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HomeMy WebLinkAboutWilderness Traveling Museumyt�oesoo,o 970 Peconic Lane Ken Reeves. rd P.O. Box 267 Recreation Supervisor' ® Peconic, NY 11958 Town of Southold 631.765.5182 �dUHjY 4 Ken.Reeves@town.southold.ny.us TOWN OF SOUTHOLD RECREATION DEPARTMENT APPLICATION FOR USE OF SOUTHOLD PARKS FACIILITIES PLEASE PRINT LEGIBLY APPLICATIONS DUE AT LEAST TWO (2) MONTHS BEFORE EVENT 4 Today's Date: � U �- `/ t L� Requesting Organization: t1—'D IQ - AIC 5- S 12,44( 0 1-t Applicant's Name: Address: P .C) _ (-J c7 �6_ s rD /5 O &y 0- Ij Home Phone: -- 7 2 Z--- 4&4 -5 - Cell: C t Z-3 ( E-mail Address: �) L L� �,¢f S 5,7—AA (f T—c—, 1-4,-0 Facility Requested: _Q © at) /J Day(s) and date(s) of use: Requested Time for Field/ParldCourt/Use: From: ne To: Requested time for lights to be on (if applicable): From: To: NOTE: LIGHTS MUST BE TURNED OFF BY 10:00 P.M. Reason For Use (Please be specific and give details): Is admission being charged? Y If yes, how much is being charged? !0 �_ op No Please provide a detailed explanation of how the proceeds are to be used: L-A/EA a 5 4 4,! Applicant's Signature: HOLD HARMLESS AGREEMENT The applicant/group/organization agrees to indemnify and hold harmless the Town of Southold, its officials, employees, and/or agents from all claims, lawsuits, hospital and/or doctor bills, actions, proceedings, and liabilities for the loss or damage to property, or any injury, the death of a person, including any expenses incurred by the Town of Southold defending any claims, lawsuits, or action that may arise as a result of the conduct, actions, including the negligence of the applicant/group/organization to the fullest extent permitted by applicable law. I have read the attached "SOUTHOLD TOWN FACILITY RULES AND REGULATIONS" and agree to abide by them. ///� Name of Organization: d t ii,�' s � ` / `�`°—� I Please Print h -S 7�!D ate Please Print (Principal/Authorized Representative) Applicant's We are glad that we are able to provide your group/organization league with a facility. Your group is required to make certain that the field is free of debris when you leave for the day. We appreciate every effort you make to clean up after your event is over. Our staff has maintenance schedules exclusive of outside groups who use our facilities and we need to make sure that the field is ready for future groups and activities. Thank you for your time and cooperation regarding this matter. FOR OFFICE USE ONLY Certificate of Insurance Required? Special Events Application Required? If yes, please fill out the attached application. Facility Is: Available {' Not Av ilable { } Recreation Department UY;S UYES Request Is: Approved Denied ONO U -NO Supervisor ,�coRo° CERTIFICATE OF LIABILITY INSURANCE MMIDD DATE 0/20 YYl1) 07/2 012 01 5 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 Phone: (631)298-0700 Fax: (631)298-3850 ROY H REEVE AGENCY, INC. PO BOX 54 13400 MAIN ROAD MATTITUCK NY 11952 CONTACT Barbara Dammers NAME: PHONE FAX (631) 298-3850 Ext 631 298 4700 ac No: E-MAIL ADDRESS: bdammers@royreeve.com INSURER(S) AFFORDING COVERAGE NAIC# INSURER Hartford Insurance Company INSURED TRAVELING WILDERNESS EXPERIENCE INC. INSURER B INSURER DBA WILDERNESS TRAVELING MUSEUM INSURER D: PO BOX 88 AQUEBOGUE NY 11931 INSURER E INSURER F rnvGaer_Gc CERTIFICATE NI IMRFR- FgR4R 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 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 INSD SUER WVD POLICY NUMBER MMIDDY EFF MMIDOPOLICY EXP LIMITS A X COMMERCIALGENERALLIABILITY X 12SBMVC0558 03/01/15 03/01/16 EACH OCCURRENCE $ 2,000,000 CLAIMS -MADE X OCCUR DAMAGE TO RENTED PREMISES (Ea o rence) $ 300,000 MED. EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ 2,000,000 GEN'LAGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 4,000,000 POLICY PRO JECTY LOC PRODUCTS - COMP/OP AGG $ 4,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS HIRED AUTOS NON -OWNED AUTOS BODILY INJURY (Per accident) $ PROPERTYDAMAGE $ (per amident) UMBRELLA Lw8 OCCUR EACH OCCURRENCE $ AGGREGATE $ AB Le LL HCLAIMS-MADE DED I RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETORWARTNERIEXECUTIVE YIN OFFICERMEMBER EXCLUDED? (Mandatory in NH) NIA PER OTH- STATUTE ER E.L. EACH ACCIDENT $ E.L. DISEASE -EA EMPLOYEE $ E.L. DISEASE -POLICY LIMIT $ 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) Certificate holder is listed as additional insured with respect to general liability as per the terms and conditions of form #SS0008(04/05) Business Liability Coverage Form as required by written contract or agreement. CERTIFICATE HOLDER CANCELLATION Town of Southold PO Box 1179 Southold, N Y 11971 Attention: SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Barbara J. Dammers ACORD 25 (2014/01) @ 1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD