HomeMy WebLinkAboutRoyal Pains (2) System Manager Edit Reports cools Help
General Modules� -
Type:I Special Events Preassigned it: 26a Issue Date: 07!0812010 I.!
Client Information Notes
Full Name... Open,4 Business Productions
Home Address J (Royal Pains) Home Phone (631)
100 Universal City Plaza
MalingAddress Wo
Universal City,CA 91608
Fee Type: Fee Amount:F $2,627.32 Print
Remuneration Fee Quantity 1.00
Total: $2,627.32 dear
UtilRies-Cash Boo
Vials Modules
0Items in List Action Date:F/-/ L Total: 0.00
.,.................................. ................
Linda Cooper(LINDAC) NUM 8/17/2010, 2.23 PM
:t/ MinijteTraq »>:
System(Manager Edit Reports Tools Help
General Modules 1 � g
__._, ..µ....,
Type
Special Events Preassigned#. 26a Issue Date: 07/013/2010
� eE
3 - � Client Information /Notes
000843588$500
00084780$2127.32
Fee Type: Fee Amount: $2,627.32 Print
m...,,__ _.�.,.,.,,_-......,,..._ .,_..,.....,
to
( Remuneration Fee Quantity: 100
Total: $2,627.32 Clear
Util4ies•Cash Boo
Vitals Modules
0Items in List Action Date: / / Total: 0.00 -11
Linda Cooper(LIN DAC) NUM 8/17/2010 2:22 PM
BAS System Man... Posale SPAN- m2microsoftOffi— td
Town of Southold
P.O Box 1179
Southold, NY 11971
RECEIPT * * *
Date: 07/08/10 Receipt#: 86805
Transaction(s): Reference Subtotal
1 1 Remuneration Fee 26a $2,627.32
Check#: 2 Total Paid: $2,627.32
OPI�N 4 BUSINESS PRODUCTIONS LLC#8 VENDOR CHECK DATE ECK NUMBER
100 UNIVERSAL CITY PLAZA
/ UNIVERSAL CITY,CA 91608 OB 000352 06/23/10 0008 A 780
TOWN OF SOUTHOLD O"� v
INVOICE INVOICE
DATE NUMBER DESCRIPTION GROSS DISCOUNT NET
06/23/10 CR062310 6/7-9:POLICE FEE-ROYAL PAINS 2,127.32 .00 2,127.32
Total 2,127.32
i
Amount S bject To Tax .00 Check No 00084780
DETACH STATEMENT BEFORE DEPOSITING
Page 1 of 1
Cooper, Linda
From: Cooper, Linda
Sent: Wednesday, June 23, 2010 10:13 AM
To: 'hartman.stephen@gmail.com'
Subject: Royal Pains in Southold
Attachments: Royal Pains in Southold_20100623091400.pdf
Hi Stephen,
Here is a copy of the invoice mailed of Open 4 Business LLC for the additional costs for police coverage
while "Royal Pains"was being filmed in Southold Town.
Let me know is you have any questions concerning this matter.
Thank you and it was a pleasure working with you.
Linda J. Cooper
Deputy Town Clerk
631-765-1800
6/23/2010
OF SO(/Tyol
ELIZABETH A.NEVILLE,RMC,CMC '` O Town Hall,53095 Main Road
TOWN CLERK J P.O. Box 1179
REGISTRAR OF VITAL STATISTICS G Southold,New York 11971
MARRIAGE OFFICER Fax(631) 765-6145
RECORDS MANAGEMENT OFFICERTelephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER �CDUI�1�,� southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
June 22, 2010
Open 4 Business LLC
"Royal Pains"
203 Meserole Ave, 2"d Fl
Brooklyn NY 11222
Contact: Stephen Hartman, Asst. Location Manager
FILMING PERMIT POLICE COSTS
Enclosed herewith are the costs for police coverage during the filming of"Royal Pains" in the
Town of Southold.
We have already received a check from you in the amount of$2000 as partial payment. Also
being held is a check for $500 as deposit for Highway Clean-Up. With your permission, I will
apply the $500 check toward the police coverage costs.
Total Amount due for Police Coverage $4627.32
Check 00084357 partial payment for police 2000.00
Check 00084358 deposit for Highway Clean-Up 500.00
Total received $2500.00
Amount Now Due $2127.32
Make checks payable to "Town of Southold".
Please do not hesitate to contact me if you have any questions concerning this bill.
*x,a4 (!!t�,
Linda J. Cooper
Deputy Town Clerk
Town of Southold Police went
IntmW Conespondence _
To: Chief Cochran
.f
a,
('�
c
CC:
From: Capt. Martin Flatley, Executive Officers
Date: 6/10/2010
Re: Filming Permit for"Royal Pains" t
The following costs were incurred by our department in providing a police presence at
the shooting of Royal Pains at Pelligrini Vineyards as requested by Stephen Hartman,
Assistant Location Manager:
P.O.William Helinski-0700-1800 hrs. shift- 16.5 hrs @ $53.54/hr=$883.41
P.O. Sean Gillen-0700-1800 hrs. shift- 16.5 hrs @$53.54/hr=$883.41
P.O. Frank Rogers-0800-2030 hrs shift- 18.75hrs @$58.17/hr=$1,090.68
P.O. Steven Zuhoski-0800-2000 hrs - 18hrs@$56.62/hr=1,019.16
..
P.O. Frank Rogers- 1100-1630hrs shift-8.25 hrs. @$58.17/hr=$479.90
P.O.John Helf Jr, 1100-1630 hrs shift- 8.25 hrs. @$32.82/hr= $270.76
Total Cost to Department= $ 4,627.32
C-- Q,-,,,- � NT
POLICE DEPARTMENT, TOWN OF SOUTHOLD, N.Y.
RECORD OF OVERTIME PDTS-20011 updated 01127/2006
PRINT AM .LAST.FIRST.MI RANK SHIELD SQUAD
�G I r�5 l d
DATE OF OVERTIME / SCHEDUL DTOUR OVERTIME STARTED OVERTIME FINISHED
& d 6)94 D Tod 00
CC`i RXe
N FOR OVERTIME LEGEN
LL/ 6A,-".,A✓/ i 4 ^4 / 6er-7,4/ Z
PERSONNEL SHORTAGE..............................I CONTRACTUAL AGREEMENTS: TOUR CARRY OVER:
SPECIAL EVENT/ASSIGNMENT*....................2 HOLIDAY..................................................10 ARREST*..............................................15
GRANT*...( IE.STOP DWI)............................3 MINIMUM RECALL.....................................I I COMMITTAL*.......................................16
COURT/HEARING*.......................................4 ON CALL....................................................12 INVESTIGATIVE*...................................17
INVESTIGATIVE*........................................5 MVA*....................................................18
ADMINISTRATIVE.......................................6 OTHER..................................................19
F/O/A*.......................................................7
TRAVEL TME............................................8
TRAININ .. ...............................................9 *CC#REQUIRED
VER REQUESTE TIME ❑PAY OVERTIME: ❑ APPROVED ❑ DISAPPROVED
�.
EM YEE'S SIGNATURE SUPERVISOR SIGNATURE DATE
3F R Y) ORS NIiNS RTII�IE CALC�ILATIONS VERIE?I•,D.
H(I.
NO
r IFNO RIASUN?
TQU WWI
I ,
(N &HA 1
I
:.
SIG3NATMICIF A0ia;wB$W7 - -"
POLICE.DEPARTMENT,TOWN OF SOUTHOLD, N.Y.
RECORD OF OVERTIME PDTS-200li updated 01/27/2006
PRINT NAME.LAST,FI T. I RANG SHIELD SQUAD
DATE`O V TIME S HE UL D TOUR OVERTIME STARTED OVERTIME FINISHED
vv
CCk REASON TOR OVE 1 LEGEND`N
PERSONNEL SHORTAGE.......................... I CONTRACTUAL AG EMENTS: TOUR CARRY OVER:
SPECIAL EVENT/ASSIGNMENT*....................2 HOLIDAY..................................................10 ARREST*............... .............................15
GRANT*...(IE.STOP DWI)............................3 MINIMUM RECALL.....................................I l COMMITTAL*.......................................16
COURT/HEARING*.......................................4 ON CALL....................................................12 INVESTIGATIVE*...................................17
INVESTIGATIVE*........................................5 MVA*...................................................18
ADMINISTRATIVE.......................................6 OTHER..................................................19
F/O/A*.......................................................7
TRAVEL TWIE..........................#I................8
TRAINING.,.............I...............p...............9 *CC#REQUIRED
OVERTIME QUESTE [j TIME AY OVERTIME: ❑APPROVED ❑ DISAPPROVED
REQUESTING EMPLOYtEtZGNATURE SUPERVISOR SIGNATURE. DATE
RTI +GAL.CUL,ATIONS'uF:RIFIED.
F43R A USI✓ONLY . I.'�3R NUNS NO
H�3L,Ibz�_• �
IvICIJIM i RICA Lt t 14OURS) IF NO,RI~A3t ISI?
TQUR G`I3ANGE(�I�1.f.�'T[M�)
ScFil3 EIS OVA `I E(TIME HALF)
A .
��—
GNO ESOR O WR.( E u HALF)
,
3'OTA1a OVt f�rTIs NT'I T..EMENT au SIGNATU�f:OF'A. MIN PFRSOI+ ATE
POLICE DEPARTMENT, TOWN OF SOUTHOLD, N.Y.
RECORD OI' OVERTIME PDTS-200li updated 01/27/2006
PRINT NAME.LAST,FIRST,MI RANK SHIELD SQUAD
(� C G E 25 _ar�c� 3 e 0 . 1 S(--,
DATE OF O ERTIME S HEDULED TOUR OVERTIME STARTED OVERTIME FINISHED
b cog to Oen 0 2-o3o O Boo 2- 030
CC# REASON FOR OVERTIME LEGEND#
F1l_m s o-T
PERSONNEL SHORTAGE..............................I CONTRACTUAL AGREEMENTS: TOUR CARRY OVER:
SPECIAL EVENT/ASSIGNMENT*....................2 HOLIDAY................................................ 10 ARREST*..............................................15
GRANT*....................................................3 MINIMUM RECALL.....................................I I COMMITTAL*.......................................I6
COURT/HEARING*.......................................4 ON CALL....................................................12 INVESTIGATIVE*...................................17
INVESTIGATIVE*........................................5 MVA*...................................................18
ADMINISTRATIVE.......................................6 OTHER..................................................19
F/O/A*.......................................................7
TRAVEL TIME.................. ........................8 *CC#REQUIRED
TRAINING........................ .. ................ .....9
OVERTIME REQUEST D TIME []PAY OVERTIME: ❑ APPROVED ❑ DISAPPROVED
::h a --�k
REQUESTING EMPLDYEE'g SIGN URE SUPERVISOR SIGNATURE DATE
FORA USE,ONLY ;OURS M OVER{IME!CALCULATI. NS VERIFIED:
HOLIDAY 0 NQ
MINIMUM RECALL(4 HOURS)
IF NO,REASON?
TOUR CHANGE(HALF TIME)
SCREDULED OVERTIME(TIME&HALF)
UNSCHEDULED OVERTIME(TIME&HALF)
TOTAL.OVERTIME ENTITLEMENT aS SIGNATURE OF ADMIN PERSON DqTE
POLICE DEPARTMENT, TOWN OF SOUTHOLD, N.Y.
RECORD OF OVERTIME PDTS-200li updated 0l/27/2006
PRINT NAME,LAST.FIRST.NO RANK SHIELD
SQUAD
NTAi I ')
DATE OF OVERTIME SCHEDULED TOUR OVERTIME STARTED OVERTIME FINISHED
06-0e -/o p1h o /�' 0194v zoo o
CC# REASON FOR OVERTIME LEGEND#
ynavd- ,Dari- �VJWINl I Z'
PERSONNEL SHORTAGE..............................I CONTRACTUAL AGREEMENTS: TOUR CARRY OVER:
SPECIAL EVENT/ASSIGNMENT*....................2 HOLIDAY................................................ 10 ARREST*..............................................15
GRANT*....................................................3 MINIMUM RECALL.....................................I I COMMITTAL*.......................................16
COURT/HEARING*.......................................4 ON CALL....................................................12 INVESTIGATIVE*...................................17
INVESTIGATIVE*........................................5 MVA*...................................................18
ADMINISTRATIVE.......................................6 OTHER..................................................
19
F/O/A*.......................................................7
TRAVEL T94E............................................8 *CC#REQUIRED
.... .......
TRAINING ..
OVERTIME REQUESTED IN ❑TIME XPAY OVERTIME: ❑ APPROVED ❑ DISAPPROVED
D �7�
REQUESTING E LOYEE'S SIGNATURE SUPERVISOR SIGNATURE DATE
FOR fkflMlN USE ONLY FIOU'Ra GINS OVERTIME CALCULATIONS VERIFIED.
HC3LlDAY
Y El NO
MINIMUM RECALL(4 HOURS) IF NO,:REASON?
TOUR CHANGE(HALF TIME)
SCHEDULED OVERTIME(TIME&HALF) /
UNSCHEDULED OVERTIME(TIME do HALF) ,
�!
TOTAL O _ PERSON D
OVERTIME ENTITLEMENT-_ SIGNATURE OF ADMIN PE --_
POLICE DEPARTMENT, TOWN OF SOUTHOLD, N.Y.
RECORD OF OVERTIME PDTS-2001i updated 01/27/2006
PRINT NAME.LAST.FIRST.MI RANK SHIELD SQUAD
Lr 2 t-j Nt,\ 1910 11 DF -
DA E OF OVERTIME SCHEDULED TOUR OVERTIME STARTED OVERTIME FINISHED
wCC# REASON F R ERTIME LEGEND#
-�/ tR2 SN 2 UlA 1, �SPERSONNELSHORTAGE..................._.........I CONTRACTUAL AGREEMENTS: R CARRY OVER:
SPECIAL EVENT/ASSIGNMENT*....................2 HOLIDAY................................................ 10 ARREST*..............................................15
GRANT*....................................................3 MINIMUM RECALL.....................................1 l COMMITTAL*.......................................16
COURT/HEAR[NG*.......................................4 ON CALL....................................................12INVESTIGATIVE*...................................17
INVEST[GATIVE*.......................... .............5 MVA*...................................................18
ADM[NISTRATIVE................................... ...6 OTHER..................................................19
F/O/A*................................ .. ................. 7
TRAVELTIME.............................._............8 *CC#REQUIRED
TRAINING..................................................9
OVERTIME REQUESTED IN ❑TIME AY OVERTIME: [IAPPROVED ElDISAPPROVED
1
REQUES EMPLOYEE'S SIGNATUR SUPERVISOR SIGNATURE DATE
FOR A IN ONLY) E10URS MINS VERTTMI CALCU,ATIC>!NS VERIMP.
1;3LIDAY
O' No
IV"UM:P,,ECALL(4 HOURS) IF NO,REASON?
TOUR CHANGE(HALF TIME)
SCHEDULED OVERTIME(TIME&HALF)
UNSCHEDULED OVERTIME(TIME&HALF) VWOU
TOTAL'OVERTIME ENTITLEMENT SIGNATURE OF ADMIN PERSON ATE
POLICE DEPARTMENT, TOWN OF SOUTHOLD, N.Y.
RECORD OF OVERTIME PDTS-2001 i updated 01/27/2006
PRINT NAME.LAST.FIRST.MI RANK SHIELD SQUAD
(� � GEi? If4A0c� -'. o s � y
DATEOFOVERTI SCHEDULED TOUR OVERTIMESTARTED OVERTIME FINISHED
too � � o o 63 O IOC) 1 b 3 o
CC# REASON FOR OVERTIME LEGEND#
PERSONNEL SHORTAGE..............................I CONTRACTUAL AGREEMENTS: YOUR CARRY OVER:
SPECIAL EVENT/ASSIGNMENT*....................2 HOLIDAY..................................................10 ARREST*..............................................15
GRANT*...(IE.STOP DWI)............................3 MINIMUM RECALL.....................................1 I COMMITTAL*.......................................16
COURT/HEARING*.......................................4 ON CALL....................................................12INVESTIGATIVE*....................................17
INVESTIGATIVE*........................................5 MVA*...................................................18
ADMINISTRATIVE.......................................6 OTHER..................................................19
F/O/A*.......................................................7
TRAVEL TIME........... ................................8
TRAINING.................. ....................... ......9 *CC#RE UIRED
OVERTI REQUE ED IN TIME ❑PAY OVERTIME: ❑APPROVED ❑DISAPPROVED
S'ky
REQUESTING EMPLOY E'S S NATURE SUPERVISOR SIGNATURE DATE
UNI. H4IIR,S MS'S ERTIME CALCIJI,ATICINS VERIPIED.
LIDAa S ❑ NO
I►�I�fi[I+� I 1�CAIri,�a1[40URS) � JP NO :REASON?
-
SCItEbULDV .: I�(TIJvII sir HALF)
UHSCHEDFli� 0? TlM {TIME&HALF) If
-
FliiTAi. I NT SIC RW'I;JRI OF A.1 MIN PERSON E
Town of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 06/23/10 Receipt#: 84687
Transaction(s): Reference Subtotal
1 1 Traffic Control Fee 26 $2,000.00
Check#: 84357 Total Paid: $2,000.00
VENDOR CHECK DATE CHECK NUMBER
OPEN 4 BUSINESS PRODUCTIONS LLC#8
100 UNIVERSAL CITY PLAZA OB000352
SOUTHOLD003506/03/10 00084357
UNIVERSAL CITY.CA 91608
IfOICE INVOICE DESCRIPTION GROSS DISCOUNT NET
NUMBER
010 Pc060210A 6/7-8:TRAFFIC CONTROL-ROYAL PA 2,000.00 00 2,000.00
Total 2,000.00
f
I
t
Amount S ject To Tax 0 Check No 00084357
ROYAL— !NS
DETACH STATEMENT BEFORE DEPOSITING
Town of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 06/14/10 Receipt#: 83479
Transaction(s): Reference Subtotal
1 1 Daily Filming Permit 26b $100.00
Cash#: 84512 Total Paid: $100.00
OPEN 4 BUSINESS PRODUCTIONS LLC#8 VENDOR CHECK DATE CHECK NUMBER
100 UNIVERSAL CITY PLAZA OB 000352 06/10/10
UNIVERSAL CITY.CA 91608 00084512
TOWN OF SOUTHOLD
INV T NUMBER INVOICE
DAT DESCRIPTION GROSS DISCOUNT NET
06/09/10 CR060910 6/9:FILM FEE-23005 MAIN RD 100.00 .00 100.00
Total 100.00
I
i
i
i
Amount S bject To Tax 00 Check No 00084512
ROYAL P"INS S2
DETACH STATEMENT BEFORE DEPOSITING
�of say
oy� lyol
ELIZABETH A.NEVILLE,RMC, CMC O Town Hall, 53095 Main Road
TOWN CLERK P.O. Box 1179
REGISTRAR,OF VITAL STATISTICS N AW Southold, New York 11971
MARRIAGE OFFICER �� Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER l Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER �MUM, southoldtown.northfork.net
RECEIVE®
OFFICE OF THE TOWN CLERK
JUN 9 2010 TOWN OF SOUTHOLD
APPLICATION FOR FILMING/STILL PHOTOGRAPHY �f'n�iv�/nti7`
.D A r�
Southold Town Clerk PERMIT NO: Abpc`j
Please Print or Type
APPLICATION DATE: 1:7-
� N /�
NAME OF APPLICANT:S TE A ic A ss l5 r R,/i �aG�+i«,�/ /�/I,✓p�E�
MAILING ADDRESS: AV '�'V'D FL, egook4 y v ,y-r 0 i-4z-
PHONE: BUSINESS: 7 ?'3 F` -� YD 3 HOME: 7 " 905-- 10 V
NAME OF ORGANIZATION/COMPANY: <�If Cjq f !!Z Lz G r`teox4z Pf lw
MAILING ADDRESS: ar 3 mEs E,- DG e AyE , a "'p F epook- NY
PHONE: Z' 19-3 F� —,R 90 3 FAX:
* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *
DESCRIBE TYPE OF ACTIVITY (e.g. Motion Picture, Commercial, Television. Catalog, Magazine, etc.):
.--
V/ aN14Z Cv EO rZ l 2 U SLi NGTW 6r1ZNB
,7 DATE(S) AND TIME(S) OF PROPOSED FILMING /PHOTOGRAPHY: T�LC��S/oma/
t 1*WFFiC C2uvrr0L- Mt9 (r., -9D CK7C (" G4eE- .fitLmt VG
PROPOSED LOCATION(S) OF FILMING/PHOTOGRAPHY: (attach additional sheet, if necessary)
�J-U,v E /CT'`/ g 010 `ry Xlyl To `1: o0 ,'��
NAME OF PERSON IN CHARGE AT SITE: S%F/,f/��r �� f j ,g55lSi 19,E i /oc'4710✓
,rArfX'6/j
NUMBER OF PERSONS AT LOCATION (cast & crew included): UP TSA lao
NUMBER AND TYPE OF VECHILES AT LOCATION: �f-e 06'hr V/v uSL y ,Q r717C/a61)
TYPE OF SPECIAL EQUIPMENT: yP®G�� %EGA`i/tS/o �*✓ , �lrN/=,���,��;P sv ,T/p �Gy�,c
/""'s
ANY SPECIAL REQUIREMENTS: W r.- 19'5 Q U 5 j /dy(�2•'^/��6.•?-
%�A��cc Cl,,� illU� aN �A �/ �� talc, d/✓E .SCEN � .
Signature Return to: Southold Town Clerk
Southold Town Hall
53095 Main Road
P.O. Box 1179
Southold, NY 11971
I
7`
OPEN 4 BUSINESS PRODUCTIONS LLC#8 CONTROLLED Di RSEMENT 00084356
ATLANTA,DEKM B GEORGIA
84 1278/811 GA
100 UNIVERSAL CITY PLAZA —��—� � �-1 CHECK NUMBER PAY EXACTLY I
UNIVERSAL CITY,CA 91608
u
OB 000352 06/03/10 00084356 ******200. 00
I
EXPOSURE TO BODY HEAT OR COLOR COPIER ROYAL PAINS S2
N WILL CAUSE SYMBOL AT RIGHT TO CHANGE COLOR.
TWO HUNDRED DOLLARS AND 00 CENT DISAPPEAR,AND THEN REGAIN COLOR
PAY exactly
I
PAY to the order of
_.. ._._._.._... ._..... -. __ .. __ MP
TOWN OF SOUTHOLD
53095 MAIN ROAD I
PO BOX 1179 MP
i
SOUTHOLD, NY 11971
1190008435611' i:061iL27884 335 916 3SBY0
. .•=I. :
. . •
OPEN 4 BUSINESS PRODUCTIONS LLC X418 AM &°WU N,GEORGIA 64-127OV611 eA 00084357
100 UNIVERSAL CITY PLAZA - .q_ � HE K NUMBER 1 PAY EXACTLY
2 UNIVERSAL CITY,CA 91608 - -N -- --
x ! iOB 000352 06/03/10 00084357 *****2, 000.00
s
a EXPOSURE TO BODY HEAT OR COLOR COPIER ROYAL PAINS S2
WILL CAUSE SYMBOL AT RIGHT TO CHANGE COLOR,
DISAPPEAR,AND THEN REGAIN COLOR.
TWO THOUSAND DOLLARS AND 00 CENT
PAY exactly
PAY to the order of
• � MN '
i1
TOWN OF SOUTHOLD
53095 MAIN ROAD
SOUBOX 1 NY 11971
MP
PO BOX 1179
v00084 3 5 Iii' 406 L L L 2 78811: 3 3 5 9 L6 3 584Ii'
impzL"IIAIN
BANK OFAMERICA"A 0 0 0 8 4 3 5 8
OPEN 4 BUSINESS PRODUCTIONS LLC 8 AT S°DIBUMEORGIA 64-1278/611 GA
100 UNIVERSAL CITY PLAZA
UNIVERSAL CITY,CA 91608 ----VENDOR-NO--__ __DATE_ CHECK NUMBEA7 I PAY EXA TLY
j OB 000352 j 06/03/10 00084358 ******500.00
i
+ EXPOSURE TO BODY HEAT ORCOLOR COPIER ROYAL PAINS S2
WILL CAUSE SYMBOL AT RIGHT TO CHANGE COLOR.
FIVE HUNDRED DOLLARS AND-00 ( SAPPEAR,AND THEN REGAIN COLOR
PAY exactly
i
PAY to the order of
MH
TOWN OF SOUTHOLD
53095 MAIN ROAD
PO BOX 1179
SOUTHOLD, NY 11971
11000084 3 58ii' i:06 L L L 2 7881: 3 3 5 9 L6 3 584ii'
OPEN 4 BUSINESS PRODUCTIONS LLC#8 VENDOR CHECK DATE CHECK NUMBER
100 UNIVERSAL CITY PLAZA
UNIVERSAL CITY,CA 91608 OB 000352 05/27/10 00084290
TOWN OF SOUTHOLD
INVOICE INVOICE
DATE NUMBER DESCRIPTION GROSS DISCOUNT NET
05/27/10 CR052710 6/7-9:APP FEE-ROYAL PAINS 100.00 .00 100.00
Total 100.00
RECEIVED
JUN 2 2010
Southc ld Town Clerk
Amount Subject To Tax .00 Check No 00084290
ROYAL P�k!NS S2 DETACH STATEMENT BEFORE DEPOSITING
OPEN 4 BUSINESS PRODUCTIONS LLC#8 VENDOR CHECK DATE CHECK NUMBER
100 UNIVERSAL CITY PLAZA OB 000352 06/03/10
UNIVERSAL CITY,CA 91608 TOWN OF SOUTHOLD 00084356
INVOICE INVOICE
DATE NUMBER DESCRIPTION GROSS DISCOUNT NET
06/02/10 CR060210 6/7-8:FILM FEE-ROYAL PAINS 200.00 .00 200.00
Total 200.00
Amount S bject To Tax 00 Check No 00084356
ROYA PAINS S2 DETACH STATEMENT BEFORE DEPOSITING
o�*OF SOUTyoI
ELIZABETH A.NEVILLE,RMC,CMC ti O Town Hall, 53095 Main Road
TOWN CLERK l P.O. Box 1179
REGISTRAR OF VITAL STATISTICSSouthold, New York 11971
G
MARRIAGE OFFICER �p Fax(631) 765-6145
.t`
RECORDS MANAGEMENT OFFICERTelephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER yC�UIY 1�,� southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
FILMING/STILL PHOTOGRAPHY
PERMIT
Issued to:
Open 4 Business, LLC—"ROYAL PAINS"
Date(s), Time(s) and Location
June 7, 2010 - 7:00am to 3:00pm(times approximate) Main Road, Cutchogue
by Pellegrini Vineyards
June 8 2010 - 7:00am to 11:00am (times approximate) Main Road, Cutchogue
by Pellegrini Vineyards
Permit No. 26
Issue Date: 6/4/2010
Elizabeth A. Neville
Southold Town Clerk
(Town Seal)
o��pF SO(/r�,ol
ELIZABETH A.NEVILLE,RMC,CMC '` O Town Hall, 53095 Main Road
TOWN CLERK l l P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Southold, New York 11971
MARRIAGE OFFICER • �� Fax(631) 765-6145
RECORDS MANAGEMENT OFFICERl Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER �COUIY 1,,� southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
To: utho,ld TownAttorney's Office
From. Linda J. Cooper, Deputy Town Clerk
Dated: May 27, 2010
Re: Filming Permit
In accordance with the Southold Town Code, Chapter 44A, Section 3, Subsection
D, the Certificate of Insurance and Indemnification Agreement for a Filming
Permit Application for Stephen Hartman for "Royal Pains" are attached hereto.
Please review and advise whether these documents meet with your approval.
Thank you. m T;F,--
Approved as.,y4ted
Disapprove for the following reasons:
�-
r
re
2010
o,,oF so�lyol
ELIZABETH A.NEVILLE,RMC,CMC ti O Town Hall, 53095 Main Road
TOWN CLERK l l�[ P.O. Box 1179
REGISTRAR OF VITAL STATISTICS G Q Southold, New York 11971
MARRIAGE OFFICER Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER Telephone(631) 765-1800
C
FREEDOM OF INFORMATION OFFICER OUsoutholdtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
FILMING/STILL PHOTOGRAPHY
PERMIT
Issued to:
Open 4 Business, LLC—"ROYAL PAINS"
Date(s), Time(s) and Location
June 7, 2010 - 7:00am to 3:00prn (times approximate) Main Road, Cutchogue
by Pellegrini Vineyards
June 8,2010 - 7:00am to 11:00am (times approximate) Main Road, Cutchogue
by Pellegrini Vineyards
Permit No. 26
Issue Date: 6/4/2010
Elizabeth A. Neville
Southold Town Clerk
(Town Seal)
RECEIVED
MAY 2 7 2010
Southold Town C'eA
APPLICATION FOR FILMING/STILL PHOTOGRAPHY
PERMIT NO:
Please Print or Type
APPLICATION DATE: June 27th, 2010
NAME OF APPLICANT: Stephen Hartman, Assistant Location Manager
MAILING ADDRESS: 203 Meserole Ave,2nd Fl Brooklyn,NY 11222
PHONE: BUSINESS: 718-389-2803 HOME: cell 617-905-1049
NAME OF ORGANIZATION/COMPANY: Owen 4 Business, LLC/"Royal Pains"
MAILING ADDRESS:,203 Meserole Ave,2"d Fl Brooklyn,NY 11222
PHONE: 718-389-2803 FAX: 718-389-3874
* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *
DESCRIBE TYPE OF ACTIVITY(e.g. Motion Picture, Commercial, Television. Catalog, Magazine, etc.):
Television Medical Comedy/Drama for the USA Network(NBC/Universal Television)
DATE(S)AND TIMES) OF PROPOSED FILMING/PHOTOGRAPHY:
June 7th, 2010—June 9`h, 2010 lam-l Opm
PROPOSED LOCATION(S) OF FILMING/PHOTOGRAPHY: (attach additional sheet, if necessary)
Pelliurini Vineyards 23005 Main Rd Cutchogue,NY 11935 (see attached sheet for all locations)
NAME OF PERSON IN CHARGE AT SITE: Stephen Hartman, Assistant Location Manager
NUMBER OF PERSONS AT LOCATION (cast&crew included) 80 crew and up to 100 extras
NUMBER AND TYPE OF VECHILES AT LOCATION: (see attached)
TYPE OF SPECIAL EQUIPMENT: Typical television camera, sound, gip,electric package and prop cars
ANY SPECIAL REQUIREMENTS: We request intermittent traffic control on Main Road for one scene,
Cutchogue Fire Department sun,Rort for one scene,and temporary closure of Love Lane for one scene.
Signature Return to: Southold Town Clerk
Southold Town Hall
53095 Main Road
P.O. Box 1179
Southold,NY 11971
Our principal staging area for base camp(hair,make-up, wardrobe, and star trailers),equipment trucks,and
crew cars will be at the Our Lady of Ostrabama Church 3000 Depot Lane in Cutchogue. This consists of 8
trailers, 2 tractor trailers,4 box trucks and up to 100 crew/actor cars. We will shuttle crew,equipment, and
actors in either passenger vans or stake bed trucks to Pelligrini Vineyards.
On June 7`h, 2010 for our first scene we would like to have a Ferrari driven by an actor pull into the
Vineyard with a camera on the grassy knoll by the road. For this scene, we would like police assistance to
intermittently hold traffic on Main Road. The sequence will take about five minutes at a time. The lockup
positions would be about 150 yards east of Pelligrini Vineyards driveway and about 20 yards to the west.
Once the Ferrari pulls into the driveway,we would release the traffic. Usually we would do this about five
times over the course of a couple of hours. The rest of the day on June 7`h, we will be working inside
Pelligrini Vineyards and we will not be on public property.
On June 8`h we will be entirely contained to Pelligrini Vineyards.
On June 9th we will start our day at Pelligrini Vineyards. In the late afternoon,we would like to film outside
the Village Cheese Shop on Love Lane in Mattituck. This scene would involve a car in the curb lane and
cameras and lighting equipment in the curb and in the street of Love Lane. We would like to close Love
Lane between Main Road and Pike Street while filming this scene. All local businesses could stay open
during filming and we will work with businesses financially impacted by the road closure. This would be
for a couple of hours between 4-9pm. We would also need space in a nearby parking lot to stage stake bed
trucks(approx 4) and passenger vans (approx 4).
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 bate
Printed name
A9y.is4gv,4, yc.a�iov� �ay�ae�r'
Title
ADDITIONAL INSURED-LOCATIONS 6 EQUIPMENT
CERTIFICATE OF INSURANCE
THIS CERTIFICATES ISW AS A MATTER OF INFORMATION Y AND CONFERS NO RIGHTS UPON THE
CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED
By THE POLICIES LISTED BELOW. COMPANIES AFFORDING COVERAGES
NAME AND ADDRESS OF INSURANCE COMPANY.
ELECTRIC INSURANCE COMPANY
75 SAM FONZO DRIVE,BEVERLY,MA 01915 cowANY A ELECTRIC INSURANCE CO
LETTER
COMPANY B
LETTER
NAME AND ADDRESS OF INSURED:
NBC Universal and its Subsidiaries COMPANY C
30 Rockefeller Plaza LETTER
New York,NY 10112 USA
COMPANY D
LETTER
THE POLICIES OF INSURANCE OSTEO BELOW HAVE SUN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR
OTTER DOCUMENT W rH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUWECT TO ALL THE TERMS,EXCLUSIONS AND
CONDITIONS OF SUCH POLICIES.
OF LIAB
COMPANY TYPE OF INSURANCE POLICY NUMBER POLICY LIMBSILITY
LETTER PERIOD EACH AGGREGATE
OCCURRENCE
A GENERALLIABnJTY GL 10-1 1/1/10
eoDxr NNJURM AND
1x1 COMMERCIAL FORM TO PROPERTY DAMAGE $2,5UO,ODO S5,000,000
P PREMISESOIERATIONS 1/1111 COMBINED
XCU
Pq PRODUCTSICOMPLETED
OPERATIONS HAZARD
M BROAD FORM PROPERTY
DAMAGE
M BLANKET CONTRACTUAL
Pq ADVERTISING LIABILITY
MIEN
DEPDENTCONTRACTORS
pq SEPARATION OF INSUREDS
IXI PEflSO'AL IUURY
OCCURRENCE FORM
A AUTOMOBIL.ELIMUTY ML 10-2 1/1/10
BODILY IuutY AND $2,500,000
Id COMPREIENSIVE FORM TO PROPERTY DAMAGE
id HIRED
D
111111 COMBINED
Ixl NON-WED
A EXCESS LIABILITY XS 10-1 1/1/10
80011Y INJURY AND
14 FOLLOWING FORM TO PROPERTY DAMAGE $2,500,000 $5,000,000
1/1/11 COMBINED
A WORKERS COMPENSATIONWC 10-1 1/1/10 PgSTATUTORY LIMITS
_
AND Includes USLSBHW and TO EACH ACCIDENT $2,500,000
EMPLOYERS LIABILITY Jones Act Coverage and 111/11 DISEASE•POLICY LIMIT $2,500,000
'AA States'Endorsement
DISEASE-EACH $2,500,000
EMPLOYEE
Show Name: Royal Pains
Production Entity: Open 4 Business Productions,LLC
Location or Description of Equipment: Location
REMARKS:Subject to their terms and conditions,the General and Automobile Liability policies include the Certificate Holder as additional insured but only where
-required by contract and limited to the extent of the Insureds negligence.
CANCELLATION: SHOULD ANY OF THE ABOVE OESCRIBEO POLICES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL 04XAVOR TO AWL 3D DAYS WRITTEN NOTICE TO THE
CERTIFICATE HOLDER NAMED TO THE LEFT BELOW BUT FAILURE TO DO SO SHALL U30SE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES.
NAME AND ADDRESS OF CERTIFICATE HOLDER: DATE ISSUED: May 27,2010
So a 1Ct4A'vC-"'JG `rte
53095 Main Road -raCv w :5C7
P.O. Box 1179 STEPHEN G.PALENSCAR
Southold, NY 11971 Authorized Reprosentattve
Blkp2002
INS-01 1 of 1 12-14-09
Town of Southold Police Department
Special Event Cost Analysis
Event: "Royal Pains" Filming
Date(s): June 9,2010
Location: Love Lane,Mattituck
Reg Hours OTHrs Hrly Wage Total Comments
Full time P.O. 7 $54.00 $567.00
Full Time P.O. 7 $54.00 $567.00
„ .. ., ,.._ Reg Hours OT Hrs Hrly Wage Total, Comments
F -
Reg Hours OT Hrs My Wage Total Comments
TC Officer _
TC Officer
TC Officer
TC Officer _
TC Officer _
Total Department Cost for Event= $ $1,134.00
Prepared by Capt.M. Flatley 5/28/2010 Page 1
Town of Southold Police Department
Special Event Cost Analysis
Event: "Royal Pains" Filming
Date(s): June 7,2010
Location: PelligAN Vineyards
Reg Hours ~OT Hrs Hrly Wage Total Comments
min. recall
Full time P.O. 47%d $216.00 see below
Full Time P.O. 4 $54.00 $216.00 see below
"*This is for anything up to 2.5 hrs.-anything more would be calculated at$54hr X 1.5
Reg Hours OT Hm Hrly Wage Total Comments
fti�r
Reg Hours OT Hrs Hrly Wage Total Comments
�TMOicer
icer _.
TC Officer
TC Officer
TC Officer
Total Department Cost for Event= $ $432.00
Prepared by Capt.M. Flatley 5/28/2010 Page 1
POLICE DEPAQ-TMENT
TOWN Of (SOUTKOM CARLISLE E. COCHRAN,JR.
Chief of Police
Telephone Emergency Dial 911
MEMORANDUM
TO: Linda J. Cooper, Deputy Town lerk
FROM: Chief Carlisle E. Cochran, Jr
DATE: June 1, 2010
RE: Filming Permit—Open 4 Business, LLC/"Royal Pains'/Stephen Hartman
As per Section 44A.3 of the Southold Town Code,it is the recommendation of the Chief
of Police that application dated May 27, 2010, Open 4 Business LLC/"Royal
Pains"/Stephen Hartman,be APPROVED.
As per Section 44A.4, Traffic Control Fee, the projected cost for traffic control will be
approximately$1566.00.
41405 Route 25 • P.O. Box 911 • Peconic, N.Y. 11958
Administrative (631) 765-2600/2601 9 Fax (631) 765-2715
Our principal staging area for base camp (hair, make-up, wardrobe, and star trailers), equipment trucks, and
crew cars will be at the Our Lady of Ostrabama Church 3000 Depot Lane in Cutchogue. This consists of 8
trailers, 2 tractor trailers, 4 box trucks and up to 100 crew/actor cars. We will shuttle crew, equipment, and
actors in either passenger vans or stake bed trucks to Pelligrini Vineyards.
On June 7"', 2010 we will be contained to Pelligrini Vineyards. If possible, we would like police assistance
slow down traffic on Main Rd for noise and picture.
to intermittently hold and/or
--U -7 t9 f Y1 — /l ' 4 171
On June 8"', 2010 for our first scene we would like to have a Ferrari driven by an actor pull into the
t1✓ Vineyard with a camera on the grassy knoll by the road. For this scene, we would like police assistance to
intermittently hold traffic on Main Road. The sequence will take about five minutes at a time. The lockup
positions would be about 150 yards east of Pelligrini Vineyards driveway and about 20 yards to the west.
Once the Ferrari pulls into the driveway, we would release the traffic. Usually we would do this about five
times over the course of a couple of hours.
On June 91h we will be inside Pelligrini Vineyards.
l ?CE11fED
JUN 2 2010
Soulhaid To,vo Clerk
RECEIVED
MAY 2 7 2010
Southold Town G'CA
APPLICATION FOR FILMING/STILL PHOTOGRAPHY
PERMIT NO:
Please Print or Type MAN
APPLICATION DATE: J 27". 2010
NAME OF APPLICANT: Stephen Hartman, Assistant Location Manager
MAILING ADDRESS:_203 Meserole Ave, 2"d FI Brooklyn,NY 11222
PHONE: BUSINESS: 718-389-2803 HOME: cell 617-905-1049
NAME OF ORGANIZATION/COMPANY: Open 4 Business, LLC/"Royal Pains"
MAILING ADDRESS:,203 Meserole Ave,2"d Fl Brooklyn,NY 11222
PHONE: 718-389-2803 FAX: 718-389-3874
DESCRIBE TYPE OF ACTIVITY(e.g. Motion Picture, Commercial, Television. Catalog, Magazine, etc.):
Television Medical Comedy/Drama for the USA Network(NBC/Universal Television)
DATE(S)AND TIMES) OF PROPOSED FILMING/PHOTOGRAPHY:
June 7d', 2010—June 9h, 2010 lam-l Opm
PROPOSED LOCATION(S) OF FILMING/PHOTOGRAPHY: (attach additional sheet, if necessary)
Pelligrini Vineyards 23005 Main Rd Cutchog_ue,NY 11935 see attached sheet for all.locations)
NAME OF PERSON IN CHARGE AT SITE: Stephen Hartman, Assistant Location Manager
NUMBER OF PERSONS AT LOCATION(cast& crew included):80 crew and up to 100 extras
NUMBER AND TYPE OF VECHILES AT LOCATION: (see attached)
TYPE OF SPECIAL EQUIPMENT: Typical television camera, sound, grip, electric package and prop cars
ANY SPECIAL REQUIREMENTS: We request intermittent traffic control on Main Road for one scene,
Cutchogue Fire Department support for one scene, and temporary closure of Love Lane for one scene.
Signature Return to:' Southold Town Clerk
Southold Town Hall
53095 Main Road
P.O. Box 1179
Southold,NY 11971
IV` Cis
t� c) O T S Q�17-trt'OL-Z)
APPLICATION FOR FILMING/STILL PHOTOGRAPHY
PERMIT NO:
Please Print or Type
APPLICATION DATE: June 27`h. 2010
NAME OF APPLICANT: Stephen Hartman, Assistant Location Manager
MAILING ADDRESS: 203 Meserole Ave, 2nd Fl Brooklyn,NY 11222
PHONE: BUSINESS: 718-389-2803 HOME: cell 617-905-1049
NAME OF ORGANIZATION /COMPANY: Open 4 Business, LLC /"Royal Pains"
MAILING ADDRESS: 203 Meserole Ave,2"d Fl Brooklyn,NY 11222
PHONE: 718-389-2803 FAX: 718-389-3874
* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *
DESCRIBE TYPE OF ACTIVITY(e.g. Motion Picture, Commercial, Television. Catalog, Magazine, etc.):
Television Medical Comedy/Drama for the USA Network(NBC/Universal Television)
DATE(S)AND TIME(S) OF PROPOSED FILMING/PHOTOGRAPHY:
June 7"', 2010—June 9h, 2010 lam-l Opm
PROPOSED LOCATIONS)OF FILMING/PHOTOGRAPHY: (attach additional sheet, if necessary)
Pelligrini Vineyards 23005 Main Rd Cutchogue,NY 11935 (see attached sheet for all locations)
NAME OF PERSON IN CHARGE AT SITE: Stephen Hartman, Assistant Location Manager
NUMBER OF PERSONS AT LOCATION (cast& crew included): 80 crew and up to 100 extras
NUMBER AND TYPE OF VECHILES AT LOCATION: (see attached)
TYPE OF SPECIAL EQUIPMENT: Typical television camera, sound, grip,electric package and prop cars
ANY SPECIAL REQUIREMENTS: We request intermittent traffic control on Main Road for one scene,
Cutchogue Fire Department support for one scene, and temporary closure of Love Lane for one scene.
Signature Return to: Southold Town Clerk
Southold Town Hall
53095 Main Road
P.O. Box 1179
Southold,NY 11971
Our principal staging area for base camp(hair,make-up, wardrobe, and star trailers),equipment trucks,and
crew cars will be at the Our Lady of Ostrabama Church 3000 Depot Lane in Cutchogue. This consists of 8
trailers, 2 tractor trailers,4 box trucks and up to 100 crew/actor cars. We will shuttle crew, equipment, and
actors in either passenger vans or stake bed trucks to Pelligrini Vineyards.
On 2fflWfor our first scene we would like to have a Ferrari driven by an actor pull into the
Vineyard with a camera on the grassy knoll by the road. For this scene, we would like police assistance to
intermittently The sequence will take about five minutes at a time. The lockup
positions would be about 150 yards east of Pelligrini Vineyards driveway and about 20 yards to the west.
Once the Ferrari pulls into the driveway, we would release the traffic. Usually we would do this about five
times over the course of a couple of hours. The rest of the day on June 7`h,we will be working inside
Pelligrini Vineyards and we will not be on public property.
On June 8`h we will be entirely contained to Pelligrini Vineyards.
On June 9`h we will start our day at Pelligrini Vineyards. In the late afternoon, we would like to film outside
the Village Cheese Shop on Love Lane in Mattituck. This scene would involve a car in the curb lane and
cameras and lighting equipment in the curb and in the street of Love Lane. We would like to close Love
Lane between Main Road and Pike Street while filming this scene. All local businesses could stay open
during filming and we will work with businesses financially impacted by the road closure. This would be
for a couple of hours between 4-9pm. We would also need space in a nearby parking lot to stage stake bed
trucks(approx 4) and passenger vans (approx 4).
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.
.� of`7
Signature bate
�e.6V to
Printed name
Title
ADDITIONAL INSURED-LOCATIONS d EOUIPMENT
CERTIFICATE OF INSURANCE
THIS CERTIFICATE IS IZ 0 A9 A MATTER OF INFORMATIONCONFERS NO RWS UPON THE
CERTIFICATEHOLDER THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED
BY THE POLICIES LISTED BELOW. COMPANIES AFFORDING COVERAGES
NAME AND ADDRESS OF INSURANCE COMPANY:
ELECTRIC INSURANCE COMPANY
75 SAM FON20 DRIVE,BEVERLY,MA 01915 cowAw A ELECTRIC INSURANCE CO
LETTER
COAPANY B
LETTER
NAME AND ADDRESS OF INSURED
NBC Universal and its Subsidiaries COMPANY C
30 Rockefeller Plaza LETTER
New York,NY 10112 USA
COMPANY D
LETTER
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED ABOVE FOR POLICY PERIRD 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.
COMPANY TYPE OF INSURANCE POLICY NUMBER POLICY LIMITS OF LIABILITY
LETTER PERIOD EACH AGGREGATE
OCCURRENCE
A GENERAL LIABILITY GL 10-1 1/1/10
BODILY INJURY AND
PQ COMMERCIAL FORM TO PROPERTY DAMAGE $2,500,000 $5,000,000
M PREMISES-OPERATIONS 1/1111 COMBINED
M XCU
PQ PRODUCTSICOMPIETED
OPERATIONS HAZARD
PQ BROAD FORM PROPERTY
DAMAGE
PQ BLANKET CONTRACTUAL
PQ ADVERTISING LIABILITY
M INDEPENDENT CONTRACTORS
PQ SEPARATION OF INSUREDS
PQPEASONAL ODURY
OCCUItREN=M
A AUTOMOBILE LIABILITY ML 10-2 1/1110
Booav INJURY AND $2,500,000
IX)COMPREHENSIVE FORM TO PROPERTY DAMAGE
Iq OWNED 111111 COMBINED
Ix)HIRED
Ix)NON WNED
A EXCESS LIABILITY XS 10-1 1/1/10
)xI FOLLOWING FORM TO
BODILY INJURY DAMAAGE $2,500,000 $5,000,000
1/1/11 COMBINED
A WORKERS COMPENSATION WC 10-1 1/1/10 AXI STATUTORY LIMITS
AND Includes USLS&HW and TO EACH ACCIDENT $2,500,000 --
EMPLOYERS LIABILITY Jones Act Coverage and 111/11 DISEASE-POLICY LIMIT $2 5W 000
'All States'Endorsement
DISEASE-EACH $2500000
EMPLOYEE
Show Name: Royal Pains
Production Entity: Open 4 Business Productions, LLC
Location or Description of Equipment: location
REMARKS:Subject to their terms and conditions,the General and Automobile Liability policies include the Certificate Holder as additional insured but only where
required by contract and limited to the extent of the Insured's negligence.
CANCELLATION: SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO AWL 30 DAYS WRITTEN NOTICE TO THE
CERTIFICATE HOLDER NAMED TO THE LEFT BELOW BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KID UPON THE INSURER ITS AGENTS OR REPRESENTATIVES.
NAME AND ADDRESS OF CERTIFICATE HOLDER: DATE ISSUED: May 27,2010
Southold Town Clerk Q �
53095 Main Road /Z�� .gi. Ioa.Ce�,�
P.O.Box 1179 STEPHEN G.PALENSCAR
Southold, NY 11971 Authorized Representative
BIk9e2002
INS-01 1 of 1 12-14-09
ADDITIONAL INSURED-LOCATIONS&EQUIPMENT
CERTIFICATE OF INSURANCE
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE
CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED
BY THE POLICIES LISTED BELOW. COMPANIES AFFORDING COVERAGES
NAME AND ADDRESS OF INSURANCE COMPANY.
ELECTRIC INSURANCE COMPANY
75 SAM FONZO DRIVE,BEVERLY,MA 01915 COMPANY A ELECTRIC INSURANCE CO
LETTER
COMPANY B
LETTER
NAME AND ADDRESS OF INSURED:
NBC Universal and its Subsidiaries COMPANY C
30 Rockefeller Plaza LETTER
New York, NY 10112 USA
COMPANY D
LETTER
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.
COMPANY TYPE OF INSURANCE POLICY NUMBER POLICY LIMITS OF LIABILnY
LETTER PERIOD EACH AGGREGATE
OCCURRENCE
A GENERAL LIABILITY GL 10-1 111/10 BODILY INJURY AND
IX]COMMERCIAL FORM TO
PROPERTY DAMAGE $2,500,000 $5,000,000
IX]PREMISES-OPERATIONS 111111 COMBINED
(XI XCU
IXI PRODUCTS/COMPLETED
OPERATIONS HAZARD
]XI BROAD FORM PROPERTY
DAMAGE
IX)BLANKET CONTRACTUAL
IN ADVERTISING LIABILITY
1)9 INDEPENDENT CONTRACTORS
IXI SEPARATION OF INSUREDS
(XI PERSONAL INJURY
OCCURRENCE FORM
A AUTOMOBILE LIABILITY ML 10-2 111/10
BODILY INJURY AND $2,500,000
Ix]COMPREHENSIVE FORM TO PROPERTY DAMAGE
IxI OWNED 111111 COMBINED
Ix]HIRED
]x]NON-OWNED
A EXCESS LIABILITY XS 10-1 111110
BODILY INJURY AND
Ix]FOLLOWING FORM TO PROPERTY DAMAGE $2,500,000 $5,000,000
1/1/11 COMBINED
A WORKERS COMPENSATION WC 10-1 111/10 lXl STATUTORY LIMITS
ANDIncludes USLSBHW and
TO EACH ACCIDENT $2,500,000
EMPLOYERS LIABILITY Jones Act Coverage and 111/11 DISEASE-POLICY LIMIT $2,500,000
"All States"Endorsement
DISEASE-EACH $2,500,000
EMPLOYEE
Show Name: Royal Pains
Production Entity: Open 4 Business Productions, LLC
Location or Description of Equipment: Location
REMARKS:Subject to their terms and conditions,the General and Automobile Liability policies include the Certificate Holder as additional insured but only where
required by contract and limited to the extent of the Insured's negligence.
CANCELLATION: SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE
CERTIFICATE HOLDER NAMED TO THE LEFT BELOW,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES.
NAME AND ADDRESS OF CERTIFICATE HOLDER: DATE ISSUED: June 2,2010
Town of Southold n
53095 Main Road
P.O. BOX 1179 STEPHEN G.PALENSCAR
Southold, NY 11971 Authorized Representative
Blkge2002
INS-01 1 of 1 12-14-09
Form w-9 Request for Taxpayer Give form to the
(Rev.November 2005) Identification Number and Certification requester. Do not
Department of the Treasury send to the IRS.
Internal Revenue Service
N Name(as shown on your income tax return)
at
rn
m
o- Business name,if different from above
c
0
d �
CL o Individual/ Exempt from backup
ts Check appropriate box: ❑ Sole proprietor ❑ Corporation ❑ Partnership ❑ Other ❑ withholding
N Address(number,street,and apt.or suite no.) Requester's name and address(optional)
-15
c �
a�
U
City,state,and ZIP code
W
a
List account number(s)here(optional)
n�
N
Taxpayer Identification Number(TIN)
Enter your TIN in the appropriate box. The TIN provided must match the name given on Line 1 to avoid Social security number
backup withholding. For individuals,this is your social security number(SSN). However, for a resident
alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is
your employer identification number(EIN). If you do not have a number, see How to get a TIN on page 3. or
Note.If the account is in more than one name, see the chart on page 4 for guidelines on whose Employer identification number
number to enter.
FTM Certification
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number(or I am waiting for a number to be issued to me), and
2. 1 am not subject to backup withholding because: (a)I am exempt from backup withholding, or(b) I have not been notified by the Internal
Revenue Service(IRS)that I am subject to backup withholding as a result of a failure to report all interest or dividends,or(c)the IRS has
notified me that I am no longer subject to backup withholding, and
3. I am a U.S. person(including a U.S. resident alien).
Certification instructions.You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup
withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply.
For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt,contributions to an individual retirement
arrangement(IRA), and generally, payments other than interest and dividends,you are not required to sign the Certification, but you must
provide your correct TIN. (See the instructions on page 4.)
Sign Signature of
Here I U.S.person ' Date '
Purpose of Form • An individual who is a citizen or resident of the United
A person who is required to file an information return with the States,
IRS, must obtain your correct taxpayer identification number • A partnership, corporation, company, or association
(TIN)to report, for example, income paid to you, real estate created or organized in the United States or under the laws
transactions, mortgage interest you paid, acquisition or of the United States, or
abandonment of secured property, cancellation of debt, or • Any estate (other than a foreign estate) or trust. See
contributions you made to an IRA. Regulations sections 301.7701-6(a) and 7(a) for additional
U.S. person.Use Form W-9 only if you are a U.S. person information.
(including a resident alien), to provide your correct TIN to the Special rules for partnerships.Partnerships that conduct a
person requesting it (the requester) and, when applicable, to: trade or business in the United States are generally required
1. Certify that the TIN you are giving is correct(or you are to pay a withholding tax on any foreign partners' share of
waiting for a number to be issued), income from such business. Further, In certain cases where a
2. Certify that you are not subject to backup withholding, or Form W-9 has not been received, a partnership is required to
3. Claim exemption from backup withholding if you are a presume that a partner is a foreign person, and pay the
withholding tax. Therefore, if you are a U.S. person that is a
U.S. exempt payee. partner in a partnership conducting a trade or business in the
In 3 above, if applicable, you are also certifying that as a United States, provide Form W-9 to the partnership to
U.S. person, your allocable share of any partnership income establish your U.S. status and avoid withholding on your
from a U.S. trade or business is not subject to the share of partnership income.
withholding tax on foreign partners' share of effectively
connected income. The person who gives Form W-9 to the partnership for
purposes of establishing its U.S. status and avoiding
Note.If a requester gives you a form other than Form W-9 to withholding on its allocable share of net income from the
request your TIN, you must use the requester's form if it is partnership conducting a trade or business in the United
substantially similar to this Form W-9. States is in the following cases:
For federal tax purposes,you are considered a person if you The U.S. owner of a disregarded entity and not the entity,
are:
Cat.No.10231X Form W-9 (Rev. 11-2005)
ismom„a New York State and Local Sales and Use Tax ST-119.1
Exempt Organization Certification (&93)
This cert'if'ication is not valid ynless all entries have been completed.
None of seller NYS Vendor ID number Name of el empt wgsniratlon iiii purdw w
MaWng sddnas M@Mng addrves
City,VMS"or post office Citi,Vila"or post office
Bude LP cods State DP code
I certify that the organization named above holds a valid Form Sr-119, Exempt Organization Certificate, and is
exempt from state and local sales and compensating use takes on its purchases.
Fater exempt orgeniration number from Form ST-119
Signature of officer of organization Titie Date prepared
Instructions
Seller You must keep this Exempt Organization Certification for at least
three years after the date of the last exempt sale substantiated
If all entries have been completed and an officer of the by the certification.
organization has signed the certification, you may accept it to
exempt sales to the organization named. The exempt purchaser
organization must be the direct purchaser and payer of record.
Any bill, invoice or receipt you provide must show the Complete this certification and give it to the seller
organization as the purchaser. payment must be from the funds You may get additional copies of form ST-119.1 at any district tax
of the exempt orgaiketlon. office or by writing to the NYS Tax Department, Taxpayer
This form may scot oe used to claim exemption for the following: Assistance Bureau,W A Harriman Campus, Albany NY 122LI.
This form may be reproduced without prior permission from the
— she purchase ct motor fuel or diesel motor fuel Including Tax Department.
No. 2 heatirc -aii (see Purchaser section) Your exemption from New York State and local sales and use tax
— rhe ten gent -ner quart tax on the retail safe d lubricating exempt
not extend to officers, members or emptopm of the
exempt organization. Personal purchases made by these
oil. This tax ie Impor eo on the retail seller and included in individuals are subject to sales and use tax.An organization's
the prirm chitrged the purchaser exemption does not extend to Its subordinalle or atMkftd units.
— the speciril foo on paging services unless the purchaser is a When making purchases, subordinate units may not line 1ha
volunteer fire or ambulance company that has been granted exemption number assigned to the parent organization. Such
exemirtion from rales and use tax pursuant to section misuse may result in the revocation of the parent Wanizaition's
1116(a)(4)of the tax law.To maim this exemption, the exempt exemption.
voluntary fire or ambulance company roust supply the you may not use this form.to make tax e?ampt purchases of
paging service with this form and a letter that identifies the motor fuel,diesel Motor fuel, lubricating oil and, if you are not a
exempt organization and states that it is exempt from the voluntary fire or ambulance company,to avoid the special fee on
special fee on paging devices because it is a voktnteer fire paging devices. Since No. 2 heating ot7 falls within the definition
or ambulance company(see Notice N-92-17 for additional of diesel motor fuel: you may not use this form to purchase It tax
information.) exempt. you must use form Fr-1020,Exemption Cerdfrcate for
The exempt organization must give you certification at the time GerW^ Tam Imposed on Di+eeel Motor Fuel and Propane or
of the organization's first purchase.A separate document Is not Form Fr-1025, CeAftao for Exemption hvm CaraM loxes
necessary for each subsequent purchase, provided than the imposed on Diesel Motor Fuel, to claim exernption on heating
exempt organization's name, address, and certificate number oil.
appear on the sales slip or billing invoice.The certification is Hospitals that have been granted an exemption from sales-and
considered part of each order and remains in force unless use tax pursuant to section 1116(ax4)of the Tax Law may claim
revoked. exemption on the purchase of motor fuel by using Form FT937,
Cerdffcate of Sales Tax and Motor Wel Tax E~Jon for
R a certification with all entries completed b not received r�tralided .
within 90 days afifter the delivery of the property or service,
you will share with the purchrnser the burden of proving the Substantial chrq and/or criminal penalties will result from the
safe was exempt. misuse of this form.
York 9411ft
""' a New York State and Local Sales and Use Tax ST-119.1
OW ftmwsExempt Organization Certification (693)
This certification is not valid unless all entries have been completed.
Name of seller NYS Verwlor ID number Name of exempt organization maldng purchases
Mating address Mailing address
City,village or post office City,village or post office
Staite ZIP code State ZIP code
I certify that the organization named above holds a valid Form ST-119, Exempt Organization Certificate, and is
exempt from state and local sales and compensating use taxes on its purchases.
Enter exempt organization number from Form ST-119
A163554
Signouure of officerion Title Date prepared
i
Supervisor, Town of Southold
Instructions
Seller You must keep this Exempt Organization Certification for at least
three years after the date of the last exempt sale substantiated
If all entries have been completed and an officer of the by the certification.
organization has signed the certification, you may accept it to
exempt sales to the organization named. The exempt Purchaser
organization must be the direct purchaser and payer of record.
Any bill, invoice or receipt you provide must show the Complete this certification and give it to the seller.
organization as the purchaser. Payment must be from the funds You may get additional copies of Form ST-119.1 at any district tax
of the exempt organization. office or by writing to the NYS Tax Department,Taxpayer
This form may not be used to claim exemption for the following: Assistance Bureau,W A Harriman Campus,Albany NY 12227.
This form may be reproduced without prior permission from the
— the purchase of motor fuel or diesel motor fuel including Taut Department.
No. 2 heating oil (see Purchaser section) Your exemption from New York State and local sales and use tax
— the ten-cents-per quart tax on the retail sale of lubricating does not extend to officers, members or employees of the
oil. This taut is imposed on the retail seller and included in exempt organization. Personal purchases made by these
the price charged the purchaser. individuals are subject to sales and use tax. An organization's
exemption does not extend to its subordinate or affiliated units.
— the special fee on paging services unless the purchaser is a When making purchases, subordinate units may not use the
volunteer fire or ambulance company that hits been granted exemption number assigned to the parent organization. Such
exemption from sales and use tax pursuant to sectlon misuse may result in the revocation of the parent organization's
1116(ax4)of the tax law. To claim this exemption, the exempt exemption,
voluntary fire or ambulance company must supply the You may not use this form to make tax exempt
paging service with this form and a letter that identifies the purchases
motor fuel, diesel motor fuel, lubricating oil and, if you are not a
exempt organization and states that it is exempt from the voluntary Tire or ambulance company, to avoid the special fee on
special fee on paging devices because it is a volunteer fire
orambulance company(see Notice N-92-17 for additional Paging devices. Since Na 2 heating oil falls within the definition
or ambulance
of diesel motor fuel; you may not use this form to purchase it tax
exempt. You must use Form FT-1020,Exemption Certificate for
The exempt organization must give you certification at the time Certain Taxes Imposed on Diesel Mohr Fuel and Propane or
of the organization's first purchase. A separate document is not Form FT-1025, Certificate for Exemption from Certain Taxes
necessary for each subsequent purchase, provided that the Imposed on Diesel Motor Fuel, to claim exemption on heating
exempt organization's name, address, and certificate number oil.
appear on the sales slip or billing invoice. The certification is Hospitals that have been granted an exemption from sales and
considered part of each order and remains in force unless use tax pursuant to section 1116(a)(4)of the Tax Law may claim
revoked. exemption on the purchase of motor fuel by using Form FT-937,
If a certification with all entries completed Is not received Certificate of Sales Tax and Motor Fuel Tax Exemption for
within 90 d after the delivery of the Qualified Hospitals.
� ry ProP�Y or service,
you will share with the purchaser the burden of proving the Substantial civil and/or criminal penalties will result from the
sale was exempt. misuse of this form.
"""York 9"Ret New York State and Local Sales and Use Tax ST-1 19.1
�°Fl Exempt Organization Certification , (6/93)
This certification is not valid unless all entries have been completed.
Name of seller NYS Vendor ID number Name of exempt organization making purchases
Mailing address Mailing address
City,village or post office City,village or post office
State ZIP code State ZIP code
I certify that the organization named above holds a valid Form ST-119, Exempt Organization Certificate, and is
exempt from state and local sales and compensating use taxes on its purchases.
Enter exempt organization number from Form ST-119
A163554
Sigru--une of officer gatilzation Title Date prepared
..t Supervisor, Town of Southold
Instructions
Seller You must keep this Exempt Organization Certification for at least
three years after the date of the last exempt sale substantiated
If all entries have been completed and an officer of the by the certification.
organization has signed the certification, you may accept it to
exempt sales to the organization named. The exempt Purchaser
organization must be the direct purchaser and payer of record.
Any bill, invoice or receipt you provide must show the Complete this certification.and give it to the seller.
organization as the purchaser. Payment must be from the funds You may get additional copies of Form ST-119.1 at any district tax
of the exempt organization. office or by writing to the NYS Tax Department, Taxpayer
This form may not be used to claim exemption for the following: Assistance Bureau, W A Harriman Campus, Albany NY 12227.
This form may be reproduced without,prior permission from the
— the purchase of motor fuel or diesel motor fuel including Tax Department.
No. 2 heating oil (see Purchaser section) Your exemption from New York State and local sales and use tax
— the ten-cents-per quart tax on the retail sale of lubricating does not extend to officers, members or employees of the
oil. This tax is imposed r exempt organization. Personal purchases made by these
the retail seller and included in individuals are subject to sales and use tax. An organization's
the price charged the purchaser. exemption does not extend to its subordinate or affiliated units.
— the special fee on paging services unless the purchaser is a When making purchases, subordinate units may.not use the
volunteer fire or ambulance company that has been granted exemption number assigned to the parent organization. Such
exemption from sales and use tax pursuant to section misuse may result in the revocation of the parent organization's
1116(a)(4)of the tax law. To claim this exemption, the exempt exemption.
voluntary fire or ambulance company must supply the You may not use this form.to make tax exempt purchases of
paging service with this form and a letter that identifies the motor fuel, diesel motor fuel, lubricating oil and, if you are not a
exempt organization and states that it is exempt from the voluntary fire or ambulance company, to avoid the special fee on
special fee on paging devices because it is a volunteer fire paging devices. Since No. 2 heating oil falls within the definition
or ambulance company (see Notice N-92-17 for additional of diesel motor fuel; you may not use this form to purchase it tax
information.) exempt. You must use Form FT-1020, Exemption Certificate for
The exempt organization must give you certification at the time Certain Taxes Imposed on Diesel Motor Fuel and Propane or
of the organization's first purchase. A separate document is not Form FT1025, Certificate for Exemption from Certain Taxes
necessary for each subsequent purchase, provided that the Imposed on Diesel Motor Fuel, to claim exemption on heating
exempt organization's name, address, and certificate number oil.
appear on the sales slip or billing invoice. The certification is Hospitals that have been granted an exemption from sales-and
considered part of each order and remains in force unless use tax pursuant to section 1116(a)(4) of the Tax Law may claim
revoked. exemption on the purchase of motor fuel by using Form FT-937,
If a certification with all entries completed is not received Certificate of Sales Tax and Motor Fuel Tax Exemption for
within 90 days after the delivery of the property or service, Oualified Hospitals.
you will share with the purchaser the burden of proving the Substantial civil and/or criminal penalties will result from the
sale was exempt. misuse of this forma
TOWN CLERK'S CHECKLIST FOR FILMING PERMIT
NOTE: All payments must be cash or certified check
Applicant:
Date Received:
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�*oF so�Tyol.
ELIZABETH A. NEVILLE,RMC, CMC '` O Town Hall, 53095 Main Road
TOWN CLERK P.O. Box 1179
REGISTRAR OF VITAL STATISTICS G Southold, New York 11971
MARRIAGE OFFICER Fax (631) 765-6145
RECORDS MANAGEMENT OFFICERl Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER �COM,� southoldtown.-northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
To: Southold Town Attorney's Office
From: Linda J. Cooper, Deputy Town Clerk
Dated: May 27, 2010
Re: Filming Permit
In accordance with the Southold Town Code, Chapter 44A, Section 3, Subsection
D, the Certificate of Insurance and Indemnification Agreement for a Filming
Permit Application for Stephen Hartman for "Royal Pains" are attached hereto.
Please review and advise whether these documents meet with your approval.
Thank you.
Approved as submitted
Disapprove for the following reasons:
Signature
�0�*0f SOuryOlO Town Hall 53095 Main Road
ELIZABETH A.NEVILLE,RMC,CMC ,
TOWN CLERK ! [ l� P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Southold, New York 11971
MARRIAGE OFFICER �� Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER Ol� Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER ��UNT`I,� southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
To: Chief Cochran, Southold Town Police
From: Linda J. Cooper, Deputy Town Clerk
Dated: May 27, 2010
Re: Filming Permit
Transmitted herewith is the application of Stephen Hartman for"Royal Pain"
filming permit. 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.
RECEIVED
MAY 2 7 2010
Southold Town G'ZA
APPLICATION FOR FILMING/STILL PHOTOGRAPHY
PERMIT NO:
Please Print or Type
APPLICATION DATE: June 27`h. 2010
NAME,OF APPLICANT: Stephen Hartman, Assistant Location Manager
MAILING ADDRESS: 203 Meserole Ave, 2nd Fl Brooklyn,NY 11222
PHONE: BUSINESS: 718-389-2803 HOME: cell 617-905-1049
NAME OF ORGANIZATION/COMPANY: Open 4 Business, LLC/"Royal Pains"
MAILING ADDRESS: 203 Meserole Ave, 2nd Fl Brooklyn,NY 11222
PHONE: 718-389-2803 FAX: 718-389-3874
DESCRIBE TYPE OF ACTIVITY(e.g. Motion Picture, Commercial,Television. Catalog, Magazine, etc.):
Television Medical Comedy/Drama for the USA Network(NBC/Universal Television)
DATE(S)AND TIME(S) OF PROPOSED FILMING/PHOTOGRAPHY:
June 7h, 2010—June 9d',2010 lam-l Opm
PROPOSED LOCATIONS)OF FILMING/PHOTOGRAPHY: (attach additional sheet, if necessary)
Pelligrini Vineyards 23005 Main Rd Cutchogue,NY 11935 (see attached sheet for all locations)
NAME OF PERSON IN CHARGE AT SITE: Stephen Hartman, Assistant Location Manager
NUMBER OF PERSONS AT LOCATION (cast&crew included): 80 crew and up to 100 extras
NUMBER AND TYPE OF VECHILES AT LOCATION: (see attached)
TYPE OF SPECIAL EQUIPMENT: Typical television camera, sound, grip, electric package and prop cars
ANY SPECIAL REQUIREMENTS: We request intermittent traffic control on Main Road for one scene,
CutchoguepFiire Department support for one scene, and temporary closure of Love Lane for one scene.
Signature Return to: Southold Town Clerk
Southold Town Hall
53095 Main Road
P.O. Box 1179
Southold,NY 11971
Our principal staging area for base camp (hair, make-up, wardrobe, and star trailers),equipment trucks,and
crew cars will be at the Our Lady of Ostrabama Church 3000 Depot Lane in Cutchogue. This consists of 8
trailers, 2 tractor trailers, 4 box trucks and up to 100 crew/actor cars. We will shuttle crew, equipment, and
actors in either passenger vans or stake bed trucks to Pelligrini Vineyards.
On June 7`h, 2010 for our first scene we would like to have a Ferrari driven by an actor pull into the
Vineyard with a camera on the grassy knoll by the road. For this scene, we would like police assistance to
intermittently hold traffic on Main Road. The sequence will take about five minutes at a time. The lockup
positions would be about 150 yards east of Pelligrini Vineyards driveway and about 20 yards to the west.
Once the Ferrari pulls into the driveway,we would release the traffic. Usually we would do this about five
times over the course of a couple of hours. The rest of the day on June 7`h, we will be working inside
Pelligrini Vineyards and we will not be on public property.
On June 8`h we will be entirely contained to Pelligrini Vineyards.
On June 9`h we will start our day at Pelligrini Vineyards. In the late afternoon, we would like to film outside
the Village Cheese Shop on Love Lane in Mattituck. This scene would involve a car in the curb lane and
cameras and lighting equipment in the curb and in the street of Love Lane. We would like to close Love
Lane between Main Road and Pike Street while filming this scene. All local businesses could stay open
during filming and we will work with businesses financially impacted by the road closure. This would be
for a couple of hours between 4-9pm. We would also need space in a nearby parking lot to stage stake bed
trucks(approx 4) and passenger vans(approx 4).
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 JA-..r�
1?
Signature ate
SJR-10 etA t- rAwwn
Printed name
Ass'%z6o,4 �yc iovt Mav�a��t—
Title
ADDITIONAL INSURED-LOCATIONS&EQUIPMENT
CERTIFICATE OF INSURANCE
THIS CERTIFICATE IS ISSUED A9 A MATTER OF INFORMATION ONLY AND CONFERSNO RIGHTS LOW THE
CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND.EMEND OR ALTER THE COVERAGE AFFORDED
BY THE POLICIES LISTED BELOW COMPANIES AFFORDING COVERAGES
NAME AND ADDRESS OF INSURANCE COMPANY:
ELECTRIC INSURANCE COMPANY
75 SAM FONZO DRIVE,BEVERLY,MA 01915 coMPANr A ELECTRIC INSURANCE CO
LETTER
COMPANY B
LETTER
NAME AND ADDRESS OF INSURED:
NBC Universal and its Subsidiaries COMPANY C
30 Rockefeller Plaza LETTER
New York,NY 10112 USA
COMPANY D
LETTER
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 POLICIESOF LIAB.
COMPANY TYPE OF INSURANCE POLICY NUMBER POLICY LIM(TSILITY
LETTER PERIOD EACH AGGREGATE
OCCURRENCE
A GENERAL LIABILITY GL 10-1 1/1/10
Booar INJURY ANO
[Xi COMMERCIAL FORM TO PROPERTY DAMAGE $2,500,000 $5,000,000
P9 PREMISES-OPERATIONS xcu1/1111 COMBINED
pQ PRODUCTSICOMNLETED
OPERATIONS HAZARD
IXl BROAD FORM PROPERTY
DAMAGE
M BLANKET CONTRACTUAL
M ADVERTISING LIABILITY
N INDEPENDENT CONTRACTORS
IXI SEPARATION OF INSUREDS
(XI PERSONAL INJURY
OCCURRENCE FORM
A AUTOMOBIL.EUABILJTY ML 10-2 1/1/10
BODILY INJURY AND $2,500,000
14 COMPREHENSIVE FORM TO PROPERTY DAMAGE
14 OWNED 1/1111 COMBINED
III HIRED
IxI NON-OWNED
A EXCESS LIABILITY XS 10-1 1/1/10
BODILYINJURYADAMAGE
$ 2,500,000 $5,000,000
I xl FOLLOWING FORM TO
111/11 COMBINED
A WORKERS COMPENSATION WC 10-1 1/1/10 I>n STATUTORY LIMITS
AND Includes USLSBHW and TO EACH ACCIDENT $2'500'000
EMPLOYERS LIABILITY Jones Ad Coverage and 1/1/11 DISEASE-POLICY LIMIT $2,500,000
'AR States'Endorsement
DISEASE-EACH
YEE $2,500,000
EMPLO
Show Name: Royal Pains
Production Entity: Open 4 Business Productions,LLC
Location or Description of Equipment: Location
REMARKS:Subject to their terms and conditions,the General and Automobile Liability policies include the Certificate Holier as additional insured but only where
required by contract and limited to the extent of the Insured's negligence.
CANCELLATION: SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRA noN DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MNL 30 DAYS WRITTEN NOTICE TO THE
CERTIFICATE HOLDER NAMED TO THE LEFT BELOW BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER ITS AGENTS OR REPRESENTATIVES.
NAME AND ADDRESS OF CERTIFICATE HOLDER: DATE ISSUED: May 27,2010
Southvi rf0WlT `le 9—1014Av&'vG n
53095 Main Road -r.9 C,&v0-
P.O. Box 1179 STEPHEN G.PALENSCAR
Southold, NY 11971 Authorized Representative
Blkgs2002
INS-01 1 of 1 12-14-09
ELIZABETH A. NEVILLE Town Hall,53095 Main Road
TOWN CLERK :' P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Southold,New York 11971
MARRIAGE OFFICER rr^ � Fax (631) 765-6145
RECORDS MANAGEMENT OFFICER Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
FAX TRANSMITTAL
To: Stephen Hartman
1-718-389-3874
From: Linda J. Cooper, Deputy Town Clerk
Dated: May 27, 2010
Re: W-9
Number of Pages (including cover): 2
If total transmittal is not received, please call 631-765-1800, Ext 210
COMMENTS:
As requested
Form WM9 Request for Taxpayer Give form to the
(Rev.October 2007) Identification Number and Certification requester. Do not
Department of the Treasury send to the IRS.
Internal Revenue Service
Name(as shown on your income tax return) '
N Town of Southold
m Business name,if different from above
a
c
0
CIL c Check appropriate box: ❑ Individual/Sole proprietor ❑ Corporation ❑ Partnership Exempt
❑ Limited liability company. Enter the tax classification(D=disregarded entity,C=corporation,P=partnership) ► _______ payee
o M ® Other(see instructions) Municipality n i c l a l i t A 16 3 5 5 4
►
CAddress(number,street,and apt,or suite no.) Requester's name and address(optional)
CL 53095 Main Road, PO Box 1179
w
City,state,and ZIP code
CL Southold, NY 11971
y List account number(s)here(optional)
W
Taxpayer Identification Number IN
Enter your TIN in the appropriate box. The TIN provided must match the name given on Line 1 to avoid Social security number
backup withholding. For individuals, this is your social security number(SSN). However, for a resident
alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is
your employer identification number(EIN). If you do not have a number, see How to get a TIN on page 3. or
Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose Employer identification number
number to enter. 11 i 6001939
Certification
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number(or I am waiting for a number to be issued to me), and
2. 1 am not subject to backup withholding because: (a)I am exempt from backup withholding, or(b) I have not been notified by the Internal
Revenue Service(IRS)that I am subject to backup withholding as a result of a failure to report all interest or dividends, or(c)the IRS has
notified me that I am no longer subject to backup withholding, and
3. 1 am a U.S. citizen or other U.S. person(defined below).
Certification instructions.You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup
withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply.
For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions'to an individual retirement
arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the Certification, but you must
provide your correct TIN See thei uctions on page 4.
Sign Signature of Cott Russell
Here U.S.person Supervisor Date ►
General Instructions Definition of a U.S, person. For federal tax purposes, you are
considered a U.S. person if you are:
Section references are to the Internal Revenue Code unless
otherwise noted. • An individual who is a U.S. citizen or U.S. resident alien,
• A partnership, corporation, company, or association created or
Purpose of Form organized in the United States or under the laws of the United
A person who is required to file an information return with the States,
IRS must obtain your correct taxpayer identification number(TIN) • An estate (other than a foreign estate), or
to report, for example, income paid to you, real estate • A domestic trust (as defined in Regulations section
transactions, mortgage interest you paid, acquisition or 301.7701-7).
abandonment of secured property, cancellation of debt, or Special rules for partnerships. Partnerships that conduct a
contributions you made to an IRA. trade or business in the United States are generally required to
Use Form W-9 only if you are a U.S. person (including a pay a withholding tax on any foreign partners' share of income
resident alien), to provide your correct TIN to the person from such business. Further, in certain cases where a Form W-9
requesting it (the requester) and, when applicable, to: has not been received, a partnership is required to presume that
1. Certify that the TIN you are giving is correct(or you are a partner is a foreign person, and pay the withholding tax.
waiting for a number to be issued), Therefore, if you are a U.S. person that is a partner in a
2. Certify that you are not subject to backup withholding, or partnership conducting a trade or business in the United States,
provide Form W-9 to the partnership to establish your U.S.
3. Claim exemption from backup withholding if you are a U.S. status and avoid withholding on your share of partnership
exempt payee. If applicable, you are also certifying that as a income.
U.S. person, your allocable share of any partnership income from The person who gives Form W-9 to the partnership for
a U.S. trade or business is not subject to the withholding tax on purposes of establishing its U.S. status and avoiding withholding
foreign partners' share of effectively connected income. on its allocable share of net income from the partnership
Note. If a requester gives you a form other than Form W-9 to conducting a trade or business in the United States is in the
request your TIN, you must use the requester's form if it is following cases:
substantially similar to this Form W-9. • The U.S. owner of a disregarded entity and not the entity,
Cat.No.10231X Form W-9 (Rev. 10-2007)