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Home My WebLink AboutSandbox StudiosELIZABETH A. NEVILLE, MMC TOWN CLERK REGISTRAR OF VITAL STATISTICS MARRIAGE OFFICER RECORDS MANAGEMENT OFFICER FREEDOM OF INFORMATION OFFICER Town Hall, 53095 Main Road P.O. Box 1179 Southold, New York 11971 Fax(631)765-6145 Telephone (631) 765-1800 www.southoldtownny.gov OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD FILMING/STILL PHOTOGRAPHY PERMIT Issued to: John Perez/Totem Creative dba Sandbox Studios Date(s), Time(s) and Location: Tuesday, May 19, 2015 6:00 AM to 7:00 PM Beach at end of ROCKY POINT ROAD EAST MARION Permit No. 1-2015 Issue Date: 5/14/15 Elizabeth A. Neville Southold Town Clerk (Town Seal) Town of Southold, New York - Payment Voucher Vendor No. Check No. Check Made Payable To: �o Contact Telephone Number l d� o� 0 — 893 O of p - Mail check to (mailing address): � Q Uo �o r N y I Q� 9 Entered by a udtt Date Town Clerk Contact Name Invoice Number Invoice Date Invoice Total Discount Net Amount Claimed Purchase Order Number Description of Goods or Services General Ledger Fund and Account Number (0 IS 250.00 250.00 Clean-up Deposit Refund T1.030 F,lmTer Yn•+ Total 250.00 Payee Certification The undersigned (Claimant) (Acting on behalf of the above named claimant) does hereby certify that the foregoing claim is true and correct, that no part has been paid, except as therein stated, that the balance therein stated is actually due and owing, and that taxes from which the Town is exempt are excluded, Signat a W D Title Department Certification I hereby certify that the materials above specified have been received by me in good condition without substitution, the services properly performed and that the quantities thereof have been verified with the exceptions or discrepancies note=FMJAJ�" Signatu&4u'LL l It l Company Name Date &P 1$' (I 5 Title, eardti Date io 1 `�Ppl A Southold Town Board - Letter Board Meeting of June 2, 2015 RESOLUTION 2015-506 ADOPTED Item # 5.12 DOC ID: 10880 THIS IS TO CERTIFY THAT THE FOLLOWING RESOLUTION NO. 2015-506 WAS ADOPTED AT THE REGULAR MEETING OF THE SOUTHOLD TOWN BOARD ON JUNE 2, 2015: WHEREAS that John Perez/Totem Creative DBA Sandbox Studios has supplied the Town of Southold with a Clean-up Deposit fee in the amount of $250.00 on May 13, 2015 for their Photo Shoot and WHEREAS the Southold Town Police Chief, Martin Flatley, has informed the Town Clerk's office that this fee may be refunded, now therefor be it RESOLVED that Town Board of the Town of Southold hereby authorizes a refund be issued in the amount of $250.00 to John Perez/Totem Creative DBA Sandbox Studios 322 West 52nd Street #339 New York, NY 10019. Elizabeth A. Neville Southold Town Clerk RESULT: ADOPTED [UNANIMOUS] MOVER: Robert Ghosio, Councilman SECONDER: Louisa P. Evans, Justice AYES: Ghosio, Dinizio Jr, Ruland, Doherty, Evans, Russell Generated June 3, 2015 Page 21 Doroski, Bonnie From: Flatley, Martin Sent: Tuesday, May 26, 2015 2:48 PM To: Doroski, Bonnie Subject: FW: Clean up deposit From: Flatley, Martin Sent: Tuesday, May 26, 2015 2:10 PM To: Flatley, Martin Subject: RE: Clean up deposit Hi Bonnie, This deposit can be released, sorry for the delay. Martin Flatley, Chief of Police Southold Town Police Department 41405 State Route 25 Peconic, New York 11958 631-765-3115 From: Flatley, Martin Sent: Thursday, May 21, 2015 1:44 PM To: Doroski, Bonnie Subject: RE: Clean up deposit I will try to get out there tomorrow and check Bonnie Sent From my Verizon Wireless 4G LTE smartphone -------- Original message -------- From: "Doroski, Bonnie" <Bonnie. Doroski@town. southold.ny. us> Date: 05/21/2015 9:01 AM (GMT -05:00) To: "Flatley, Martin" <mflatley@town.southold.ny.us> Subject: Clean up deposit Good morning! Just wondering if I can return the cleanup deposit from the photoshoot that took place on Tuesday May 191h at the end of Rocky Point Road? Thanks, Bonnie 1 S ELIZABETH A. NEVILLE, MMC TOWN CLERK REGISTRAR OF VITAL STATISTICS MARRIAGE OFFICER RECORDS MANAGEMENT OFFICER FREEDOM OF INFORMATION OFFICER Town Hall, 53095 Main Road P.O. Box 1179 Southold, New York 11971 Fax (631) 765-6145 Telephone (631) 765-1800 www.southoldtownny.gov OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD Q�kQAC 01 QbAl( , To:�lanrin From: Bonnie J. Doroski, Deputy Town Clerk Dated: May 14, 2015 Re: Film Permit No. 1-2015 Cleanup Deposit In accordance with §44A-5 of the Southold Town Code, please advise if the $250.00 daily Cleanup deposit may be returned to the applicant; if not, please provide a statement setting forth the actual cost to the town of providing said cleanup service. Cleanup was not required at the location(s) identified on the permit. The deposit may be returned. Cleanup was required. Actual cost statement is attached. Please respond within five (5) business days Signature Date ELIZABETH A. NEVILLE, MMC TOWN CLERK REGISTRAR OF VITAL STATISTICS MARRIAGE OFFICER RECORDS MANAGEMENT OFFICER FREEDOM OF INFORMATION OFFICER Town Hall, 53095 Main Road P.O. Box 1179 Southold, New York 11971 Fax (631) 765-6145 Telephone (631) 765-1800 www.southoldtownny.gov OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD PARKING PERMIT DATE: TUESDAY, MAY 199 2015 TIME: 6:00 AM — 7:00 PM LOCATION: Beach at end of Rocky Point Road, East Marion Filming/Still Photography One Location/ Three -Vehicles Place this Permit on' the -Dashboard, Passenger side of Vehicle TOWN CLERK'S CHECKLIST FOR FILMING PERMIT NOTE: All payments must be cash or certified check ant: Date Received: 25-( I ? l 1 . ✓ 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. 56 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 6113 Forward certificate of insurance and indemnification agreement to Town Attorney fapproval ✓ 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. e/ Beach Parking fee - $10 per vehicle, per day between May 1 and September30. ISSUED PERMIT Countersign application V/ Issue permit with name of applicant, locations(s), date(s), and time(s) NOTIFICATION of ISSUED PERMIT 64 ✓ Chief of Police ti/ 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 I�- 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. Doroski, Bonnie From: Flatley, Martin Sent: Wednesday, May 13, 2015 4:15 PM To: Doroski, Bonnie; Duffy, Bill Cc: Blasko, Regina; Krauza, Lynne Subject: RE: Emailing: filming permit_20150513092354 I have no objections to this filming taking place on May 19, if passes please make sure the vehicles associated with the shoot are displaying a placard on the windshield for special parking Martin Flatley, Chief of Police Southold Town Police Department 41405 State Route 25 Peconic, New York 11958 631-765-3115 -----Original Message ----- From: Doroski, Bonnie Sent: Wednesday, May 13, 2015 10:27 AM To: Flatley, Martin; Duffy, Bill Cc: Blasko, Regina; Krauza, Lynne Subject: Emailing: filming permit_20150513092354 Please review the attached permit and advise me of your decision. As you can see, they want the shoot to take place next week. Thank you. Bonnie J. Doroski Deputy Town Clerk Your message is ready to be sent with the following file or link attachments: filming permit_20150513092354 Note: To protect against computer viruses, e-mail programs may prevent sending or receiving certain types of file attachments. Check your e-mail security settings to determine how attachments are handled. Doroski, Bonnie From: Duffy, Bill Sent: Thursday, May 14, 2015 1:49 PM To: Doroski, Bonnie Subject: RE: Emailing: filming permit_20150513092354 I have no objection to the permit being issued. -----Original Message ----- From: Doroski, Bonnie Sent: Wednesday, May 13, 2015 10:27 AM To: Flatley, Martin; Duffy, Bill Cc: Blasko, Regina; Krauza, Lynne Subject: Emailing: filming permit_20150513092354 Please review the attached permit and advise me of your decision. As you can see, they want the shoot to take place next week. Thank you. Bonnie J. Doroski Deputy Town Clerk Your message is ready to be sent with the following file or link attachments: filming permit_20150513092354 Note: To protect against computer viruses, e-mail programs may prevent sending or receiving certain types of file attachments. Check your e-mail security settings to determine how attachments are handled. 1 Doroski, Bonnie From: Doroski, Bonnie Sent: Wednesday, May 13, 2015 10:27 AM To: Flatley, Martin; Duffy, Bill Cc: Blasko, Regina; Krauza, Lynne Subject: Emailing: filming permit 20150513092354 Attachments: filming permit_20150513092354.pdf Please review the attached permit and advise me of your decision. As you can see, they want the shoot to take place next week. Thank you. Bonnie J. Doroski Deputy Town Clerk Your message is ready to be sent with the following file or link attachments: filming permit_20150513092354 Note: To protect against computer viruses, e-mail programs may prevent sending or receiving certain types of file attachments. Check your e-mail security settings to determine how attachments are handled. ELIZABETH A. NEVILLE, MMC TOWN CLERK REGISTRAR OF VITAL STATISTICS MARRIAGE OFFICER RECORDS MANAGEMENT OFFICER FREEDOM OF INFORMATION OFFICER o�OgVFFO��►�oG y Town Hall, 53095 Main Road P.O. Box 1179 Southold, New York 11971 Fax (631) 765-6145 Telephone (631) 765-1800 www.southoldtownn,y.gov OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD To: Chief Flatley, Southold Town Police Bill Duffy, Town Attorney From: Bonnie Doroski, Deputy Town Clerk Dated: May 13, .2015 Re: Filming Permit Transmitted herewith is the application of John Perez for a Filming/Still Photography permit to take place on the beach at the end of Rocky Point Road, East Marion on Tuesday, May 19, 2015 from 6:00 AM to 7:00 PM. In accordance with Section 139.0 of the Town Code please review the application and advise this office of approval or disapproval of the application and whether a traffic control fee is required and the amount needed. REGIST, RAR OF VrrAL STATIFIOS MARRIAGE OFFICER ORDS MANAGEMENT, OFFICER FREEDOM OF nqFORMATION OFFICER III, v all OID33 4� 'l s 'i 'Ibwa Hatt 53095 Main Road P.O. Bag 1179 SouthaK N'ewYbrk 11671 Fax (681) 76&6M TbI'eghme (631) 765-1864 wwwr southoldtownnggov APPLICATION FOR FILAMG/S`ILL PHOTOGRAPHY �� PERMIT NO: Please Frim aa° 73►Fe DAT APPLICATIO/�/,� /2, Z61Ioi E: // NAME OF APPLICANT: .% h 01 MAILING ADDRESS: .�?ZZ West xlLj vo,/ . /j�� 1r�0( f PHONE: BUSINESS: ;?1Z— 2a3 - 973 HOME: NAME OF ORGANIZATION / CCiM PANY: mAnjNG ADDRESS: 12-1 l/ ,'de New Vvrl , /(,l c/ /00/3 PHONE: FAX: DESCRIBE TYPE OF ACTIVITY (e.g. Motion Picture, Commercial, Television. Catalog, Magazine, etc.): DATE(S) AND TIME(S) OF'PROPOSED FILMING / PHOTOGRAPHY: PROPOSED LOCATION(S) OF FILMING/ PHOTOGRAPHY: (attach additional sheet, if necessary) NAME OF PERSON IN CHARGE AT SITE: Lt Z ;&Ibvilpi NUMBER OF PERSONS AT LOCATION (cast & crust included): NUMBER ANIS TYPE OF VECHILFS AT LOCATION: (/ J �D� t�io•� e ��L� Jr ,�t5 TYPE OF SPECfA ' EQUIPMENT: _� , (SLR �a4wt ��t �� ' J'riir/ . / lT4 s , G� �� to I _ ANY SPECIAL REQ�2eATy �/ rv►, Ts, ► LoMI 4'PVAI qM4wyvL- Sigwture� Return to: Southold Town Cleric~ � Southold Town Hall 53095 Main Road P.O. Box 1179 Southold, NY 119'7` 1 INDEACIMCATION AGREEMENT TOWN OF SOUTHOLD FR.N04GISTILL PHOTOGRAPHY PERA?ffr The Applicant shall indemnify and held harmless the Toren from and against all suits, claims, demands or actions for any damage andfor injury sustained or alleged to be sustained by any, party or parties in connection with the performance of filming or still photography by the Applicants his employees or agentsor any ' 3 subcontractor and in case of any such action brought against the Tams the applicant shall immediately take charge of and defend the same at his open cost and expense. In additions the Applicaut wili name the Tort as an: additional insured an i any applicable policies. I 5/12/15 gad= Date r. Rachel Dunn- . Printed: name _ Producer TrtIle P91lvv. ■IL/Tm v�.n r �r�vr� �. yr a_�r�u�a_� ��.�vnrl��v� 5/12/2015 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(ies) 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 Edgewood Partners Ins. Center CONTACT lAE: Jackie Tom NA PHONE 650.295.4656 No): 650.295.4622 aC No, Ext E-MAIL SS: jackie.tom@epicbrokers.com Lic#OB29730 (415) 356-3900 INSURER(S) AFFORDING COVERAGE NAICIR 135 Main Street, 21th Floor INSURER A: Philadelphia Indemnity Insuranc 18058 San Francisco, CA 94105 INSURED Sandbox Studio, LLC 555 Minnesota St San Francisco, CA 94107 INSURER B: RSUI Indemnity Company INSURER C INSURER D INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR 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. LTR TYPE OF INSURANCE INSRL WVO POLICY NUMBER MM/DDDY EFFMM/DDY EXP LIMITS A GENERAL LIABILITY X PHPK1311677 DWOU2015 03/0612016 EACH OCCURRENCE $1,000,000 MERCIAL GENERAL LIABILITY PREMISES Fa o�urrence $1,000,000 CLAIMS -MADE � OCCUR [!�Oim MED EXP (Any one person) $1,000 PERSONAL & ADV INJURY $1,000,000 GENERAL AGGREGATE $3,000,000 PRODUCTS - COMP/OP AGG $ 3,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY JECT LOC $ A AUTOMOBILE LIABIL" PHPK1311677 06/2015 03/06/201 ,4 SINGLE LIMIT 1,000,000 X ANY AUTO BODILY INJURY (Per person) $ ALL OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS AUTOS X X AUTOS-01MJF� Perraccide DAMAGE $ HIRED AUTOS A X UMBRELLA LIAB X OCCUR PHUB493958 D310612015 03/0612016 EACH OCCURRENCE $5 000 000 EXCESS LIAB CLAIMS -MADE AGGREGATE s5,000,000 DEC) I X RETENTION $10000 $ WORKERS COMPENSATION WC STATU- OTH- IMIT ER AND EMPLOYERS' LIABILITY Y/N ANY PR OPRIETOR/PARTNER/EXECUTIVE EL EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? N/A (Mandatory in NH) EL DISEASE - EA EMPLOYEE $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE- POLICY LIMIT $ A Rented/leased/Bor PHPK1311677 3/06/2015 03/06/201 $500,000 IM Equipment $1,000 Deductible B Excess LiabilityNHA237793 4/20/2015 03/06/201 $5M excess of $5M DESCRIPTION OF OPERATIONS / LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) Southold Town is named as additional insured with respects to the general liability policy. Southold Town Clerk SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Southold Town Hall;53095 Main Road ACCORDANCE WITH THE POLICY PROVISIONS. PO BOX 1179 Southold, NY 11971 AUTHORED REPRESENTATIVE re) iOsin--i in Ar`r1Qr7 All rennre. rncnn ELMABUM A. Nh'V*HXX, MKC �y`� lbwn Full, 53095 Mam Road TOWN CLEM a P.O. BGX 1179 Southold, New Yak 11971 REMMAR OF VITAL STAIMICS Fa: (631) 765 145 MARRIAGE OFFICER 'j' aQ�' % tephone (681) 766-1800 RECORDS MANAGFAC .'. T OFFICER www aoathotdtownny gve FREEDOM OF DWORMATION OFFICER OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD APPLICATION FOR FILMING/STILL PHOTOGRAPHY PERMIT NO: Please Print or 7)We APPLICATION DATE: NAME OF APPLICAN MAILING ADDRESS: PHONE: BUSINESS: Z/Z— Z03 " F73� HOME: p NAME OF ORGANIZATION I COMPANY: %DZL�%'l�N-� MAILING ADDRESS: 12-/ PHONE: � `/Lo '-' 2 2 L 5'3 FAX: DESCRIBE TYPE OF ACTIVITY (e.g. Motion Picture, Commercial, Television. Catalog, Magazine, etc.): DATE(S) AND TIME(S) O PROPOSED FILMING / PHOTOGRAPHY: PROPOSED LOCATION(S) OF FILMING/ PHOTOGRAPHY: (attach additional sheet, if necessary) NAME OF PERSON IN CHARGE AT SITE: NUMBER OF PERSONS AT LOCATION (cast & crew included): �5 NUMBER AND TYPE OF VECHILES__A//T LOCATION: TYPE OF SPECIAL EQUIPMENT: �5, w SL /Z �,4 Qti �'� Ir�r%rI . LA � aw -a ANY SPECIAL REQUIREMENTS: J��m,'rs �4hoD� �?DQc% WPI%rbc c ,oc A .4 .- AA 16 /.ice.. /%/n�.l'if�itA4.1 -- �. Signature Return to: Southold Town Clerk Southold Town Hall 53095 Main Read P.O. Box 1179 Southold, NY 11971 INDEMNEMATION AGREEMENT TOWN OF SOUTHOLD FILMINO/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. Rachet Dunn! Printed dame Producer � Title C r I17tVVI ■L/r. VLSI'! 111... IVM I L. V1" L.1P%L71L.1 I ■ 11\a7LJ I'1 M§vL_0_ .711""lo 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), AUTHORRED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: Ifthe certificate holder is an ADDITIONAL INSURED, the pollcy(les) must be endorsed. H SUBROGATION IS WANED, subject to the terms and conditions of the policy, certain policies may require an endorsement A statement on this certificate does not confer rlptrts to the certificate holder In lieu of such endorsement(s).. PRODUCER Edgewood Partners Ins. Center WAcT Jackie Tom N N :650.295.4656 No 650,29SA622 Llc#OB29730 (415) 356-3900 E—WILjackie.tom®eplcbrokers.com 135 Main Street, 21th Floor *=REINS) AFFORDIN(COVERAGE NAIC8 San Francisco, CA 94105 INSURER A: Philadelphia Indemnity Insuranc 18058 PHPK1311677 INSURED Sandbox Studio, LLC INSURER 0: RSUI Indemnity Company ISU`ERC: 555 Minnesota St INSURER D San Francisco, CA 94107 INSURE.( E INSURER F: 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 CONTRACTOR 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 LTR TYPE OF INSURANCE ADDLSUBF INSR Wyk POLICY NUMBER POLICY EFF IAh /TON POLICY EXP MID LIMITS A GENERAL LIABILITY X PHPK1311677 15 03/064201453 $1,000,000 X COMMERCIAL GENERAL LIABILITY �EAACCHGOECTCURpRENCE PREMISES�Ea�o EmrDence)_ $1,000,000 CLAIMS -MADE I X] OCCUR MED EXP (Any one person) $1.000 PERSONAL &ADV INJURY $1,000,000 GENERAL AGGREGATE 0,000,001) GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMPIOP AGG 0 000 000 POLICY PRO- LOC--+ _ $ A AUTOMOBILE LIABILITY PHPKI311677 Dumm 03/064201 COMBINED SINGLE LIMIT.(Ea accident) 1,000,000 X ANY AUTO -BODILY INJURY (Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident)S X X PROPERTYDAMAGE i HIRED AUTOS AUT�� $ A X UMBRELLA LLAB X OCCUR PHUB493958 3106/2015 OVOW2016 EACH OCCURRENCE $5,000,000 EXCESS LIAB CLAIMS -MADE AGGREGATE $5,000,000 DED I X RETENTK)Nb10000 $ WORKERS COMPENSATION _ W OTH- AND EMPLOYERS'LIABILITY �AITdU ANY PROPRIETOR/PARTNERIEXECUTIVEY/N OFFICERIMEMBER EXCLUDED? N/A EL EACH ACCIDENT $ (Mandatory In NK). E.L. DISEASE - EA EMPLOYEE S I yes, describe under DESCRIPTION OF OPERATIONS below E.L DISEASE - POLICY LIMIT S A Rented/leasedBor PHPK1311677 62015 0310 201 $500,000 IM Equipment tO/2015.03/060201 $1,000 Deductible B Excess Liability NHA237793 $5M excess of $5M DESCRIPTION OF OPERATIONS/ LOCATIONS /VEHICLES (Attach ACORD 101, Addllonal Remarka ScheduK if more apace is required) Southold Town Is named as additional insured with respects to the general liability policy. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Southold Town Clerk THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Southold Town Hall;53095 Main Road ACCORDANCE WITH THE POLICY PROVISIONS. PO BOX 1179 AUTHORIZED REPRESENTATIVE Southold, NY 11971