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HomeMy WebLinkAboutMazzoni, HenryTown of Southold, New York - Payment Voucher Vendor No. ........................ ehe.c,,0......... 4o:: ..................................... Vendor Name LLC. Vendor Address i3&,5 )lnteied ey' AVditDAW Vendor Telephone Number r 1 1 36L Town Clerk. Vendor Contact epi r ,- Invoice Number Invoice Date Invoice Total Discount Net Amount Claimed Purchase Order Number Description of Goods or Services Gerteyal T ed .fir fund arid: Qecoupti:i ititi�b$r... . 9'7 f5UOn �00G �® d ::......................................... :l c� y L-( ...................................... ............................... ................... I............ ........... ............:....................:...... i ........................................... ............... . Tota] OO l� ................................ ....................•............... .......... 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. Sig atur itle 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 noted, and ament is approved. Signata' e��ej�/ Company Name Date C { 7— Ig I Title DateS� 4 Date: 06/22/15 Quantity 1 1 3 4 3 Notes: Payment Type CK #1733 ***RECEIPT*** Transactions Application Fee - Non -Refund Beach - Guest Beach Permits Clean -Up Deposit Daily Filming Permit Receipt#: 188268 Reference Subtotal BMS Design $100.00 0490 $40.00 bms design 4 $30.00 bms design 2 $1,000.00 bms design 3 $300.00 Amount Paid By $1,470.00 Blush, Group New York Lic Southold Town Clerk's Office 53095 Main Road, PO Box 1179 Southold, NY 11971 Name: Blush, Group New York Lic 1385 Seabury Avenue Bronx, NY 11354 Clerk ID: LYNDAR Total Paid: $1,470.00 Internal ID- bms design 3 ELIZABETH A. NEVILLE, MMC TOWN CLERK REGISTRAR OF VITAL STATISTICS MARRIAGE OFFICER RECORDS MANAGEMENT OFFICER FREEDOM OF INFORMATION OFFICER `Ibwn Hall, 53095 Main Road P.O. Box 1179 Southold, New York 11971 Fax (631) 765-6145 Telephone (631) 765-1800 www.soutlioldtownny.gov OFFICE OF THE TOWN CLERK RECEIVED TOWN OF SOUTHOLD APPLICATION FOR FILMING/STILL PHOTOGRAPHY JUN 2 2 2015 PERMIT NO: Please Print or Type\ Southold I'®wn Clerk` APPLICATION DATE: , A � & NAME OF APPLICANT: MAILING ADDRESS: j V(9 -0 ` l fay 4-M J'--0, %-I (A.LI J 1 AL -t- 6\.l �j PHONE: BUSINESS: ;�-� _ (e1 - () HOME: ��L�`1- i - c9 NAME OF ORGANIZATION /COMPANY: MAILINGADDRESS: ? ?� �`�c�. CVrZ k�,'�s.__��ti' d+') rn �iC t 1'\; PHONE: �l - ��� ` QC)5, I FAX: DESCRIBE TYPE OF ACTIVITY (e.g. Motion Picture, Commercial, Television. Catalog, Magazine, etc.): DATE(S) AND TIME(S) OF PROPOSED FILMING / PHOTOGRAPHY: '7�, (AAe k 1 dI � - 14 1 r \I -b, PROPOSED LOCATION(S) OF FILMING/ PHOTOGRAPHY: (attach additional sheet, if necessary) NAME OF PERSON IN CI -TARGE AT SITE:v-` - ��. NUMBER OF PERSONS AT LOCATION (cast & crew included): 12 NUMBER AND TYPE OF VECHILES AT LOCATION: TYPE OF SPECIAL EQUIPMENT: (-,rz s,� arse cl ANY SPECIAL REQUIREMENTS: Return to: Southold Town Clerk Southold Town Hall 53095 Main Road P.O. Box 1179 Southold, NY 11971 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. K fes/ Printed i ni iN r� Title 0V, f Date TOWN CLERK'S CHECKLIST FOR FILMING PERMIT NOTE: All payments must be cash or certified check late Received: � � 15 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. V/ 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 complet d application to Chief of Police for approval or disapproval 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. 0v1�R ? Beach Parking fee - $10 per vehicle, per day between May 1 and September 30. ISSUED PERMIT Countersign application J ' 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. ELIZABETH A. NEVILLE, MMC TOWN CLERK REGISTRAR OF VITAL STATISTICS MARRIAGE OFFICER RECORDS MANAGEMENT OFFICER FREEDOM OF INFORMATION OFFICER o�oS�FFOL��OG y� N S !� y'yol .dao Town Hall, 530Q5 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: June 27, 2015 June 28, 2015 June 30, 2015 July 1, 2015 TIME: 6:00 A.M. TO 11:00 P.M. LOCATION: Rocky Point Beach, East Marion BMS DESIGNS, INC PLACE THIS PERMIT ON THE DASHBOARD, PASSENGER SIDE OF VEHICLE - E 2zabeth A. Neville Town Seal Southold Town Clerk ***RECEIPT*** Date: 06/22/15 Receipt#: 188268 Quantity Transactions Reference Subtotal 1 Application Fee - Non -Refund BMS Design $100.00 1 Beach - Guest 0490 $40.00 3 Beach Permits bms design 4 $30.00 4 Clean -Up Deposit bms design 2 $1,000.00 3 Daily Filming Permit bms design 3 $300.00 Total Paid: $1,470.00 Notes Payment Type Amount Paid By CK #1733 $1,470.00 Blush, Group New York Llc Southold Town Clerk's Office 53095 Main Road, PO Box 1179 Southold, NY 11971 Name: Blush, Group New York Llc 1385 Seabury Avenue Bronx, NY 11354 Clerk ID: LYNDAR Internal ID: bms design 3 Rudder, Lynda From: Flatley, Martin Sent: Friday, June 19, 2015 3:35 PM To: Rudder, Lynda; Blasko, Regina; Duffy, Bill; Kiely, Stephen; Krauza, Lynne; Kruszeski, Frank Subject: RE: Film Permit I have no objection to this permit being issued as long as any vehicles associated with the shoot are issued placards for parking at the street end. Martin Flatley, Chief of Police Southold Town Police Department 41405 State Route 25 Peconic, New York 11958 631-765-3115 -----Original Message ----- From: Rudder, Lynda Sent: Friday, June 19, 2015 3:19 PM To: Blasko, Regina; Duffy, Bill; Flatley, Martin; Kiely, Stephen; Krauza, Lynne; Kruszeski, Frank Subject: Film Permit Importance: High Please provide approval/disapproval and cost analysis. Please note date of shoot. Rudder, Lynda From: Flatley, Martin Sent: Friday, June 19, 2015 3:35 PM To: Rudder, Lynda; Blasko, Regina; Duffy, Bill; Kiely, Stephen; Krauza, Lynne; Kruszeski, Frank Subject: RE: Film Permit I have no objection to this permit being issued as long as any vehicles associated with the shoot are issued placards for parking at the street end. Martin Flatley, Chief of Police Southold Town Police Department 41405 State Route 25 Peconic, New York 11958 631-765-3115 -----Original Message ----- From: Rudder, Lynda Sent: Friday, June 19, 2015 3:19 PM To: Blasko, Regina; Duffy, Bill; Flatley, Martin; Kiely, Stephen; Krauza, Lynne; Kruszeski, Frank Subject: Film Permit Importance: High Please provide approval/disapproval and cost analysis. Please note date of shoot. 1 06/1912015 00:28 9182240886 BAYOUTH TNS AGENCY PAGE 02103 DATE (MMIDOIYYM CERTIFICATE OF UABILITY INSURANCE 0611712015 THIS CERTIFICATE IS ISSUED AS MATTER OF lNFOi2MAT10N QNLYAND�ND i�R ALTER FERS NO TFIE COVERAGE AFFORDI 9D BY THE FICATE DPOLIC EIS CERTIFICATE DOES NOT Ar OR NEGATIVELY AMEND, BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT GONSTITUT>= A CONTRACT i3ETWEE.N THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: ff the certificate holder is an ADffi IONAL INSURED, the poliCy(les) Must be ®ndorsed, If SUR$O�riATIQN IS'WAIVED, subject to the terms and If the iorlS Of the holdpolicer certain potiClas may raquir an endorsfament. A statement on this certificate does nQt' confer fights to the ^n.Nfieafa holder in lieu of such endorsemen s). PRODUCER Standard Lines Services P.P. Box 668 OK 74005 INSURED SMS Designs, Ina PO Bax 1929 Sapulpa OK 74066 (800)570-0767 DVERAOES CERTIFICATE num�>GR: THIS IS TO CERTIFY T1iAT THE POLICIES OF INSURANCE LISTEC BELOW HAVE 13EP ISSUED TO QUIREMENT . , TERM OR CONDITION OF ANY CONTRAOR INSURED NAMED ABOVE FOR THE POLICY K THIS WDIMAY K ISSUED OR MAY PERTAIN. THE 14SURANCE AFFORDED BY THE POLICIES DE$ R MD HEREIN SW UBJECTPTO ALL 717E TERMS, CERTIFICATE EXCLUSIONS AND CONDITIONS OF SUCH PODL IES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.LIM11'& g POLICY NUMB R MIA EFF LICOY R TYPE OF INSURANCk $1,000,000 2084522469 10/29/2014 10/28/2015 EACHC-cuRii6NCE: l CgMrdeRCIAL CaF-NERAL LIABIV'r'! $300,00.0 PREMI � Ea coca n = $ CLAIMS -MADE OCCUR MED FXP An OTre p9man ? �1 O,OOO PERSONAL&ADV INJURY $ $11000,000 !t $2,000000 GFN'L AGGREGATE LIMIT APPLIES PER; PRO- LOC 1% POLICY � JECT NUW OTHER. AUTOMOBILELIARIu1Y 20845224639 1012812074 4012812016 ANY AUTO A AUTO NFA A O$ULED 1/ H1RED AUTOS 2 AIOPrNOSWNED UM1111MLLALIAO OCCUR ExceSSLIAB CLAIMS.MADE pgp RETENTION S A WORKSR$CONPENSATION 2064520754. 10/28/2014 10/28/2015 AND EMPLOYERS' UABILH Y Y 1 N ANYpROPRIE oPJPARTNERIE%ECUTNEr7W MBINED NGLELIMI $ $1,000,000 et1 BODILY INJURY (Per P. -MI ffi BODILY INJURY (Pet acclden4) $ PPtOPEFdYDAh1AGE $ S I. DEOCRIPTION OF QPERA7IONS l LOCATIONS I VEHICLES IACQRO 161, AAdWOMI AGM&FRB 609dul6, MSY he aNaehed irlJAofo sPet9I9 fey4lrai) GENERAL LIABILITY: Blanket Additional Insured When requlred by written contract (Form #SB146932D). $100,000 $100,000 Southold, New York ATTN: Scott RVaGeII .SHOULD ANY OF THF- ABOVE DESCRIBED POLICIES EIE CANCELLED BEFORE DBA: 53095 Main Rd THE E?CPIIRATION DATE THEREOF, NOTICE WILL BE pELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, PO Box 1179 AUTHPRM REPREOUNTATWE Southold NY 11971 (71988 2014pCORD 1309PCI rlghts'reservt ACORD 26 (2014/01) The ACORD name and logo are registered marks of ACORD �sg CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DDIYYY1) 06!23/2015 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(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Standard Lines Services P.O. Box 668 CONTACT NAME: PHONEo�t (800) 570-0767 AX No): c E-MAIL ADDRESS: INSURERS AFFORDING COVERAGE NAIC # / COMMERCIALGENERALLIABILITY CLAIMS -MADE IV OCCUR INSURER A: Continental Casualty Company 20443 Bartlesville OK 74005 INSURED INSURER B : INSURER C : BMS Designs, Inc INSURER D PO Box 1929 INSURER E: INSURER F: Sapulpa OK 74066 rnvcoence CF0TIt=1r%ATE NUMBER* REV151UN NuriastR: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER MM/DDY EFF MM IC EXP LIMITS A / COMMERCIALGENERALLIABILITY CLAIMS -MADE IV OCCUR 2084522469 10/28/2014 10/28/2015 EACH OCCURRENCE $ $1,000,000 A PREMISES EaE occurrenceE $ $3001000 MED EXP (Any one person) $ $10,000 X X PERSONAL BADV INJURY $ $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ $2,000,000 PRODUCTS - COMP/OP AGG $ $2,000,000 ✓ POLICY ❑ jE F7 LOC $ OTHER: AUTOMOBILE LIABILITY 2084522469 10/28/2014 10/28/2015 EaaocdeDISINGLE LIMIT $ $1,000,000 BODILY INJURY (Per person) $ AUTO BODILY INJURY (Per accident) $ A IANY ALL OWNED SCHEDULED AUTOS AUTOS HIRED AUTOS ✓ NON -OWNED AUTOS (Per PROPERTY $ $ UMBRELLALIAB OCCUR EACH OCCURRENCE • $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED I I RETENTION $ $ A WORKERS EMPLOYCOMPENSATION ILII AND EMPLOYERS' LIABILITY ANYPROPRIETOR/PARTNER/EXECUTIVE Y❑ OFFICERIMEMBEREXCLUDED? (Mandatory In NH) N / A 2084520754 10/28/2014 10/28/2015 ✓ STATUTE ERH E.L. EACH ACCIDENT $ $ 1 OO,000 E.L. DISEASE - EA EMPLOYEE $ $100,000 E.L. DISEASE - POLICY LIMIT $ $ 500,000 If yes, describe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/ LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, may.be attached if more space is required) Photography / Modeling. ' GENERAL LIABILITY: Blanket Additional Insured when required by written contract (Form #SB 146932 E). Blanket Waiver of Subrogation when required by written contract (Form #SB 146932 E). Blanket Primary/Non-Contributory when required by written contract (Form #SB 146932 E). Certificate Holder is an Additional Insured Per Form #SB 146932 E. Town of Southold ATTN: Steve Kyle PO Box 1179 NY 11971 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 49 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD Rudder, Lynda From: hmazzoni@nyc.rr.com Sent: Monday, June 22, 2015 6:25 PM To: Rudder, Lynda Subject: Re: Filming Henry Mazzoni 146-04 25th Road Flushing, New York 11354 Sent from my T -Mobile 4G LTE device ------ Original message ------ From: Rudder, Lynda Date: Mon, Jun 22, 2015 1:08 PM To: hmazzoni@nyc.rr.com; Subject:Filming I am issuing the filming permit. Where would you like the permit sent and how? Lynda M Rudder Deputy Town Clerk Principal Account Clerk Southold Town Clerk's Office 53095 Main Road, PO Box 1179 Southold, NY 11971 631/765-1800 ext 210 631/765-6145 Rudder, Lynda From: Krauza, Lynne Sent: Thursday, June 25, 2015 3:57 PM To: Rudder, Lynda Cc: Kiely, Stephen Subject: FW: RE: Fwd: Emailing: Mazzoni_20150625142934 Hi Lynnie, Stephen said the insurance certificate for Mr. Mazzoni is approved even without the PO Box, Thanks. Lynne -----Original Message ----- From: Krauza, Lynne Sent: Thursday, June 25, 2015 3:55 PM To: Kiely, Stephen Cc: Rudder, Lynda Subject: FW: RE: Fwd: Emailing: Mazzoni_20150625142934 F/Y/I -----Original Message ----- From: Krauza, Lynne Sent: Thursday, June 25, 2015 3:27 PM To: 'larryb@tulsacoxmail.com' Subject: RE: RE: Fwd: Emailing: Mazzoni_20150625142934 Please add the P.O. Box 1179 to the Certificate Holder box along with the street address. Thanks. -----Original Message ----- From: larryb@tulsacoxmail.com [mailto:larryb@tuisacoxmail.com] Sent: Thursday, June 25, 2015 3:11 PM To: Krauza, Lynne Subject: FW: RE: Fwd: Emailing: Mazzoni_20150625142934 LARRY BAYOUTH BAYOUTH INS. AGENCY SAPULPA, OKLAHOMA -------- Begin forwarded message -------- Subject: RE: Fwd: Emailing: Mazzoni_20150625142934 Date: 6/25/15 2:04:06 PM From: "Claire M. Poteet" <Claire.Poteet@sls-ins.com> To: "'larryb@tulsacoxmail.com"' <larryb@tulsacoxmail.com> Attached is the certificate you requested. Please feel free to let me know if you need anything else. Thanks, Claire Poteet Commercial Lines Underwriting Assistant Standard Lines Services A Division of Graham -Rogers Inc Phone: 800-570-0767 ext 203 Direct: 918-886-6030 Fax: 918-336-2178 www.sls-ins.com/ Want certificates faster? Ask me about CERTSERV!! -----Original Message ----- From: larrvb@tulsacoxmail.com[mailto:larryb@tulsacoxmail.com] Sent: Thursday, June 25, 2015 1:52 PM To: Claire M. Poteet Subject: FW: Fwd: Emailing: Mazzoni_20150625142934 LARRY BAYOUTH BAYOUTH INS. AGENCY SAPULPA, OKLAHOMA -------- Begin forwarded message -------- Subject: Fwd: Emailing: Mazzoni_20150625142934 Date: 6/25/15 1:35:49 PM From: hmazzoni@nvc.rr.com To: IarryB@Tulsacoxmail.com Cc: monica@blushprom.com Sent from my T -Mobile 4G LTE device ------ Original message ------From: Krauza, Lynne Date: Thu, Jun 25, 2015 2:33 PMTo:'hmazzoni@nyc.rr.com';Cc: Kiely, Stephen;Rudder, Lynda;Subject:Emailing: Mazzoni_ 20150625142934 Hi Mr. Mazzoni,Attached please find the insurance certificate that we discussed. Kindly have your insurance agent remove the language crossed out under the description section and remove the reference to Mr. Kiely in the certificate holder box and add the street address listed on said form. Kindly send us the revised insurance certificate. Thanks.Lynne KrauzaSecretary to the Town AttorneyTown of Southold Your message is ready to be sent with the following file or link attachments: Mazzoni_ 20150625142934Note: 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. CONFIDENTIALITY NOTICE: The information contained in this communication, including attachments, may contain privileged and confidential information that is intended only for the exclusive use of the addressee. If the reader of this message is not the intended recipient, or the employee or agent responsible for delivering it to the intended recipient, you are hereby notified that any dissemination, distribution or copying of this communication is strictly prohibited. If you have received this communication in error please notify us by telephone immediately. BINDING NOTICE: Insurance coverage cannot be bound, amended or cancelled via an e-mail message without confirmation from an authorized representative of Graham -Rogers.