.com] Sent: Friday, April 12, 2013 9:02 AM To: Cooper, Linda Subject: Re: question/permit Thanks linda!! Please forgive my typos Sent from my iPhone On Apr 12, 2013, at 8:59 AM, "Cooper, Linda" <Linda.Cooper cr,town.southold.ny.us> wrote: There is a light rain right now; however the wind is quite blustery. Not a problem if the documents are copies and if you use the permit in the vehicles instead of the car permits. Since the police know there is a photo shoot there wont be a problem but I will remind the police department that the shoot is taking place today. I feel sorry for anyone having to work outdoors today. Linda T Cooper Deputy Town Clerk Town of Southold 631-765-1800 Life may not be the party we hoped for,but as long as we arehere, we might as well dance! The difference between try and triumph is a little"umph".� From: On The Mark Locations [mailto:denaOonthemarklocations.com] Sent: Friday, April 12, 2013 8:54 AM To: Cooper, Linda Subject: question/permit Good morning, 'The Neiman Marcus photo shoot group are out there, 4/12/2013 Page 3 of 3 even in this bad weather. Is it pouring down rain there? I am in the city. The location manager called me last night to say he had left the original of the permit and the papers for the cars in the city by mistake. I had scanned the permit for documentation purposes, so I had them print that out and put in each car window and motor home. I had not scanned the car papers. Will that suffice or is there an issue that they don't have original with them? Please advise, If it is a problem, the location manager could zoom over to Town Hall and pick up another? Once again, Thank you for all your help, best Dena Dena Zemsky On The Mark Locations, Ltd. http:/www.onthemarklocations.com dena(a)onthemarklocations.com 0.212 571 1522 F.646 837 7320 C.917 208 2957 4/12/2013 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. Digitally signed by Dru Ammons Dni Ammnnsnp DN:cn=Dru Ammons,o=Brynn Creative,ou, 'I-i1riVlhr.r �nrr. a-1 IC sig"We Date:2013.04.0415:051DW5'00' _Dru Ammons Printed name Producer Title 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. --:;A 4 4-44,t... f 1 -�,� J 4/4/13 Signature Date Brynn isom Printed name Executive Producer Title FOLt Q Town Hall,53095 Main Road ELIZABETH A-NEVILLE,MMC P.O.Box 1179 TOWN CLERK = Southold,New York 11971 � 31)765-6 (6 14b Telephone(6 (631)765-1800 REGISTRAR OF VITAL STATISTICS Fax�O� MARRIAGE OFFICER �� a� southoldtown.northfork.net RECORDS OF MANAGEMENT OFFICER 1 �' FREEDOM OF INFORMATION OFFICER OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD FILMING/STILL PHOTOGRAPHY PERMIT Issued to: On The Mark a ent for Neiman Marcus Fashion Shoot Date(s),Time(s) and Location Friday.Aril 12 2013 7-00 am to 7:00 In Rock Point Beach at the end of Rocky Point Road East Marion New York Permit No. 034 Issue Date: April 4.2013 Elizabeth A.Neville Southold Town Clerk (Town Seal) Page 1 of 1 Cooper, Linda From: Cooper, Linda Sent: Wednesday, April 03, 2013 10:45 AM To: Flatley, Martin Cc: Kruszeski, Frank; Blasko, Regina Subject: Filming Permit request Attachments: Filming Permit request_20130403104507.pdf 4/3/2013 _� 168058 AC1fJRL?`' CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 164�14/3/2013 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 pollcy(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 CONTA NAME:: Yasmine Luevano Commercial Lines—(972)588-6456 PHONE 972.588.6428 IC N 855.605.8264 Wells Fargo Insurance Services USA,Inc. Ao E-MAIL Yasmine.Luevano@wellsfargo.Com 5151 Belt Line Road,Suite 200 INSURERS AFFORDING COVERAGE NAIC• Dallas,TX 75254 INSURERA: Liberty Mutual Fire Insurance Cc 23035 INSURED INSURERS: Liberty Insurance Corporation 42404 The Neiman Marcus Group,Inc. INSURER C: 1201 Elm Street,Suite 2900 INSURER 0: INSURER E: Dallas TX 75270 INSURER F: COVERAGES CERTIFICATE NUMBER: 5882395 REVISION NUMBER: See below 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 ADDL UBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER MMIDD/YYYY MM/DD/YYYY LIMITS A GENERAL LIABILITY EB2611O04216342 08/01/12 08/01/13 EACH OCCURRENCE $ 1,500,000 KFNTFU X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence) $ 500,000 CLAIMS-MADE �OCCUR MED EXP An one person) $ X SIR-$500,000 PERSONAL&ADV INJURY $ 2,000,000 GENERAL AGGREGATE $ 10,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY F PROj F LOC $ A AUTOMOBILE LIABILITY AS2611004216462 08/01/12 08/01/13 COMBINED SING LE LIMIT 2,000,000 Ea accident) IxANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR HCLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION X WC STATU- OTH- B AND EMPLOYERS'LIABILITY Y/N WA761 D004216322 08/01/12 08/01/13 IQBY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE 1,000,000 OFFICER/MEMBER EXCLUDED? ❑N NIA Excludes Texas E.L.EACH ACCIDENT $ (Mandatory In NH) E.L.DISEASE-EA EMPLOYEd$ 1,000,000 Use,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space Is required) RE:Photo Shoot on April 12,2013 only. Town Of Southold and Rocky Point Beach(End of Rocky Point Rd.,East Marion,NY 11939)are listed as additional insureds with respect to the General Liability policy as required by written contract. CERTIFICATE HOLDER CANCELLATION Town Of Southold/Rocky Point Beach Greenport SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 53095 Main Road THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Southold NY 11971 AUTHORIZED REPRESENTATIVE The ACORD name and logo are registered marks of ACORD ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) Page 1 of 2 Cooper, Linda From: Flatley, Martin Sent: Wednesday, April 03, 2013 4:01 PM To: Cooper, Linda Subject: RE: Filming Permit request That's fine,then I have no objection to the shoot, no cost to PD Martin Flatley Chief of Police Southold Town Police Department 41405 State Rt. 25 Peconic, N.Y. 11958 631-765-3115 From: Cooper, Linda Sent: Wednesday, April 03, 2013 4:00 PM To: Flatley, Martin Cc: Kruszeski, Frank; Blasko, Regina Subject: RE: Filming Permit request Thanks. When I spoke with the agent, she said there would be no need for any type of police involvement; it's a simple fashion shoot on the beach. Linda,T Cooper Deputy Town Clerk Town of Southold 631-765-1800 Life may not be the party we hoped for,but as long as we are here, we might as well dance! The difference between try and triumph is a little"umph"! From: Flatley, Martin Sent: Wednesday, April 03, 2013 3:53 PM To: Cooper, Linda Cc: Kruszeski, Frank; Blasko, Regina Subject: RE: Filming Permit request H Linda, I have no objections to this filming permit being approved. I don't anticipate any cost to the department because of it's location. However, if the company feels that they would need a perimeter set up for their shoot for any type of safety reasons, then I would need to change this reply. Martin Flatley Chief of Police Southold Town Police Department 41405 State Rt. 25 Peconic, N.Y. 11958 631-765-3115 From: Cooper, Linda 4/4/2013 Page 2 of 2 Sent: Wednesday, April 03, 2013 10:45 AM To: Flatley, Martin Cc: Kruszeski, Frank; Blasko, Regina Subject: Filming Permit request 4/4/2013 a TOWN CLERK'S CHECKLIST FOR FILMING PERMIT NOTE: All payments must be cash or certified check Applicant: 0 ill TH L-' �'}?f��C. (q6 g-, Date Received: 4- 3 - 1 -6 va evn 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$1,000,000 (one million dollars) per occurrence for the duration of the filming or still photography. Indemnification agreement stating the applicant agrees to assume all liability for and will indemnify and hold the town harmless of and free from any and all damages that occur to persons or property by reason of said filming or still photography. Forward completed application to Chief of Police for approval or disapproval and determination if Traffic Control Fee is required Approved Disapproved No Fee Required Fee in the amount of$ required Forward certificate of insurance and indemnification agreement to Town Attorney for approval 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. o��SUFFoc,(co ELIZABETH A.NEVILLE,MMC �� Gy Town Hall, 53095 Main Road TOWN CLERK p P.O. Box 1179 Go = Southold,New York 11971 REGISTRAR OF VITAL STATISTICS p .1C Fax(631)765-6145 MARRIAGE OFFICER 'I' RECORDS OF MANAGEMENT OFFICER �o! .� Telephone n.no 7 fork. 0 FREEDOM OF INFORMATION OFFICER southoldtown.northfork.net OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD To: Chief Flatley, Southold Town Police From: Linda J. Cooper, Deputy Town Clerk Dated: April 3, 2013 Re: Filming Permit Transmitted herewith is the application of On The Mark for a photo shoot permit to take place on the beach at the end of Rocky Point Road in East Marion on Friday, April 12, 2013 from lam to 7pm. In accordance with Section 139.0 of the Town Code please review the application and advice of approval or disapproval of the application and whether a traffic control fee is required and the amount needed. i i j13 APPLICATION FOR FILMING/STILL PHOTOGRAPHY >y;Jn Clerk PERMIT NO: Please Print or Type APPLICATION DATE: 4/2/13 NAME OF APPLICANT: On The Mark Location agent for Neiman Marcus Fashion Shoot. MAILING ADDRESS: 310 Greenwich St 438G,NY,NY 10013 PHONE: BUSINESS: 212-571-1522 HOME: NAME OF ORGANIZATION/COMPANY: OTM working for Brynn Creative/Neiman Marcus MAILING ADDRESS: 4641 Belclaire Ave, Dallas, 'I'X 75209 PHONE: 214-673-5496 FAX: DESCRIBE TYPE OF ACTIVITY (e.g. Motion Picture, Commercial,Television. Catalog,Magazine, etc.): Clothing photoshoot for Neiman Marcus DATE(S)AND TIME(S) OF PROPOSED FILMING/PHOTOGRAPHY: April 12,2013 7am-7pm PROPOSED LOCATION(S)OF FILMING/PHOTOGRAPHY: (attach additional sheet, if necessary) Rocky Point Beach NAME OF PERSON IN CHARGE AT SITE:+John Perez—cell phone 212 -203-8938 NUMBER OF PERSONS AT LOCATION (cast& crew included): 14 NUMBER AND TYPE OF VECHILES AT LOCATION: 1 Motorhome, one 15 passenger van, Q*6 passenger vehichle TYPE OF SPECIAL EQUIPMENT:_none—just print photography equipment ANY SPECIAL REQUIREMENTS: �Signdt `te Return to: Southold Town Clerk Southold Town Hall l 53095 Main Road P.O. Box 1179 Southold,NY 11971 'ay NY G/hHiL APA 3 2013 Southold Town Clerk