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Home My WebLink AboutMazzoni, Henry (2) JUL 1 1 2017 Southold Towrl APPLICATION FOR FILMING/STILL P110TOG APPY PERMIT NO: Please Print or Type APPLICATION DATE: NAME OF APPLICANT: Henry Mazzoni _. MAILING ADDRESS: 146-04 25'h Road Flushing,NY 11.354 --__ _- PHONE: BUSINESS: _347-672-2051 __— HOME: _347-672-2051 NAME OF ORGANIZATION/COMPANY: _Blush Group New York, LLC MATLTNG ADDRESS: 146-0425" Load L lashing,NY 11354 PHONE: 347-672-2051 DESCRIBE TYPE OF ACTiviTY(e.g. Motion.Picture, Commercial,'Television. Catalog, Magazine, etc.): ._Catalog, Magazine _ _..._ __— DATE(S) AND TIME(S) OF PROPOSED FILMING/PHOTOGRAPHY: July 14-15, 2017 : _--- PROPOSED LOCATION(S) OF FILMING/PHOTOGRAPHY: (attach additional sheet, if necessary) _Rocky Point Beach NAMI OF PERSON IN CHARGE AT SITE: henry Mazzoni NUM.BER OF PERSONS AT LOCATION (cast&crew included): _10T__ NUMBER.AND TYPE OF VECHIL ES A"T` I..,OCATION: 2: Car and RV____...__....____._ �— TYPE OF SPECIAL EQtJIPMENI'--.___photographic ANY SP ? REQtfIREMEN'TS: _.—__......................_. ..__. Signature --- Return to: Southold Town Clerk Southold Town Hall 53095 Main Road P.O. 1179 Southold,NY 11971 BLUSH-1 OP ID:JW2 DATE(MM1DDlYYYY) L• CERTIFICATE OF LIABILITY INSURANCE07111117 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 Ileu of such endorsement(s). PRODUCER 914-232-7711 NAME cT Jane West The Niles Agency914-232-0387 PHON u Ext•914-232-7711 arc No:914-232-0387 41 Katonah Ave Katonah,NY 10536 n'ooREss: ane nilesa enc ,Com Gene Barto INSURERS AFFORDING COVERAGE NAtC p INSURER A;Sentinel Insurance Co 11000 INSURED Blush Group New York LLC INSURER B..The Travelers Indemnl Co 25658 1385 Seabury Avenue INSURER C:Trav Prop Cas Ins Co 36161 Bronx, NY 10461 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 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 AbU SU TR TYPE OF INSURANCE POLICY NUMBER MMIDDNM Y EFF MMMD/ YYYLICY Y LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000+00 A X COMMERCIAL GENERAL LIABILITY X 38 SBA SX9691 10126/16 10128/17 PR MISES tEa oocurrence) S 1,000,00 CLAIMS-MADE D OCCUR MED EXP(Any one person) S 10,00 PERSONAL&ADV INJURY $ 1'000'00 GENERAL AGGREGATE S 2,000,0011 GEN•L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG S 2,000,00 X POLICY F7 PRO• LOC $ AUTOMOBILE LIABILITY C a a81 idenntSINGLE LIMIT $ 1,000,00 A ANY AUTO 38 SBA BX9691 10128116 10128/17 BODILY INJURY(Per person) $ ALLOWNED SCHEDULED BODILY INJURY(Per accident) $ X WIRED AUTOS TOS X NON OWNED PROPERTY DAMAGE $ AUTOS P 'accident X UMBRELLA LIAR X OCCUR EACH OCCURRENCE S _ 5,000,00 A EXCESS UAB CLAIMS-MADE 38 SBA BX9691 10/26116 10126117 AGGREGATE S _ 5,000,00 DED I X I RETENTION$ 10000 S WORKERS COMPENSATION X WC STATU- DTH- AND EMPLOYERS'LIABIUTY B ANY FROPRIETOR/PARTNERIEXECUTIVE Y� NIA A UB-1H152497-16 05/11/17 05/11118 E.L.EACH ACCIDENT $ SO®,®® OFFICERIMEMSER EXCLUDED? 600,00 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If as,describe under E.L.DISEASE-POLICY LIMIT S 500,00 DESCRIPTION OF OPERATIONS below C Business Personal OC-61M5496A-16-ND 04/08/17 04/08/18 BPP 2,500,00 Property Ded 2,50 DESCRIPTION OF OPERATIONS I LOCATIONS t VEHICLES(Attach ACORD 101,Additional Remarks Schedule,it more space Is requlred) Photo shoot 7/15/17 - 7/16/17 Rocky Point Beach East Marion NY. Certificate holden is listed as additional insured when required by written contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of Southold 53095 Route 25 AUTHORIZED REPRESENTATIVE Southold,NY 11971 ®1988-2010 ACORD CORPORATION. All rights reserved. ACORD 26(2010105) The ACORD name and logo are registered marks of ACORD 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'Fown as an additional insured on any applicable policies. 7-10-17 Date Sig ire '�z, .—Henry Printed nanie -.-Owner Title