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Home My WebLink AboutMattituck/Cutchogue Little League r ' isw4"•.... 970 Peconic Lane sz�oe sovr�i Ken Reeves 1�Q,_ °ro P.O.Box 267 Recreation Supervisor n 41' 614 Peconic,NY 119 Town of Southold ~"4.44: °`+%�+ 631.765.5182 _ V 1 �r*comm , �„ j i, Ken.Reeves@toi - outhold.ny.us TOWN OF SOUTHOLD APR - 1 2015 RECREATION DEPARTMENT SUPERVISOR'S OFFICE TOWN OF SOUTHOLD APPLICATION FOR USE OF SOUTHOLD PARKS FACIILITIES PLEASE PRINT LEGIBLY APPLICATIONS DUE AT LEAST TWO (2) MONTHS BEFORE EVENT Payment is due at time of application Today's Date: Icaa- (V� Requesting Organization: rT41 hACIL j t e 0 �T tX 9O.- Applicant's Name: 1_a t_A ( jV (Sfe 1.1 Address: PO bb 49S Ma 'CX-- Jv t l Home Phone:(f \ tR." '((1(a)Business: Cell: (a I-a'?E,3c0 E-mail Address: I Cl.US m i l e cL c&.O 1 ' calm Facility Requested: li €i L taLsi_e.Y u n U 'Reid Day(s) and date(s) of use: *B.(231/\ ("MN-kali 45162-1 1 (r 51&r'd3.-{ _ � ` - m ti mon- 3 m �c �udC j gam � Requested Time for Field/Park/Court/Use: From: Q .,\Doe- To: Requested time for lights to be on (if applicable). Field/court lighting will not be available from January 1—March 1. From: To: NOTE: LIGHTS MUST BE TURNED OFF BY 10:00 P.M. Reason For Use(Please be specific and give details): Q—a-COL/0 jr.01Q--S p/taelle.,Q Is admission being charged? Yes No y If yes,how much is being charged? Please provide a detailed explanation of how the proceeds are to be used: 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. f Name of Organization: 1 1 Ck CAL- CUJC*W ` e_. Lii-it Lc14AeI Please Pdi t 5b , tO Luc&I NU) w ate Please Print(Principal Authorized Representative) Applicant's Signature: AAA 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. 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. i��f�V�tifi/'',`�t/r/"ii�iiiii�ii�i�i�/tii��ii�itii��tii`fi��i�i��tii�i`ftii�iiti/ii��iIi�i�ili�i�i��/��i�i�i es/se't/ /% f 1>/: 4 />/>/ !/•\/>/ its*//%/�l%/'>/WAA •!.r/>/: •,>he4l•.�/WA� /•//>//>/>/>Af/W.N FOR OFFICE USE ONLY Certificate of Insurance Required? la YES LINO Special Events Application Required? U YES tNO If yes,please fill out the attached application. Facility Is: Request Is: Available {,---r- Approved 44.7 Not Avalable { } Denied { } 1 ie300-€ VAIF ' Recreation Department Supervisor CERTIFICATE OF LIABILITY INSURANCE DATE 3/2'7/16 Keystone Risk Managers,LLC CERTIFICATE# 2323609-2 1995 Point Township Drive Northumberland,PA 17867 2 2 36 AODmONALNAMED INSURED: INSURERS AFFORDING COVERAGE: PIATTITUCK CUTCHOGUE LL INSURER A: LEXINGTON INSURANCE COMPANY LAURAL OLSEN PO LOX 425 INSURER B: NATIONAL UNION FIRE INSURANCE (Non-liability) COMPANY OF PITTSBURGH,PA MATTITUCK NY 11952 INSURER C: AIG SPECIALTY INSURANCE COMPANY COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR AMYL TYPE OF INSURANCE POLICY NUMBER PoucY EFFECTIVE POLICY EXPIRATION LIMITS LTR INSRD DATE MM/DDIYYYY DATE MM/DWYYYY GENERAL LIABILITY EACH OCCURRENCE $2, 000, 000 A X X OCCURRENCE 011225814 1/07/2016 1/01/2017 GENERALAGGREGATE $2, 000, OOO X INCL.PARTICIPANTS Property Damage Deductible:$250 FRoAoCzra ora $2, 000, 000 X SEXUAL ABUSE slcc R s $2, 000, 000 WtuAt.ttala $2, 000, 000 MEDICAL PAYMENTS PERSON EACH LOSS $1,000,000 A n DIRECTORS&OFFICERS 19330955 1/01/2016 1/O1/2017 AGGREGATE $1,000,000 EACH LOSS $35,000 A CRIME COVERAGE Crime Deductible:$250 Property/$1,000 Money AGGREGATE NONE B X SPORTS EXCESS ACCIDENT M aMaxrt$100,000 Po icy Excess SR091 O543�E 1/01/2016 1/01/2017 Do4.$50 "X"INDICATES COVERAGE SELECTED FOR ADDITIONAL NAMED INSURED ADDITIONAL INSURED Who'Is an Insured(SECTION 10 of the General Liability policy Is amended to Include as en Insured the person or organization shown-in the schedule,but only with rospect to liability arising out of the above named little League's maintenance or use of ball fields,or other premises loaned,debated,or rented to that Utile League by such person or organizations and subject to the following additional exclusions: 1. Structural alterations,new construction,maintenance,repair or demolition operations performed by or on behalf of the person or organization designated In the Schedule unless performed by the above named Little League and 2. That part of the bat field or other premises not being used by the above named Little League, NAME AND ADDRESS OF PERSON OR ORGANIZATION: 1. TOWN OF SOUTHOLD 2. MATTITUCR PARK DISTRICT 3. MATTITUCK SCHOOL DISTRICT 4. NEW SUFFOLK SCHOOL DISTRICT INSURED CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES TO THE ABOVE NAMED LITTLE LEAGUE EE CANCELED BEFORE THE Little League Baseball Risk Purchasing Group,Inc. EXOPTIAONSATEATETHOF OONGAIONATOTHESLfIew}r WAeESWTILOMIL3O DAYS WRITTEN NOTICE 539 U.S.RT.15 HIGHWAY r South Williamsport,PA 17702 AUTHORIZEDREFTISSlj+f•'OII�E'- / •P - Standish, Lauren From: Reeves, Ken Sent: Monday, April 18,2016 12:15 PM To: Russell, Scott Cc: 'Duffy, Bill Subject: RE: Mattituck-Cutchogue Little League Opening Day Ceremony Sorry...just spoke with Laural and they would need to know as soon as possible if they will be allowed to have the bounce houses at their opening day ceremony as they need time to order them. If this needs to be discussed by the board, is there any way to have it put on the agenda for tomorrow's meeting? Sorry for the late notice,just heard about the bounce houses not long ago. Ken From: Reeves, Ken Sent: Monday, April 18, 2016 12:07 PM To: Russell, Scott Cc: Duffy, Bill Subject: Mattituck-Cutchogue Little League Opening Day Ceremony Good Afternoon: Mattituck-Cutchogue Little League is having an opening day ceremony on Saturday, May 7 for their players at the fields in Laurel. They would like to have 2 bounce houses at their event. We did receive an application for use of the fields for their league and games (see attached) along with a certificate of insurance. The application does not specify holding an opening day ceremony. Will they need a special events application for this type of event? Should this be discussed at a town board meeting? Thank you for your assistance regarding this matter. Ken 1