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HomeMy WebLinkAboutModern Maturity MagazineTOWN CLERK'S CHECKLIST FOR FILMING PEI NOTE: All payments must be cash or certified check a kll'- _ FAXIsd SING" ,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. emnification 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 an termination 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 Attorneyfor ap Wval 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. 4 (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 I and September 30. ISSUED PERMIT �untersign application ..Issue permit with name of applicant, locations(s), date(s), and time(s) NOTIFICATION of ISSUED PERMIT -----Chief of Police Chief Building Inspector Marshal �e 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) /Ifnot cleanup is required, Superintendent of Highways will notify wn Clerk and Town Clerk will remit the $250 certified check to Aa 0� applicant. 0 ELIZABETH A. NEVILLE TOWN CLERK REGISTRAR OF VITAL STATISTICS MARRIAGE OFFICER RECORDS MANAGEMENT OFFICER FREEDOM OF INFORMATION OFFICER o�os�FFo�,��oG ce a oy� OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD May 22, 2001 CERTIFIED MAIL RETURN RECEIPT REQUESTED Wendy Tiefenbacher Modern Maturity Magazine 601 E St., NW Washington, DC 20049 Dear Ms. Tiefenbacher: • Town Hall, 53095 Main Road P.O. Box 1179 Southold, New York 11971 Fax (631) 765-6145 Telephone (631) 765-1800 Returned herewith is AARP check No. 415431 in the amount of $250 that was being held for cleanup fees as required by the Southold Town Code, Chapter 44A. An inspection of the permit site was made and no cleanup was necessary. I hope all went well with your shoot. If I can be of any assistance in the future, please do not hesitate to contact me. Very truly yours, Linda J. Cooper Deputy Town Clerk Enc. lists 1543 L"I 1:07 L9 23 2841: 776571,100485u' • ELIZABETH A. NEVILLE TOWN CLERK REGISTRAR, OF VITAL STATISTICS MARRIAGE OFFICER RECORDS MANAGEMENT OFFICER FREEDOM OF INFORMATION OFFICER o��s�FFO(�►�o� W3 Z Ol' 9 OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD • To: Raymond Jacobs, Superintendent of Highways From: Linda J. Cooper, Deputy Town Clerk Dated: May 18, 2001 Re: Film Permit No. 004 Cleanup Deposit Town Hall, 53095 Main Road P.O. Box 1179 Southold, New York 11971 Fax (631) 765-6145 Telephone (631) 765-1800 In accordance with §44A-5 of the Southold Town Code, please advise if the $250.00 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. Zaeanup was not required at the location(s) identified on the permit. The deposit may be returned. Cleanup was required. Actual cost statement is attached. Date 05/16/2001 WED 15:44 FAX 202 434 6818 MODERN MATURITY [6001 ll-W^V ll4 c y a,: 'YDatc [Mdd YY) ..e• srk: s, .1 :.. ,'! :q;A �:a.•���`.: `�"`%•''J•!``'' y:ii�s',"L! � ta: t� .� { `:ry�' � ^ e�, . � r ��fµ��,�.,�': L � � `:. :•i�r 'a�' aPA'�.r %�'1: i::V'Y:s ' • �s �"'�� �iq"s�, }•"fir' .:1r1 w� i t 4f�i.. r'A;S� �.S:?.. t. i+�� �P IS ISa'9® AS l� C� =moi (23.;Z) 682-7500 a�ax nso oars° 'a awz� m� rodUCer ,�� D S)ir?S Al1�• ACORDIA NORTHEAST mveRacs ax s��' 90 PARK AVENUE NEW YORK, NY 10016 Cotttpany Hartford Insurance Company Company Rnav=ed AARPCol-TOM B company C AARP Company 601 E Street N.W. nt- Sop D ?' ,. ;,;7: �y -,Lamm -. 5:t'''>,-•:.�.: ;s. :5;.}`xs%xY;�r ti, •ass- nn�5 is.�.ifj , ,;fit ::, �( ; th. l i.;': ` ')' y..: INSURED NAMED ABOVB FOR TIM POLICY MMM7TMTRL1PM '�:a f:K• y�l; c•'AYf�V.CERTIFY TFi�T TI{T POLICIES OP INSI]kANCE Li9TED D&LOW HAVE ANY CON IfiTOD TO TAE S HALYIBEISIS"C7ED RYMAI�OPERTMff NT TTHE IPSO�PERN TAFFORDSDBYOTHB POLICIBSTP-ACT OR I�DESCRIRW HEREINIs SUBJECT TOER DOCUMENT WITH RZ.J�CT TQ YCALL TA2 USIONS AND COND I7:'IONS Off' •�� poLICI $. LYMXTS sHUPa TAY PAzn CLA FMTRL1PM I ku:raEver LT!¢TS Cu rn% OF M05=201cmu PoI.xC�r L Gs�� LIbBIXXZT A Commc=cial Gcneral�riar' 10CSEJ54907 ks• Clairne Madc Occur owncrte 6 Cont protective Tammuz LI onaTy Any Auto All owned Autos Scheduled AuLota Hired Avto8 Non -owned Avtos tAALB LIABYLI'nr Anv Auto EXCESS LIABILM _jDmbralla Form Orher Thaw Umbrcila Fon WORZERS. mac" AND ZMpIj)7WW1 LTA13X= The Prop 11%tor/ Inc P.i =era�Exec=lve _. 1/01/01I01/01/02 ec,,mined Single Limit Bodily Injury (per person) Bo ly Injury (per accident) ;Property Damage r.. n.,9,, _ ra b%aide Desaupi'Coa of oI'L�A'Ilalas/I�r2rio�1S/V�Y��s/sf+'fiCSAL rci�1S gg ZE: Modern maid Towhship1O53095oNaiA RogdonSou.thold,aNy. mayi17, 2001.beaeh rhe Township of Southold included as additional insured as lessor. gt7'r OF 7S� At1pV8 AI�SSCRIBB� PMICTBS BE C224C%M."" BaPME TOR 'I4lP I�A'Rst F, iTIL ISSUING cafWARY WILL BNDLAVVRt AV mmm LtA7r5 ►1iLiT�f NmiO3 70 TRR CEHx 11(:hAE RULDW ovum, TV IBE Acrr PAIIDRE TO HALL 9= NOTICE SSAI+Y, IWQM No OMMGMIC" MTLTTY OF AM KRWD UP= Mo COMPANY, ITS AaMM OR RKM- odern Maturity 01 E Street Y ashington, DC 20049 • ELIZABETH A. NEVILLE TOWN CLERK REGISTRAR OF VITAL STATISTICS MARRIAGE OFFICER RECORDS MANAGEMENT OFFICER FREEDOM OF INFORMATION OFFICER o�OS�FFO��co� y� H Z oy� • o�� OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD Town Hall, 53095 Main Road P.O. Box 1179 Southold, New York 11971 Fax (631) 765-6145 Telephone (631) 765-1800 FILMING PERMIT NO 004 OF 2001 PARKING PERMIT DATE: THURSDAY, MAY 17, 2001 TIME: Sunrise to sunset LOCATION: Beach at Lighthouse Road, Southold • ELIZABETH A. NEVILLE TOWN CLERK REGISTRAR, OF VITAL STATISTICS MARRIAGE OFFICER RECORDS MANAGEMENT OFFICER FREEDOM OF INFORMATION OFFICER o�oS�FFat,��o� G7 ti Z oy� � o�rm OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD To: Chief Cochran, Southold Town Police Mike Verity, Senior Building Inspector Fire Marshal Ed Forrester, Code Enforcement Officer Raymond Jacobs, Superintendent of Highways From: Linda J. Cooper, Deputy Town Clerk Dated: May 16, 2001 Re: Filming Permit No. 004 • Town Hall, 53095 Main Road P.O. Box 1179 Southold, New York 11971 Fax (631) 765-6145 Telephone (631) 765-1800 In accordance with Town Code 44A-9 you are being notified that a Film Permit was issued to Modern Maturity Magazine. See following page for a copy of the permit. P*,qf f01,��o ELIZABETH A. NEVILLE TOWN CLERK y Z REGISTRAR, OF VITAL STATISTICS S • MARRIAGE OFFICER y �� RECORDS MANAGEMENT OFFICER FREEDOM OF INFORMATION OFFICER OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD Town Hall, 53095 Main Road P.O. Box 1179 Southold, New York 11971 Fax (631) 765.6145 Telephone (631) 765-1800 FILMING/STILL PHOTOGRAPHY PERMIT Issued to: MODERN MATURITY MAGAZINE — Wendy Tiefenbacher, Photo Editor Location(s), Time(s) and Date(s) THURSDAY, MAY 17, 2001 SUNRISE TO SUNSET HORTON'S POINT (a), LIGHTHOUSE ROAD BEACH Permit No. 004 Issue Date: MAY 16, 2001 Qo IT- ' L� Elizabeth A. Neville Southold Town Clerk (Town Seal) Date: 05/16/01 Transaction(s): 1 1 Town Of Southold • P.O Box 1179 • Southold, NY 11971 * * * RECEIPT * * Application Fee - Non -Refund Dailv Filminq Permit Receipt#: 0 Subtotal $100.00 $100.00 Town Of Southold • P.O Box 1179 • Southold, NY 11971 ***RECEIPT*** Date: 05/16/01 Receipt#: 0 Transaction(s): Subtotal 1 Application Fee - Non -Refund $100.00 1 Daily Filming Permit $100.00 Total Paid: $200.00 I Name: A, A R P 601 E Street, N. W. Washington, D. C. 20049 Clerk ID: LINDAC Internal ID: 32139 • ELIZABETH A. NEVILLE TOWN CLERK REGISTRAR OF VITAL STATISTICS MARRIAGE OFFICER RECORDS MANAGEMENT OFFICER FREEDOM OF INFORMATION OFFICER OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD To: Southold Town Attorney's Office From: Linda J. Cooper Dated: 5/16/01 Re: Filming Permit 11 Town Hall, 53095 Main Road P.O. Box 1179 Southold, New York 11971 Fax (631) 765-6145 Telephone (631) 765-1800 In accordance with the Southold Town Code, Chapter 44A, Section 3, Subsection D, the Certificate of Insurance and Indemnification Agreement for Modern MaturityMagazine is attached hereto. Please review and advise whether these documents meet with your approval. Thank you. Approved as submitted Disapprove for the following reasons: gnature Date ELIZABETH A. NEVILLE TOWN CLERK REGISTRAR OF VITAL STATISTICS MARRIAGE OFFICER RECORDS MANAGEMENT OFFICER FREEDOM OF INFORMATION OFFICER o�oS�FFot�.�oG CIO Z oy� • o�� OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD Town Hall, 53095 Main Road P.O. Box 1179 Southold, New York 11971 Fax (631) 765-6145 Telephone (631) 765-1800 To: Southold Town Attorney's Office From: Linda J. Cooper Dated: 5/16/01 Re: Filming Permit In accordance with the Southold Town Code, Chapter 44A, Section 3, Subsection D, the Certificate of Insurance and Indemnification Agreement for Modern Maturity Magazine is attached hereto. Please review and advise whether these documents meet with your approval. Thank you. Approved as submitted Disapprove for the following reasons: Signature Date 05/14/2001 MON 10:59 FAX 202 434 6818 MODERN MATURITY Z001 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 eba D o Printed na)Ae OU4— Tit e /1CL �c G! Z r% -C I l v�v a 05/15/2001 TUE 17:33 FAX 202 434 6818 MODERN MATURITY Z002 05/15/01 15:59 FAX 212 953 6449 ACONDIA ty-iUUlfUvl .xt .r., y';r:. '•.r'%' "•.`y�."s2r'vi: J/;;rr;"�y,s> ;i;;.`te''`:^ G,i Co.,.(mm dd • yyl •�.q rrf: S':f%' ^rs ++g$��Y•:S" ,S ..'•S�f. 'pVMS.- � :? 'ry�'�:{ y::JCh 'J, 1., ':i:!� •': rs.��. f\�'�'f'.?• .S''•,yS1.�i .fKT •+5:1:yS°; T,Ih ..�V' v'{..f l.1�M:t: f. •�"�J'•Y !/!vy {':`� '�iS i' • r: ';.r4> : ,::,<•;``�'f"•y`.::n,:P.t,�q S'r �•� x'7'3 6, •�: �: 74 PTT 9RS�F� '.�• •b: •:.4� � '¢ .k �..'":�+7C:. MS. S I' ��-; •Se }��I��r1. vv,, .Y n„ �� �'' �>,•ti. ' { ..� �p7•;[...iE., 'f' 'a n;i� '�'�.4;;Sk ? ♦ S i•. �. d,4 „.�1, .. � 7 K�`i �'..:.::.i�•..•''}:::.i?::: + Y :•a ,FJ.?:'i:.°'E'>,;.>¢v �;:;i'� �,?r�%kt•>,�,' 212) 682-7500 zs °� II+ICJsTB IS LQTJ6D 2S T !9n=Plai us I j3ND p87pffi[.q kID RISS Uec@i 17CE CEBSIFICA72 8OL1UM- producer ACORDIA NORTHEAST Ulna Tm CERTIFICIk113 ECYPS 2= PJQM, Elam OR ALTER mE Cavffitpwm Yd'pv DED By T= POLICIES fiELDfI- 90 PARK AVENUE ,NEW YORK, NY 10016 ING AARPCnl-TOM AARP 601 E Street N.W. Company I;artford Insurance Company Company Compoxty C Company .:S::.Cdr:1, yr,:,S.,w'?i :'r,''.,✓_P'??�i:i:;•;•A`::' ..�..'.''4chs�:;•,r s�•., ._ A6..a. na•ss..;ti.z , -.., - - THIS IS TO CERTIFY TRAT THE POLICIES OF INSVRANCES . MTP BELOWHAVP REEK ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY INDICATED. NOTwITHSTANOING ANY RFIQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT To WHICH THIS CERTIFICATE MAY bfi IS5UEb OR MAY PY'�RTAIN. TIMI INSURANCE AVIORDED BY THE POLICIRS DESCRIBED HlrREIN IS SUBJECT TO ALL THE 'PERMS EXCLUSIONS AND CONDITIONS OF `UCH POLICIES. LI Ooli P.ICXY HAVE PEEN REDUCED BY PAID CLA MS. pOL7CY My CTYwFD EKPIU CION LlMrls CO 7MM OF 324 CE PCTt.ICX N Lm GEKMLkL LIAI1 LITY A CQ-rercial Canna -K41 Liab JOCSEJ54907 Claim Made w1otcur ,ownar's 6 Cant Protecti�: Crlonx LIABILrry Dy Auto L1 Ownrd AutoE cheduled AUtO. ix.d Autos on -owed Autos C LTABIISV AuCO 7occgss I.TMILrry Umbrella Porm Ocher Than Umbrella Farm TiORAMMS' Q]'4-'R1wF'"IOK AND EMPICYl3R_S T�171BILITY The Pgnprietctl. n Incl 1/Dl/01101/01/02 I- fi Combined q}ngle Limic Bodily Injury (par person) Bodily Injvly (Per accident) Prvperty Dsmage n..fn nn1v - sa ACcidC ch Ac S DESCRIPTION OF OP si'RATIO'PS/IA�3►'fiI4NS/V1DII�4/SPECllIL ITl�is tS. Modern MaNY t1ty Fashion Shoot at Southold Town Hall, 53095 Main Road, The Township of Southbld�!Tncl.uded as additional insured as lessor. odern Maturity 01 E Street NW ashington, DC 20049 LD AWY OP MM AEoiR rmrcv Im POLIMW BE CJr,I'1C£I r.rzn nEFORF: THU MTrmv nr'TE TI•MMOF, TM Issunir. COMPANY WILL 0MEAvOR To MAIL LQ_DAYS KA=M P =rICB To THE CMT1rTC aE HOLDER la%I To ZIP BoT FILTLOR9 To MAIL SUCH NOTICE SI MLL I2POS9 No O1aLIC•.7l'LION •LIAt31.ifITX Or Any XnW 13lV►1 272E COMPANY. ITS AG6PrS5 OR BEPR-U- zw. Ra —reaentattve • • POLICE DEPAMMENT TOWN Of 6OUTHOLD CARLISLE E. COCHRAN, JR. Chief of Police Telephone Emergency Dial 911 TO: Linda Cooper, Deputy Town Clerk FROM: Chief Carlisle E. Cochran, Jr. DATE: May 14, 2001 RE: WENDY TIEFENBACHER - MODERN MATURITY After reviewing the application, it appears there will be no need for police presence at the filming site as long as their vehicles will not interfere with the entrance and exit at the Maritime Museum (Lighthouse). 41405 Route 25 • P.O. Box 911 • Peconic, N.Y. 11958 Administrative (631) 765-2600/2601 • Fax (631) 765-2715 • 0 May -14-01 10:06A Southol:Policra 631 765 2715 P_01 • POLIC I, D T) 1��yML1`1T 'f( -)WN C t' (SOUTI O )LLQ Telephone Frnert;ency Dial 911 MEMORANDUM TO- Linda Cooper, Deputy Town Clerk FROM: Chief Carlisle E. Cochran, Jr. CC-- DATE: May 14, 2001 RE- WFNDY TIEFENBA.CHER - MODERN MATURITY (:Alu.ISLE li, COCHRAN, JR. c. in't'o/ r�0 Ict, Atter reviewing the application, it appears there will be no need for police presence at the filming site as long as their vehicles will not interfere with the entrance and exit at the Maritime Museum (Lighthouse). 4140; Rnurr 2S • P.O. , T.Y. 11`.158 A111 inistratiYC (6:31) 701;-2600/2601 • F:u: (631) 76; 2715 0, CLda 05/15/2001 TUE 17:33 FAX 202 434 6818 MODERN MATURITY ID r4- rv-1 t 1�6 ceoe -7( 74— f e ce i ae, - 6 c4Gi; a B L I 0 A T Cm ool MEMO modernmaturity ®GENERATION 601 E. STREET N.W. WASHINGTON. OC 20)49 (202)434-686D FAX: (202)434-6883 1 0 N E 05/11/2001 FRI 16:05 FAX 202 434 6818 o5/10/01 16:52 FAX Z1Z 953 6449 • MODERN MATURITY ACORDIA 0 Lo 001 0002 p.r� gg . Pg liare mm/uLLIyy) gg .,AT R, Ml M VO N Fi a, NO .0 0giJ3 OJr)l -TI Q0.•Y• . (2 12) 682 -7500 "M COMIFICZ= Is xssoio As A xhrm op n0%PJeXIQ1ff AM Cc"ZXS )40 RIGMS URCW TIM 00t= BOLD"K_ ACONORTHEAST C*WM1M= noesMW APMO, 1kvnND OR ALMM TXM 90 PARK AVENUE covomm zd%%0MW 1W DEE POLI= 13sum- N-EW YORK, NY 10016 Company Hartford insurance Company A Company T­7,rad XAR C01 -TOM Company C AARP Company 601 E Street N.W. Inc D as 1-nell-M Ni:,*?W: WE 0 •in Z NNlv 11 To THE INSLrBSD tZ4MED ABOVE FOR THE POLICY ThIS IS TO CERTIFY THAT T poLIC1jog OW IDTSVWCE LISTEZ) BELOW HAVE BEEN ISSUED RESPECT 0 WHICH Or, OTHER DOCUMENT WITH RES , T THIS INDICATED- tMTWITESTANDING ANY REQ1UIRBM0NT, TERM OR CONDITION or ANY CONTRACT By THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSOWCE IM AFFORDED 3 AHOWNIMAY HAVE BEZN REDTJ= ay PhID CLAIMS. TF.RMS, EXCLOSIONS AND CO=ITTQNS or SUCI.1 POLICIES, I WLICT POLCSr 8 E3EPnU46TI0K L3MTS TYM OP mn-aumcm Pdacy NUMMM p XZTZ Lrm General Aggregato owtALLT,IIII,ITX A ?CQmMWrciQJ, Gaheral Liab 01/01/01 01/01/02 UaWsOPa A411 II0CSEJ54907 Made Zoo Cur Personatr-com l a Adw InJUEY L_7ciaimB I Eaph Do Ownor's & Cont PXO1Ze0r,1-Q Fire barna I Med E= (any one prr!gnn) NA A - jkMrVvB1IZ LIMYLITY Combined Single Limit Any AuLo )j0411,ly injury All Q�cd Autos (per person) Scheduled Aljk.z Bodily Injury Hired A1.1ros (per acoidenL) Non -owned Autos jprope=ty Damage Au Lo only - Sa Accidont 2ir(o Other Than Auto only Sack Accident Acmragato ;Any Bagh QqeQrreAcQ EXCESS LIABILITY A re oto mbrella Form Umbrella Ocher Than Umbrella Form Inarurory DRYS'C011M9XFW3LLM AM r5L Ego Accident S NmK,QYERS I LTMILITY EL Disease-l'ojjcy Limit 6 The Prxetior(i". incl paxic= INMR10yqc offioii�r arc: E�cl CrilfflR DBSCPXPTIC" OF OPER=Qt?S/YOMTICM/VM=cTJL't/$PBCPZ RE: modern Maturity Fashion Shoot at Horton's Point, at .the lighthouse beach in Southold Township, 53095 Main Road, Southold, NY 11971 j'tEMMA. W MI'MiMe gg x suo= mr Or xim Amavz msemni= PoLicins BB cANcsLLv0 ua­ Tm MTM L11FAWP, THS ISSUING COPWANY WILL RNPeAVOR TO POLIL WTICK TO INS C3ZRT1FICA= M-13BR kON31) TO TM FT, IpUr pAILMtE -.Lo MAIL SaM IMTICE SUML MAK)SE 110 OFALIPATICK 4odern MaturityOke ; Amy m MW up= TCompmy, ITS Mowl's M REIME- 501 E Street Rashington, DC 20049 T, a ION"-, 05/11/2001 FRI 16:06 FAX 202 434 6818 MODERN MATURITY Q003 • • Edwards, Carolyn M (CEdwards) To:, KJackson Subject: Revised Request for Certificate of Insurance for Fashion Shoot 1. Date of Event: Thursday, May 17, 2001 2. Event name and full location address: Modern Maturity Fashion Shoot at Horton's Point, at the lighthouse beach in Southold Township, 53095 Main Road, P.O. Box 1179, Southold, New York 11971 3. Amount of coverage being requested: $1,000,000 4. AARP Contact, address, phone and fax: Wendy Tifenbacher, Modern Maturity Director of Photography, 202-434-6827, fax: 202-434-6818;601 E Street, N.W., Washington, D.C. 20049 5. Host contact: a) Linda Cooper, Southold Town Clerk, Southold Town Hall, 53095 Main Road, Southold, NY 11971; (631) 765-1801 b) Wendy Tifenbacher, Modern Maturity Director of Photography, 202-434-6827, fax: 202-434-6818; 601 E Street, N.W., Washington, D.C. 20049 6. Mailing contact: Modern Maturity, 601 E Street, N.W., Washington, D.C. 20049 7. Name of certificate holder: Modern Maturity 8. Certificate of holder to be insured: No Additional interests: None 1 05/11/2001 FRI 16:05 FAX 202 434 6818 MODERN MATURITY . 0a/ 7 'i 1 eS modarnmalurlty ®GENERATION 601 E. STREET N.W. WASHINGTON, DC 20049 (202)434-6860 FAX: (202) 434-6883 AARP p U B L I 0 A T 0 N S 05/11/2001 FRI 16:06 FAX 202 434 6818 MODERN MATURITY 0 004 TOWN OF SOUTHOLD APPLICATION FOR FILMING/STILL PHOTOGRAPHY RLBASE PRINT OR TYPE APPLICATION DATE: cc) PERMIT NO: NAME OF APPi,ICANT: WATLING ADDRESS : PHONE: Dust mss ob oZ)_ -Z HOME tiaME. OF ORGANIZATION, COMPANY: XAILMN4 ADDRESS: � / / 19- S f36 y PHONE: FAX: %2O2 ..-A& . + ... r r 4.0. - i M f * * * * 4-* A 6.. A... -T A..* •.... ► ► • t i I . • i .. i . i ..... . DESCRIBE TYPI OF ACTIVITY (e.g. Notion picture, Commercial, Television„ Catalog. Magazine, etc_): DATE(S) )WD TT14E(S) OF PROPOSED b'IT.1410G/FHOTOGRAPHY: 9 PROPOSED LOCATIOj(S► OF FILHINQ/PHOTOORAPVY: attach additional sheet, iE raeceasary. Horton's Point, at the lighthouse beach in Southold Township NAME OF E'ERSQN IN CHARGE AT SITE: NMORR OF PERSONS AT LOCATION (CAST 6r CR.E'A INCLQDBD) NUMSSR AND TYPLT of V$1KICLES AT LOCATION, TYPE OF SHSCIAL RauIPMEZg7; None ANY SPECIAL. XXQdTRSZUWTB : l sic)fiatu eturn to:. Southold Town Clerk Southold Town Hall 53095 Main Road P. O. Box 1179 Southold, NY 11971 05/11/2001 FRI 16:06 FAX 202 434 6818 MODERN MATURITY AARP CHECK REST Note: Instructions for using this form are on reverse -side amount Date 250.00 Re uired ASAP tequired $ 9 Make Check Payable to: Southold Town Clerk (631) 765-1801 Name: gg Address: yS�844hh oAaino�oadall Southold, NY 11971 Vendor Tax ID Number Required:1EBO�a 1❑E9 3❑E9 Tax Payer's Telephone Number Required: (631) 765-1801 reason for Check Cleanup deposit fee for photo shoot :xplanation Payment Special Instructions: Please send a certified check by FEDEX First Overnight delivery (mailing label attached) NOTE: A PAYMENT CHECKLIST IS ATTACHED Any questions, please call Carolyn Edwards, X6839 (Include information regarding attachments, delivery method, etc- When using Federal Express or Courier Services, please include recipient's street address, name of contact person, and contact person's telephone number). Company No. GL Account No. Cost Center No. Tac Code 1 �io2�� Requested by: (Signature) ate: Printed Name of RequestereekaV} Approved by: (Signature) Dater Printed Name of Approved by:�� Approved by: (Signature) (_�i��'!/t� �/C t/1'7'�_Date: � / Printed Name of Approved by: �>n�C% �' J /0-7 I.D. TYPE: NUMBER POSTED BY: ❑ STAFF ❑ VOLUNTEER ❑ VENDOR ❑ SPECIAL CODE AUTHORIZED BY: CHECK NO.: __ __ CHECK DATE: Nli/HA-0357(1-98) . E181 IM 005 05/11/2001 FRI 16:07 FAX 202 434 6818 MODERN MATURITY •• AARP CHECK REQUEST Note: Instructions for using this form are on reverse -side Amount Date RASAP 100.00 Required Required Make Check Payable to: Southold Town Clerk (631) 765-1801 Name: SQuLjjD-Td Town fla Address: 53095 Main Road Southold, NY 11971 Vendor Tax ID Number Required: 0000aa000 (631) 765-1801 Tax Payer's Telephone Number Required: ReasonforCheck Film Fee - permit fee for a photo shoot to take place Explanation: Payment Special Instructions: Please send a certified check by FEDEX First Overnight delivery (mailing label attached) NOTE: A PAYMENT CHECKLIST IS ATTACHED Any questions, please call Carolyn Edwards - X6839 (Include information regarding attachments, delivery method, etc. When using Federal Express or Courier Services, please include recipient's street address, name of contact person, and contact person's telephone number). Company No. GL Account No. EHEEF-6] - R 5 D 0 Requested by: (Signature) 1 Printed Name of Requester Approved by: (Signature) Printed Name of Approved Approved by: (Signature) Printed Name of Cost Center No. Tac Code -1 6 1 DEMME] " �� T�� j� A ,t 1 !ia n I I r' a I '� �."nrL* Q.'m EM I.D. TYPE: NUMBER POSTED BY: ❑ STAFF ❑ VOLUNTEER ❑ VENDOR ❑ SPECIAL CODE AUTHORIZED BY: CHECK NO.: CHECK DATE: NH/HA-0357(l -98) - E181 Q 006 05/11/2001 FRI 16:08 FAX 202 434 6818 MODERN MATURITY Z007 • • AARP CHECK REQUEST Note: Instructions for using this forth are on reverse -side Amount Date RUSH - Required $ 100.00 Required ASAP Make Check Payable to: Name: Southold Town Clerk (631) 765-1801 Southold Town Hall Address: �3g95$Mai nl14gad1971 outho, Vendor Tax ED Number Required: FEQ©UD©FEIF91 Tax Payer's Telephone Number Required: Reason for Check Nonrefundable application fee X)6*XX&Uydf XX to have a Explanation: photo shoot in the town .of Southold, NY Payment Special Instructions: Please send a certified check by FEDEX First Overnight delivery (label attached) NOTE: A PAYMENT CHECKLIST IS ATTACHED Any questions, please call Carolyn Edwards - X6839 (Include information regarding attachments, delivery method, etc. When using Federal Fvpress or Courier Services, please include recipient's street address, name of contact person, and contact person's telephone number). Company No. GL Account No. Cost Center No. Tac Code F11 Fol E F -ol -E5 ]E5 9 10 - 11 61 EI�E]EIE " A FT]HE Requested by: (Signature) bAp V L, Date:s a z Printed Name of Requester % " I Gti Approved by: (Signature) _ / y�ici �.Wi' Date: I J Printed Name of Approved by: _ G�2%L ✓�'�y"fl�V" Approved by: (Signature) Date: Printed Name of Approved by: AUTHORIZED BY: CHECK NO.: CHECK DATE: NWHA-0357(1-913) . E1 81 ELIZABETH A. NEVILLE 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 OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD FAX TRANSMITTAL To: Chief Cochran, Southold Town Police From: Linda Cooper, Deputy Town Clerk Dated: May 11, 2001 Number of Pages (including cover): 3 If total transmittal is not received, please call 765-1800. COMMENTS: The Film Permit Application for Modern Maturity Magazine film shoot on 5/17/01 ELIZABETH A. NEVILLE TOWN CLERK REGISTRAR OF VITAL STATISTICS MARRIAGE OFFICER RECORDS MANAGEMENT OFFICER FREEDOM OF INFORMATION OFFICER OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD To: Chief Cochran, Southold Town Police From: Linda J. Cooper Dated: 5111101 Re: Filming Permit Town Hall, 53095 Main Road P.O. Box 1179 Southold, New York 11971 Fax (631) 765-6145 Telephone (631) 765-1800 Transmitted herewith is the application of Wendy Tiefenbacher of Modern Maturity Magazine for a Filming Permit. In accordance with Section 44A.3 of the Town Code please review the application and advise of approval or disapproval of the application and whether a traffic control fee is required and the amount needed. 05/11/2001 FRI 13:45 FAX 202 434 6818 MODERN MATURITY TOWN OF SOUTHOLD APPLICATION FOR FILMING/STILL PHOTOGRAPHY PLBABtd PRz"T OR typE APPLICATION DATE: %S 6 UO NAME OF APPI+ICANi': / e l c ' bQAILING ADDRRSS: A o / C PERMIT NO: ac�eV' e -e �- A) CLs PHONE: BUS71MOS �d - T37�` A �. HOME HAMS, OF ORGANIZATION, COMPANY: / (o Ol e % I� � G� �rl l� al G MAILrMC ADDRE5Sc o / C S" re G PHONE: &t2e 7 j? `f- �� % P1SX: o2 J _ zl-- 3 / �+ wwwirwaaaaararraawpyry Vr`Miiwi riawi.►w.+ww wwiwr.+w..Fwww+.rra rrwwrwwwwr. Z002 RIAV TYPE OF ACTIVITY (e.g, Xotion picture, Commercial, Television, Catalog, s e, etc_): , / r r—�r� � 4 l — S� ! r .�D. /�-O � � � � � �1 (.� a 7" r �o r ..���r • 0 G r . � s .f K � DATE*($) AND TINE(S) OF PROPOSED VILHIOG/PHOTOGRAPHY: PROPOSED LQCATION(S) OF FILMING/PHOTOQRAPHY: attach additional sheet, if neceeeary. S o r' If �' , �► c c ; o 01� �w s l�, Nva OF PERSON IN CBARGE AT SITE: � t? ��T e a c /t e r NUMHBR OF P8R5nti5 AT .LOCATION (CAST & CREW INCLLJDgD) : Q p / cZ NUNBRR AND TYPR OF VWXCLE5 AT LOCATION; � S�a-! / �o CAdrL V a'O.- TYPE or SPECIAL EQ4=PMRt;`r: So &,e ANY SPECZAi, PXQUIVIUCINPS; b, o h 2 Signature I Return to: Southold Town Clerk S4dthold Town Hall 53095 Main Road P. O. Box 1179 Southold, NY 11971 • E 05/11/2001 FRI 13:45 FAX 202 434 6818 • MODERN MATURITY [fool mo cis rnmaturIty ®GENERATION 601 E. STREET N.W. WASHINGTON, DC 20049 (202)434-6880 FAX: (202) 434-6883 AARP P a a Lk t U B L I C A T I 0 N S 1�